Unacceptable variation in abdominoperineal excision rates for rectal cancer: time to intervene?
OBJECTIVE
To determine the variation in the rates of use of abdominoperineal excision (APE) by cancer network, hospital trust and surgeon across England between 1998 and 2004 and determine if any variation could be explained by differences in patient characteristics such as stage of disease, age, gender or socioeconomic deprivation.


METHODS
Retrospective study of a population-based dataset comprised of cancer registry and hospital episode statistics data.


METHODS
All NHS providers of rectal cancer surgery within England.


METHODS
31,223 patients diagnosed with rectal cancer and receiving a major abdominal procedure within the NHS in England between 1998 and 2004.


METHODS
Rates and odds of use of APE were determined in relation to patient case-mix and each patient's managing surgeon, trust and cancer network.


RESULTS
The rate of use of APE decreased from 30.5% in 1998 to 23.0% in 2004. Males, the economically deprived and those managed by surgeons operating on fewer than seven rectal cancer cases per year were all significantly more likely to receive an APE. There were also significant variations in the odds of receiving an APE over time and between individual surgeons and hospital trusts independently of patient case-mix.


CONCLUSIONS
Over the study period the use of APE decreased but statistically significant variation was observed in its application independently of case mix. Reducing this variation will remove inequalities, reduce colostomy rates, and improve outcomes in rectal cancer. Rates of APE use could be a national performance measure.
Centre for Epidemiology and Biostatistics, University of Leeds, St James's Institute of Oncology, St James's Hospital, Leeds LS9 7TF, UK. eva.morris@nycris.leedsth.nhs.uk
E
E
Morris
P
P
Quirke
J D
JD
Thomas
L
L
Fairley
B
B
Cottier
D
D
Forman
D000230:Adenocarcinoma / Q000401:mortality / Q000601:surgery*; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000601:surgery*; D003107:Colorectal Surgery / Q000379:methods / Q000706:statistics & numerical data; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care; D012004:Rectal Neoplasms / Q000401:mortality / Q000601:surgery*; D012042:Registries; D012189:Retrospective Studies; D012923:Social Class; D013222:State Medicine / Q000706:statistics & numerical data; D054047:Surgical Stomas / Q000706:statistics & numerical data