Improving Outcomes Guidance Research Articles

Recommendations for laboratory testing of UK patients with acute myeloid leukaemia.

Recommendations for laboratory testing of UK patients with acute myeloid leukaemia.

Implementation of the updated NICE haematological cancers (NG47) improving outcomes guidelines across Specialist Integrated Haematological Malignancy Diagnostic Services (SIHMDS) in England: a UK NEQAS LI survey

AimsHaematological malignancies represent a diverse group of diseases with complex diagnostic requirements. National Institute for Health and Care Excellence (NICE) Haematological Cancer: Improving Outcomes Guidance was published in 2003 and...

Editorial introductions

Editorial introductions

Centralisation of radical cystectomies for bladder cancer in England, a decade on from the 'Improving Outcomes Guidance': the case for super centralisation.

To analyse the impact of centralisation of radical cystectomy (RC) provision for bladder cancer in England, on postoperative mortality, length of stay (LoS), complications and re-intervention rates, from implementation of centralisation from 2003 until 2014. In 2002, UK policymakers introduced the 'Improving Outcomes Guidance' (IOG) for urological cancers after a global cancer surgery commission identified substantial shortcomings in provision of care of RCs. One key recommendation was centralisation of RCs to high-output centres. No study has yet robustly analysed the changes since the introduction of the IOG, to assess a national healthcare system that has mature data on such institutional transformation. RCs performed for bladder cancer in England between 2003/2004 and 2013/2014 were analysed from Hospital Episode Statistics (HES) data. Outcomes including 30-day, 90-day, and 1-year all-cause postoperative mortality; median LoS; complication and re-intervention rates, were calculated. Multivariable statistical analysis was undertaken to describe the relationship between each surgeon and the providers' annual case volume and mortality. In all, 15292 RCs were identified. The percentage of RCs performed in discordance with the IOG guidelines reduced from 65% to 12.4%, corresponding with an improvement in 30-day mortality from 2.7% to 1.5% (P = 0.024). Procedures adhering to the IOG guidelines had better 30-day mortality (2.1% vs 2.9%; P = 0.003) than those that did not, and better 1-year mortality (21.5% vs 25.6%; P < 0.001), LoS (14 vs 16days; P < 0.001), and re- intervention rates (30.0% vs 33.6%; P < 0.001). Each single extra surgery per centre reduced the odds of death at 30days by 1.5% (odds ratio [OR] 0.985, 95% confidence interval [CI] 0.977-0.992) and 1% at 1year (OR 0.990, 95% CI 0.988-0.993), and significantly reduced rates of re-intervention. Centralisation has been implemented across England since the publication of the IOG guidelines in 2002. The improved outcomes shown, including that a single extra procedure per year per centre can significantly reduce mortality and re-intervention, may serve to offer healthcare planners an evidence base to propose new guidance for further optimisation of surgical provision, and hope for other healthcare systems that such widespread institutional change is achievable and positive.

Haematological cancers: improving outcomes. A summary of updated NICE service guidance in relation to Specialist Integrated Haematological Malignancy Diagnostic Services (SIHMDS)

Haematological malignancies are a diverse group of cancers that affect the blood, bone marrow and lymphatic systems. Laboratory diagnosis of haematological malignancies is dependent on combining several technologies, including morphology,...

PP24. ‘FIND OUT FASTER’: THE APPLICATION OF NEW CANCER PATHWAY STANDARDS TO PATIENTS REFERRED WITH SUSPECTED DIAGNOSIS OF MENINGIOMA

AbstractINTRODUCTION: The Improving Outcomes Guidance for patients with Brain & CNS tumours differs from other tumour sites in that it provides standards for the management of patients with benign tumours. Recently, the Department of Health has proposed new ‘Find out faster’ targets for cancer waiting times which aim to reduce the time between referral with a suspected malignancy and the communication of a definitive diagnosis. The new targets are:• 50% of patients to receive communication of a definitive diagnosis within 14 days.• 95% of patients to receive communication of a definitive diagnosis within 28 days.Can these targets be met for patients referred with a suspected diagnosis of benign meningioma? METHOD: Retrospective audit of the pathways of 50 consecutive patients referred to our Brain & CNS tumours MDT with a suspected diagnosis of meningioma between 13/02/2015 and 26/12/2015. Data was validated from MDT records, e-CAMIS, PACS and Specialist Nurse records. RESULTS: Complete data was available for 46 patients: 4 patients were excluded due to incomplete data. All patients had a radiological diagnosis of a meningioma at the MDT meeting. 43.48% (20/46) patients received a radiological diagnosis within 14 days and 65.22% (30/46) within 28 days. Thus 34.78% (16/46) were seen after 28 days (range: 29 to 205 days). Communication of diagnosis was through a letter to the GP or another medical specialty (5/46) or at outpatient review (41/46). 7 of the 46 patients underwent craniotomy and excision of tumour (range: 2 to 109 days after referral; 3 within 14 days, 1 within 28 days.) Only 1 patient (14.29%) received a histological diagnosis by day 28; the remainder received their diagnoses between day 35 - 140. All resected tumours were meningioma, WHO Grade 1. The main delay from referral to diagnosis for radiological diagnosis was clinic appointment availability; one patient cancelled their scheduled appointment several times (205 days from referral to radiological diagnosis) and there were no documented reasons for any other cause of delay. For histological diagnosis, it was the time from surgery to clinic appointment. CONCLUSION: Historically the application of “targets” for treatment times in the management of tumours has only related to cancer. The inclusion of meningiomas, the majority which are benign in nature, within the Improving Outcomes Guidance for brain and CNS tumours recognises that they can give rise to significant neurological, cognitive and psychological symptoms similar to those caused by malignant tumours. However, at present no “targets” exist for the management of benign intracranial tumours. The application of the “finding out faster” targets to the meningioma pathway gives insight to the relative slow pace of management of his tumour group. It also raises concerns regarding the definitions used in “finding out faster” such as date of referral and whether communicating a radiological diagnosis is adequate to achieve the target. We would argue that the development and introduction of targets for treatment time in benign intracranial tumour should be introduced.

The impact of socio-economic deprivation on incidence, treatment and mortality from prostate cancer in England, 1990–2010

Objective: To explore any association between socio-economic deprivation and prostate cancer diagnosis and/or treatment. Patients and methods: Data was extracted as follows: We gained the incident cases and staging from the National Cancer Data Repository, survival from the Cancer Information System, mortality from the Office for National Statistics, treatment data from Hospital Episode Statistics and National Clinical Analysis and Specialised Applications Team. Our analysis regarding socio-economic deprivation was controlled for age distribution. Results: We recorded 518,453 diagnoses of prostate cancer; 174,579 prostate cancer deaths; 33,889 prostatectomies and 21,351 radiotherapy treatments. Incidence is increasing in all groups, but the highest is amongst the least deprived. Mortality is decreasing, with survival consistently better in the least deprived. Prostatectomies are more frequent in the least deprived; however, this gap is narrowing. Conclusions: Prostate cancer incidence, survival and treatment are associated with socio-economic deprivation. Prostatectomy rates show a decrease in the gap of inequality. Multiple potential confounding factors, such as rates of prostate specific antigen (PSA) testing and access to health care are associated with socio-economic deprivation. The unifying influences of Improving Outcomes Guidance and the National Treatment Guidelines are intended to counteract the above inequalities. Particularly in prostate cancer, where long-term gain depends on multiple factors, individualised treatment decisions are paramount.

WHAT'S THE ‘E’ IN E-LEARNING FOR SPIRITUALITY: A COMPARISON OF ONLINE AND FACE TO FACE COURSE VERSIONS FOR HEALTHCARE WORKERS

BackgroundHealthcare staff feel unprepared for dealing with spiritual and religious needs of patients and families. Indeed many are uncertain whether it is part of their role at all. However the...

Influence of a Regional Centralised Upper Gastrointestinal Cancer Service Model on Patient Safety, Quality of Care and Survival

AimsThe aim of this study was to determine outcomes of a reconfigured centralised upper gastrointestinal (UGI) cancer service model, allied to an enhanced recovery programme, when compared with historical controls in a UK cancer network. Materials and methodsDetails of 606 consecutive patients diagnosed with UGI cancer were collected prospectively and outcomes before (n = 251) and after (n = 355) centralisation compared. Primary outcome measures were rates of curative treatment intent, operative morbidity, length of hospital stay and survival. ResultsThe rate of curative treatment intent increased from 21 to 36% after centralisation (P < 0.0001). Operative morbidity (mortality) and length of hospital stay before and after centralisation were 40% (2.5%) and 16 days, compared with 45% (2.4%) and 13 days, respectively (P = 0.024). The median and 1 year survival (all patients) improved from 8.7 months and 39.0% to 10.8 months and 46.8%, respectively, after centralisation (P = 0.032). On multivariate analysis, age (hazard ratio 1.894, 95% confidence interval 0.743–4.781, P < 0.0001), centralisation (hazard ratio 0.809, 95% confidence interval 0.668–0.979, P = 0.03) and overall radiological TNM stage (hazard ratio 3.905, 95% confidence interval 1.413–11.270, P < 0.0001) were independently associated with survival. ConclusionThese outcomes confirm the patient safety, quality of care and survival improvements achievable by compliance with National Health Service Improving Outcomes Guidance.

OC-057 10 Years on from the improving outcomes guidance—development of a tertiary pancreatic cancer unit

IntroductionIn 2001 the National Institute for Clinical Excellence (NICE) published guidance on best practice for cancer services entitled Improving Outcomes Guidance (IOG). These guidelines specified centralisation, increased patient volume (>200...

PMO-045 Perioperative dietetic consultation leads to improved nutritional status at 2 week follow-up in patients with oesphagogastric cancer

IntroductionPatients with oesophagogastric cancer are at high risk of malnutrition.1 The aim of this study was to assess the effect of advice provided by a dietitian peri-operatively on nutritional status...

‘Opening the gate’ – What's the difference?

BackgroundNICE Supportive and Palliative Care Improving Outcomes Guidance 2004 states clearly that health professionals should be in a position to assess the spiritual and religious needs of patients and either...

UK radical prostatectomy outcomes and surgeon case volume: based on an analysis of the British Association of Urological Surgeons Complex Operations Database

To undertake a detailed analysis of the British Association of Urological Surgeons (BAUS) Section of Oncology Complex Operations Database to report UK outcomes of radical prostatectomy (RP) with particular reference to the case volume of the operating surgeon. All RP entries on the BAUS complex operations database were extracted from its commencement in January 2004 to September 2009. Patient age, prostate-specific antigen (PSA) levels, clinical tumour stage and biopsy Gleason score were analyzed together with operative variables, including the surgical approach, lymphadenectomy status, blood loss, hospital length of stay and individual surgeon case volume. The postoperative variables assessed included surgical specimen Gleason score and pathological tumour stage, prostate weight and the presence of positive surgical margins (PSM), as well as evidence of biochemical recurrence. A total of 8032 RP cases were entered on the database and Follow-up data was available on 4206 cases. Mean patient age was 61.8 years and the mean presenting PSA was 8.3 ng/mL. Open RP procedures were performed on 5429 patients and laparoscopic RP on 2219. The positive surgical margin (PSM) rate for the entire series was 38%. Analysis of PSM by pathological stage revealed a pT2 PSM rate of 24%. Multivariate analysis of variables which might affect PSM revealed pre-operative clinical TNM stage, surgeon case volume, RP specimen Gleason score and pathological TNM stage were significant parameters (P < 0.01). When prostate weight and PSM status were analysed, these was a significant association between smaller prostate weight and PSM status. Interestingly, 45% of high grade Gleason 8-10 needle biopsy cancers were downgraded to Gleason scores 7 or less on RP analysis. Analysis of annual surgeon caseload revealed that 54% of surgeons performed an average of less than 10 procedures per annum and 6% of surgeons performed an average of 30 or more procedures per annum. When individual outcome variables where examined against surgeon case activity it was demonstrated that outcomes are clearly improved beyond 20 cases and there is a trend to continued improvement up to the series maximum of 40 cases per annum. High volume surgeons have less peri-operative and postoperative complications and better surgical and disease-free outcomes than low volume surgeons. In the UK, raising the current minimum Improving Outcomes Guidance threshold from five RP cases per surgeon per annum to no less than 20 (and ideally to 35 or more cases per annum) could potentially improve overall outcomes.

Implementation of neuro-oncology service reconfiguration in accordance with NICE guidance provides enhanced clinical care for patients with glioblastoma multiforme

Background:Brain tumours account for <2% of all primary neoplasms but are responsible for 7% of the years of life lost from cancer before age 70 years. The latest survival trends for patients with CNS malignancies have remained largely static. The objective of this study was to evaluate the change in practice as a result of implementing the Improving Outcomes Guidance from the UK National Institute for Health and Clinical Excellence (NICE).Methods:Patients were identified from the local cancer registry and hospital databases. We compared time from diagnosis to treatment, proportion of patients discussed at multidisciplinary team (MDT) meetings, treatment received, length of inpatient stay and survival. Inpatient and imaging costs were also estimated.Results:Service reconfiguration and implementation of NICE guidance resulted in significantly more patients being discussed by the MDT—increased from 66 to 87%, reduced emergency admission in favour of elective surgery, reduced median hospital stay from 8 to 4.5 days, increased use of post-operative MRI from 17 to 91% facilitating early discharge and treatment planning, and reduced cost of inpatient stay from £2096 in 2006 to £1316 in 2009. Patients treated with optimal surgery followed by radiotherapy with concomitant and adjuvant temozolomide achieved outcomes comparable to those reported in clinical trials: median overall survival 18 months (2-year survival 35%).Conclusions:Advancing the management of neuro-oncology patients by moving from an emergency-based system of patient referral and management to a more planned elective outpatient-based pattern of care improves patient experience and has the potential to deliver better outcomes and research opportunities.

Primary excision of cutaneous melanoma

First, we would like to say that the National Institute of Health and Clinical Excellence skin cancer improving outcomes guidance (IOG), far from being arbitrary, was based on appraisal of a wide range of evidence. Regrettably, prior to the IOG, some high-risk skin cancer patients received treatment below an acceptable standard from less experienced practitioners, including curetted and otherwise incompletely excised melanomas, as well as melanomas that had been repeatedly frozen or simply misdiagnosed as benign. The IOG was intended to level up to best practice, and this has largely been achieved. Results of the study by Murchie et al indicate that the GPs concerned carried out adequate excisions,1 but we are not told how many benign lesions were needlessly excised, nor is there information about quality of scars, follow-up, or other important factors. The IOG has delivered integrated services in which multidisciplinary teams provide evidence-based holistic …

‘Listening to Patients’: what is the value of age-appropriate care to teenagers and young adults with cancer?

Current healthcare policy increasingly recognises the importance of patient experience in determining care. The 2005 UK National Institute for Health and Clinical Excellence Improving Outcomes Guidance encompasses caring for young people with cancer in an age-appropriate model of care developing regional principal treatment centres for this purpose. When published this was based upon limited outcomes evidence, and only a small amount of teenage and young adult patient and parent opinion. We have systematically reviewed the literature between 1996 and 2008, examining how far the experiences of this patient group support or refute the current policy. The recent literature describes with increasing consistency that teenage and young adult cancer patients have specific care needs, and gain benefits from an age-appropriate environment of care, including peer group support, age-appropriate information, recreational and vocational support, and staff expert in both the cancer and care of their age group. Many patients are prepared to travel to receive such care, if services are not in place to deliver excellent shared care between principal treatment centres and services nearer home. Some of these needs are unmet in non-specialist units. There remains, however, a paucity of rigorous comparative studies quantifying the value of specialist cancer care for this patient group.

Revised UK guidelines for the management of cutaneous melanoma 2010

These guidelines for the management of cutaneous melanoma present an evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiology, diagnosis, investigation, and follow-up.

Guidelines for the management of soft tissue sarcomas.

These guidelines were drawn up following a consensus meeting of UK sarcoma specialists convened under the auspices of the British Sarcoma Group and are intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. The guidelines published by the European Society of Medical Oncology (ESMO) and the National Comprehensive Cancer Network (NCCN) were used as the basis for discussion and adapted according to UK clinical practice and local requirements. Note was also taken of the National Institute for Health and Clinical Excellence (NICE) improving outcomes guidance (IOG) for people with sarcoma and existing technology appraisals. The guidelines are not intended to challenge NICE guidance but discrepancies may exist where current guidance does not reflect an international standard of care owing to the ever-evolving nature of cancer treatment. It is acknowledged that these guidelines will require updating on a regular basis. An appendix lists the key recommendations which are summarised below. Any patient with a suspected soft tissue sarcoma should be referred to a diagnostic centre and managed by a specialist sarcoma multidisciplinary team. Surgical excision followed by post operative radiotherapy is the standard management of high grade limb sarcomas although occasionally amputation remains the only option. Pre-operative treatment with chemotherapy or radiotherapy should be considered for patients with borderline resectable tumours. Isolated limb perfusion may permit limb salvage in some cases where amputation is the only other option. Adjuvant chemotherapy is not routinely recommended but may be considered in certain specific situations. Regular follow up is recommended to assess local control and the development of metastatic disease. Single agent doxorubicin is the standard first line therapy for metastatic disease. Ifosfamide is an alternative if anthracyclines are contraindicated. Combination therapy may be considered in individual patients. Second line agents include ifosfamide, dacarbazine, trabectedin and the combination of gemcitabine + docetaxel. Surgical resection of local recurrence and pulmonary metastases should be considered in individual patients. There is specific guidance on the management of retroperitoneal and uterine sarcomas.

The impact of Improving Outcomes Guidance on the management and outcomes of patients with carcinoma of the penis

The Improving Outcomes Guidance (IOG) for patients with carcinoma of the penis states that treatment should be provided supraregionally to populations of 4 million or greater who treat over 25 cases of penis cancer each year. This study assesses the impact of this guidance on the management and outcomes of patients with the disease in our region. We retrospectively compared the records of 44 patients with carcinoma of the penis treated in our institution between 1969 and 1990 with 101 patients treated between 2002 and 2006, i.e. after supraregional centralisation of the service. There was no significant change in the stage or grade of the tumours. However, the results show that, in modern times, there was a significant increase in the amount of penis-preserving and nodal surgery as well as a fall in mortality. The improved survival is greatest in patients with poorly-differentiated disease who may, therefore, have benefited from aggressive nodal surgery. The centralisation of surgery for carcinoma of the penis results in improved outcomes both in terms of penis preservation and improved survival and this supports the IOG guidance.

Provision of radical pelvic urological surgery in England, and compliance with improving outcomes guidance

To investigate compliance with Improving Outcomes Guidance (IOG) for radical pelvic surgery in England, and explore the pattern of service provision for radical cystectomy (RC) and radical prostatectomy (RP) before and after the introduction of IOG. For the period 2000/01-2006/07, all admissions for RC and RP were extracted from Hospital Episode Statistics (HES). At the institutional level, the numbers of RC and RP cases were combined to assess adherence to IOG. The IOG catchment populations for each institution were calculated by linking HES data to census ward population data. The pattern of service provision for RC and RP was independently assessed by assigning institutions into low-, medium- and high-volume groups of roughly equal volumes a priori, based on the ascending order of annual RC or RP rate, respectively. For RC it was also possible to explore the between-institution referral activity for RC by identifying the 'final endoscopic bladder procedure' that occurred immediately before the RC for each patient. This gave an indication of where the diagnosis and decision for RC had been made. The percentage of institutions achieving the recommended IOG minimal case volume of 50 per year increased significantly between 2000/01 and 2006/07 (36% in odds per year, P < 0.001; odds ratio 1.36, 95% confidence interval 1.24-1.50), although absolute numbers remained relatively low (34% in 2006/07). Only one institution had a catchment population greater than the recommended 1 million. The total number of institutions performing RC decreased significantly over the years (P = 0.03), whereas for RP the decrease was not significant (P = 0.6). The decrease reflected a decline in the number of low-volume institutions, both for RC and RP, although this decline was not more than expected by chance. There had been a significant increase in the percentage of patients referred to another provider for their RC, from 5.5% in 2000/01 to 19.6% in 2006/07 (28% rise in odds per year, P < 0.001: odds ratio 1.28, 95% confidence interval 1.23-1.33). There was evidence of centralization of radical pelvic urological surgery, although it is only relatively recently that this seems to have taken place with any certainty. The absolute numbers of providers achieving the IOG minimum caseload standard was relatively low. What impact this has had, if any, on the quality of patient care is yet to be fully determined.