1. National data in thoracic surgery
Doug West
SCTS Thoracic Audit Lead
2014 LCCOP slides courtesy Richard Page (SCTS/Liverpool Heart and Chest)
Ian Woolhouse (NLCA/QEH Birmingham) and Arthur Yelland (HSCIC Leeds)

2. Overview Long term trends from the SCTS registry
New structures: the COP
Insights from the 2014 COP
Future development and challenges

3. The SCTS thoracic registry

4. Long term trends

9. Current situation: SCTS returns

10. Pneumonectomy as percentage of all lung cancer resections
Provisional

11. Pneumonectomy as a percentage of all lung cancer resections by unit 2013-14

12. Pneumonectomy as a percentage of all lung cancer resections 2013-14
N=341 open, 3 VATS

14. Sleeve lobectomy as a percentage of all lung cancer resections

15. VATS as a percentage of lobectomies for lung cancer
: n=1271 VATS, 3140 open

16. VATS as a percentage of all lobectomies for lung cancer

17. The Lung Cancer Surgery Consultant Outcomes Publication (LCCOP)
Public facing
Online at mynhs (england.nhs.uk) and SCTS.org
Searchable at unit and consultant level

18. HQIP COP in Thoracic Surgery
SCTS / NLCA supported
2012 NLCA data
Validated locally by SCTS audit leads
Outcomes: 30 and 90 mortality after any lung resection for primary lung cancer, resection rates
MDT and surgeon unit-level results, not individual

19. Transparency agenda Individual clinician based Risk adjusted
Publicly reportable
Positive and negative outliers identified from 2015

20. COP via SCTS.org

21. 2014 COP: other specialties
Adult cardiac surgery
NACSA (NICOR)
Bariatric surgery
National Bariatric Surgery Register
Colorectal surgery
National Bowel Cancer Audit Programme
Head and Neck
DAHNO
Interventional Cardiology
NICOR
Orthopaedic surgery
National Joint Registry
Thyroid and Endocrine
BAETS
Upper GI Surgery
National oesophago-gastric audit
Urology
BAUS
Vascular surgery
National Vascular Registry
Neurosurgery
National Neurosurgery Audit Programme
Urogynaecology
BSUG Audit

22. Wider Context NLCA re-commissioned late 2014
NLCA moving from NHSCIC Leeds to RCP/Nottingham
Tightening of regulations on Section 251 applications

23. Lung Cancer Surgery COP
2014 LCCOP slides courtesy Richard Page (SCTS/Liverpool Heart and Chest)
Ian Woolhouse (NLCA/QEH Birmingham) and Arthur Yelland (HSCIC Leeds)

24. Numbers of Operations per Unit
2014 LCCOP slides courtesy Richard Page (SCTS/Liverpool Heart and Chest)
Ian Woolhouse (NLCA/QEH Birmingham) and Arthur Yelland (HSCIC Leeds)

25. NLCA + SCTS Surgery 2012 Primary lung cancer resections
2014 LCCOP slides courtesy Richard Page (SCTS/Liverpool Heart and Chest)
Ian Woolhouse (NLCA/QEH Birmingham) and Arthur Yelland (HSCIC Leeds)

26. MDT Resection Rate vs MDT Volume

27. Central vs Peripheral MDTs
2014 LCCOP slides courtesy Richard Page (SCTS/Liverpool Heart and Chest)
Ian Woolhouse (NLCA/QEH Birmingham) and Arthur Yelland (HSCIC Leeds)

28. Resection Rate by Unit
2014 LCCOP slides courtesy Richard Page (SCTS/Liverpool Heart and Chest)
Ian Woolhouse (NLCA/QEH Birmingham) and Arthur Yelland (HSCIC Leeds)

29. 30-day Mortality By Trust

30. Numbers of procedures per surgeon
Mean = 34
Median = 30
4th quartile
Slide: Richard Page

31. Number of operations per surgeon

32. Future of the LCCOP: short term
NLCA re-commissioning limits change
2015 same outputs as 2014
30 and 90 day mortality
Resection rate
Not risk adjusted
Unit / MDT based reporting
Units will validate all data

33. Can we assess thoracic surgeons by mortality after lung resection?

35. Challenges-long term Risk adjustment Devolved nations Essential
May need new adjustment tool
Thoracoscore AOC (Barua 2012, Badley 2012)
ESOS (Poullis 2013, Barua 2012)
Devolved nations
Data sharing vs. separate systems
SCTS audit representation from NI and Scotland

36. What happens to outliers?
“Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.”
H Walter Harrison
IBM

37. (Likely!) outliers protocol
Letter to unit lead and medical director jointly from NLCA/SCTS (MDT Lead also for resection rate alert)
Local review advised / expected
All surgeons (+MDT lead if relevant) plus Trust management
Retrospective risk stratification- Thoracoscore or other
Assessment of other local evidence- peer review, internal audit, appraisal/revalidation
Involvement of Royal College advised (alert) or expected (alarm)
SCTS support outlined

38. Linking alerts and alarms to Quality Improvement
Report and action to NLCA, commissioners.
Reported to next peer review
Included in next appraisal
Targeted audit within NLCA
Natural outcome for alerts / alarms
Might also be self-referred, or from peer review
Nature TBC

39. Outcome measures: what is right?
Mortality
easily defined
fixed periods best
Isolated use may encourage “gaming” and risk avoidance
Longer term outcomes in cancer surgery
Quality of life
Patient involvement
?Cost
Patient defined
Surgeon defined

40. COP 2.0- is resection for primary lung cancer enough?
Lung cancer resection about a quarter of all non-endoscopy activity

41. COP 2.0- is resection for primary lung cancer enough?
Only 32% of deaths occur after resection of lung cancer (2012-3)

42. The (ideal) future
Routine public reporting of cancer and non-cancer activity
Team based reporting (?some role for rolling summed individual data)
Process and outcome endpoints
Risk adjustment, model updating over time
Reduced burden on reporting units
Immediate link to Quality Improvement at alert and alarm levels

43. Acknowledgements NLCA SCTS Ian Woolhouse Richard Hubbard Mick Peake
Rhona Buckingham
Roy Castle
Jesme Fox
Lorraine Dallas
Richard Page
Simon Kendall
Joel Dunning
Eric Lim
Carol Tan
David Jenkins