1. Colorectal Surgery – Outcomes and Scoring Dermot Burke The General Infirmary at Leeds

7. BirminghamBirmingham37 70 Derby CountyDerby County38 70 SunderlandSunderland38 67 PrestonPreston37 65 WolvesWolves38 65 West BromwichWest Bromwich37 63 CardiffCardiff38 63 SouthamptonSouthampton38 60 Stoke CityStoke City38 58 ColchesterColchester38 53 Crystal PalaceCrystal Palace37 52 Sheffield WedSheffield Wed38 52 PlymouthPlymouth36 49 Coventry CitCoventry City38 49 Norwich CityNorwich City37 47 LeicesterLeicester37 46 IpswichIpswich38 45 BurnleyBurnley36 41 HullHull38 41 SouthendSouthend38 38 BarnsleyBarnsley37 38 QPRQPR37 37 LutonLuton38 36 Leeds UnitedLeeds United38 35

9. Commissioned analysis of surgical performance by using routine data: lessons from Bristol inquiry. Spiegelhalter DJ, Aylin P, Best NG, Evans SJW, Murray GD. J R Statist Soc (Ser A) 2002;165:1-31 Colorectal Surgery Why Score?

10. http://heartsurgery.healthcarecommission.org.uk

12. ASA 1Fit and well 2Mild systemic disease 3Severe, limiting systemic disease 4Incapacitating systemic disease 5Moribund

14. APACHE APACHE (1981) 34 physiological variables APACHE II (1985)12 physiological variables age and chronic health history. APACHE III (2001)17 physiologic variables age and chronic health history prior treatment location & diagnosis

15. APACHE II Temperature - core Mean arterial pressure Heart rate Respiratory rate Oxygenation FIO2 Arterial pH Serum sodium Serum potassium Serum creatinine Haematocrit White blood cell count

16. APACHE II Developed for use in intensive care setting Takes no account of surgical insult

17. What is POSSUM?

18. Alien invasion: How the possum became public enemy No 1

19. What is POSSUM? Physiological and Operative Severity Score for the enUmeration of Morbidity and Mortality

20. What is POSSUM? A method of operative risk prediction that allows for case-mix

21. What is POSSUM? 18 variables 12 physiological6 operative

22. PhysiologicalOperative Age Operation Cardiac status Number of procedures ECG Blood loss Respiratory status Peritoneal contamination BP Extent of malignancy Pulse Elective / emergency GCS Hb WCC Urea Sodium Potassium

23. POSSUM maths Each factor divided into 1, 2, 3, or 4 levels weighting of 1, 2, 4 or 8 applied to that level Amount (ml) <100 101- 500 501 – 1000 >1000 Weighting 1 2 4 8 Level 1 2 3 4 e.g. blood loss

24. Original POSSUM equations Morbidity In [R/(1-R)] = -5.91 + (0.16*phys score) + ( 0.19*op sev score) Mortality In [R/(1-R)] = -7.04 + (0.13*phys score) + ( 0.16*op sev score) Minimum risk of mortality = 0.40%

25. P-POSSUM Minimum risk of mortality = 0.22% In [R/(1-R)] = -9.06 + (0.169*phys score) + (0.155*op sev score)

26. CR-POSSUM Age, Cardiac status, BP, Pulse, Hb, Urea Operation, Peritoneal contamination, Extent of malignancy, Emergency / Elective Physiological (6): Operative (4): Tekkis et alBr J Surg 2004, 91: 1174-1182 ln[R/(1 − R)] = −9 ・ 167 + (0 ・ 338*phys score) + (0 ・ 308*op sev score)

27. CR-POSSUM Minimum risk of mortality = 0.27% Overpredicts young, fit, elective Underpredictselderly, emergency Tekkis et alBr J Surg 2004, 91: 1174-1182

28. Validation of CR-POSSUM Patients (n) P-POSSUMCR-POSSUMActual Deaths General51923 (4.4%)19 (3.7%)18 (3.5%) Colorectal79336 (4.5%)25 (3.2%)28 (3.5%) Total1312594446 Shutt D et al, 2005, ACPGBI

29. ACPGBI scores Predictive score for patients with colorectal cancer (age, ASA, stage, urgency, cancer resection) Predictive model for patients with malignant bowel obstruction (age, ASA, stage, urgency)

30. Practicalities

34. Arsenal 12 12 0 0 70 2 68 36 Everton 14 10 3 1 32 13 19 31 Charlton Athletic 11 9 1 1 37 13 24 28 Leeds United 11 8 2 1 34 18 16 25 Blackburn Rovers 16 7 8 1 29 29 0 22 Chelsea 11 6 2 3 25 10 15 21 Bristol 11 7 4 0 29 23 6 21 Birmingham City 14 4 6 4 22 21 1 16 Doncaster Rovers 14 4 9 1 17 35 -18 13 Sunderland 17 3 13 1 12 60 -48 10 Cardiff City 16 2 11 3 20 40 -20 9 Fulham 15 1 14 0 9 72 -6 3

35. Man Utd29 23 3 3 66 19 +47 72 Chelsea28 19 6 3 50 19 +31 63 Liverpool29 16 5 8 44 20 +24 53 Arsenal27 15 7 5 50 23 +27 52 Bolton30 14 6 10 34 34 0 48 Everton29 11 10 8 37 26 +11 43 Reading29 13 4 12 43 38 +5 43 Tottenham30 12 7 11 40 43 -3 43 Portsmouth29 11 8 10 36 31 +5 41 Blackburn30 12 5 13 35 39 -4 41 Newcastle29 10 7 12 34 37 -3 37 Middlesborough 29 9 9 11 32 34 -2 36 Aston Villa28 7 12 9 29 34 -5 33 Fulham29 7 12 10 31 44 -13 33 Wigan29 9 5 15 30 44 -14 32 Sheffield Utd29 8 7 14 25 41 -16 31 Man City27 8 6 13 20 33 -13 30 Charlton29 6 6 17 26 49 -23 24 West Ham30 5 6 19 21 50 -29 21 Watford29 3 11 15 18 43 -25 20 Man Utd29 23 3 3 66 19 +47 72 Chelsea28 19 6 3 50 19 +31 63 Liverpool29 16 5 8 44 20 +24 53 Arsenal27 15 7 5 50 23 +27 52 Bolton30 14 6 10 34 34 0 48 Everton29 11 10 8 37 26 +11 43 Reading29 13 4 12 43 38 +5 43 Tottenham30 12 7 11 40 43 -3 43 Portsmouth29 11 8 10 36 31 +5 41 Blackburn30 12 5 13 35 39 -4 41 Newcastle29 10 7 12 34 37 -3 37 Middlesborough 29 9 9 11 32 34 -2 36 Aston Villa28 7 12 9 29 34 -5 33 Fulham29 7 12 10 31 44 -13 33 Wigan29 9 5 15 30 44 -14 32 Sheffield Utd29 8 7 14 25 41 -16 31 Man City27 8 6 13 20 33 -13 30 Charlton29 6 6 17 26 49 -23 24 West Ham30 5 6 19 21 50 -29 21 Watford29 3 11 15 18 43 -25 20