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P-POSSUM and the NELA Score Overpredict Mortality for Laparoscopic Emergency Bowel Surgery: An Analysis of the NELA Database

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Abstract

Background

Risk stratification has become a key part of the care processes for patients having emergency bowel surgery. This study aimed to determine if operative approach influences risk-model performance, and risk-adjusted mortality rates in the United Kingdom.

Methods

A prospectively planned analysis was conducted using National Emergency Laparotomy Audit (NELA) data from December 2013 to November 2018. The risk-models investigated were P-POSSUM and the NELA Score, with model performance assessed in terms of discrimination and calibration. Risk-adjusted mortality was assessed using Standardised Mortality Ratios (SMR). Analysis was performed for the total cohort, and cases performed open, laparoscopically and converted to open. Sub-analysis was performed for cases with ≤ 20% predicted mortality.

Results

Data were available for 116 396 patients with P-POSSUM predicted mortality, and 46 935 patients with the NELA score. Both models displayed excellent discrimination with little variation between operative approaches (c-statistic: P-POSSUM 0.801–0.836; NELA Score 0.811–0.862). The NELA score was well calibrated across all deciles of risk, but P-POSSUM over-predicted risk beyond 20% mortality. Calibration plots for operative approach demonstrated that both models increasingly over-predicted mortality for laparoscopy, relative to open and converted to open surgery. SMRs calculated using both models consistently demonstrated that risk-adjusted mortality with laparoscopy was a third lower than open surgery.

Conclusion

Risk-adjusted mortality for emergency bowel surgery is lower for laparoscopy than open surgery, with P-POSSUM and NELA score both over-predicting mortality for laparoscopy. Operative approach should be considered in the development of future risk-models that rely on operative data.

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Funding

This project has not received any research funding.

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Authors and Affiliations

  1. Department of General Surgery, Portsmouth Hospitals University NHS Trust, Southwick Hill Road, Portsmouth, PO6 3LY, UK

    Alexander R. Darbyshire, Philip H. Pucher & Stuart J. Mercer

  2. Centre for Healthcare Modelling and Informatics, University of Portsmouth, Buckingham Building, Lion Terrace, Portsmouth, PO1 3HE, UK

    Ina Kostakis & David Prytherch

Authors
  1. Alexander R. Darbyshire
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  2. Ina Kostakis
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  3. Philip H. Pucher
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  4. David Prytherch
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  5. Stuart J. Mercer
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Contributions

Project initiation: SM and AD. Planning of statistical analysis: AD, IK, DP and PP. Cleaning and analysis of data: AD, IK and SM. Interpretation of results: AD, IK, DP, PP and SM. Drafting of initial version of paper: AD and IK. Revision of paper: AD, IK, DP, PP and SM.

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Correspondence to Alexander R. Darbyshire.

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Darbyshire, A.R., Kostakis, I., Pucher, P.H. et al. P-POSSUM and the NELA Score Overpredict Mortality for Laparoscopic Emergency Bowel Surgery: An Analysis of the NELA Database. World J Surg 46, 552–560 (2022). https://doi.org/10.1007/s00268-021-06404-w

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  • DOI: https://doi.org/10.1007/s00268-021-06404-w

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