Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Carol J. Peden; Tim Stephens; Graham Martin; Brennan Kahan; Ann Thomson; Kate Rivett; Duncan Wells; Gerry Richardson; Sally Kerry; Julian Bion; Rupert M. Pearse; Carol Peden; Brennan Kahan; Stephen Brett; Gareth Ackland; Mike Grocott; Peter Holt; Glenn Robert; Obioha Ukoumunne; Justin Waring; Kirsty Everingham; Mandeep Phull; David Cromwell; Fan Yang; Neil Smith; David Murray; Simon Howell; Simon Walker; Robert Sutcliffe; Gordon Forbes; John Wells; Neil Kukreja; Michael Chadwick; Stelios Chatzimichail; Chris Lewis; Mark Wilkinson; Emma Davis; James Harris; Simon Harris; Paul Mclaren; Steven Henderson; Gudrun Kunst; Savvas Papagrigoriadis; Michael Martin; Guy Finch; Stephen Baxter; Simon Sleight; Rob Chambers; Hannah Smith; Thomas Evans

doi:10.1016/S0140-6736(18)32521-2

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Carol J. Peden, Tim Stephens, Graham Martin, Brennan Kahan, Ann Thomson, Kate Rivett, Duncan Wells, Gerry Richardson, Sally Kerry, Julian Bion, Rupert M. Pearse^*, Carol Peden, Brennan Kahan, Stephen Brett, Gareth Ackland, Mike Grocott, Peter Holt, Glenn Robert, Obioha Ukoumunne, Justin WaringKirsty Everingham, Mandeep Phull, David Cromwell, Fan Yang, Neil Smith, David Murray, Simon Howell, Simon Walker, Robert Sutcliffe, Gordon Forbes, John Wells, Neil Kukreja, Michael Chadwick, Stelios Chatzimichail, Chris Lewis, Mark Wilkinson, Emma Davis, James Harris, Simon Harris, Paul Mclaren, Steven Henderson, Gudrun Kunst, Savvas Papagrigoriadis, Michael Martin, Guy Finch, Stephen Baxter, Simon Sleight, Rob Chambers, Hannah Smith, Thomas Evans

^*Corresponding author for this work

Biostatistics & Health Informatics

Research output: Contribution to journal › Article › peer-review

124 Citations (Scopus)

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	https://doi.org/10.1016/S0140-6736(18)32521-2
Publication status	Published - 1 Jun 2019

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10.1016/S0140-6736(18)32521-2

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Peden, C. J., Stephens, T., Martin, G., Kahan, B., Thomson, A., Rivett, K., Wells, D., Richardson, G., Kerry, S., Bion, J., Pearse, R. M., Peden, C., Kahan, B., Brett, S., Ackland, G., Grocott, M., Holt, P., Robert, G., Ukoumunne, O., ... Evans, T. (2019). Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial. The Lancet, 393(10187), 2213-2221. https://doi.org/10.1016/S0140-6736(18)32521-2

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title = "Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial",

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.",

author = "Peden, {Carol J.} and Tim Stephens and Graham Martin and Brennan Kahan and Ann Thomson and Kate Rivett and Duncan Wells and Gerry Richardson and Sally Kerry and Julian Bion and Pearse, {Rupert M.} and Carol Peden and Brennan Kahan and Stephen Brett and Gareth Ackland and Mike Grocott and Peter Holt and Glenn Robert and Obioha Ukoumunne and Justin Waring and Kirsty Everingham and Mandeep Phull and David Cromwell and Fan Yang and Neil Smith and David Murray and Simon Howell and Simon Walker and Robert Sutcliffe and Gordon Forbes and John Wells and Neil Kukreja and Michael Chadwick and Stelios Chatzimichail and Chris Lewis and Mark Wilkinson and Emma Davis and James Harris and Simon Harris and Paul Mclaren and Steven Henderson and Gudrun Kunst and Savvas Papagrigoriadis and Michael Martin and Guy Finch and Stephen Baxter and Simon Sleight and Rob Chambers and Hannah Smith and Thomas Evans",

year = "2019",

month = jun,

day = "1",

doi = "10.1016/S0140-6736(18)32521-2",

language = "English",

volume = "393",

pages = "2213--2221",

journal = "The Lancet",

issn = "0140-6736",

publisher = "Elsevier",

number = "10187",

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Peden, CJ, Stephens, T, Martin, G, Kahan, B, Thomson, A, Rivett, K, Wells, D, Richardson, G, Kerry, S, Bion, J, Pearse, RM, Peden, C, Kahan, B, Brett, S, Ackland, G, Grocott, M, Holt, P, Robert, G, Ukoumunne, O, Waring, J, Everingham, K, Phull, M, Cromwell, D, Yang, F, Smith, N, Murray, D, Howell, S, Walker, S, Sutcliffe, R, Forbes, G, Wells, J, Kukreja, N, Chadwick, M, Chatzimichail, S, Lewis, C, Wilkinson, M, Davis, E, Harris, J, Harris, S, Mclaren, P, Henderson, S, Kunst, G, Papagrigoriadis, S, Martin, M, Finch, G, Baxter, S, Sleight, S, Chambers, R, Smith, H & Evans, T 2019, 'Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial', The Lancet, vol. 393, no. 10187, pp. 2213-2221. https://doi.org/10.1016/S0140-6736(18)32521-2

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

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 - Yang, Fan

AU - Smith, Neil

AU - Murray, David

AU - Howell, Simon

AU - Walker, Simon

AU - Sutcliffe, Robert

AU - Forbes, Gordon

AU - Wells, John

AU - Kukreja, Neil

AU - Chadwick, Michael

AU - Chatzimichail, Stelios

AU - Lewis, Chris

AU - Wilkinson, Mark

AU - Davis, Emma

AU - Harris, James

AU - Harris, Simon

AU - Mclaren, Paul

AU - Henderson, Steven

AU - Kunst, Gudrun

AU - Papagrigoriadis, Savvas

AU - Martin, Michael

AU - Finch, Guy

AU - Baxter, Stephen

AU - Sleight, Simon

AU - Chambers, Rob

AU - Smith, Hannah

AU - Evans, Thomas

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.

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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 -

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

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