Archive for the 'SCOAP Data' Category

SCOAP Community Speaks Up: Colorectal Surgery

We were recently asked by a colleague at Northwest Hospital, “Why does it seem as if SCOAP is always picking on colorectal surgeons?”

Some of the most common, hospitalization-requiring procedures we perform are colon and rectal resections.  While most surgeons only do a few of these procedures in any given year, SCOAP reports information on thousands of cases per year.  These cases offer many opportunities for quality improvement (QI).  As any surgeon knows, any time an anastomosis is created there is a risk of serious adverse outcomes.  For rectal cancer, great surgical and coordinated oncologic care can mean the difference between disease-free survival and a horrible recurrence.  For patients with diverticulitis, the indications for operation are in evolution, and there is significant variability in the use of these procedures across the state.  Reducing the risk of leak, delivering optimal coordinated care for patients with rectal cancer and assuring that all operations for diverticulitis are performed appropriately are just some of the goals of SCOAP.

Colorectal Interest Group Defines Metrics
Over the last year, groups of surgeons with an interest in focused clinical topics have been meeting monthly to help create the next generation SCOAP metrics that will add even greater value to surgeons and create opportunities to improve care.  A colorectal interest group has been working to improve rectal cancer care and diverticulitis management, and added a set of metrics about these conditions to SCOAP in January 2010.  All SCOAP surgeons are welcome to join this group.  The initial data about rectal cancer coming in to SCOAP indicate that there are significant opportunities to improve care delivery and quality.  SCOAP is finding significant under-reporting and under-use of standard preoperative staging tests to appropriately stage patients with rectal cancer; inconsistent reporting and use of neoadjuvant chemo/radiotherapy for Stage 3 patients; and a persistent subgroup of diverticulitis patients who don’t appear to have had standard indications for surgery reported.  As you see in this month’s data figure, while surgeons at just 5 hospitals perform 64% of the resections, another 27 hospitals perform the balance.  These cases are done in all of our communities, and QI initiatives in colorectal surgery have a spill-over effect to other procedures.  Getting colorectal resection “right” means an opportunity to impact almost all the people in our state.

 With the leadership of the colorectal workgroup, here is what SCOAP plans to focus on in the next year:

Universal Preoperative Staging of Rectal Cancer
Preoperative staging of rectal cancer with endoscopic transrectal ultrasound (EUS/TRUS) is essential for planning coordinated care.  Preoperative staging of rectal cancer can be either local or distant. Local staging incorporates the assessment of wall invasion, circumferential involvement, and nodal status. Distant staging assesses metastatic disease. The National Cancer Institute guideline for rectal cancer treatment[1] recommends that the initial staging procedures  include rigid proctoscopy, colonoscopy to rule out cancers elsewhere in the bowel, and a  computed tomography (CT) scan to rule out metastatic disease as well as endorectal ultrasound EUS/TRUS) or MRI.  MRI may be as accurate as EUS for staging of superficial tumors;[2] however, limited availability, high cost, and the limited field of view makes EUS the standard in most hospitals.

Universal Neoadjuvant Therapy in Indicated Patients
Preoperative combined modality therapy (CMT) including radiation and chemotherapy followed by radical resection is the preferred treatment paradigm for locally advanced rectal cancer (transrectal ultrasound staged uT3-T4 and/or N1-N2) in the United States, because the treatment decreases the size of the tumor and improves local control and sphincter preservation.  The landmark German Rectal Cancer Study, a large randomized trial of over 400 rectal cancer patients, demonstrated that local control was significantly improved when chemoradiotherapy was administered preoperatively.[3]  Castaldo et al[4]  corroborated these findings in the US SEER registry.

 The goals of this group are to help Washington state achieve universal preoperative staging (as appropriate), neoadjuvant treatment (as appropriate), and the use of total mesorectal excision (as appropriate) for rectal cancer, and universal appropriate indications of of diverticulitis cases.  To address issues of imprecise data gathering and variability in care delivery, the colorectal interest group also worked to create an operating room dictation template for colorectal cases that we are hoping will be adopted by all surgeons (download this guide at the SCOAP website). 

 Join the WA State Rectal Cancer Summit Planned for June 17th, Lake Chelan
To accomplish these broad goals, we are planning to create a half-day colorectal interest group meeting at the 2011 SCOAP Annual Retreat (June 17 in Chelan).  The day will include a focus on best practices in rectal cancer care and bring together surgeons and pathologists from across the state who are working in this area.  The goal of the summit will be to address the SCOAP data on rectal cancer care delivery, share best practices, and create interventions to improve care delivery. 

Many of you only operate on 1-2 rectal cancer patients a year, but we are trying to gather ALL surgeons who do this procedure to join the colorectal interest group phone calls.  If you do not operate on patients for diverticulitis or rectal cancer, please pass this on to one of your colleagues who does that work, but join SCOAP in one of our other interest groups (Vascular, Bariatric, Cancer care, Pediatric, Outpatient, Spine, Urology, Gynecology).

With these interest groups we are hoping to do something that is unique – lead QI without the government or insurers “making us do it.”  We are trying to do this in a way that honors our profession and keeps our patients central, but we need your help.

We ask only that you get involved.  The easiest way is to join the next colorectal work group phone meeting – Tuesday, December 15 at 6:30.  Contact Sarah Lawrence for call in information.

Please contact Rosa Johnson if you can attend the SCOAP Annual Retreat on June 17th and the colorectal interest group session that afternoon.

 Thanks for all you do to make SCOAP a success.

[1] National Cancer Institute. Rectal Cancer Treatment (PDQ) Health Professional Version. 20 September 2010

[2] Bianchi P, Ceriani C, Palmisano A, et al. A prospective comparison of endorectal ultrasound and pelvic magnetic resonance in the preoperative staging of rectal cancer. Annales de Italian Chirurgie 2006;77:41–6.

 [3] Sauer R, Becker H, Hohenberger W, et al: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731-1740, 2004

[4] Castaldo ET, Parikh AA, Pinson CW, Feurer ID, Merchant NB. Improvement of survival with response to neoadjuvant radiation therapy for rectal cancer. Arch Surg 2009; 144(2):129–34.


SCOAP Making a Difference: Enhancing Recovery of GI Function

At the SCOAP Annual Retreat on May 4, 2010, Dr. Anthony Senagore, Professor of Surgery at Michigan State University, spoke about several controversial issues around avoiding post-operative ileus, including ways to limit ileus by avoiding prolonged PCA use, prudent management of epidural use, and increased use of opiod antagonists like Entereg. 

SCOAP is addressing these issues in the following ways:   
1) Tracking on prolonged use of PCA – Beginning in Q1 2011, we will track the number of days with PCA.
2) Tracking on the adequacy of epidurals to allow patients to void – Beginning in Q1 2010, we will track foley catheter use beyond postoperative day 2 among patients receiving epidurals.  This is one way to asses if an epidural is high enough to allow mobility.
3) Increased opioid use – We continue to track the use of Entereg, and be part of the emerging evidence that determines if Entereg is making a difference in the community at large.  

Dr. Senagore’s slides can be viewed here.  

For more information on the retreat, visit the Retreats page on the SCOAP website.