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Risk adjusted benchmarking of abdominoperineal excision for rectal adenocarcinoma in the context of the Belgian PROCARE improvement project
  1. Freddy Penninckx1,
  2. Steffen Fieuws2,
  3. Koen Beirens3,
  4. Pieter Demetter4,
  5. Wim Ceelen5,
  6. Alex Kartheuser6,
  7. Gaetan Molle7,
  8. Jean Van de Stadt8,
  9. Koen Vindevoghel9,
  10. Elizabeth Van Eycken3,
  11. on behalf of PROCARE*
  1. 1Department of Abdominal Surgery, UZ Gasthuisberg, Leuven, Belgium
  2. 2I-Biostat, Katholieke Universiteit Leuven and Universiteit Hasselt, Leuven, Belgium
  3. 3Belgian Cancer Registry, Brussels, Belgium
  4. 4Department of Pathology, Erasme University Hospital, Brussels, Belgium
  5. 5Department of Surgery, University Hospital, Gent, Belgium
  6. 6Colorectal Surgery Unit, Cliniques universitaires Saint-Luc, Brussels, Belgium
  7. 7Department of Digestive Surgery, Hôpital de Jolimont, Jolimont, Belgium
  8. 8Department of Surgery, Erasme University Hospital, Brussels, Belgium
  9. 9Department of Surgery, OLV van Lourdes Ziekenhuis, Waregem, Belgium
  1. Correspondence to Dr F Penninckx, Department of Abdominal Surgery, UZ Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium; freddy.penninckx{at}


Objective The abdominoperineal excision (APE) rate, a quality of care indicator in rectal cancer surgery, has been criticised if not adjusted for confounding factors. This study evaluates variability in APE rate between centres participating in PROCARE, a Belgian improvement initiative, before and after risk adjustment. It also explores the effect of merging the Hartmann resections (HR) rate with that of APE on benchmarking.

Design Data of 3197 patients who underwent elective radical resection for invasive rectal adenocarcinoma up to 15 cm were registered between January 2006 and March 2011 by 59 centres, each with at least 10 patients in the registry. Variability of APE or merged APE/HR rates between centres was analysed before and after adjustment for gender, age, ASA score (3 or more), tumour level (rectal third), depth of tumour invasion (cT4) and preoperative incontinence.

Results The overall APE rate was 21.1% (95% CI 19.7 to 22.5%). Significant variation of the APE rate was observed before and after risk adjustment (p<0.0001). For cancers in the lower rectal third, the overall APE rate increased to 45.8% (95% CI 43.1 to 48.5%). Also, variation between centres increased. Risk adjustment influenced the identification of outliers. HR was performed in only 2.6% of patients. However, merging of risk adjusted APE and HR rates identified other centres with outlying definitive colostomy rates than APE rate alone.

Conclusion Significant variation of the APE rate was observed. Adjustment for confounding factors as well as merging HR with APE rates were found to be important for the assessment of performances.

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  • * The PROCARE steering group consists of delegates from all Belgian scientific organisations involved in the treatment of rectal cancer—that is, the Belgian Section of Colorectal Surgery, a section of the Royal Belgian Society of Surgery (C Bertrand, D De Coninck, M Duinslaeger, A Kartheuser, F Penninckx, J Van de Stadt, W Vaneerdeweg); the Belgian Society of Surgical Oncology (D Claeys); the Belgian Group for Endoscopic Surgery (D Burnon); the Belgian Society of Radiotherapy–Oncology (K Haustermans, P Scalliet, Ph Spaas); the Belgian Society of Pathology and the Digestive Pathology Club (P Demetter, A Jouret-Mourin, C Sempoux); the Belgian Society of Medical Oncology (W Demey, Y Humblet, E Van Cutsem); the Belgian Group for Digestive Oncology (S Laurent, E Van Cutsem, JL Van Laethem); the Royal Belgian Society of Radiology (E Danse, B Op de Beeck, P Smeets); the Société Royale Belge de Gastro-entérologie (M Melange, J Rahier); the Vlaamse Vereniging voor Gastro-enterologie Flemish Society for Gastroenterology (M Cabooter, P Pattyn, M Peeters); and the Belgian Society of Gastrointestinal Endoscopy (M Buset). Also represented are: the Belgian Professional Surgical Association (L Haeck, B Mansvelt, K Vindevoghel); the Foundation Belgian Cancer Registry (E Van Eycken); and the RIZIV/INAMI (J-P Dercq, A Thijs). FP chairs the PROCARE Steering Group. KB is a senior researcher at the Belgian Cancer Registry. SF is a statistician at I-Biostat, Katholieke Universiteit Leuven and Universiteit Hasselt, Belgium.

  • Funding PROCARE was supported by the Foundation against Cancer in 2006–2007 and by the RIZIV/INAMI, Belgian Ministry of Social Affairs, from 2007 until 2012. Their sponsorship allowed training and registration. The sponsors had no influence or role in the study design, data analysis, data interpretation or writing this report.

  • Competing interests None.

  • Ethics approval This was a national survey and analysis of anonymised data submitted on a voluntary basis by participating centres in the context of a national (Belgian) improvement project.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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