A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT

• Published in: Health services and delivery research 2019-09, Vol.7 (32), p.1-96
• Main Authors: Peden, Carol J, Stephens, Tim, Martin, Graham, Kahan, Brennan C, Thomson, Ann, Everingham, Kirsty, Kocman, David, Lourtie, Jose, Drake, Sharon, Girling, Alan, Lilford, Richard, Rivett, Kate, Wells, Duncan, Mahajan, Ravi, Holt, Peter, Yang, Fan, Walker, Simon, Richardson, Gerry, Kerry, Sally, Anderson, Iain, Murray, Dave, Cromwell, David, Phull, Mandeep, Grocott, Mike PW, Bion, Julian, Pearse, Rupert M
• Format: Article
• Language: English
• Subjects: OPERATIVE/MORTALITY; POSTOPERATIVE CARE; STEPPED WEDGE CLUSTER RANDOMISED TRIAL; SURGICAL PROCEDURES
• ISSN: 2050-4349; 2050-4357
• DOI: 10.3310/hsdr07320

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. Objectives: The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis. Design: This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals. Setting: The trial was set in acute surgical services of 93 NHS hospitals. Participants: Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible. Intervention: The intervention was a QI programme to implement an evidence-based care pathway. Main outcome measures: The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years. Data sources: Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires. Results: Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagemen