Measuring the complexity and uncertainty of surgery and postsurgical care

A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study

BACKGROUND

A majority of the 2 billion children lacking access to safe, timely and affordable surgical care reside in low-and middle-income countries. A barrier to tackling this issue is the paucity of information regarding children's journey to surgical care. We aimed to explore children's journeys and its implications on accessing general paediatric surgical care at Muhimbili National Hospital (MNH), a tertiary centre in Tanzania.

METHODS

A prospective observational cohort study was undertaken at MNH, recruiting patients undergoing elective and emergency surgeries. Data on socio-demographic, clinical, symptoms onset and 30-days post-operative were collected. Descriptive statistics and Mann-Whitney, Kruskal-Wallis and Fisher's exact tests were used for data analysis.

RESULT

We recruited 154 children with a median age of 36 months. The majority were referred from regional hospitals due to a lack of paediatric surgery expertise. The time taken to seeking care was significantly greater in those who self-referred (p = 0.0186). Of these participants, 68.4 and 31.1% were able to reach a referring health facility and MNH, respectively, within 2 h of deciding to seek care. Overall insurance coverage was 75.32%. The median out of pocket expenditure for receiving care was $69.00. The incidence of surgical site infection was 10.2%, and only 2 patients died.

CONCLUSION

Although there have been significant efforts to improve access to safe, timely and affordable surgical care, there is still a need to strengthen children's surgical care system. Investing in regional hospitals may be an effective approach to improve access to children surgical care.

A cross-sectional retrospective analysis of the regionalization of complex surgery

Background

The Veterans Health Administration (VHA) system has assigned a surgical complexity level to each of its medical centers by specifying requirements to perform standard, intermediate or complex surgical procedures. No study to similarly describe the patterns of relative surgical complexity among a population of United States (U.S) civilian hospitals has been completed.

Methods

Design: single year, retrospective, cross-sectional.

Setting/Participants: the study used Florida Inpatient Discharge Data from short-term acute hospitals for calendar year 2009. Two hundred hospitals with 2,542,920 discharges were organized into four quartiles (Q 1, 2, 3, 4) based on the number of complex procedures per hospital. The VHA surgical complexity matrix was applied to assign relative complexity to each procedure. The Clinical Classification Software (CCS) system assigned complex procedures to clinically meaningful groups. For outcome comparisons, propensity score matching methods adjusted for the surgical procedure, age, gender, race, comorbidities, mechanical ventilator use and type of admission.

Main Outcome Measures: in-hospital mortality and length-of-stay (LOS).

Results

Only 5.2% of all inpatient discharges involve a complex procedure. The highest volume complex procedure hospitals (Q4) have 49.8% of all discharges but 70.1% of all complex procedures. In the 133,436 discharges with a primary complex procedure, 374 separate specific procedures are identified, only about one third of which are performed in the lowest volume complex procedure (Q1) hospitals. Complex operations of the digestive, respiratory, integumentary and musculoskeletal systems are the least concentrated and proportionately more likely to occur in the lower volume hospitals. Operations of the cardiovascular system and certain technology dependent miscellaneous diagnostic and therapeutic procedures are the most concentrated in high volume hospitals. Organ transplants are only done in Q4 hospitals. There were no significant differences in in-hospital mortality rates and the longest lengths of stay were found in higher volume hospitals.

Conclusions

Complex surgery in Florida is effectively regionalized so that small volume hospitals operating within the range of complex procedures appropriate to their capabilities provide no increased risk of post surgical mortality.

Case and care complexity in the medically ill

The authors have argued that complexity in general health care is increasingly prevalent because of the increase in patients who have multimorbid conditions, and the increased professional and technical possibilities of medicine. In the increasingly complex care systems, it is necessary-specifically when treating patients in need of integrated care by several providers-that an optimal match between case and care complexity be found in order to prevent poor outcomes in this vulnerable group. The authors discussed several approaches to case complexity that can be identified in the literature. Most of them seem unsuitable for adjusting case and care complexity, and inadequate for designing multidisciplinary care. Theoretic approaches to case complexity may be of interest, but did not result in clinically meaningful information. The INTERMED, which can be considered the first empirically based instrument to link case and care complexity, is an attempt to improve care delivery and outcomes for the complex medically ill.

Ad Astra per Aspera: A Journey from the Periphery

I review my scholarly career, focusing first on the places and people important to my development as an organizational sociologist. Then, drawing on distinctions proposed by Boyer, I discuss four types of scholarly work in which I have been engaged: (1) the scholarship of discovery, in which I studied principally authority systems, organizational effectiveness and institutional structures and processes; (2) the scholarship of teaching, where I describe the variety of courses I have taught; (3) the scholarship of application, involving primarily my work with policy groups at the national level; and (4) the scholarship of integration, including my writing of textbooks and attempts to create community among organizational scholars. I assert that more value should be placed by the academy on the latter three types of scholarship.

Care Complexity in the General Hospital Results From a European Study

There is increasing pressure to effectively treat patients with complex care needs from the moment of admission to the general hospital. In this study, the authors developed a measurement strategy for hospital-based care complexity. The authors' four-factor model describes the interrelations between complexity indicators, highlighting differences between length of stay (LOS), objective complexity (such as medications or consultations), complexity ratings by the nurse, and complexity ratings by the doctor. Their findings illustrate limitations in the use of LOS as a sole indicator for care complexity. The authors show how objective and subjective complexity indicators can be used for early and valid detection of patients needing interdisciplinary care.

Measuring hospital output: a review of the service mix and case mix approaches

This paper presents a survey of the literature on the definition and measurement of hospital output concentrating on those studies that have used either 'service-mix' or 'case-mix' as their basic output measure. The service-mix approach is described as a supply side analysis in which the nature of a hospital's output is determined by the character and range of its facilities and services. In contrast, the case-mix approach is essentially a demand side analysis which regards each hospital's case load as being determined by the needs and demands of the population served, with facilities and services the dependent variables. It is also argued that hospital output measurement has rarely been tackled directly. Typically such work has been secondary to the principle research objectives which have related to the study of hospital cost structure and economies of scale. The units developed have been, for the most part, partial measures which satisfy the requirements of their particular investigators but which, until recently, have had little potential for wider application. The call for more effective cost control in health care through reimbursement systems and review procedures, particularly in the United States, has led to an upsurge of interest in hospital output measurement and to a consequent improvement in techniques.