Every year, more than 250,000 high-risk patients in the NHS face a difficult choice about major surgery, yet many go into the operating theatre without understanding the long-term odds. The problem is a dangerous information gap. One in three high-risk patients who choose surgery will suffer serious complications that permanently reduce their quality of life, but both doctors and patients are poorly aware of these long-term risks. As a result, decisions are often made without the full picture. This project aims to close that gap by systematically identifying what outcomes matter most to older patients—those aged 60 and over facing joint replacement, bowel cancer surgery, or heart bypass—and comparing those values with what surgeons believe. If successful, the research will produce a tablet-based decision-support tool that gives individual patients personalised forecasts of their long-term outcomes after surgery versus non-surgical alternatives. Tested in a cluster randomised trial across 60 NHS hospitals with 568 patients, the intervention could transform how high-risk surgical decisions are made. Rather than relying on vague warnings, patients and doctors would share a concrete, data-driven picture of what the future likely holds. The team plans to roll out the tool to every NHS surgical hospital through the Centre for Perioperative Care, potentially reducing regret, improving informed consent, and aligning treatment choices with what patients actually value.
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Background Each year in the NHS, more than 250,000 high-risk patients contemplate major surgery. These patients are typically older with long-term disease. One in three high-risk patients choosing surgery will experience serious medical complications leading to long-term decline in health and quality of life. Awareness of these long-term risks is poor amongst both doctors and patients. Consequently, many high-risk patients do not receive the information they need to make an informed decision about surgery. Aims To understand values and beliefs about long-term outcomes amongst high-risk patients contemplating major surgery, how these differ from doctors opinions, how these affect decisions about surgical treatments, and whether opinions change after surgery. To describe the healthcare burden, long-term mortality, components of quality of life and other outcomes that high-risk patients consider when contemplating major surgery. To co-design a decision support intervention with patients and doctors, utilising a series of computational models, to provide individual patient forecasts of long-term outcomes following surgical and non-surgical treatments. To evaluate this intervention in a clinical trial. Methods Population: High-risk surgical patients aged ≥60 years contemplating surgery in one of three contrasting scenarios: major joint replacement for osteoarthritis, colorectal resection for bowel cancer and coronary artery bypass grafting for ischaemic heart disease. Project 1: Ninety interviews within 15 patient-doctor case studies and 12 patient and doctor focus groups, to identify and weigh the importance of different post-operative health outcomes to patients. In a qualitative dynamic decision making analysis, including 50 high-risk patients and 20 doctors, we will explore how decisions are made about major surgery and how framing of information influences this. Project 2: Analysis of Hospital Episode Statistics data describing 15 million surgical episodes from 2005-2015 to describe long-term (≥2 years) mortality, morbidity and other outcomes. Analysis of data from 5000 primary care patients undergoing high-risk major surgery to determine factors associated with increased primary and secondary healthcare use in the years following surgery. Creation of a detailed quality of life resource using published and unpublished data. Project 3: We will co-design a decision support intervention with patients and doctors, incorporating a series of computational risk models, for use on a tablet computer during the shared decision making process. Project 4: We will evaluate the clinical effectiveness of the intervention in a cluster randomised trial of 568 high-risk patients contemplating major surgery in 60 NHS hospitals (clusters) with integrated health economic and process evaluations. Timelines for delivery Projects 1 & 2 complete by end of year 2; Intervention ready for clinical feasibility study by middle of year 3; Trial recruitment complete by end of year 5; Programme delivered by end of year 6. Impact & dissemination We will work with the Centre for Perioperative Care (hosted by the Royal College of Anaesthetists) to engage all the relevant stakeholder groups, along with 173 local Perioperative Medicine leads to promote implementation in every NHS surgical hospital. We will work with patients to publicise our work using social and mainstream media, at major scientific meetings, and in scientific journals.
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