The epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction in Varsinais-Suomi Hospital District

BACKGROUND AND AIMS

The epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction have been poorly investigated in Finland. This study evaluated the epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction in a well defined geographical area (Hospital District).

MATERIAL AND METHODS

All inpatient episodes between 1.1.1999 and 31.12.1999 due to postoperative adhesion induced intestinal obstruction in Varsinais-Suomi Hospital District were evaluated retrospectively using individual patient records.

RESULTS

123 hospitalizations due to postoperative adhesion-related intestinal obstruction were observed during the study period. The total number of preceding operations was 176 considering altogether 101 patients. The most prevalent single initial operations causing adhesion induced intestinal obstruction were colorectal, upper abdominal, and female reproductive system procedures. Of all treatment episodes 32% were operative and mortality was 2%. The median days of hospital stay (range) of all inpatient episodes, operative episodes, and conservative episodes were 6 (1-58), 11 (2-34) and 4 (1-58), respectively. Patient dependent factors associated with increased likelihood to operative treatment of obstruction were: female gender (40% in females vs 23% in males, P = 0.042) and previous gynaecological surgery (70% of the patients, P = 0.032). Intraoperative findings were obstruction in 70%, strangulation in 20%, necrosis in 8%, and perforation in 2% of operations. Bowel resection was needed in 38% of operations. Preceding gynaecological surgery increased the likelihood of bowel strangulation as an intraoperative finding.

CONCLUSION

The epidemiology, treatment patterns and results of postoperative adhesion induced intestinal obstruction are of the average international level in the Varsinais-Suomi Hospital District. The treatment patterns among the different hospitals in the Hospital District are similar. Female gender is associated with increased risk for operative treatment of adhesive obstruction. Previous gynaecological surgery increases the likelihood of operative treatment and complicated obstruction.

A randomized trial of choice of treatment in prostate cancer: the effect of intervention on the treatment chosen

OBJECTIVE

To determine whether different approaches in the choice of treatment affect the treatment chosen by the patient for prostate cancer.

PATIENTS AND METHODS

We conducted a randomized trial with 210 men who had a histologically confirmed diagnosis of prostate cancer in 1993-94 at four major hospitals in Finland. After obtaining informed consent the men were randomized either to an intervention arm, in which there was greater patient participation in the choice of treatment following a structured procedure, or a control arm in which the standard approach, i.e. a standardized treatment protocol, was used. The main outcome measure of the analysis was the primary treatment chosen for prostate cancer.

RESULTS

In the enhanced participation arm patients not eligible for radical prostatectomy chose orchidectomy less frequently and favoured nonsurgical endocrine treatment than in the treatment protocol arm. Radical prostatectomy was the most commonly chosen treatment option in both arms among men with operable cancer. The way treatment options were presented affected the treatment chosen for prostate cancer.

CONCLUSION

Patients with prostate cancer are willing and able to take an active role in making decisions. The preferences of patients with prostate cancer in the choice of treatment may differ from the priorities of the physicians.

Population-based study of the surgical workload and economic impact of bowel obstruction caused by postoperative adhesions

BACKGROUND

Intestinal obstruction is the most severe consequence of adhesion formation. This study examined the annual surgical workload and costs of intestinal obstruction caused by postoperative intra-abdominal adhesions.

METHODS

The study was a retrospective case-note review of patients hospitalized for intestinal obstruction caused by postoperative adhesions in a well defined geographical area. The surgical workload and direct costs of inpatient care were analysed.

RESULTS

There were 138 admissions for postoperative adhesion-related intestinal obstruction during the study with a total of 1118 inpatient days. The median hospital stay was 4 (range 1-58) days among patients who had non-operative treatment and 11 (range 2-34) days for those who had surgery. Surgery was necessary in 40 patients (29.0 per cent). The mean operating time (time from skin incision to last stitch) and the mean time spent in the operating theatre were 79 and 141 min respectively. The cumulative operating time for the surgical group was 52 h 20 min and the cumulative theatre time was 93 h 44 min. The annual direct hospital cost for postoperative adhesional intestinal obstruction was pound 181 653 in the district studied and the estimated cost for the whole of Finland was pound 2 077 796.

CONCLUSION

This population-based study indicates that the workload and costs associated with bowel obstruction caused by postoperative adhesions are substantial.

A randomized trial of the choice of treatment in prostate cancer: design and baseline characteristics

OBJECTIVE

To assess the effects of different approaches to decision-making on the treatment chosen for prostate cancer and on the patients' quality of life in prostate cancer.

PATIENTS AND METHODS

A multicentre randomized trial was conducted, including all histologically confirmed cases of prostate cancer diagnosed between September 1993 and November 1994 in four Finnish hospitals. In the intervention group, the role of the patient in the choice of treatment was actively emphasized. In the control group, the treatment was chosen using standardized treatment protocols. The first intermediate endpoint was the patient's participation in decision-making and the next will be the treatment chosen in the intervention and control groups. The main outcome will be the quality of life. Clinical data on prognostic factors including age, tumour grade, stage, functional status and serum prostate-specific antigen (PSA) concentration was collected for comparison between the arms, and between those enrolled or not.

RESULTS

In all, 210 of 251 eligible patients were randomized into the two arms. Patients were randomized before obtaining informed consent, which led to four patients already randomized refusing to participate. The 41 patients not enrolled were of similar age and grade distribution, but more frequently had extensive disease than had those enrolled in the trial. Three patients were unable to participate because of rapid deterioration in their general condition after randomization. There were no clear differences in baseline characteristics (including age, functional status, tumour grade and stage) of the patients between the arms. The distribution of PSA level differed slightly between the arms, which may require adjustment in the analyses. Patients in the intervention arm participated in decision-making more actively than those in the control arm.

CONCLUSION

Randomized studies on ethical issues such as the patient's role in choosing treatment are feasible and likely to provide important information.

Using multicriteria methods in environmental planning and management

In environmental planning and decision processes several alternatives are analyzed in terms of multiple noncommensurate criteria, and many different stakeholders with conflicting preferences are involved. Based on our experience in real-life applications, we discuss how multicriteria decision aid (MCDA) methods can be used successfully in such processes. MCDA methods support these processes by providing a framework for collecting, storing, and processing all relevant information, thus making the decision process traceable and transparent. It is therefore possible to understand and explain why, under several conflicting preferences, a particular decision was made. The MCDA framework also makes the requirements for new information explicit, thus supporting the allocation of resources for the process.