Abstract
Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme.
| Original language | English |
|---|---|
| Pages (from-to) | 2213-2221 |
| Number of pages | 9 |
| Journal | The Lancet |
| Volume | 393 |
| Issue number | 10187 |
| DOIs | |
| Publication status | Published - 01 Jun 2019 |
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In: The Lancet, Vol. 393, No. 10187, 01.06.2019, p. 2213-2221.
Research output: Contribution to journal › Article › peer-review
TY - JOUR
T1 - Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH)
T2 - a stepped-wedge cluster-randomised trial
AU - Peden, Carol J.
AU - Stephens, Tim
AU - Martin, Graham
AU - Kahan, Brennan C.
AU - Thomson, Ann
AU - Rivett, Kate
AU - Wells, Duncan
AU - Richardson, Gerry
AU - Kerry, Sally
AU - Bion, Julian
AU - Pearse, Rupert M.
AU - Peden, Carol
AU - Kahan, Brennan
AU - Brett, Stephen
AU - Ackland, Gareth
AU - Grocott, Mike
AU - Holt, Peter
AU - Robert, Glenn
AU - Ukoumunne, Obioha
AU - Waring, Justin
AU - Everingham, Kirsty
AU - Phull, Mandeep
AU - Cromwell, David
AU - Evley, Rachel
AU - Lilford, Richard
AU - Kocman, David
AU - Asaria, Miqdad
AU - Tarrant, Carolyn
AU - Yang, Fan
AU - Abraham, Ajit
AU - Bothma, Pieter
AU - Conway, Daniel
AU - Stapleton, Clare
AU - Edwards, Mark
AU - Minto, Gary
AU - Saunders, David
AU - Owen, Tom
AU - Waldmann, Carl
AU - Hayden, Paul
AU - Gillies, Michael
AU - Tighe, Sean
AU - Smith, Neil
AU - Mythen, Monty
AU - Murray, David
AU - Lobo, Dileep
AU - Leuwer, Martin
AU - Kirk-Bayley, Justin
AU - Howell, Simon
AU - Gordon, Anthony
AU - Anderson, Iain
AU - Lourtie, Jose
AU - Walker, Simon
AU - Drake, Sharon
AU - Murray, Dave
AU - Watson, Nick
AU - Szakmany, Tamas
AU - Sutcliffe, Robert
AU - Mahajan, Ravi
AU - Girling, Alan
AU - Forbes, Gordon
AU - Faiz, Omar
AU - Blunt, Mark
AU - Singh, Surjait
AU - Steel, Alistair
AU - Wong, Kate
AU - Cabreros, Leilani
AU - Chitre, Vivek
AU - Obideyi, Ayodele
AU - Ali, Dhiraj
AU - Blenk, Karl
AU - Broad, Dan
AU - Brodbeck, Andreas
AU - Dumpala, Rajesh
AU - Engel, Arnth
AU - Ganepola, Ranjit
AU - Garg, Sudha
AU - Gay, Mike
AU - Karlikowsk, Michael
AU - Lams, Edward
AU - Millican, Dean
AU - Misane, Inga
AU - Mull, Ajaya
AU - Naik, Veena
AU - Pushpa, Nathan
AU - Nutt, Chris
AU - Sagadai, Saravanna
AU - Stuart, Hazel
AU - Noble, Paul
AU - Van De Velde, Niko
AU - Hudson, Liam
AU - Benlloch, Raoul
AU - Singh, Satish
AU - Verma, Karan
AU - Laba, Damian
AU - Carmichael, Jack
AU - Richardson, Peter
AU - Wilson, Graham
AU - Lewis, Ricky
AU - Surendran, Karthik
AU - El-Damatty, Essam
AU - Gurung, Sarada
AU - Raulusaite, Ilona
AU - Gerstina, Nabua
AU - Rochester, Chloe
AU - Kuldip, Rai
AU - Lindner, Andrew
AU - Murray, Therese
AU - Vivek, Chitre
AU - Lal, Roshan
AU - Downey, Sarah
AU - Velchuru, Vamsi
AU - Aryal, Kamal
AU - Guruswamy, Raman
AU - Shankar, Kirosh
AU - Porter, Helen
AU - Tutton, Matthew
AU - Agostini, Helen
AU - Fletcher, Simon
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AU - Hutchinson, Steve
AU - Maiya, Bala
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AU - Northey, Martin
AU - Gokhale, Jay
AU - Mosley, Frances
AU - Alexander, Peter
AU - Sharma, Abhiram
AU - Brady, Will
AU - Hopper, John
AU - Hill, Oliver
AU - Varma, Sandeep
AU - Macklin, Christopher
AU - Rose, Alastair
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AU - Simeson, Karen
AU - Sim, Kevin
AU - Chadwick, Michael
AU - Kuduvalli, Preeti
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AU - Wilson, Lawrence
AU - Vimalchandran, Dale
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AU - Patel, Hitesh
AU - Mateo, Dolores
AU - Raj, Ashok
AU - Machesney, Michael
AU - Abdul, Nazar
AU - Jemmet, Kim
AU - Campbell, Marta
AU - Inglis, David
AU - Parker, Thomas
AU - Medici, Thomas
AU - Chan, Peter
AU - Borgeaud, Nathan
AU - Mukherjee, Dipankar
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AU - Harwood, Elizabeth
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AU - Davis, Huw
AU - Williams, Gail
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AU - Hurford, Dom
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AU - Baker, Susie
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AU - Silsby, Joseph
AU - Black, Helen
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AU - Riddington, David
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AU - Cruickshank, Neil
AU - Susarla, Jay
AU - Leno, Emma
AU - Colley, Julie
AU - Burtenshaw, Andrew
AU - Lake, Stephen
AU - Greenwood, Jamie
AU - Bhardwaj, Sian
AU - Thrush, Jessica
AU - Wollaston, Julie
AU - Sonksen, Julian
AU - Patel, Rajan
AU - Jennings, Adrian
AU - Stanley, David
AU - Wright, Jenny
AU - Horner, Chris
AU - Baig, Faisal
AU - Cooke, Katie
AU - Singh, Jagdeep
AU - Claxton, Andrew
AU - Mirza, Nazzia
AU - Hester, Simon
AU - Knight, Georgia
AU - Kumar, Peeyush
AU - Saran, Taj
AU - Marangoni, Gabriele
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N1 - Funding Information: CJP reports personal fees from Merck, the Institute for Healthcare Improvement, and Fidelity Health outside the submitted work. RMP reports personal fees from GlaxoSmithkline, grants and personal fees from Edwards Lifesciences, grants from Intersurgical, grants from B Braun, and personal fees from Medtronic outside the submitted work. CJP, RMP, SK, KR, and GM report grants from National Institute for Health Research during the conduct of this trial. All other authors declare no competing interests. Funding Information: We wish to thank all members of the EPOCH trial group who are listed in the appendix . This was an investigator-initiated study funded by the National Institute for Health Research (UK) Health Services and Delivery Research programme. RMP is a National Institute for Health Research Research Professor. The trial was sponsored by Queen Mary University of London (London, UK). EPOCH investigators were entirely responsible for study design, conduct, and data analysis. RMP and BCK had full data access. All authors were responsible for data interpretation, drafting and critical revision of the manuscript, and the decision to submit for publication. Publisher Copyright: © 2019 Elsevier Ltd
PY - 2019/6/1
Y1 - 2019/6/1
N2 - Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme.
AB - Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme.
UR - http://www.scopus.com/inward/record.url?scp=85066238574&partnerID=8YFLogxK
U2 - 10.1016/S0140-6736(18)32521-2
DO - 10.1016/S0140-6736(18)32521-2
M3 - Article
C2 - 31030986
AN - SCOPUS:85066238574
SN - 0140-6736
VL - 393
SP - 2213
EP - 2221
JO - The Lancet
JF - The Lancet
IS - 10187
ER -