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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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Title: Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial
Authors: Peden, CJ
Stephens, T
Martin, G
Kahan, BC
Thomson, A
Rivett, K
Wells, D
Richardson, G
Kerry, S
Bion, J
Pearse, RM
Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial group
Item Type: Journal Article
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.
Issue Date: 1-Jun-2019
Date of Acceptance: 5-Oct-2018
URI: http://hdl.handle.net/10044/1/71383
DOI: https://dx.doi.org/10.1016/S0140-6736(18)32521-2
ISSN: 0140-6736
Publisher: Elsevier
Start Page: 2213
End Page: 2221
Journal / Book Title: Lancet
Volume: 393
Issue: 10187
Copyright Statement: © 2019 Elsevier Ltd. All rights reserved. This manuscript is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Licence http://creativecommons.org/licenses/by-nc-nd/4.0/
Keywords: Aged
Aged, 80 and over
Cluster Analysis
Critical Pathways
Digestive System Surgical Procedures
Emergency Treatment
Female
Humans
Male
Middle Aged
Program Evaluation
Quality Improvement
State Medicine
Survival Analysis
United Kingdom
Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial group
Humans
Emergency Treatment
Digestive System Surgical Procedures
Cluster Analysis
Survival Analysis
Program Evaluation
Aged
Aged, 80 and over
Middle Aged
State Medicine
Critical Pathways
Female
Male
Quality Improvement
United Kingdom
Aged
Aged, 80 and over
Cluster Analysis
Critical Pathways
Digestive System Surgical Procedures
Emergency Treatment
Female
Humans
Male
Middle Aged
Program Evaluation
Quality Improvement
State Medicine
Survival Analysis
United Kingdom
General & Internal Medicine
11 Medical and Health Sciences
Publication Status: Published
Conference Place: England
Embargo Date: 2019-10-25
Online Publication Date: 2019-04-25
Appears in Collections:Division of Surgery



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