A retrospective analysis to determine the effect of independent treatment centres on the case mix for microsurgical training

Cost-effective and adaptable cataract surgery simulation with basic technology

Purpose

To assess the subjective validity of a cost-effective and adaptable cataract surgery simulation technique using basic technology.

Methods

We devised and filmed a range of simulation techniques that mimic steps of phacoemulsification cataract surgery using various “everyday” basic materials. This video was combined in a “parallel” fashion with live cataract surgery so that all steps of surgery were simulated. Subsequently, we distributed an online subjective validation questionnaire on Google Forms with the embedded simulation video in a generic invitation that was forwarded via email and/or text messages/WhatsApp messenger amongst Ophthalmologists of all grades within our regions (Kent, Surrey and Sussex, London and Wales Postgraduate Deaneries).

Results

Face validity: 66 (99%) participants agreed that the explanations in the video were clear and 53 (79%) concurred with the realistic feel of simulated technique. Instrumentation and adaptations demonstrated were deemed user friendly and conducive to replicate by 99% participants. Content validity: 60 (90%) of participants agreed the techniques described in the video reflected the technical skills required to train cataract surgeons. Forty-nine (74%) agreed that the simulation techniques were relevant for acquiring other generic and transferable microsurgical and manual dexterity skills.

Conclusions

We demonstrated subjective validity of our cost-effective cataract simulation technique. Our model can be used as an adjunct to intraocular and virtual reality training for cataract surgery by removing the barrier of cost and improved exposure to real instruments used in cataract surgery.

The impact of the National Treatment Purchase Fund on numbers of core urology training cases at University Hospital Galway

Since the National Treatment Purchase Fund (NTPF) scheme was introduced in 2002, public patients waiting longer than three months for investigations and treatment are offered care in the private medical sector. Our aim was to assess the impact of the NTPF scheme on the number of training cases performed at University Hospital Galway (UHG). The number and type of urological procedures performed in the private medical sector under the NTFP scheme in 2008 were obtained from the UHG waiting list office. The number of these procedures performed on public patients by trainees at UHG in 2008 was determined retrospectively by reviewing theatre records. A significant number of core urology procedures were performed in the private sector via the NTPF scheme. Cancer centre designation and implementation of the EWTD will also place further pressures on urological training opportunities in Ireland.

Private sector treatment centres are treating less complex patients than the NHS

OBJECTIVES

In England, patients can choose to have their NHS elective care delivered by private (or 'independent sector') providers or by the NHS. Providers are paid a fixed tariff for each type of procedure. Our objectives were to compare NHS providers with private treatment centres in terms of (a) the quality of data coding and (b) patient complexity.

DESIGN

We compared elective patients aged 18 years and over treated in the NHS and private sectors using the Hospital Episode Statistics (HES) data for 2007-2008. The absence of diagnostic information was used as a measure of data quality. We analysed differences in complexity for each of the 30 Healthcare Resource Groups (HRGs) that together account for 78% of coded private treatment centre activity. Statistical significance was assessed at the 1% level.

SETTING

Hospitals and treatment centres.

MAIN OUTCOME MEASURES

Patient complexity was assessed by four characteristics: age; number of diagnoses; number of procedures; and income deprivation of residential area.

RESULTS

NHS providers treated almost 7 million adult elective patients in 2007-2008. Fewer than 100,000 patients were treated by private providers (1.3% of elective activity). Less than 1% of NHS patients lacked diagnostic information compared to 36% of patients treated by private providers. For the top 30 HRGs, NHS patients had significantly (p<0.01) higher levels of co-morbidity, underwent more procedures and were more likely to come from deprived areas compared with patients treated by private providers. Although patients treated in private settings tended to be younger, the difference was not statistically significant.

CONCLUSIONS

Some private companies provide poor quality data. In general, the NHS is treating more complex patients than private providers. If complexity drives costs, then a fair reimbursement system would require higher payments for NHS providers.

Higher surgical training in ophthalmology: trends in cumulative surgical experience 1993-2008

INTRODUCTION

Recent years have seen significant changes in the provision surgical training for ophthalmology. The aim of this study is to establish the patterns in long-term trends of cumulative surgical experience of ophthalmology trainees in the United Kingdom.

MATERIALS AND METHODS

Data were obtained from the department of training and education at the Royal College of Ophthalmologists (RCOphth). The cumulative surgical experience of all ophthalmology higher surgical trainees attaining accreditation, CCST, or CCT between 1993-2001 and 2005-2008 was included for descriptive analysis.

RESULTS

Cumulative cataract surgical experience per trainee has been relatively stable at levels between 500 and 600 for most years. The cumulative experience vitreoretinal and corneal graft surgery have historically been low with a large outlier effect, although trends demonstrate a decrease in the median numbers of procedures. Squint surgery has seen a downward trend with a decrease in the median numbers from 121 in 1993 to 43 in 2008. Oculoplastics procedures demonstrate a decrease in overall numbers from 46 in 1993 to 15 in 2001. A jump from 2005 coincides with changes in the definition of what is counted as an oculoplastics procedure. The role of the RCOphth in legislating minimum levels of experience has had an impact on the data distribution manifest by the truncation of the inferior quartile of many of the dataspreads.

DISCUSSION

These data demonstrate that although the cumulative experience of cataract surgery for trainees has remained stable, there has been a reduction in the median numbers of subspecialty procedures performed over the past 15 years.

Are English treatment centres treating less complex patients?

Activity-based funding involves remunerating healthcare providers a fixed price per patient in each payment category. However, no categorisation system can account perfectly for differences in patient complexity. Differences may be systematic if providers routinely attract high-risk patients or engage in patient selection. Such differences may be evident in the English National Health Service (NHS) following the introduction of treatment centres that concentrate on providing a small number of high-volume procedures. We analyse data for more than 3.3 million patients to assess whether the complexity of those treated in hospitals and treatment centres differs within twenty-nine payment categories, defined by Healthcare Resource Groups (HRGs). We find that patients treated in hospitals were more likely to come from more deprived areas, to have more diagnoses and to undergo significantly more procedures than patients seen by treatment centres, suggesting that hospitals are treating more complex cases. If these observed differences between hospitals and treatment centres drive costs, then payments should be refined to ensure fair reimbursement.