Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Carol J Peden, Tim Stephens, Graham Martin, Brennan Kahan, Ann Thomson, Kate Rivett, Duncan Wells, Gerry Richardson, Sally Kerry, Julian Bion, Rupert M Pearse, Rupert Pearse, Carol Peden, Tim Stephens, Julian Bion, Graham Martin, Ann Thomson, Brennan Kahan, Sally Kerry, Kate RivettDuncan Wells, Gerry Richardson, Stephen Brett, Gareth Ackland, Mike Grocott, Peter Holt, Glenn Robert, Obioha Ukoumunne, Justin Waring, Kirsty Everingham, Mandeep Phull, David Cromwell, Rachel Evley, Richard Lilford, David Kocman, Miqdad Asaria, Justin Waring, Carolyn Tarrant, Fan Yang, Ajit Abraham, Pieter Bothma, Daniel Conway, Clare Stapleton, Mark Edwards, Gary Minto, David Saunders, Tom Owen, Carl Waldmann, Paul Hayden, Michael Gillies, Sean Tighe, Neil Smith, Monty Mythen, David Murray, Dileep Lobo, Martin Leuwer, Justin Kirk-bayley, Simon Howell, Anthony Gordon, Iain Anderson, Jose Lourtie, Simon Walker, Sharon Drake, Dave Murray, Nick Watson, Tamas Szakmany, Robert Sutcliffe, Graham Martin, Ravi Mahajan, Alan Girling, Gordon Forbes, Omar Faiz, Mark Blunt, Surjait Singh, Alistair Steel, Kate Wong, Leilani Cabreros, Pieter Bothma, Vivek Chitre, Ayodele Obideyi, Dhiraj Ali, Karl Blenk, Dan Broad, Andreas Brodbeck, Rajesh Dumpala, Arnth Engel, Ranjit Ganepola, Sudha Garg, Mike Gay, Michael Karlikowsk, Edward Lams, Dean Millican, Inga Misane, Ajaya Mull, Veena Naik, Nathan Pushpa, Chris Nutt, Saravanna Sagadai, Hazel Stuart, Paul Noble, Niko Van De Velde, Liam Hudson, Raoul Benlloch, Satish Singh, Karan Verma, Damian Laba, Jack Carmichael, Peter Richardson, Graham Wilson, Ricky Lewis, Karthik Surendran, Essam El-damatty, Sarada Gurung, Ilona Raulusaite, Nabua Gerstina, Chloe Rochester, Rai Kuldip, Andrew Lindner, Therese Murray, Chitre Vivek, Roshan Lal, Sarah Downey, Vamsi Velchuru, Kamal Aryal, Raman Guruswamy, Kirosh Shankar, Helen Porter, Matthew Tutton, Helen Agostini, Simon Fletcher, Richard Wharton, Steve Hutchinson, Bala Maiya, Richard Howard-griffin, Michael Crabtree, Vlad Kushakovsky, Abdel Omer, Senthil Nadarajavan, Stephanie Bell, Vishal Patil, Asif Jah, Razeen Mahroof, Nicholas Watson, John Tansley, Gareth Moncaster, Neil Flint, Andrew Miller, Marcus Wood, Andreou Prematie, Sally Roth, Sarah Bowery, Dawn Hales, Tanuja Shah, Gill Tierney, Craig Morris, Syed Iftikhar, Amit Shukla, Grainne O'dwyer, Adam Wolverson, Ferdinand Adams, Laura Perrin-brown, Tim White, Sarah Beavis, Victoria Banks, John Abercrombie, Jonathon Mole, Avninder Chana, Ayan Banerjea, David Humes, Rajpal Dhingsa, John Wells, Stephanie Brown, Kenneth Adegoke, Barclay Tofte, Ana Alegria, Nat Natarajan, Mansoor Akhtar, Samer Doughan, John Mackinnon, Biju Aravind, Esther Cook, Mark Snazelle, Matt Gardner, Lee Baldwin, Simon Bailey, Greg Lawton, Nandita Divekar, Neil Kukreja, Mansoor Sange, Mark Watson, Mallikarjunappa Satisha, Michael Protopapas, Zakaulla Belagodu, Shameem Sarfi, Pasupathy Raju, Brenda Stacey, Tim Campbell-smith, Simon Parrington, Somi Desikan, Andrew Brennan, John Griffith, Steve Fletcher, Catherine Farrow, Stewart Prestwich, Laura Graham, Martin Northey, Jay Gokhale, Frances Mosley, Peter Alexander, Abhiram Sharma, Will Brady, John Hopper, Oliver Hill, Sandeep Varma, Christopher Macklin, Alastair Rose, Harjeet Narula, Sarah Buckley, Karen Simeson, Kevin Sim, Michael Chadwick, Preeti Kuduvalli, Susan Dowling, Amanda Mccairn, Lawrence Wilson, Dale Vimalchandran, Anita Jhamatt, Nicole Robin, David Monk, Martin Leuwer, David Bottomley, Oliver Zuzan, Ingeborg Welters, Davina Ross-anderson, Charles Knowles, Nick Bunker, Ying Hu, Marta Januszewska, Phoebe Bodger, Edyta Niebrzegowska, Carmen Correia, Richard Haslop, Tom Abbott, Tabitha Tanqueray, Sanjay Wijeykoon, Susan Jain, Jens Full, Tamzin Cuming, Flora Bailey, Stelios Chatzimichail, Pedro Cunha, Almas Rehman, Manab Mohanty, Nicola Radford, Otto Mohr, Hitesh Patel, Dolores Mateo, Ashok Raj, Michael Machesney, Nazar Abdul, Kim Jemmet, Marta Campbell, David Inglis, Thomas Parker, Thomas Medici, Peter Chan, Nathan Borgeaud, Dipankar Mukherjee, Oluremi Odejinmi, Tomas Jovaisa, Elizabeth Harwood, Ramani Moonesinghe, Jonathan Mccullough, Jigna Modha, Sanjiv Patel, James Limb, Sheshagiri Bengeri, Amir Rafi, Elizabeth Hall, James Brown, Bruce Gibson, Una Mcnelis, Mike Bradburn, Maria Lawson, Sara Pick, Matthew Gaughan, David Browell, Vanessa Linnett, Jenny Ritzema, Paul O'loughlin, Sean Cope, John Corson, Alistair Roy, Julie Furneval, Anitha Holtham, Sophie Noblett, Chris Dawson, Elizabeth Hall, Mike Bradburn, Fiona Mcmenemie, David Saunders, Stefan Pulsa, Ian Clement, Verity Calder, Katherine Allen, Catherine Rimmer, Helen Reed, Christine Boyd, Diane Monkhouse, Peter Davies, Jost Mullenheim, Emanuel Cirstea, Martyn Cain, Kirsty Baillie, Tom Owen, Arnab Bhowmick, Keiarash Jovestani, Sean Mcmullan, Emma Durant, Alexandra Williams, Donna Doyle, Jason Cupitt, Jonathon Barker, Nick Harper, Emma Brennan, Daren Subar, Robert Shawcross, Dominic Sebastian, Panna Patel, Gillian O'connell, Jyrki Karvonen, Maitra Ishaan, Alison Hool, Karen Burns, Carol Mcarthur, Tezas Stergios, Singh Gursevak, Makvana Sonia, Heather Pratt, Kaighan Lynne, Sean Mcafee, Chris Lewis, Wael Khalaf, Chris Coldwell, Christine Bronder, Mark Wilkinson, Emma Davis, Glenn Arnold, Paul Ziprin, Rachel Bartlett, Martin Stotz, Rovan D'souza, Phillippa Pemberton, Banwari Agarwal, Anita Sugavanam, Melanie Tan, Massimo Varcada, Craig Lyness, Andrew Thorniley, Ash Prabhudesai, Ruth Griffin, Shubha Vashisht, James Harris, Julie Wakeford, Sergei Vaganov, Yasser Mohsen, Alister Myers, Qamar Iqbal, Simon Harris, Sami Ijaz, James Burrow, Paul Ziprin, Francesca Rubulotta, James Burrow, Nabil El-masry, Nicola Stranix, Tamsin Rope, Lampros Liasis, Tariq Husain, Josef Watfah, Megan Griffiths, Janindra Warusavitarne, Charles Cartwright, Linden Baxter, Rakhee Visavadia, Malcolm Sim, Chris Wilson, Paul Harrison, Dewi Williams, Maria Bews-hair, Wayne Wrathall, Catherine Jardine, Paul Mclaren, Fanus Dreyer, Paddy Collins, Jennifer Edwards, Susan Moug, Kevin Rooney, Erin Mcilveen, Steven Henderson, Linda Graham, Gail Stark, Lynn Taylor, Mark Munro, Lynn Stewart, Natalie Dickinson, Laura Rooney, Lindsay Bailey, Diane Murray, Tim Geary, Simon Gibson, Colin Pow, Kerwei Tan, Richard Stevenson, Ewen Harrison, Peter Lamb, Kate Carey, Laura Fitton, Fabian Cook, Magen Schwarz, Alan Morrison, Gavin Bryce, Khaled Razouk, Kathryn Cain, Gudrun Kunst, Savvas Papagrigoriadis, Phil Hopkins, Adrian Fawcet, Britta O'carroll-kuehn, Amira Girgis, Stas Janokowski, Sami Farhat, Stella Vig, Nada Hadi, Anthony Parsons, Maurizio Cecconi, David Melville, Richard Hartopp, Justin Woods, Isabella Karat, David Gerrard, Edward Curtis, Krishnamurthy Somasekar, Tom Morgan-jones, Michael Martin, Mark Henwood, Gordon Milne, Ajit Sivasankaranand, Alexandra Scott, Xavier Escofet, Piroska Toth-tarsoly, Majed Al Shama, Valerie Hilton, Huw Davis, Gail Williams, Tim Harvard, Peter Fitzgerald, Dom Hurford, Tamas Szakmany, Babu Muthuswamy, Gethin Williams, Jack Parry Jones, Nick Mason, Ramesh Rajagopal, Shrisha Shenoy, Magdy Khater, Richard Morgan, Nikolaos Makris, Anil Hermandes, Andrew White, Guy Finch, Matt Outram, Jonny Wilkinson, Jennifer Spimpolo, Debbie Shaw, Marion Obichere, Giovanni Brescia, Flavia Menezes, Helena Stafford, Malcolm Watters, Chris Thorn, Julian Stone, Sam Andrews, Nicola Lythell, Helen Langton, Clare Stapleton, Stephen Baxter, Roy Fernandes, Rame Sunthareswaran, Alastair Ankers, Kumar Panikkar, Simon Sleight, Belinda Cornforth, Louise Bell, Phil Dodd, Fenella Welsh, Geoff Watson, Frankie Dorman, Guy Nash, James Bromilow, Fran Haigh, David Pogson, Stuart Mercer, Vanessa Tucker, Carolyn Way, James Kirby-bott, Jenny Mclachan, Rob Chambers, Rachael Craven, Jane Blazeby, Dan Freshwater-turner, Lorna Burrows, Helen Howes, Iain Christie, Mark Coleman, Gary Minto, Sam Waddy, Grant Sanders, Abigail Patrick, Catherine Pitman, Susan Tyson, Hannah Smith, Guy Rousseau, Mark Cartmell, Jan Hanousek, Nigel Hollister, Lynsey Kightly, Mark Pulletz, Anjay Talwar, Susie Baker, Ruth Thomas, Richard Gibbs, Hamish Noble, Joseph Silsby, Helen Black, Thomas Evans, Robert Debrunner, Nicola Cook, Stacy Hodges, Amanda Stevens, Rowena Felipe, Jonathan Paddle, Denzil May, Alison Pickford, Sid Riddington, Olga Tucker, Simon Smart, Jeremy Marwick, Nigel Suggett, Ewen Griffiths, David Riddington, Kathryn Gill, Neil Cruickshank, Jay Susarla, Emma Leno, Julie Colley, Andrew Burtenshaw, Stephen Lake, Jamie Greenwood, Sian Bhardwaj, Jessica Thrush, Julie Wollaston, Julian Sonksen, Rajan Patel, Adrian Jennings, David Stanley, Jenny Wright, Chris Horner, Faisal Baig, Katie Cooke, Jagdeep Singh, Andrew Claxton, Nazzia Mirza, Simon Hester, Georgia Knight, Peeyush Kumar, Taj Saran, Gabriele Marangoni, Roger Townsend, Andy Thacker, Anne Scase, Meghna Sharma, Beth Hale

Research output: Contribution to journalArticlepeer-review

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
Stepped-wedge cluster randomised trial of patients aged ≥40 years undergoing emergency open major abdominal surgery. Hospitals were organised into 15 geographical clusters and commenced the QI programme in random order, based on a computer generated random sequence, over an 85-week period. The trial included an ethnographic study in six hospitals. The primary outcome measure was mortality within 90 days of surgery. 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.
Findings
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. The primary outcome occurred in 1393 patients in the usual care group (16%) compared with 1210 patients in the QI group (16%) (HR QI vs usual care: 1.11 [0.96-1.28]). There were only modest overall improvements in processes of patient care following QI implementation. The ethnographic study revealed good QI engagement but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success.
Interpretation
There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The success of the QI intervention may have been limited by the time and resources needed to improve patient care.
Funding
National Institute for Health Research, Health Services and Delivery Research.
Original languageEnglish
Pages (from-to)2213-2221
JournalThe Lancet
Volume393
Issue number10187
Early online date25 Apr 2019
DOIs
Publication statusPublished - 1 Jun 2019

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