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Di J, Lu XS, Sun M, Zhao ZM, Zhang CD. Hospital volume-mortality association after esophagectomy for cancer: a systematic review and meta-analysis. Int J Surg 2024; 110:3021-3029. [PMID: 38353697 DOI: 10.1097/js9.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Postoperative mortality plays an important role in evaluating the surgical safety of esophagectomy. Although postoperative mortality after esophagectomy is partly influenced by the yearly hospital surgical case volume (hospital volume), this association remains unclear. METHODS Studies assessing the association between hospital volume and postoperative mortality in patients who underwent esophagectomy for esophageal cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random effects model. The dose-response association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with PROSPERO. RESULTS Fifty-six studies including 385 469 participants were included. A higher-volume hospital significantly reduced the risk of postesophagectomy mortality by 53% compared with their lower-volume counterparts (odds ratio, 0.47; 95% CI: 0.42-0.53). Similar results were found in subgroup analyses. Volume-outcome analysis suggested that postesophagectomy mortality rates remained roughly stable after the hospital volume reached a plateau of 45 esophagectomies per year. CONCLUSIONS Higher-volume hospitals had significantly lower postesophagectomy mortality rates in patients with esophageal cancer, with a threshold of 45 esophagectomies per year for a high-volume hospital. This remarkable negative correlation showed the benefit of a better safety in centralization of esophagectomy to a high-volume hospital.
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Affiliation(s)
| | | | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, People's Republic of China
| | - Zhe-Ming Zhao
- Department of Surgical Oncology, The Fourth Affiliated Hospital of China Medical University, Shenyang
| | - Chun-Dong Zhang
- Central Laboratory
- Department of Surgical Oncology, The Fourth Affiliated Hospital of China Medical University, Shenyang
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Ning FL, Gu WJ, Zhao ZM, Du WY, Sun M, Cao SY, Zeng YJ, Abe M, Zhang CD. Association between hospital surgical case volume and postoperative mortality in patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis. Int J Surg 2023; 109:936-945. [PMID: 36917144 PMCID: PMC10389614 DOI: 10.1097/js9.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/06/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Postoperative mortality is an important indicator for evaluating surgical safety. Postoperative mortality is influenced by hospital volume; however, this association is not fully understood. This study aimed to investigate the volume-outcome association between the hospital surgical case volume for gastrectomies per year (hospital volume) and the risk of postoperative mortality in patients undergoing a gastrectomy for gastric cancer. METHODS Studies assessing the association between hospital volume and the postoperative mortality in patients who underwent gastrectomy for gastric cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random-effects model. The volume-outcome association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with Prospective Register of Systematic Reviews (PROSPERO). RESULTS Thirty studies including 586 993 participants were included. The risk of postgastrectomy mortality in patients with gastric cancer was 35% lower in hospitals with higher surgical case volumes than in their lower-volume counterparts (odds ratio: 0.65; 95% CI: 0.56-0.76; P <0.001). This relationship was consistent and robust in most subgroup analyses. Volume-outcome analysis found that the postgastrectomy mortality rate remained stable or was reduced after the hospital volume reached a plateau of 100 gastrectomy cases per year. CONCLUSIONS The current findings suggest that a higher-volume hospital can reduce the risk of postgastrectomy mortality in patients with gastric cancer, and that greater than or equal to 100 gastrectomies for gastric cancer per year may be defined as a high hospital surgical case volume.
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Affiliation(s)
- Fei-Long Ning
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Wan-Jie Gu
- Departments of Intensive Care Unit
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou
| | - Zhe-Ming Zhao
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang
| | - Wan-Ying Du
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan
| | - Shi-Yi Cao
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong-Ji Zeng
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Masanobu Abe
- Division for Health Service Promotion, The University of Tokyo, Tokyo, Japan
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang
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Petrella F, Casiraghi M, Radice D, Bardoni C, Cara A, Mohamed S, Sances D, Spaggiari L. Unplanned Return to the Operating Room after Elective Oncologic Thoracic Surgery: A Further Quality Indicator in Surgical Oncology. Cancers (Basel) 2022; 14:cancers14092064. [PMID: 35565193 PMCID: PMC9104285 DOI: 10.3390/cancers14092064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 01/25/2023] Open
Abstract
Background: An unplanned return to the operating room (UROR) is defined as a readmission to the operating room because of a complication or an untoward outcome related to the initial surgery. The aim of the present report is to evaluate the role of URORs after elective oncologic thoracic surgery. Methods: In the study, 4012 consecutive patients were enrolled; among them, 71 patients (1.76%) had an unplanned return to the operating room. Age, sex, Charlson comorbidity index, induction treatments, type of the first operation, indication to readmission to the operating room and type of second operation, length of stay, complication after reoperation and outcomes were collected. Results: The mean age was 63.3 (SD: 13.0); there were 53 male patients (74.6%); the type of the first procedure was: lower lobectomy (11.3%), middle lobectomy (1.4%), upper lobectomy (22.5%), metastasectomy (5.6%), extrapleural pneumonectomy (4.2%), pneumonectomy (40.9%), pleural biopsy (5.6%) and other procedures (8.5%). Patients presenting complications after UROR had undergone a significantly longer first procedure (p < 0.02), had a longer length of stay (p < 0.001) and had higher post-operative mortality (p < 0.001). Conclusions: The patients experiencing UROR after elective oncologic thoracic surgery have significantly higher morbidity and mortality rates when compared to standard thoracic surgery. Bronchopleural fistula remains the most lethal complication in patients undergoing UROR.
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Affiliation(s)
- Francesco Petrella
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, 20122 Milan, Italy
- Correspondence: or ; Tel.: +39-0257489362; Fax: +39-0294379218
| | - Monica Casiraghi
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
| | - Davide Radice
- Division of Epidemiology and Biostatistics, IRCCS European Institute of Oncology, 20141 Milan, Italy;
| | - Claudia Bardoni
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
| | - Andrea Cara
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
| | - Shehab Mohamed
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
| | - Daniele Sances
- Division of Anesthesiology, IRCCS European Institute of Oncology, 20141 Milan, Italy;
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy; (M.C.); (C.B.); (A.C.); (S.M.); (L.S.)
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, 20122 Milan, Italy
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Application of the Clavien-Dindo classification to a pediatric surgical network. J Pediatr Surg 2020; 55:312-315. [PMID: 31727385 DOI: 10.1016/j.jpedsurg.2019.10.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/26/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION A comprehensive validated system to evaluate surgical complications is required in our specialty to facilitate comparison and audit. The Clavien-Dindo (CD) classification of post-surgical complications was originally described in an adult general surgical setting in 1992 and has become widely used. We aimed to apply this to a pediatric surgical setting. METHODS Data were collected on emergency and elective surgical activity together with complications in a prospective audit over a recent 4-month period in three geographical conjoined regional pediatric surgical units (including two major trauma centres). Briefly the CD classification codes complications according to degree of harm and magnitude of intervention required [I - V (death) with III and IV sub-divided according to whether general anesthesia was needed]. Length of stay and mode of admission were recorded. Data are given as median (range). Non-parametric comparison was used, and a p value of <0.05 was regarded as significant. RESULTS During the period JULY - OCT 2018 (inclusive), there were 1822 admissions (elective, n = 1186: emergency, n = 636) and 1556 operations (elective, n = 1189, and of these 393 were urological). There were 69 patient complications: CDI (n = 7), CD-II (n = 19), CD-IIIa (n = 4), CD-IIIb (n = 28), CD-IV (n = 4), CD-V (n = 7). Deaths were principally in neonates and due to NEC (n = 6) at 2.5 (1-140) days post-operatively. There was a single post-traumatic death in an adolescent. LOS was 9 (0-217) days in CD I-IV. The incidence of any complication was 4.4%, of serious complication (defined as ≥CD III) 2.6% (A = 2.1%, B = 2.0%, and C = 3.2%: p = 0.16), and of death 0.45%. The most frequent complications were wound infection (n = 12) and post-appendicectomy collections/abscess (n = 10). CONCLUSIONS This appears to be the 1st report of the C-D classification in a general pediatric surgery network and can be considered a benchmark. The risk of death or serious harm is very low in such a practice. TYPE OF STUDY Prospective Cohort Study. LEVEL OF EVIDENCE IIb.
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Lao C, Lees D, Patel S, White D, Lawrenson R. Geographical and ethnic differences of osteoarthritis-associated hip and knee replacement surgeries in New Zealand: a population-based cross-sectional study. BMJ Open 2019; 9:e032993. [PMID: 31542769 PMCID: PMC6756428 DOI: 10.1136/bmjopen-2019-032993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To (1) explore the regional and ethnic differences in rates of publicly funded osteoarthritis-associated hip and knee replacement surgeries and (2) investigate the mortality after surgery. DESIGN Population-based, retrospective, cross-sectional study. SETTING General population in New Zealand. PARTICIPANTS Patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgeries in 2005-2017. Patients aged 14-99 years were included. PRIMARY AND SECONDARY OUTCOME MEASURES Age-standardised rate, standardised mortality ratio (SMR) and 30 days, 90 days and 1 year mortality. RESULTS We identified 53 439 primary hip replacements and 50 072 primary knee replacements with a diagnosis of osteoarthritis. The number and age-standardised rates of hip and knee replacements increased over time. Māori had the highest age-standardised rate of hip replacements, followed by European/others and Pacific, and Asian had the lowest rate. Pacific had the highest age-standardised rate of knee replacements, followed by Māori and European/others, and Asian had the lowest rate. The Northern Health Network had the lowest rate of hip surgeries, and the Southern Health Network had the lowest rate of knee surgeries. The SMRs of patients undergoing hip and knee replacements were lower than the general population: 0.92 (95% CI 0.89 to 0.95) for hip and 0.79 (95% CI 0.76 to 0.82) for knee. The SMRs were decreasing over time. The patterns of 30 days, 90 days and 1 year mortality were similar to the SMR. CONCLUSIONS The numbers of publicly funded osteoarthritis-associated primary hip and knee replacements are steadily increasing. Māori people had the highest age-standardised rate of hip replacements and Pacific people had the highest rate of knee replacements. The Northern Health Network had the lowest rate of hip surgeries, and the Southern Health Network had the lowest rate of knee surgeries. Compared with the general population, patients who had hip and knee replacements have a better life expectancy.
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Affiliation(s)
- Chunhuan Lao
- Waikato Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - David Lees
- Orthopaedic Department, Tauranga Hospital, Tauranga, New Zealand
| | - Sandeep Patel
- Orthopaedic Department, Waikato Hospital, Hamilton, New Zealand
| | - Douglas White
- Rheumatology Department, Waikato District Health Board, Hamilton, New Zealand
- Waikato Clinical School, The University of Auckland, Auckland, New Zealand
| | - Ross Lawrenson
- Waikato Medical Research Centre, University of Waikato, Hamilton, New Zealand
- Strategy and Funding, Waikato District Health Board, Hamilton, New Zealand
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Abstract
Background Patients are attracted to acupuncture partly by its reputation for having low risks. The safety of acupuncture should be established by positive evidence. Methods Two prospective surveys were conducted among different groups of professionals in the UK, including doctors, physiotherapists and practitioners primarily trained in acupuncture. Participants monitored adverse events over a defined period of time, and reported minor and significant events on purpose designed forms. Results A total of 652 acupuncturists reported 6733 adverse reactions including tiredness in 66 229 patients, an adverse event rate of 10.2%. The most common events were tiredness (3%) bleeding or bruising (3%), aggravation of symptoms (2%) and pain at the needling site (1%). There were no serious adverse events. A total of 86 (0.1%) of the treatments was associated with an event that the practitioner judged to be significant though without persistent consequences for the patient's health. Conclusion The risks associated with acupuncture can be classified as negligible, and acupuncture is a very safe treatment in the hands of competent practitioners.
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Cecil E, Wilkinson S, Bottle A, Esmail A, Vincent C, Aylin PP. National hospital mortality surveillance system: a descriptive analysis. BMJ Qual Saf 2018; 27:974-981. [PMID: 30297377 PMCID: PMC6288692 DOI: 10.1136/bmjqs-2018-008364] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/16/2018] [Accepted: 09/04/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To provide a description of the Imperial College Mortality Surveillance System and subsequent investigations by the Care Quality Commission (CQC) in National Health Service (NHS) hospitals receiving mortality alerts. BACKGROUND The mortality surveillance system has generated monthly mortality alerts since 2007, on 122 individual diagnosis and surgical procedure groups, using routinely collected hospital administrative data for all English acute NHS hospital trusts. The CQC, the English national regulator, is notified of each alert. This study describes the findings of CQC investigations of alerting trusts. METHODS We carried out (1) a descriptive analysis of alerts (2007-2016) and (2) an audit of CQC investigations in a subset of alerts (2011-2013). RESULTS Between April 2007 and October 2016, 860 alerts were generated and 76% (654 alerts) were sent to trusts. Alert volumes varied over time (range: 40-101). Septicaemia (except in labour) was the most commonly alerting group (11.5% alerts sent). We reviewed CQC communications in a subset of 204 alerts from 96 trusts. The CQC investigated 75% (154/204) of alerts. In 90% of these pursued alerts, trusts returned evidence of local case note reviews (140/154). These reviews found areas of care that could be improved in 69% (106/154) of alerts. In 25% (38/154) trusts considered that identified failings in care could have impacted on patient outcomes. The CQC investigations resulted in full trust action plans in 77% (118/154) of all pursued alerts. CONCLUSION The mortality surveillance system has generated a large number of alerts since 2007. Quality of care problems were found in 69% of alerts with CQC investigations, and one in four trusts reported that failings in care may have an impact on patient outcomes. Identifying whether mortality alerts are the most efficient means to highlight areas of substandard care will require further investigation.
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Affiliation(s)
- Elizabeth Cecil
- Primary Care and Public Health, Imperial College London, London, UK
| | - Samantha Wilkinson
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Alex Bottle
- Primary Care and Public Health, Imperial College London, London, UK
| | - Aneez Esmail
- Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | | | - Paul P Aylin
- Primary Care and Public Health, Imperial College London, London, UK
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Hansen D, Hansen E, Retegan C, Morphet J, Beiles CB. Validation of data submitted by the treating surgeon in the Victorian Audit of Surgical Mortality. ANZ J Surg 2018; 89:16-19. [DOI: 10.1111/ans.14910] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 09/13/2018] [Accepted: 09/15/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Dylan Hansen
- Victorian Audit of Surgical Mortality (VASM); Royal Australasian College of Surgeons; Melbourne Victoria Australia
| | - Emma Hansen
- Nursing and Midwifery; Monash University; Melbourne Victoria Australia
| | - Claudia Retegan
- Victorian Audit of Surgical Mortality (VASM); Royal Australasian College of Surgeons; Melbourne Victoria Australia
| | - Julia Morphet
- Nursing and Midwifery; Monash University; Melbourne Victoria Australia
| | - Charles Barry Beiles
- Victorian Audit of Surgical Mortality (VASM); Royal Australasian College of Surgeons; Melbourne Victoria Australia
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Saarinen I, Malmivaara A, Miikki R, Kaipia A. Systematic review of hospital-wide complication registries. BJS Open 2018; 2:293-300. [PMID: 30263980 PMCID: PMC6156167 DOI: 10.1002/bjs5.87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/18/2018] [Indexed: 11/24/2022] Open
Abstract
Background An institutional registry covering all surgical specialties could be an implementation tool in quality benchmarking between hospitals and aid determination of their cost‐effectiveness. The objective of this systematic literature review was to evaluate original articles on existing prospective surgical registries that can be used by single institutions across surgical specialties. Method A systematic review of the literature using PRISMA guidelines was conducted for articles focusing on hospital‐wide surgical registries. Single‐specialty retrospective registries, non‐defined outcome measures or system protocols, and studies not in English were excluded. Results Five articles were included for analysis. Evaluation of the articles revealed wide methodological heterogeneity in the classification and categorization of complications and data collection methods. Conclusion Ideal surgical quality monitoring systems should be real‐time, contain patient‐related risk factors, and encompass all surgical specialties. At present, such institutional registries are rarely reported and no consensus exists on their standard definitions and methodology.
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Affiliation(s)
- I Saarinen
- Department of Surgery Satakunta Central Hospital Pori Finland
| | - A Malmivaara
- Centre for Health and Social Economics, National Institute for Health and Welfare Helsinki Finland
| | - R Miikki
- Centre for Health and Social Economics, National Institute for Health and Welfare Helsinki Finland
| | - A Kaipia
- Department of Surgery Satakunta Central Hospital Pori Finland.,Department of Urology Tampere University Hospital Tampere Finland
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Mizushima T, Yamamoto H, Marubashi S, Kamiya K, Wakabayashi G, Miyata H, Seto Y, Doki Y, Mori M. Validity and significance of 30-day mortality rate as a quality indicator for gastrointestinal cancer surgeries. Ann Gastroenterol Surg 2018; 2:231-240. [PMID: 29863181 PMCID: PMC5980515 DOI: 10.1002/ags3.12070] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/13/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND AIM Benchmarking has proven beneficial in improving the quality of surgery. Mortality rate is an objective indicator, of which the 30-day mortality rate is the most widely used. However, as a result of recent advances in medical care, the 30-day mortality rate may not cover overall surgery-related mortalities. We examined the significance and validity of the 30-day mortality rate as a quality indicator. METHODS The present study was conducted on cancer surgeries of esophagectomy, total gastrectomy, distal gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, and pancreaticoduodenectomy that were registered in the first halves of 2012, 2013 and 2014 in a Japanese nationwide large-scale database. This study examined the mortality curve for each surgical procedure, "sensitivity of surgery-related death" (capture ratio) at each time point between days 30-180, and the association between mortality within 30 days, mortality after 31 days, and preoperative, perioperative, and postoperative factors. RESULTS Surgery-related mortality rates of each surgical procedure were 0.6%-3.0%. Regarding 30-day mortality rates, only 38.7% (esophagectomy) to 53.3% (right hemicolectomy) of surgery-related mortalities were captured. The capture ratio of surgery-related deaths reached 90% or higher for 120-day to 150-day mortality rates. Factors associated with mortality rate within 30 days/after the 31st day were different, depending on the type of surgical procedure. CONCLUSION Thirty-day mortality rate is useful as a quality indicator, but is not necessarily sufficient for all surgical procedures. Quality of surgery may require evaluation by combining 30-day mortality rates with other indicators, depending on the surgical procedure.
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Affiliation(s)
- Tsunekazu Mizushima
- Department of SurgeryGastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality AssessmentGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Shigeru Marubashi
- Department of Regenerative SurgeryFukushima Medical UniversityFukushimaJapan
| | - Kinji Kamiya
- Second Department of SurgeryHamamatsu University School of MedicineHamamatsuJapan
| | - Go Wakabayashi
- Database CommitteeThe Japanese Society of Gastroenterological SurgeryTokyoJapan
| | - Hiroaki Miyata
- Department of Healthcare Quality AssessmentGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Yasuyuki Seto
- The Japanese Society of Gastroenterological SurgeryTokyoJapan
| | - Yuichiro Doki
- Department of SurgeryGastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Masaki Mori
- Department of SurgeryGastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
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Abstract
BACKGROUND Death rates after surgery are increasingly analysed for clinical audit and quality assessment. Many studies commonly provide information only on deaths that occur during hospital stay, known as in-hospital death rates. By using hospital data set linked to death certificate registry, we recorded in- and out-hospital deaths within 30 and 60 post-operative days. METHODS The study included all consecutive surgical procedures (denominator) under general or locoregional anaesthesia in adult patients admitted for elective or non-elective inpatient surgery. Patients undergoing planned day-case surgery or obstetrical procedures were excluded. The primary outcome was 30- and 60-day post-operative mortality rate (numerator) whether before or after discharge. RESULTS The study material consisted of a sample of 36,494 surgical procedures corresponding to 28,202 patients. At 30-day, 384 (crude mortality rate of 1.1%) patients died, 314 (82%) during their hospitalisation and 70 (18%) after discharge. Factors that were associated with in-hospital mortality are ASA scores, emergency, duration of surgery and rate of admission to critical care unit. Within the 30-60 days interval, we recorded 231 supplemental deaths, 103 (45%) after discharge. CONCLUSION In-hospital mortality alone is an incomplete measure of mortality even within 30 days of care. To identify the missing deaths, hospital records need to be linked to data from death certificate. This connection with the national death registry will allow obtaining the rate of in-hospital and out-hospital death.
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Affiliation(s)
- Philippe Dony
- Department of Anaesthesia, University Hospital Centre of Charleroi, Lodelinsart, Belgium
| | - Magali Pirson
- Health Economics, Health Facility Administration and Nursing Science, Free University of Brussels, Brussels, Belgium
| | - Jean G. Boogaerts
- Department of Anaesthesia, University Hospital Centre of Charleroi, Lodelinsart, Belgium
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Aylin P, Bottle A, Burnett S, Cecil E, Charles KL, Dawson P, D’Lima D, Esmail A, Vincent C, Wilkinson S, Benn J. Evaluation of a national surveillance system for mortality alerts: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundSince 2007, Imperial College London has generated monthly mortality alerts, based on statistical process control charts and using routinely collected hospital administrative data, for all English acute NHS hospital trusts. The impact of this system has not yet been studied.ObjectivesTo improve understanding of mortality alerts and evaluate their impact as an intervention to reduce mortality.DesignMixed methods.SettingEnglish NHS acute hospital trusts.ParticipantsEleven trusts were included in the case study. The survey involved 78 alerting trusts.Main outcome measuresRelative risk of mortality and perceived efficacy of the alerting system.Data sourcesHospital Episodes Statistics, published indicators on quality and safety, Care Quality Commission (CQC) reports, interviews and documentary evidence from case studies, and a national evaluative survey.MethodsDescriptive analysis of alerts; association with other measures of quality; associated change in mortality using an interrupted time series approach; in-depth qualitative case studies of institutional response to alerts; and a national cross-sectional evaluative survey administered to describe the organisational structure for mortality governance and perceptions of efficacy of alerts.ResultsA total of 690 mortality alerts generated between April 2007 and December 2014. CQC pursued 75% (154/206) of alerts sent between 2011 and 2013. Patient care was cited as a factor in 70% of all investigations and in 89% of sepsis alerts. Alerts were associated with indicators on bed occupancy, hospital mortality, staffing, financial status, and patient and trainee satisfaction. On average, the risk of death fell by 58% during the 9-month lag following an alert, levelling afterwards and reaching an expected risk within 18 months of the alert. Acute myocardial infarction (AMI) and sepsis alerts instigated institutional responses across all the case study sites, although most sites were undertaking some parallel activities at a more general level to address known problems in care in these and other areas. Responses included case note review and coding improvements, changes in patient pathways, changes in diagnosis of sepsis and AMI, staff training in case note write-up and coding, greater transparency in patient deterioration, and infrastructure changes. Survey data revealed that 86% of responding trusts had a dedicated trust-level lead for mortality reduction and 92% had a dedicated trust-level mortality group or committee in place. Trusts reported that mortality reduction was a high priority and that there was strong senior leadership support for mortality monitoring. The weakest areas reported concerned the accuracy of coding, the quality of specialty-level mortality data and understanding trends in specialty-level mortality data.LimitationsOwing to the correlational nature of our analysis, we could not ascribe a causal link between mortality alerts and reductions in mortality. The complexity of the institutional context and behaviour hindered our capacity to attribute locally reported changes specifically to the effects of the alerts rather than to ongoing institutional strategy.ConclusionsThe mortality alert surveillance system reflects aspects of quality care and is valued by trusts. Alerts were considered a useful focus for identifying problems and implementing interventions around mortality.Future workA further analysis of site visits and survey material, the application of evaluative framework to other interventions, a blinded case note review and the dissemination of findings.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Paul Aylin
- Dr Foster Unit at Imperial, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Alex Bottle
- Dr Foster Unit at Imperial, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Susan Burnett
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Elizabeth Cecil
- Dr Foster Unit at Imperial, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Kathryn L Charles
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Paul Dawson
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Danielle D’Lima
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Aneez Esmail
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | | | - Samantha Wilkinson
- Dr Foster Unit at Imperial, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jonathan Benn
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
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Alyami M, Kim BJ, Villeneuve L, Vaudoyer D, Képénékian V, Bakrin N, Gilly FN, Cotte E, Glehen O, Passot G. Ninety-day post-operative morbidity and mortality using the National Cancer Institute’s common terminology criteria for adverse events better describe post-operative outcome after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Int J Hyperthermia 2017; 34:532-537. [DOI: 10.1080/02656736.2017.1367846] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Mohammad Alyami
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
- King Salman Scholarship Program, Saudi Arabian Cultural Bureau, Paris, France
| | - Bradford J. Kim
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laurent Villeneuve
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
- Pole IMER, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
| | - Delphine Vaudoyer
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
| | - Vahan Képénékian
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Naoual Bakrin
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Francois-Noel Gilly
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Eddy Cotte
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Olivier Glehen
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Guillaume Passot
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
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Fisher JC, Kuenzler KA, Tomita SS, Sinha P, Shah P, Ginsburg HB. Increased capture of pediatric surgical complications utilizing a novel case-log web application to enhance quality improvement. J Pediatr Surg 2017; 52:166-171. [PMID: 27856010 DOI: 10.1016/j.jpedsurg.2016.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 01/06/2023]
Abstract
PURPOSE Documenting surgical complications is limited by multiple barriers and is not fostered in the electronic health record. Tracking complications is essential for quality improvement (QI) and required for board certification. Current registry platforms do not facilitate meaningful complication reporting. We developed a novel web application that improves accuracy and reduces barriers to documenting complications. METHODS We deployed a custom web application that allows pediatric surgeons to maintain case logs. The program includes a module for entering complication data in real time. Reminders to enter outcome data occur at key postoperative intervals to optimize recall of events. Between October 1, 2014, and March 31, 2015, frequencies of surgical complications captured by the existing hospital reporting system were compared with data aggregated by our application. RESULTS 780 cases were captured by the web application, compared with 276 cases registered by the hospital system. We observed an increase in the capture of major complications when compared to the hospital dataset (14 events vs. 4 events). CONCLUSIONS This web application improved real-time reporting of surgical complications, exceeding the accuracy of administrative datasets. Custom informatics solutions may help reduce barriers to self-reporting of adverse events and improve the data that presently inform pediatric surgical QI. TYPE OF STUDY Diagnostic study/Retrospective study. LEVEL OF EVIDENCE Level III - case control study.
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Affiliation(s)
- Jason C Fisher
- Division of Pediatric Surgery, Department of Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY.
| | - Keith A Kuenzler
- Division of Pediatric Surgery, Department of Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
| | - Sandra S Tomita
- Division of Pediatric Surgery, Department of Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
| | - Prashant Sinha
- Division of General Surgery, Department of Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
| | - Paresh Shah
- Division of General Surgery, Department of Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
| | - Howard B Ginsburg
- Division of Pediatric Surgery, Department of Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
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Clinical events reported by surgeons assessing their peers. Am J Surg 2016; 212:748-754. [DOI: 10.1016/j.amjsurg.2016.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/23/2015] [Accepted: 01/03/2016] [Indexed: 11/24/2022]
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Ninety-day Postoperative Mortality Is a Legitimate Measure of Hepatopancreatobiliary Surgical Quality. Ann Surg 2016; 262:1071-8. [PMID: 25590497 DOI: 10.1097/sla.0000000000001048] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the legitimacy of 90-day mortality as a measure of hepatopancreatobiliary quality. BACKGROUND The 90-day mortality rate has been increasingly but not universally reported after hepatopancreatobiliary surgery. The legitimacy of this definition as a measure of surgical quality has not been evaluated. METHODS We retrospectively reviewed the causes of all deaths that occurred within 365 postoperative days in patients undergoing hepatectomy (n = 2811) and/or pancreatectomy (n = 1092) from January 1997 to December 2012. The rates of surgery-related, disease-related, and overall mortality within 30 days, within 30 days or during the index hospitalization, within 90 days, and within 180 days after surgery were calculated. RESULTS Seventy-nine (3%) surgery-related deaths and 92 (3%) disease-related deaths occurred within 365 days after hepatectomy. Twenty (2%) surgery-related deaths and 112 (10%) disease-related deaths occurred within 365 days after pancreatectomy. The overall mortality rates at 99 and 118 days optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. The 90-day overall mortality rate was a less sensitive but equivalently specific measure of surgery-related death. CONCLUSIONS AND RELEVANCE The 99- and 118-day definitions of postoperative mortality optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. However, among commonly reported metrics, the 90-day overall mortality rate represents a legitimate measure of surgical quality.
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After Pancreatectomy, the “90 Days from Surgery” Definition Is Superior to the “30 Days from Discharge” Definition for Capture of Clinically Relevant Readmissions. J Gastrointest Surg 2016; 20:77-84; discussion 84. [PMID: 26493976 DOI: 10.1007/s11605-015-2984-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 10/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies by different authors have reported their readmission rates after pancreatectomy as either “30 days from discharge” or “90 days from surgery.” The objective of this study was to determine which of these definitions captures the most surgery-related complications. METHODS A prospectively maintained database at a high volume center was queried to identify all individuals who underwent pancreatectomy between 2000 and 2012 for any diagnosis. The data was analyzed at 30 days after discharge and 90 days after operation. The optimal timing for complication reporting was defined as the time point that maximized the capture of surgery-related readmissions and direct major surgical complications while minimizing the capture of disease (cancer)-related readmissions. RESULTS There were 1123 patients included during the study time period. The median age was 63 years old, and 55.6% were male. Operations included 833 (74.2%) pancreaticoduodenectomies, 257 (22.9%) distal pancreatectomies, 18 (1.6%) total pancreatectomies, and 15 (1.3%) central pancreatectomies. Surgery-related readmissions occurred in 248 (22%) individuals, while readmission related to malignant disease progression occurred in 25 (2%) individuals. The 30 days from discharge definition captured 184 surgery-related readmissions and 1 disease-related readmission (sensitivity 0.74, specificity 0.96). The 90 days from surgery definition captured 215 surgery-related readmissions and 1 disease-related readmission (sensitivity 0.87, specificity 0.96). Major surgical complication was the only independent factor associated with readmission not captured by the 30 days from discharge definition (p = 0.002, HR 3.94, 95% CI 1.44–12.22). CONCLUSION The 90 days from surgery definition was superior to the 30 days from discharge definition, especially with regards to readmission related to major surgical complications.
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Rey-Conde T, Shakya R, Allen J, Clarke E, North JB, Wysocki AP, Ware RS. Surgical mortality audit data validity. ANZ J Surg 2015; 86:644-7. [DOI: 10.1111/ans.13416] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Therese Rey-Conde
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - Riyaz Shakya
- School of Medicine; Griffith University; Brisbane Queensland Australia
| | - Jennifer Allen
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
- School of Public Health; The University of Queensland; Brisbane Queensland Australia
| | - Evelyn Clarke
- School of Public Health; The University of Queensland; Brisbane Queensland Australia
| | - John B. North
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - Arkadiusz Peter Wysocki
- School of Medicine; Griffith University; Brisbane Queensland Australia
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Robert S. Ware
- School of Public Health; The University of Queensland; Brisbane Queensland Australia
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Allen J, North JB, Wysocki AP, Ware RS, Rey-Conde T. Surgical care for the aged: a retrospective cross-sectional study of a national surgical mortality audit. BMJ Open 2015; 5:e006981. [PMID: 26009574 PMCID: PMC4452745 DOI: 10.1136/bmjopen-2014-006981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES It is assumed that increased age signifies increased surgical care. Few surgical studies describe the differences in care provided to older patients compared with younger patients. We aimed to examine the relationships between increasing age, preoperative factors and markers of postoperative care in adults who died in-hospital after surgery in Australia. DESIGN This retrospective cross-sectional study extracted data from a national surgical mortality audit--an independent, peer-reviewed process. SETTING From January 2009 to December 2012, 111 public and 61 private Australian hospitals notified the audit of in-hospital deaths after general anaesthetic surgery or if the patient was admitted under a surgeon. PARTICIPANTS Notified deaths totalled 19,723. We excluded deaths if patients were brain dead, younger than 17 years or never had an operation (n=11,376). From this baseline population, we divided 11,201 deaths into three patient age groups: youngest (17-64 years), medium (65-79 years) and oldest (≥80 years). OUTCOME MEASURES Univariable and multivariable logistic regression analyses determined the relationships between increasing age and the measured preoperative factors and postoperative variables. RESULTS The baseline population's median age was 78 years (IQR 66-85), 43.7% (4892/11,201) were 80 years or older and 83.4% (9319/11,173) had emergency admissions. The oldest group had increased trauma and emergency admissions than the medium and youngest age groups. Seven of the eight measured markers of postoperative care demonstrate strong and significant relationships with increasing age. The oldest group compared with the medium group had decreased rates of: unplanned returns to theatre (11.2% (526/4709) vs 20.2% (726/3586)), unplanned intensive care admissions (16.3% (545/3350) vs 24.0% (601/2504)) and treatment in intensive care units (59.7% (2689/4507) vs 76.7% (2754/3590)). CONCLUSIONS The oldest patients received lower levels of care than the medium and youngest age groups.
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Affiliation(s)
- Jennifer Allen
- Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, Brisbane, Queensland, Australia
- School of Population Health, The University of Queensland, Brisbane, Queensland, Australia
| | - John B North
- Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, Brisbane, Queensland, Australia
| | | | - Robert S Ware
- School of Population Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Therese Rey-Conde
- Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, Brisbane, Queensland, Australia
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Krell RW, Hozain A, Kao LS, Dimick JB. Reliability of risk-adjusted outcomes for profiling hospital surgical quality. JAMA Surg 2014; 149:467-74. [PMID: 24623045 DOI: 10.1001/jamasurg.2013.4249] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Quality improvement platforms commonly use risk-adjusted morbidity and mortality to profile hospital performance. However, given small hospital caseloads and low event rates for some procedures, it is unclear whether these outcomes reliably reflect hospital performance. OBJECTIVE To determine the reliability of risk-adjusted morbidity and mortality for hospital performance profiling using clinical registry data. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program, 2009. Participants included all patients (N = 55,466) who underwent colon resection, pancreatic resection, laparoscopic gastric bypass, ventral hernia repair, abdominal aortic aneurysm repair, and lower extremity bypass. MAIN OUTCOMES AND MEASURES Outcomes included risk-adjusted overall morbidity, severe morbidity, and mortality. We assessed reliability (0-1 scale: 0, completely unreliable; and 1, perfectly reliable) for all 3 outcomes. We also quantified the number of hospitals meeting minimum acceptable reliability thresholds (>0.70, good reliability; and >0.50, fair reliability) for each outcome. RESULTS For overall morbidity, the most common outcome studied, the mean reliability depended on sample size (ie, how high the hospital caseload was) and the event rate (ie, how frequently the outcome occurred). For example, mean reliability for overall morbidity was low for abdominal aortic aneurysm repair (reliability, 0.29; sample size, 25 cases per year; and event rate, 18.3%). In contrast, mean reliability for overall morbidity was higher for colon resection (reliability, 0.61; sample size, 114 cases per year; and event rate, 26.8%). Colon resection (37.7% of hospitals), pancreatic resection (7.1% of hospitals), and laparoscopic gastric bypass (11.5% of hospitals) were the only procedures for which any hospitals met a reliability threshold of 0.70 for overall morbidity. Because severe morbidity and mortality are less frequent outcomes, their mean reliability was lower, and even fewer hospitals met the thresholds for minimum reliability. CONCLUSIONS AND RELEVANCE Most commonly reported outcome measures have low reliability for differentiating hospital performance. This is especially important for clinical registries that sample rather than collect 100% of cases, which can limit hospital case accrual. Eliminating sampling to achieve the highest possible caseloads, adjusting for reliability, and using advanced modeling strategies (eg, hierarchical modeling) are necessary for clinical registries to increase their benchmarking reliability.
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Affiliation(s)
- Robert W Krell
- Department of Surgery, University of Michigan Health System, Ann Arbor
| | - Ahmed Hozain
- Department of Surgery, Michigan State University College of Human Medicine, East Lansing
| | - Lillian S Kao
- Department of Surgery, The University of Texas at Houston Medical School, Houston
| | - Justin B Dimick
- Department of Surgery, University of Michigan Health System, Ann Arbor
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Reporting of Adverse Events in Surgical Trials: Critical Appraisal of Current Practice. World J Surg 2014; 39:80-7. [DOI: 10.1007/s00268-014-2776-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Kester BS, Merkow RP, Ju MH, Peabody TD, Bentrem DJ, Ko CY, Bilimoria KY. Effect of post-discharge venous thromboembolism on hospital quality comparisons following hip and knee arthroplasty. J Bone Joint Surg Am 2014; 96:1476-84. [PMID: 25187587 DOI: 10.2106/jbjs.m.01248] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Symptomatic pre-discharge venous thromboembolism (VTE) rates after total or partial hip or knee arthroplasty have been proposed as patient safety indicators. However, assessing only pre-discharge VTE rates may be suboptimal for quality measurement as the duration of stay is relatively short and the VTE risk extends beyond the inpatient setting. METHODS Patients who underwent total or partial hip or knee arthroplasty were identified in the 2008 through 2010 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Outcomes of interest were the deep venous thrombosis (DVT), pulmonary embolism (PE), and overall VTE rates within thirty days after surgery and the rates during the pre-discharge and post-discharge portions of this time period. Risk-adjusted hospital rankings based on only pre-discharge (inpatient) events were compared with those based on both pre-discharge and post-discharge events within thirty days of surgery. RESULTS A total of 23,924 patients underwent total or partial hip arthroplasty (8499) or knee arthroplasty (15,425) at ninety-five hospitals. For hip arthroplasty, the VTE rate was 0.9%, with 57.9% of the events occurring after discharge. For knee arthroplasty, the VTE rate was 1.9%, with 38.3% of the events occurring after discharge. The median time of VTE occurrence was eleven days postoperatively for hip arthroplasty and three days for knee arthroplasty. The median duration of stay was three days for both hip and knee arthroplasty. When hospitals were ranked according to VTE rates, hospital outlier status designations changed when post-discharge events were included (κ = 0.386; 44% false-positive rate for low outliers). The median change in hospital quality ranking was 7 (interquartile range, 2 to 17), with a rank correlation of r = 0.82. CONCLUSIONS Nearly twice as many VTE complications were captured if both pre-discharge and post-discharge events were considered, and inclusion of post-discharge events changed hospital quality rankings. These data suggest that inclusion of post-discharge events should be considered when comparing the quality of hospitals on the basis of postoperative VTE rates. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Benjamin S Kester
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 North St. Clair Street, 22nd Floor, Chicago, IL 60611. E-mail address for K.Y. Bilimoria:
| | - Ryan P Merkow
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 North St. Clair Street, 22nd Floor, Chicago, IL 60611. E-mail address for K.Y. Bilimoria:
| | - Mila H Ju
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 North St. Clair Street, 22nd Floor, Chicago, IL 60611. E-mail address for K.Y. Bilimoria:
| | - Terrance D Peabody
- Department of Orthopaedic Surgery, Northwestern University, Galter Pavilion-Northwestern Memorial Hospital, 676 North St. Clair Street, Chicago, IL 60611
| | - David J Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, NMH/Arkes Family Pavilion Suite 650, 676 North St. Clair Street, Chicago, IL 60611
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 North St. Clair Street, 22nd Floor, Chicago, IL 60611. E-mail address for K.Y. Bilimoria:
| | - Karl Y Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 North St. Clair Street, 22nd Floor, Chicago, IL 60611. E-mail address for K.Y. Bilimoria:
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Quality Assessment of Partial Nephrectomy Complications Reporting: “Time to Get the Head Out of the Sand”. Eur Urol 2014; 66:527-8. [DOI: 10.1016/j.eururo.2014.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 04/21/2014] [Indexed: 11/18/2022]
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Fowler AJ, Agha RA, Sevdalis N. Surveillance and quality improvement in the United Kingdom: Is there a meeting point? Surgeon 2014; 12:177-80. [DOI: 10.1016/j.surge.2014.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/09/2014] [Accepted: 03/13/2014] [Indexed: 11/25/2022]
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Predictive Risk Model of 30-Day Mortality in Plastic and Reconstructive Surgery Patients. Plast Reconstr Surg 2014; 134:156-164. [DOI: 10.1097/prs.0000000000000273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
BACKGROUND The aim was to study the nature of iatrogenic vascular injuries (IVIs) associated with postoperative death within 30 days. METHODS Patients who had undergone vascular surgery for IVIs and were reported prospectively to the Swedish national vascular registry during 1987-2008 were identified. They were cross-checked with the national population registry. Those who died within 30 days of surgery were studied regarding case records and death certificates. RESULTS A total of 56 patients with postoperative death within 30 days after IVI were identified. Among them, 52 case records were retrieved (93 %). In 24 cases the IVIs were caused by puncture during endovascular procedures (13 hemorrhage, 11 occlusive thrombosis), 11 by penetrating trauma during open surgery, 6 by occlusion after external compression, 6 by percutaneous accidental arterial puncture. Main symptoms were peripheral ischemia (19/52, 37 %), external bleeding (14, 27 %), and hypovolemic shock without external bleeding (10, 19 %). Main specialties involved were interventional radiology (n = 18), general surgery (n = 9), and interventional cardiology (n = 8). Overall, 22 (42 %) were avoidable, and only 13 (25 %) underwent autopsy. Within 2 weeks, 36 patients (69 %) were dead. Also, there was a higher proportion with uncertain correlation between IVI and death. CONCLUSIONS Interventional radiology, general surgery, and cardiology are the main specialities involved in IVIs with lethal outcome. Not all fatalities after IVI are attributable to the injury itself, but almost half of the injuries were considered avoidable.
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Affiliation(s)
- H Rudström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 751 85 Uppsala, Sweden.
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Montroni I, Ghignone F, Rosati G, Zattoni D, Manaresi A, Taffurelli M, Ugolini G. The challenge of education in colorectal cancer surgery: a comparison of early oncological results, morbidity, and mortality between residents and attending surgeons performing an open right colectomy. JOURNAL OF SURGICAL EDUCATION 2014; 71:254-261. [PMID: 24602718 DOI: 10.1016/j.jsurg.2013.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/04/2013] [Accepted: 08/09/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Ongoing education in surgical oncology is mandatory in a modern residency program. Achieving acceptable morbidity and mortality rates, together with oncological adequacy, is mandatory. The aim of the study was to compare early surgical outcomes in 2 groups of patients, those operated on by a surgical resident supervised by an attending surgeon and those operated on by 2 attending surgeons. DESIGN Data from consecutive patients with right colon cancer undergoing a right hemicolectomy were collected and analyzed. The patients were divided into 2 groups according to the surgeons' credentials: residents supervised by an attending surgeon and 2 attending surgeons. To evaluate the specific case mix of the 2 groups, the Portsmouth-Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (P-POSSUM) was calculated. Observed over expected 30-day morbidity and mortality rates were compared for the 2 groups. The number of lymph nodes retrieved was chosen to determine oncological appropriateness. Duration of the procedures was also recorded. RESULTS From January 2008 to January 2012, 139 patients underwent an right hemicolectomy (76 resections performed by surgical residents and 63 by attending surgeons). Patient characteristics according to the P-POSSUM score and cancer stage were equivalent in the 2 groups. Observed over expected mortality and morbidity rates according to P-POSSUM were 0%/3.5% and 21.6%/40.5%, respectively, for the resident group (p = nonsignificant, p = 0.01) and 4.7%/5.8% and 25.4%/42.9%, respectively, for the attending surgeons (p = nonsignificant). The node count was 23.6 nodes for residents and 23.1 for the attending surgeons. The length of surgery was 159.9 minutes vs 159.4 minutes for residents and attending surgeons, respectively. CONCLUSIONS Surgical oncology training of residents by expert surgeons cannot put patient's safety at risk. Our study showed that oncological accuracy and the 30-day complication rate were equivalent to the standard of care in both groups. Duration of the procedure was not affected by the presence of a trainee.
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Affiliation(s)
- Isacco Montroni
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Italy.
| | - Federico Ghignone
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Italy
| | - Giancarlo Rosati
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Italy
| | - Davide Zattoni
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Italy
| | - Alessio Manaresi
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Italy
| | - Mario Taffurelli
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Italy
| | - Giampaolo Ugolini
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Italy
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North JB, Blackford FJ, Wall D, Allen J, Faint S, Ware RS, Rey-Conde T. Analysis of the causes and effects of delay before diagnosis using surgical mortality data. Br J Surg 2012; 100:419-25. [PMID: 23225342 DOI: 10.1002/bjs.8986] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND The aim of the study was to assess the causes and effects of delay in diagnosis in surgical patients who died in 20 public hospitals participating in the Queensland Audit of Surgical Mortality (QASM) in Australia. METHODS This was a retrospective cross-sectional analysis (June 2007 to December 2011) of deaths reported to QASM. Deaths were assigned to one of two groups (no delay or delay in diagnosis). Logistic regression was used to compare the association of delay with surgical complications, both overall and by surgical specialty. RESULTS A total of 3139 deaths were reported. Diagnostic delay was reported in 293 (9·3 per cent). The primary cause of delay was attributed to diagnostic support services (41·7 per cent). Some 174 (13·8 per cent) of 1259 general (gastrointestinal) surgery patients experienced delayed diagnosis. Delay across all surgical specialties was associated with an increased risk of unplanned return to theatre (odds ratio (OR) 1·77, 95 per cent confidence interval 1·24 to 2·52), of being treated in intensive care (OR 1·71, 1·15 to 2·54) and of postoperative complications (OR 1·39, 1·05 to 1·85). CONCLUSION General (gastrointestinal) surgery patients who experienced delayed diagnosis were at increased risk of postoperative complications.
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Affiliation(s)
- J B North
- Queensland Audit of Surgical Mortality, Royal Australasian College of Surgeons, Brisbane, Queensland, Australia
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Damhuis RAM, Wijnhoven BPL, Plaisier PW, Kirkels WJ, Kranse R, van Lanschot JJ. Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types. Br J Surg 2012; 99:1149-54. [PMID: 22718521 DOI: 10.1002/bjs.8813] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Various definitions are used to calculate postoperative mortality. As variation hampers comparability between reports, a study was performed to evaluate the impact of using different definitions for several types of cancer surgery. METHODS Population-based data for the period 1997-2008 were retrieved from the Rotterdam Cancer Registry for resectional surgery of oesophageal, gastric, colonic, rectal, breast, lung, renal and bladder cancer. Postoperative deaths were tabulated as 30-day, in-hospital or 90-day mortality. Postdischarge deaths were defined as those occurring after discharge from hospital but within 30 days. RESULTS This study included 40,474 patients. Thirty-day mortality rates were highest after gastric (8·8 per cent) and colonic (6·0 per cent) surgery, and lowest after breast (0·2 per cent) and renal (2·0 per cent) procedures. For most tumour types, the difference between 30-day and in-hospital rates was less than 1 per cent. For bladder and oesophageal cancer, however, the in-hospital mortality rate was considerably higher at 5·1 per cent (+1·3 per cent) and 7·3 per cent (+2·8 per cent) respectively. For gastric, colonic and lung cancer, 1·0 per cent of patients died after discharge. For gastric, lung and bladder cancer, more than 3 per cent of patients died between discharge and 90 days. CONCLUSION The 30-day definition is recommended as an international standard because it includes the great majority of surgery-related deaths and is not subject to discharge procedures. The 90-day definition, however, captures mortality from multiple causes; although this may be of less interest to surgeons, the data may be valuable when providing information to patients before surgery.
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Affiliation(s)
- R A M Damhuis
- Comprehensive Cancer Centre the Netherlands, Utrecht, The Netherlands.
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Schwarz D, Schwarz R, Gauchan B, Andrews J, Sharma R, Karelas G, Rajbhandari R, Acharya B, Mate K, Bista A, Bista MG, Sox C, Smith-Rohrberg Maru D. Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Qual Saf 2011; 20:1082-8. [PMID: 21949441 PMCID: PMC3228264 DOI: 10.1136/bmjqs-2011-000273] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Problem In hospitals in rural, resource-limited settings, there is an acute need for simple, practical strategies to improve healthcare quality. Setting A district hospital in remote western Nepal. Key measures for improvement To provide a mechanism for systems-level reflection so that staff can identify targets for quality improvement in healthcare delivery. Strategies for change To develop a morbidity and mortality conference (M&M) quality improvement initiative that aims to facilitate structured analysis of patient care and identify barriers to providing quality care, which can subsequently be improved. Design The authors designed an M&M involving clinical and non-clinical staff in conducting root-cause analyses of healthcare delivery at their hospital. Weekly conferences focus on seven domains of causal analysis: operations, supply chain, equipment, personnel, outreach, societal, and structural. Each conference focuses on assessing the care provided, and identifying ways in which services can be improved in the future. Effects of change Staff reception of the M&Ms was positive. In these M&Ms, staff identified problem areas in healthcare delivery and steps for improvement. Subsequently, changes were made in hospital workflow, supply procurement, and on-site training. Lessons learnt While widely practiced throughout the world, M&Ms typically do not involve both clinical and non-clinical staff members and do not take a systems-level approach. The authors' experience suggests that the adapted M&M conference is a simple, feasible tool for quality improvement in resource-limited settings. Senior managerial commitment is crucial to ensure successful implementation of M&Ms, given the challenging logistics of implementing these programmes in resource-limited health facilities.
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Richards CH, Leitch EF, Anderson JH, McKee RF, McMillan DC, Horgan PG. The revised ACPGBI model is a simple and accurate predictor of operative mortality after potentially curative resection of colorectal cancer. Ann Surg Oncol 2011; 18:3680-5. [PMID: 21674271 DOI: 10.1245/s10434-011-1805-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Association of Coloproctology of Great Britain and Ireland (ACPGBI) risk-adjustment model for colorectal cancer surgery has been recently revised. The aim of the present study was to compare the performance of the revised ACPGBI model, the original ACPGBI model, P-POSSUM, and CR-POSSUM, in the prediction of operative mortality after resection of colorectal cancer. METHODS A total of 423 patients who underwent potentially curative resection of colorectal cancer at a single institution (1997-2007) were included. Data used in the construction of the ACPGBI model was collected prospectively. The models were compared by examining observed to expected (O:E) ratios, the Hosmer-Lemeshow (H-L) goodness-of-fit test, and area under the receiver operator characteristic curve (AUC) analysis. RESULTS The 30-day mortality rate was 4%. The performance of the models was as follows: revised ACPGBI model (O:E ratio = 1.05, AUC = 0.73, H-L = 11.02), original ACPGBI model (O:E ratio = 0.58, AUC = 0.76, H-L = 14.23), P-POSSUM (O:E ratio = 0.87, AUC = 0.79, H-L = 10.63), and CR-POSSUM (O:E ratio = 0.63, AUC = 0.84, H-L = 15.84). In subgroup analysis, the revised ACPGBI model performed well in both elective cases (O:E ratio = 1.06) and emergency cases (O:E ratio = 0.91). CONCLUSIONS The revised ACPGBI model is simple to construct and accurately predicts operative mortality after potentially curative resection of colorectal cancer.
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Affiliation(s)
- Colin H Richards
- Glasgow University Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK.
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Predictive value of POSSUM and ACPGBI scoring in mortality and morbidity of colorectal resection: a case-control study. J Gastrointest Surg 2011; 15:294-303. [PMID: 20936370 PMCID: PMC3035786 DOI: 10.1007/s11605-010-1354-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 09/17/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preoperative risk prediction to assess mortality and morbidity may be helpful to surgical decision making. The aim of this study was to compare mortality and morbidity of colorectal resections performed in a tertiary referral center with mortality and morbidity as predicted with physiological and operative score for enumeration of mortality and morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), and colorectal POSSUM (CR-POSSUM). The second aim of this study was to analyze the accuracy of different POSSUM scores in surgery performed for malignancy, inflammatory bowel diseases, and diverticulitis. POSSUM scoring was also evaluated in colorectal resection in acute vs. elective setting. In procedures performed for malignancy, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) score was assessed in the same way for comparison. METHODS POSSUM, P-POSSUM, and CR-POSSUM predictor equations for mortality were applied in a retrospective case-control study to 734 patients who had undergone colorectal resection. The total group was assessed first. Second, the predictive value of outcome after surgery was assessed for malignancy (n = 386), inflammatory bowel diseases (n = 113), diverticulitis (n = 91), and other indications, e.g., trauma, endometriosis, volvulus, or ischemia (n = 144). Third, all subgroups were assessed in relation to the setting in which surgery was performed: acute or elective. In patients with malignancy, the ACPGBI score was calculated as well. In all groups, receiver operating characteristic (ROC) curves were constructed. RESULTS POSSUM, P-POSSUM, and CR-POSSUM have a significant predictive value for outcome after colorectal surgery. Within the total population as well as in all four subgroups, there is no difference in the area under the curve between the POSSUM, P-POSSUM, and CR-POSSUM scores. In the subgroup analysis, smallest areas under the ROC curve are seen in operations performed for malignancy, which is significantly worse than for diverticulitis and in operations performed for other indications. For elective procedures, P-POSSUM and CR-POSSUM predict outcome significantly worse in patients operated for carcinoma than in patients with diverticulitis. In acute surgical interventions, CR-POSSUM predicts mortality better in diverticulitis than in patients operated for other indications. The ACPGBI score has a larger area under the curve than any of the POSSUM scores. Morbidity as predicted by POSSUM is most accurate in procedures for diverticulitis and worst when the indication is malignancy. CONCLUSION The POSSUM scores predict outcome significantly better than can be expected by chance alone. Regarding the indication for surgery, each POSSUM score predicts outcome in patients operated for diverticulitis or other indications more accurately than for malignancy. The ACPGBI score is found to be superior to the various POSSUM scores in patients who have (elective) resection of colorectal malignancy.
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Abstract
BACKGROUND/AIM The first option for gallbladder surgery is laparoscopic cholecystectomy. The aim of this study is to analyze the outcomes for all patients who underwent laparoscopic cholecystectomy at a secondary level of care. PATIENTS AND METHODS Between 2005 and 2008, 968 consecutive laparoscopic cholecystectomies were performed at King Fahad Hospital. We collected and analyzed data including age, gender, body mass index (kg/m2), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), co-morbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay. RESULTS Nine hundred and sixty-eight patients had laparoscopic cholecystectomy at the center. There were 824 females and 144 males; the age range was 15-64 (mean 32.9 ± 12.7 years). The operating time was 45 to 180 min (median 85 min); the complication rate was 4.03% (39 patients). CONCLUSION Laparoscopic cholecystectomy could be performed safely in the majority of patients with cholelithiasis, by an experienced surgical team at a secondary level of care.
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Affiliation(s)
- Abdulrahman S. Al-Mulhim
- Department of Surgery, College of Medicine at Al –Ahsa, King Faisal University - Al –Ahsa, Saudi Arabia,Address for correspondence: Dr. Abdulrahman S. Al-Mulhim, Department of Surgery, Medical College - Al-Ahsa, King Faisal University, P.O. Box 1164, Hofuf, Al-Hassa 31982, Saudi Arabia. E-mail:
| | - Tarek T. Amin
- Family and Community Medicine Department, College of Medicine at Al –Ahsa, King Faisal University - Al –Ahsa, Saudi Arabia
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Bilimoria KY, Cohen ME, Merkow RP, Wang X, Bentrem DJ, Ingraham AM, Richards K, Hall BL, Ko CY. Comparison of outlier identification methods in hospital surgical quality improvement programs. J Gastrointest Surg 2010; 14:1600-7. [PMID: 20824379 DOI: 10.1007/s11605-010-1316-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 08/09/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgeons and hospitals are being increasingly assessed by third parties regarding surgical quality and outcomes, and much of this information is reported publicly. Our objective was to compare various methods used to classify hospitals as outliers in established surgical quality assessment programs by applying each approach to a single data set. METHODS Using American College of Surgeons National Surgical Quality Improvement Program data (7/2008-6/2009), hospital risk-adjusted 30-day morbidity and mortality were assessed for general surgery at 231 hospitals (cases = 217,630) and for colorectal surgery at 109 hospitals (cases = 17,251). The number of outliers (poor performers) identified using different methods and criteria were compared. RESULTS The overall morbidity was 10.3% for general surgery and 25.3% for colorectal surgery. The mortality was 1.6% for general surgery and 4.0% for colorectal surgery. Programs used different methods (logistic regression, hierarchical modeling, partitioning) and criteria (P < 0.01, P < 0.05, P < 0.10) to identify outliers. Depending on outlier identification methods and criteria employed, when each approach was applied to this single dataset, the number of outliers ranged from 7 to 57 hospitals for general surgery morbidity, 1 to 57 hospitals for general surgery mortality, 4 to 27 hospitals for colorectal morbidity, and 0 to 27 hospitals for colorectal mortality. CONCLUSIONS There was considerable variation in the number of outliers identified using different detection approaches. Quality programs seem to be utilizing outlier identification methods contrary to what might be expected, thus they should justify their methodology based on the intent of the program (i.e., quality improvement vs. reimbursement). Surgeons and hospitals should be aware of variability in methods used to assess their performance as these outlier designations will likely have referral and reimbursement consequences.
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Affiliation(s)
- Karl Y Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, 633 N. St. Clair Street, 22nd Floor, Chicago, IL 60611, USA.
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The accuracy of complications documented in a prospective complication registry. J Surg Res 2010; 173:54-9. [PMID: 20934713 DOI: 10.1016/j.jss.2010.08.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Revised: 06/15/2010] [Accepted: 08/23/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The objectives of this study were to evaluate the accuracy of a prospective complication registry for documenting complications and identify possible factors for non-registering. METHODS Five hundred randomly selected patients admitted at the Department of Surgery of St. Elisabeth Hospital Tilburg, The Netherlands, in the year 2005, were evaluated for incidence and type of complications by an examination of their medical records and compared with a prospective complication registry. The system was independently reviewed by two persons for missing complications. Patient files with missing complications in the registry were screened for factors possibly responsible for non-registering. RESULTS Two hundred thirteen complications were detected, 58 (27%) missing in the registry. There were 50 different types of complications documented. The number of events missing per category were: drug-related (50%, n = 4), organ dysfunction (44%, n = 14), infection-related (25%, n = 19), surgery/intervention-related (23%, n = 14), and hospital-provider errors (19%, n = 7). Not all clinically important complications were adequately documented (e.g., anastomotic leakage). The kappa score was 0.695, making the interrater reliability substantial. CONCLUSION The accuracy of registering complications is fairly acceptable compared to the ranges mentioned in literature. It is disappointing that clinically important events are missing in the registry. The inaccuracy could be explained by a great diversity of documented events, due to a broad definition, suggesting ignorance of the responsible team of which events to register.
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Abstract
BACKGROUND Hospitals increasingly rely on surgical quality assessment programs that require considerable resources to capture outcomes after hospital discharge. However, it is unclear whether capturing postdischarge complications and deaths is important. Our objectives were (1) to determine the frequency of postdischarge complications and deaths and (2) to determine whether hospital rankings change with inclusion of postdischarge outcomes. METHODS From 181 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program, 329,951 patients were identified (2006-2007). Mortality and 19 complications within 30 days of the index operation were categorized as occurring before or after discharge. Risk-adjusted hospital rankings were compared based on whether only predischarge (inpatient) versus both pre- and postdischarge (inpatient and outpatient within 30 days of operation) morbidity and mortality were included. RESULTS Postdischarge complications accounted for 32.9% of all complications. Certain complications occurred frequently after discharge: surgical site infections (66.0%), urinary tract infections (39.4%), pulmonary embolisms (42.2%), and deep venous thromboses (34.5%). Of all patients experiencing complications, 39.7% had only postdischarge complications. Of 5827 postoperative deaths, 23.6% occurred after discharge. Hospital quality rankings changed when postdischarge outcomes were excluded versus included for morbidity (median hospital rank change: 16 ranks; interquartile range, 7-36) and mortality (median hospital rank change: 14 ranks; interquartile range, 6-29), and there was disagreement in outlier status designations depending on whether postdischarge events were included (morbidity: kappa = 0.546; mortality: kappa = 0.507). CONCLUSIONS A substantial proportion of postoperative complications and deaths occur after hospital discharge. Inclusion of postdischarge events considerably affects hospital quality rankings and outlier status designations. Quality improvement programs and research that do not consider postdischarge outcomes may offer incomplete information to hospitals, payers, providers, and patients.
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Ugolini G, Rosati G, Montroni I, Manaresi A, Blume JF, Schifano D, Zattoni D, Taffurelli M. A Preliminary Audit Experience of Surgery for Rectal Cancer after Neoadjuvant Chemoradiation Therapy. TUMORI JOURNAL 2010; 96:260-5. [DOI: 10.1177/030089161009600212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background A surgical audit is a systematic critical analysis of surgical performance, with the goal to improve the quality of patient care. Rectal cancer surgery is one of the most delicate procedures in the field of surgical oncology, with significant variations in terms of complications from center to center. Neoadjuvant chemoradiation therapy leads to a significant reduction in local recurrences in patients with locally advanced lower and medium rectal cancer. The aim of the study was to evaluate the influence of neoadjuvant chemoradiation therapy on postoperative morbidity and mortality in patients with rectal cancer. Methods and study design From January 1,2003, to December 31, 2007, patients who underwent elective surgical resection for lower and medium rectal cancer in our Surgical Unit were prospectively analyzed. Patients (n = 42) were divided into two groups: 1) those treated with neoadjuvant chemotherapy and consequent surgical resection (19/42); 2) those treated with primary surgical treatment (23/42). P-POSSUM (Portsmouth Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity) and CR-POSSUM (ColoRectal-POSSUM) scores were calculated for each patient group. Thirty-day mortality and morbidity rates were prospectively collected in a comprehensive data base. Data were evaluated by comparing the predictions of the two scoring systems in both study groups with clinically observed mortality and morbidity rates. Results In group 1, no death was registered (0/19). The P-POSSUM and CR-POSSUM expected mortality was 2.43% and 4.52%, respectively (P >0.05). In group 2, a single death was documented (1/23, 4.35%). The P-POSSUM and CR-POSSUM expected mortality was 2.1% and 4.94%, respectively. The postoperative complications rate for group 1 was 10.52% (2/19) compared to 34.88% as expected from the P-POSSUM score (P <0.05). In group 2, a postoperative complication rate of 39.13% (9/23) was observed compared to 34.26% as expected from the P-POSSUM score (P >0.05). Conclusions No significant influence on morbidity or mortality was detected in patients who underwent neoadjuvant radio-chemotherapy.
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Affiliation(s)
- Giampaolo Ugolini
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Giancarlo Rosati
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Isacco Montroni
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Alessio Manaresi
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | | | - Domenico Schifano
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Davide Zattoni
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Mario Taffurelli
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
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Ugolini G, Rosati G, Montroni I, Zanotti S, Manaresi A, Giampaolo L, Blume JF, Taffurelli M. Can elderly patients with colorectal cancer tolerate planned surgical treatment? A practical approach to a common dilemma. Colorectal Dis 2009; 11:750-5. [PMID: 19708094 DOI: 10.1111/j.1463-1318.2008.01676.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Analysing the effectiveness of a surgical procedure is mandatory in every modern health-care system. The aging of the population stresses the need for a good standard of care. This study tests the hypothesis that porthsmouth-physiologic operative severity score for enumeration of morbidity and mortality (P-POSSUM) and colorectal-POSSUM (CR-POSSUM) would be useful clinical auditing tools in colorectal cancer surgery for aged patients. METHOD One hundred and seventy-seven consecutive patients over 70 years of age underwent emergency or elective surgery from January 2003 to December 2005. Demographic, clinical and surgical information, score systems' prediction, complications and 30-day mortality data were prospectively entered in a comprehensive database. The observed over expected morbidity and mortality rate was calculated. RESULTS Thirty-day observed mortality was 10.3% (19/177) while P-POSSUM and CR-POSSUM expected mortality were, respectively, 11.21% (P = NS) and 13.08% (P = NS). Overall observed morbidity was 42.7%, P-POSSUM prediction was 59.3% (P = 0.002). Morbidity and mortality data were analysed for specific subgroups of patients (resection and anastomosis/resection and stoma/palliative; emergency/elective). CONCLUSION P-POSSUM and CR-POSSUM are useful tools to predict mortality in elderly patients. P-POSSUM significantly overestimated the risk of complications. A more accurate tool for preoperative assessment for aged patients is probably needed to predict the post-surgical outcome.
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Affiliation(s)
- G Ugolini
- Department of General Surgery, Emergency Surgery and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
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Ugolini G, Rosati G, Montroni I, Zanotti S, Manaresi A, Giampaolo L, Taffurelli M, Pricolo V. An easy-to-use solution for clinical audit in colorectal cancer surgery. Surgery 2008; 145:86-92. [PMID: 19081479 DOI: 10.1016/j.surg.2008.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 07/07/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical audit has been increasingly required for the accreditation process in every modern healthcare system. Data collection and analysis are excessively time-consuming in everyday practice. The primary aim of our study was to evaluate the effectiveness of an innovative database to assist surgeons in monitoring clinical practice outcomes in colorectal cancer surgery. The second purpose was to compare observed mortality rates to 3 risk-predicting operative scoring systems. METHODS Data were evaluated from 208 consecutive patients undergoing elective and emergency surgery for colorectal cancer over a 2-year period (2003-2004). A new database was developed with specific queries to compare the observed and the expected mortality rates according to 3 scoring systems: the Portsmouth-Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (P-POSSUM), the ColoRectal-Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (CR-POSSUM), and the Association of ColoProctology or Great Britain & Ireland (ACPGBI) score. Results were discussed at regular intervals. Surgeons' satisfaction with each system was evaluated with a questionnaire. RESULTS The observed mortality rate was 6.25%, which was significantly lower than the values predicted by CR-POSSUM and ACPGBI colorectal scores (9.14% and 19.42%, respectively; P < .05). P-POSSUM was the most accurate predictor of mortality, with a value of 7.93%. A total of 80% of the surgical staff considered this type of surgical audit activity as clinically useful. CONCLUSION The study confirms the usefulness of a dedicated database in a surgical audit activity. The ACPGBI colorectal score largely overestimated 30-day mortality in our experience.
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Affiliation(s)
- Giampaolo Ugolini
- Department of General Surgery, Emergency Surgery and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
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Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RD. A Morbidity and Mortality Conference-Based Classification System for Adverse Events: Surgical Outcome Analysis: Part I. J Surg Res 2008; 147:172-7. [DOI: 10.1016/j.jss.2008.02.054] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2008] [Revised: 02/21/2008] [Accepted: 02/23/2008] [Indexed: 11/30/2022]
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A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. J Surg Res 2008; 153:95-104. [PMID: 18511079 DOI: 10.1016/j.jss.2008.02.051] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2008] [Revised: 02/21/2008] [Accepted: 02/23/2008] [Indexed: 12/27/2022]
Abstract
BACKGROUND An effective report card system for adverse outcome error analysis following surgery is lacking. We hypothesized that a memorialized database could be used in conjunction with error analysis and management evaluation at Morbidity & Mortality conference to generate individualized report cards for Attending Surgeon and System performance. STUDY DESIGN Prospectively collected data from September 2000 through April 2005 were reported following Morbidity & Mortality review on 1618 adverse outcomes, including 219 deaths, following 29,237 operative procedures, in a complete loop to approximately 60 individual surgeons and responsible system personnel. RESULTS A 40% reduction of gross mortality (P < 0.001) and 43% reduction of age-adjusted mortality were achieved over 4 years at the Academic Center. Quality issues were identified at a rate three times greater than required by New York State regulations and increased from a baseline 4.96% to 32.7% (odds ratio 1.94; P < 0.03) in cases associated with mortality. A detailed review demonstrated a significant increase (P < 0.001) in system errors and physician-related diagnostic and judgment errors associated with mortality highlighted those practices and processes involved, and contrasted the results between academic (43% mortality improvement) and community (no improvement) hospitals. CONCLUSIONS The findings suggest that structured concurrent data collection combined with non-punitive error-based case review and individualized report cards can be used to provide detailed feedback on surgical performance to individual surgeons and possibly improve clinical outcomes.
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Scott IA, Poole PJ, Jayathissa S. Improving quality and safety of hospital care: a reappraisal and an agenda for clinically relevant reform. Intern Med J 2008; 38:44-55. [PMID: 18190414 DOI: 10.1111/j.1445-5994.2007.01456.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Improving quality and safety of hospital care is now firmly on the health-care agenda. Various agencies within different levels of government are pursuing initiatives targeting hospitals and health professionals that aim to identify, quantify and lessen medical error and suboptimal care. Although not denying the value of such 'top-down' initiatives, more attention may be needed towards 'bottom-up' reform led by practising physicians. This article discusses factors integral to delivery of safe, high-quality care grouped under six themes: clinical workforce, teamwork, patient participation in care decisions, indications for health-care interventions, clinical governance and information systems. Following this discussion, a 20-point action plan is proposed as an agenda for future reform capable of being led by physicians, together with some cautionary notes about relying too heavily on information technology, use of non-clinical quality personnel and quantitative evaluative approaches as primary strategies in improving quality.
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Affiliation(s)
- I A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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Hariharan S, Zbar A. Risk Scoring in Perioperative and Surgical Intensive Care Patients: A Review. ACTA ACUST UNITED AC 2006; 63:226-36. [PMID: 16757378 DOI: 10.1016/j.cursur.2006.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Assessing the risk and predicting the outcome of surgery, trauma, and surgical intensive care is an important aspect of perioperative practice. There have been attempts to devise and validate many scoring systems to predict the prognosis of patients having a similar severity of illness. This article reviews some of the commonly used systems with respect to their development, strengths, and limitations. SOURCES Published literature describing risk assessment scores and physiologic scoring systems for preoperative assessment, trauma, and surgical intensive care patients. PRINCIPAL FINDINGS Risk scores used in preoperative evaluation assist the clinician in optimizing the patient before, during, and after surgery. Scoring systems applied in intensive care units are useful as guidelines rather than accurate predictors of prognosis for individual patient. Many models are used for audit purposes, and some are used as performance measures and quality indicators of a unit; however, both utilities are controversial because of poor adjustment of these systems to case-mixtures. CONCLUSIONS Risk assessment scores may assist in the perioperative risk evaluation with respect to organ systems. Prognostication of critically ill patients belonging to a category of illness may be done using physiological scoring systems taking into account the difference in the case-mix of the particular unit.
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Affiliation(s)
- Seetharaman Hariharan
- Department of Anesthesia and Intensive Care, The University of the West Indies, St. Augustine, Trinidad, West Indies.
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Abstract
In the past, the detection and response to adverse clinical events were viewed as an inherent part of professionalism; and, if perceived problems were not sorted out at that level, the ultimate expression of dissatisfaction was litigation. There are now demands for the adoption of more transparent and effective processes for risk management. Reviews of surgical practice have highlighted the presence of unacceptable levels of avoidable adverse events. This is being resolved in two ways. First, attention is being directed to the extent that training and experience have on outcomes after surgery, and both appear to be important. Second, a greater appreciation of human factors engineering has promoted a greater involvement of surgeons in processes involving teamwork and non-technical skills. The community wants surgeons who are competent and health-care systems that minimize risk. In recent times attention has been focused on the turmoil associated with change; but, when events are viewed over a period of several decades, there has been considerable progress towards these ideals. Further advancement would be aided by removing the adversarial nature of malpractice systems that have failed to maintain standards.
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Affiliation(s)
- Farah Aziz
- Department of Surgery, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia
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Thompson AM, Ashraf Z, Burton H, Stonebridge PA. Mapping changes in surgical mortality over 9 years by peer review audit. Br J Surg 2005; 92:1449-52. [PMID: 15997442 DOI: 10.1002/bjs.5082] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
There is increasing public scrutiny of deaths among surgical patients. This analysis sought evidence of changes in practice over time in the management of patients who died under surgical care.
Methods
The surgeons and anaesthetists in National Health Service hospitals providing the care of all surgical patients in Scotland participated in the Scottish Audit of Surgical Mortality (SASM). Data from peer review audit, critical event analysis and individual feedback of deaths while in surgical care over 9 years (1994–2002) were examined for trends over time.
Results
Over a 9-year period, 40 448 patients died while in surgical care. Consultant surgeon and anaesthetist involvement in decision making and operating increased significantly (P < 0·001), and death after elective surgery declined to 0·27 per cent of elective operations. Adverse events were more frequently due to failures of hospital systems or process than to individual clinician errors. Fewer adverse events were identified as having contributed to or caused the death of patients over time (P < 0·001). Failure to use deep vein thrombosis (DVT) prophylaxis and failure to use high-dependency or intensive therapy units (HDU/ITU) became less common, once highlighted by the SASM.
Conclusion
Through continuous peer review audit, the SASM has mapped and may have contributed to changes in surgical and anaesthetic practice over a 9-year period, indicating that the rate of adverse events can be decreased by changing clinician practice (DVT prophylaxis) and provision of facilities (HDU/ITU). Similar approaches should be considered by other medical specialties.
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Affiliation(s)
- A M Thompson
- Department of Surgery and Molecular Oncology, University of Dundee, Dundee, UK.
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Gillion JF. Le taux brut de mortalité postopératoire est-il un critère pertinent d'efficience d'une équipe chirurgicale ? Étude prospective des suites opératoires de 11 756 patients. ACTA ACUST UNITED AC 2005; 130:400-6. [PMID: 15925320 DOI: 10.1016/j.anchir.2005.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2004] [Accepted: 01/19/2005] [Indexed: 11/26/2022]
Abstract
AIM Evaluation of the crude postoperative mortality rate as a relevant criterion of the efficiency of a surgical team. MATERIAL AND METHODS [corrected] We studied prospectively the postoperative course of 11,756 consecutive patients who underwent a general surgery procedure between January 1(st) 1987 and December 31 2002. RESULTS Seventy-three of patients died (0.60 percent). The median age at the time of death was 77 years old. None of the 5046 patients under 40 years old died. The operations were emergent in 3,265 patients (28 percent). The mortality rate of the 3,952 digestive surgery patients was 1.00 percent (40/3,952 patients). Among them, the mortality rate increased to 3.56 percent (17/478 patients) in case of an emergency procedure excluding procedures for non-suppurative appendicitis. Although only 8 percent of the patients were operated for a cancer (968/11,756 patients), they accounted for 49 percent of the postoperative deaths. In this cohort, the crude mortality rate varied by twice as much as were taken in account (73 deaths) or not (34 deaths) the palliative procedures in terminal phase patients, and the last-chance procedures in patients in imminent-death condition. Six hundred and twenty patients (5.3 percent) experienced at least one postoperative complication, surgical in 166 patients, and parietal in 258 patients. CONCLUSION This study shows that a long-term rigorous self-assessment is feasible. It confirms that the crude mortality rate is not a relevant criterion to evaluate the efficiency of a surgical team, suggests that an "avoided death" concept is more representative of medical team work and more rewarding for them and allows us to propose an index taking in account the rate of postoperative complications not followed by death.
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Affiliation(s)
- J-F Gillion
- Service de chirurgie viscérale, hôpital privé d'Antony, 1 rue Velpeau, 92160 Antony, France.
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Nørgaard M, Skriver MV, Gregersen H, Pedersen G, Schønheyder HC, Sørensen HT. The data quality of haematological malignancy ICD-10 diagnoses in a population-based Hospital Discharge Registry. Eur J Cancer Prev 2005; 14:201-6. [PMID: 15901987 DOI: 10.1097/00008469-200506000-00002] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objectives of this study were to estimate the data quality of haematological malignancy diagnoses in a hospital discharge registry, and to quantify the impact of any misclassification of diagnoses on survival estimates. We included all patients > or = 15 years living in North Jutland County, Denmark with a first-time discharge diagnosis of a haematological malignancy registered in the Hospital Discharge Registry and the Danish Cancer Registry, the reference standard, from 1994 to 1999. We estimated completeness and positive predictive value (PPV) of haematological malignancies and specific subcategories, as a measure of data quality, and compared mortality rates based on data from the two registries by Cox regression analysis. Completeness in the Hospital Discharge Registry for all haematological malignancies was 91.5% (95% confidence interval (CI) 89.6-93.1) and PPV was 84.5% (95% CI 82.2-86.5). Reviews of the pathological files showed misclassified cases in both registries and thus indicated that both completeness and PPV of the Hospital Discharge Registry were underestimates. Mortality rate ratio for all haematological malignancies when registered in the Hospital Discharge Registry compared with being registered in the Danish Cancer Registry was 0.98 (95% CI 0.88-1.09). Discharge data had some misclassifications but these had no major impact on survival estimates.
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Affiliation(s)
- M Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, DK-8000 Aarhus C, Denmark.
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49
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Abstract
The British public's confidence in doctors and hospitals has been dented in recent years. Use of an independent review of deaths before, during, or after surgery reflects an attempt to improve care in this area and may also help to restore the public's trust in their health service
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Affiliation(s)
- A M Thompson
- Department of Surgery and Molecular Oncology, University of Dundee, Dundee DD1 9SY.
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Haga Y, Wada Y, Takeuchi H, Kimura O, Furuya T, Sameshima H, Ishikawa M. Estimation of physiologic ability and surgical stress (E-PASS) for a surgical audit in elective digestive surgery. Surgery 2004; 135:586-94. [PMID: 15179364 DOI: 10.1016/j.surg.2003.11.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND This study was undertaken to establish an equation to estimate mortality with the use of the prediction scoring system designated as the Estimation of Physiologic Ability and Surgical Stress (E-PASS), and to evaluate the system's usefulness in defining quality of care by comparing it with the Physiologic and Operative Severity Score for the enUmeration for Mortality and morbidity (POSSUM) and Portsmouth-possum (P-POSSUM) scoring systems previously generated for surgical audit. METHODS Patients (n=5212; group A) who underwent elective gastrointestinal surgery were analyzed to establish equations for estimated 30-day and in-hospital mortality rates. The usefulness of E-PASS was evaluated in another series of 1934 patients (group B) who underwent elective digestive surgery in 6 national hospitals. The ratio of observed to estimated mortality rates (OE ratio) of each hospital was defined as a measure of quality. RESULTS In group A, 30-day and in-hospital mortality rates increased as the Comprehensive Risk Score (CRS) increased, providing equations for estimated mortality rates. There was an excellent correlation between the estimated and observed mortality rates in individual diseases: R=0.958, N=6, P=.0027 for in-hospital mortality; R=0.937, N=6, P=.0059 for 30-day mortality. In all patients of group B, the E-PASS system estimated the 30-day mortality rates by 0.63-fold (linear analysis), whereas the POSSUM score was 11.0-fold (exponential analysis). The E-PASS system estimated the in-hospital mortality rates by 1.2-fold (linear analysis), whereas the P-POSSUM score was 4.5-fold (linear analysis). The OE ratios for 30-day mortality among the 6 hospitals defined by E-PASS correlated well with those defined by POSSUM: R=0.996, N=6, P<.0001. Similarly, the OE ratios for in-hospital mortality defined by E-PASS were also highly correlated with those defined by P-POSSUM:(R=0.929, N=6, P=.0075. CONCLUSIONS The E-PASS scoring system may be useful in defining surgical quality and may be more accurate than existing systems in evaluating elective digestive surgery.
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Affiliation(s)
- Yoshio Haga
- Department of Surgery, Kumamoto National Hospital, Ninomaru, Japan
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