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24-04-2012 | Surgery | Article

Clinical factors ‘a key determinant’ of rectal cancer care quality


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MedWire News: Clinical factors must be taken into consideration when comparing rates of abdominoperineal excision (APE) among hospitals, say Belgian researchers.

The team found that adjusting for age, gender, and preoperative cancer markers significantly altered the institutional rate of APE - a quality of care indicator for rectal cancer surgery - casting doubt on previous studies that did not include such information.

"Audit of APE rate cannot be based on administrative data only," emphasize Freddy Penninckx (UZ Gasthuisberg, Leuven) and co-workers in Gut.

The researchers examined the variability in APE rate among Belgian hospitals participating in PROCARE, an initiative to monitor the use of APE versus a sphincter-sparing operation (SSO), at 82 centers between January 2006 and March 2011.

Overall, 3197 patients with rectal cancer, at 57 centers reporting data for more than 10 patients, underwent elective radical rectal resection, defined as APE, Hartmann resection (HR), or SSO with colo-anal anastomosis for invasive rectal adenocarcinoma between 0 and 15 cm above the anal verge.

The researchers adjusted the data for six confounding factors associated with APE use: age over 60 years, male gender, American Society of Anesthesiologist score of 3 or above, tumor level (by rectal third), depth of tumor invasion (cT4), and the presence of preoperative incontinence.

The overall rate of APE was 21.1% but this varied significantly across hospitals both before and after adjusting for risk factors. Funnel plotting before adjustment suggested eight clinics were outside the 95% and 99% prediction limits for APE rate; after adjustment, just three of these clinics, plus three new clinics, had unusually high rates of APE.

Adjusting for rectal cancer risk factors also altered the distribution of outlying clinics in analysis of patients with cancers in the lower rectal third, and when data on APE and HR - a procedure commonly chosen for very elderly or frail patients with high-risk disease - were combined, the researchers report.

"Methodologically sound and credible benchmarking is essential as clinicians will learn from their own performance and process statistics as well as from their colleagues with 'best practices'," Penninckx et al say. "The latter needs to be defined."

The researchers note that research should include markers for care quality other than APE to prevent undue pressure on surgeons to perform inappropriate SSO.

"It is evident that postoperative fecal incontinence reduces quality of life and that function saving is more important than sphincter saving per se", the team writes, adding that "it is mandatory to monitor several quality of care indicators and interpret them in their proper context."

MedWire ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012

By Lynda Williams

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