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Colorectal Surgery – Outcomes and Scoring

Colorectal Surgery – Outcomes and Scoring. Dermot Burke The General Infirmary at Leeds. Birmingham 37 70 Derby County 38 70 Sunderland 38 67 Preston 37 65 Wolves 38 65 West Bromwich 37 63 Cardiff 38 63 Southampton 38 60 Stoke City 38 58 Colchester 38 53

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Colorectal Surgery – Outcomes and Scoring

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

  2. Birmingham 37 70 Derby County 38 70 Sunderland 38 67 Preston 37 65 Wolves 38 65 West Bromwich 37 63 Cardiff 38 63 Southampton 38 60 Stoke City 38 58 Colchester 38 53 Crystal Palace 37 52 Sheffield Wed 38 52 Plymouth 36 49 Coventry City 38 49 Norwich City 37 47 Leicester 37 46 Ipswich 38 45 Burnley 36 41 Hull 38 41 Southend 38 38 Barnsley 37 38 QPR 37 37 Luton 38 36 Leeds United 38 35

  3. Colorectal SurgeryWhy Score? 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

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

  5. ASA • Fit and well • Mild systemic disease • Severe, limiting systemic disease • Incapacitating systemic disease • Moribund

  6. 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

  7. 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

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

  9. What is POSSUM?

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

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

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

  13. What is POSSUM? 18 variables 12 physiological 6 operative

  14. PhysiologicalOperative Age OperationCardiac status Number of proceduresECG Blood lossRespiratory status Peritoneal contaminationBP Extent of malignancy Pulse Elective / emergency GCS HbWCCUreaSodiumPotassium

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

  16. 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%

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

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

  19. CR-POSSUM Overpredicts young, fit, elective Underpredicts elderly, emergency Minimum risk of mortality = 0.27% Tekkis et al Br J Surg 2004, 91: 1174-1182

  20. Validation of CR-POSSUM Shutt D et al, 2005, ACPGBI

  21. 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)

  22. Practicalities

  23. 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

  24. Man Utd 29 23 3 3 66 19 +47 72 Chelsea 28 19 6 3 50 19 +31 63 Liverpool 29 16 5 8 44 20 +24 53 Arsenal 27 15 7 5 50 23 +27 52 Bolton 30 14 6 10 34 34 0 48 Everton 29 11 10 8 37 26 +11 43 Reading 29 13 4 12 43 38 +5 43 Tottenham 30 12 7 11 40 43 -3 43 Portsmouth 29 11 8 10 36 31 +5 41 Blackburn 30 12 5 13 35 39 -4 41 Newcastle 29 10 7 12 34 37 -3 37 Middlesborough 29 9 9 11 32 34 -2 36 Aston Villa 28 7 12 9 29 34 -5 33 Fulham 29 7 12 10 31 44 -13 33 Wigan 29 9 5 15 30 44 -14 32 Sheffield Utd 29 8 7 14 25 41 -16 31 Man City 27 8 6 13 20 33 -13 30 Charlton 29 6 6 17 26 49 -23 24 West Ham 30 5 6 19 21 50 -29 21 Watford 29 3 11 15 18 43 -25 20 Man Utd 29 23 3 3 66 19 +47 72 Chelsea 28 19 6 3 50 19 +31 63 Liverpool 29 16 5 8 44 20 +24 53 Arsenal 27 15 7 5 50 23 +27 52 Bolton 30 14 6 10 34 34 0 48 Everton 29 11 10 8 37 26 +11 43 Reading 29 13 4 12 43 38 +5 43 Tottenham 30 12 7 11 40 43 -3 43 Portsmouth 29 11 8 10 36 31 +5 41 Blackburn 30 12 5 13 35 39 -4 41 Newcastle 29 10 7 12 34 37 -3 37 Middlesborough 29 9 9 11 32 34 -2 36 Aston Villa 28 7 12 9 29 34 -5 33 Fulham 29 7 12 10 31 44 -13 33 Wigan 29 9 5 15 30 44 -14 32 Sheffield Utd 29 8 7 14 25 41 -16 31 Man City 27 8 6 13 20 33 -13 30 Charlton 29 6 6 17 26 49 -23 24 West Ham 30 5 6 19 21 50 -29 21 Watford 29 3 11 15 18 43 -25 20

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