Impact of surgery for stress incontinence on morbidity: cohort study

OBJECTIVES

To describe the impact of surgery for stress incontinence on the severity of symptoms, other mental and physical symptoms, and overall health. To describe the incidence of postoperative complications.

DESIGN

Prospective cohort study; questionnaires completed by patients before and 3, 6, and 12 months after surgery. Questionnaires completed by surgeons both before and after surgery.

SETTING

18 hospitals in the North Thames region.

SUBJECTS

442 women treated surgically for stress incontinence between January 1993 and June 1994. 367 women returned the 3 month questionnaire; 364 returned the 6 month questionnaire; and 359 returned the 12 month questionnaire. 49 surgeons provided perioperative information on 285 of the 442 women and postoperative information on 278.

MAIN OUTCOME MEASURES

Stress incontinence symptom severity index, other urinary symptoms, bowel function, mental health, complications, global measures.

RESULTS

Most women (288; 87%) reported an improvement in the severity of their stress incontinence, though only 92 (28%) were cured (continent). These improvements persisted for at least 12 months. The likelihood of improvement was similar regardless of whether urodynamic pressure studies had been conducted before surgery. Following surgery, women were less likely to suffer from urinary frequency, nocturia, postvoid fullness, dysuria, and urgency. While mental health improved for 194 (71%), a quarter of women reported deterioration. Only 37 (10%) were satisfied with postoperative pain control. A third experienced one or more complications while in hospital, most commonly difficulty urinating. This problem affected 1 in 11 women after discharge. A year after surgery two thirds of women reported feeling better (251; 72%), that the outcome met or exceeded their expectations (230; 66%), and that they would recommend the operation to a friend in a similar situation (239; 68%), and that they would recommend the operation to a friend in a similar situation (239; 68%). Surgeons tended to be more optimistic about the effects of surgery; they were satisfied with the outcome in 176 (85%) cases and would again treat 245 (94%) of the women as they had done previously.

CONCLUSIONS

Although surgery reduces the severity of stress incontinence it is not as effective as current textbooks suggest. Women considering surgery should be provided with more accurate information on the likelihood of an improvement in symptoms and the occurrence of complications, including postoperative pain. Urgency and urge incontinence should not be considered contraindications to surgery. The need for urodynamic assessment before surgery should be reappraised.

Efficacy of combination therapy in non-insulin dependent diabetes mellitus

Secondary failure of oral hypoglycaemic agents raises the dilemma of whether to institute therapy with insulin alone, or in combination. We reviewed our experience of combination therapy following secondary failure of oral hypoglycaemic therapy. Seventeen subjects were receiving combination therapy for 6 months or more. Such treatment was associated with a significant fall in HbA1C--from 10.7 +/- 0.38 per cent to 8.3 +/- 0.35 per cent (p < 0.01) after 6 months and remained significantly reduced at 12 months (8.7 +/- 0.34 per cent (p < 0.01)). Mean body weight, systolic and diastolic blood pressure were unchanged during treatment with adjuvant insulin therapy. Insulin therapy is a useful adjunct in the daily management of subjects with NIDDM who experience secondary failure of oral hypoglycaemic agents.

Reliability of a comorbidity measure: the Index of Co-Existent Disease (ICED)

The reliability of an established comorbidity index (the Index of Co-Existent Disease) was tested using retrospective data from the case notes of elderly patients who had undergone total hip replacement. Inter-rater reliability was examined twice, first with two raters (n = 39) and then with three (n = 49). Intra-rater reliability was assessed using one rater (n = 45). Reasons for any lack of reliability were explored. The inter-rater reliability of the ICED was moderate (kappa 0.5-0.6). While the Functional Severity index performed well (kappa 0.6-1.0), the Index of Disease Severity subindex was less reliable (kappa 0.4-0.5). Differences between raters had an impact on the observed association between comorbidity and serious post-operative complications. Intra-rater reliability was excellent (kappa 0.9). Several reasons why inter-rater reliability was only moderate were identified, mostly related to uncertainties in applying the ICED. The reliability of the ICED needs to be improved before it is used more widely with retrospective data. This might be achieved by further clarification of the instructions for its use.

Regional variation in intervention rates: what are the implications for patient selection?

BACKGROUND

Whereas geographical variations in intervention rates are well recognized, little is known about their implications for patient selection. This study looks at how the relative probability of being treated in different regions within England vary with a person's need for treatment, and whether higher intervention rates are associated with a greater probability of treatment at all levels of need or confined to only certain levels.

METHODS

The method was modelling of retrospective data from population surveys, patient cohort studies and population intervention rates. Two southern regions (SW Thames and Wessex) and two northern regions (Northern and Mersey) were compared. Subjects were men aged 55 years and above in the population with urinary symptoms suggestive of benign prostatic hyperplasia and men undergoing surgical treatment. The ratio of probability of surgery in the southern regions to that in the northern regions by level of symptom severity was determined.

RESULTS

The rate of surgery in the southern regions was 26.5 per cent higher than in the north. A higher proportion of patients in the north had severe symptoms before surgery (58 per cent vs 52 per cent; p = 0.002). The probabilities of being operated on in a given year varied by symptom severity in both the north and the south. The probability was higher in the south at all levels of symptom severity: none/mild (ratio = 1.44; p > 0.01), low-moderate (ratio = 1.35; p = 0.003), high-moderate (ratio = 1.53; p < 0.0001), and severe (ratio = 1.15; p > 0.01). On testing the sensitivity of the key assumptions by assuming a more severe distribution of symptoms in the south, the differences at none/mild and low-moderate symptom levels were enhanced but differences at high-moderate and severe symptom levels were reversed.

CONCLUSIONS

As few men with mild symptoms qualify for surgery and most men with severe symptoms are operated on, any difference in patient selection between high and low rate regions is inevitably confined to the intermediate group of men with moderate symptoms. Surgeons appear to be rationing their resources in a sensible way, though perhaps not as stringently as could be achieved.

A national strategy for research and development: lessons from England

Increasing concern about the state of basic and clinical research in England during the 1980s led to an influential parliamentary review. Surprisingly, the review recommended the strengthening of public health and health services research through the establishment of a research and development (R&D) program for the National Health Service (NHS). The program that started in 1991 was unique in that it was fully integrated into the management structure of the NHS. No country had ever attempted such an ambitious approach. While a review of the first five years of the program reveals many achievements, it also raises several concerns: Debate about the philosophy and aims of the program continues; the need to maintain political support requires constant attention; policy changes in other areas need to be accommodated; central control of a national, coordinated R&D program has to be guarded; methods of priority setting need to be enhanced; insufficient human resources to run the program have to be contended with; and the program needs to be rigorously evaluated. Other countries with a unified health system could learn much from the English experience. Countries with pluralist systems might benefit from specific parts of the experience.

Impact of the 1991 NHS reforms on the availability and use of coronary revascularisation in the UK (1987-1995)

OBJECTIVE

To describe changes in the availability, utilisation, and waiting times for coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) between 1987/88 and 1994/95 and to review commissioning of these services.

DESIGN

A series of cross sectional surveys and interviews with purchasers and providers.

SETTING

Four health regions in the United Kingdom.

PATIENTS

All residents aged 25 years or more who underwent coronary revascularisation.

RESULTS

There has been little change in the availability of consultants in cardiology in specialist centres, while the number of non-consultant cardiologists has risen significantly. The availability of consultant surgeons more than doubled in some regions, while non-consultant surgical staff increased by 40-90%. The NHS rate of use of both CABG and PTCA has increased steadily since 1987/88. In 1994/95, only two districts had CABG rates of less than 300 per million population. The additional contribution of privately funded cases varied between 14-23% for CABG and 7-30% for PTCA. Regional rates varied 1.3-fold for CABG and threefold for PTCA in 1994/95, while district rates of CABG varied 3.6-fold and PTCA 18-fold. Revascularisation rates were higher in districts with least need in 1991/92 and this persisted over the following three years. The overall waiting time for CABG (214 days) was largely unchanged from 1992/93 (234 days). The overall waiting time for PTCA (138 days) was 25% shorter than in 1992/93 (185 days). Prioritisation of patients waiting over a year had not yet adversely affected the waiting time of more urgent patients. Commissioning has faced a complex web of interconnected problems which, in general, caused more problems for purchasers than providers initially but which appear to be of increasing concern to providers.

CONCLUSIONS

The 1991 NHS reforms had had no observable impact on the availability and use of coronary revascularisation by 1995. Continued monitoring is necessary to detect any delayed effect.

Does a shorter length of hospital stay affect the outcome and costs of hysterectomy in southern England?

STUDY OBJECTIVE

To see whether a shorter postoperative length of stay (LOS) for a major procedure, abdominal hysterectomy for benign conditions, was associated with health outcome, the use of formal and lay care after discharge, cost, and satisfaction.

DESIGN

Prospective cohort study.

SETTING

Three hospitals in London and three in Hertfordshire and Bedfordshire.

PATIENTS

A total of 363 women undergoing total abdominal hysterectomy with or without oophorectomy: 112 with a short postoperative LOS (five days or less) and 251 with a standard LOS (six days or more).

MAIN OUTCOME MEASURES

Wound infection within 10 days and six weeks; change in general health status (Nottingham health profile) after six weeks; general health and change in social activity (lifestyle index) three months after surgery. Mean cost difference for hospitals, use of formal and lay care after discharge, and patient satisfaction.

RESULTS

Short LOS was associated with benefits: a lower risk of wound infection in the first 10 days (odds ratio 0.44; p = 0.03) and no deterioration in physical mobility (measured using the NHP) after six weeks- and with adverse outcomes: constipation six weeks later (OR 0.48; p < 0.001) and moderate or severe urinary symptoms six weeks (OR 0.69; p < 0.004) and three months (OR 0.65; p < 0.008) later. On multivariate analysis, the only outcome to remain significantly associated with LOS was physical mobility after six weeks (p = 0.024). There was no significant difference between short and standard stay women as regards their use of formal or lay care after discharge from hospital. The mean cost of hospital care was Pounds251 (in 1992) less for short than for standard stay patients. Most women (73% at six weeks) felt their LOS was appropriate. Short stay women were more likely to feel it was too short, though the difference was not statistically significant.

CONCLUSIONS

Short postoperative stays do not seem to be associated with any adverse outcomes and result in modest financial saving to the health service. There is potential for greater use of early discharge.

Why we need observational studies to evaluate the effectiveness of health care

The view is widely held that experimental methods (randomised controlled trials) are the "gold standard" for evaluation and that observational methods (cohort and case control studies) have little or no value. This ignores the limitations of randomised trials, which may prove unnecessary, inappropriate, impossible, or inadequate. Many of the problems of conducting randomised trials could often, in theory, be overcome, but the practical implications for researchers and funding bodies mean that this is often not possible. The false conflict between those who advocate randomised trials in all situations and those who believe observational data provide sufficient evidence needs to be replaced with mutual recognition of the complementary roles of the two approaches. Researchers should be united in their quest for scientific rigour in evaluation, regardless of the method used.

Why we need observational studies to evaluate the effectiveness of health care

The view is widely held that experimental methods (randomised controlled trials) are the "gold standard" for evaluation and that observational methods (cohort and case control studies) have little or no value. This ignores the limitations of randomised trials, which may prove unnecessary, inappropriate, impossible, or inadequate. Many of the problems of conducting randomised trials could often, in theory, be overcome, but the practical implications for researchers and funding bodies mean that this is often not possible. The false conflict between those who advocate randomised trials in all situations and those who believe observational data provide sufficient evidence needs to be replaced with mutual recognition of the complementary roles of the two approaches. Researchers should be united in their quest for scientific rigour in evaluation, regardless of the method used.

The effect of prostatectomy on symptom severity and quality of life

OBJECTIVE

To determine the effectiveness of prostatectomy in reducing symptom severity and bother and in improving disease-specific and general quality of life.

PATIENTS AND METHODS

A prospective, cohort study was performed in National Health Service and private hospitals in the Northern, Wessex, Mersey, and South-West Thames Health Regions which comprised 5276 men undergoing prostatectomy recruited by 101 of the 106 (96%) surgeons (specialist and non-specialist) performing prostatectomy during a 6-month period. Patients were assessed using the American Urological Association (AUA) Symptom Index Score, the AUA symptom bother score, disease-specific and generic quality-of-life scores, the occurrence of adverse events (urinary incontinence, erectile impotence and retrograde ejaculation) and three global (general) questions on the results of their treatment. The outcome was assessed 3 months after surgery.

RESULTS

Prostatectomy was effective in reducing both symptoms (initial mean score 20.1 reduced to 7.4, P < 0.001) and symptom bother (initial mean score 14.4 reduced to 4.3, P < 0.001). Not all men experienced a good reduction in symptoms; 121 (3.9%) were worse, 301 (9.6%) were the same, and 721 (23%) experienced only slight improvement. The type of operation, grade of principal operator and use of pre-operative investigations were not associated with the extent of symptomatic improvement. Changes in symptom severity were highly correlated with changes in bothersomeness++ and disease-specific quality of life but not with generic quality of life. A third of men who were continent before surgery reported some incontinence 3 months later, although only 6% found it a problem. Two-thirds of men experienced retrograde ejaculation and 31% experienced some erectile impotence following surgery.

CONCLUSIONS

Prostatectomy is effective in reducing symptoms in most men. Men who experience a substantial reduction in symptoms were more likely to report a favourable outcome. The study confirmed that approximately one-third of men reported an unfavourable result 3 months after their operation.

Development of a symptom severity index and a symptom impact index for stress incontinence in women

Stress incontinence is a common problem among women, yet there is no adequately validated instrument for measuring women's views of its severity (disease-specific health status). The only instrument for measuring the impact or bothersomeness of symptoms (disease-specific quality of life) has poor internal consistency. This paper describes the development and psychometric assessment of two new indexes, a Symptom Severity Index and a Symptom Impact Index. Following several qualitative enquiries, a questionnaire was developed and administered to 442 women undergoing stress incontinence surgery. The face and content validity of the items comprising the indexes was good. The Severity Index (0-20) showed good variability (median 14, interquartile range 6) and adequate internal consistency (alpha 0.76). The Impact Index (0-12) also had good variability (median 5, interquartile range 3.5) and internal consistency (alpha 0.80). Convergent and discriminant validity were demonstrated for both indexes. Test-retest reliability was high. While responsiveness is still to be tested, the two indexes are psychometrically strong and can be used to measure the severity and impact of stress incontinence in women.

Appropriateness of total hip replacement in the United Kingdom

The paper discusses the use of consensus models in determining the application of Total Hip Replacement surgery. The paper notes the wide national and international variation in use of this procedure but considers it in the broader context of reaching consensus on other surgical interventions.

The feasibility and cost of a large multicentre audit of process and outcome of prostatectomy

Objective--To determine the feasibility of performing multicentre process and outcome audits of common interventions taking prostatic procedures as an example. Design--Prospective, cohort study. Setting--All National Health Service and independent hospitals in Northern, Wessex, Mersey, and South West Thames health regions. Patients--5361 men undergoing prostatectomy identified by 103 of the 107 urologists and general surgeons performing prostatectomy in the study regions. Main measures-- Rates of participation by surgeons and patients; completeness of clinical data provided by surgeons; patient response rate and completeness of patient derived data; and cost. Results--Most surgeons (103,96%) agreed to participate. Overall, the proportion of eligible patients invited to take part was high (89%), although this was only measured in South West Thames, where dedicated data collectors were employed. Few men (80, 1.5%) declined to participate. Of those surviving for three months after surgery, 82.4% (4226) completed and returned the postal questionnaire. The response rate was higher in South West Thames (86.7%) than in the other regions (80.6%-80.8%). The audit was well received: 91% of patients found the questionnaire easy to complete and only 2.3% of them disapproved. Completeness of data was high with both the hospital and patient questionnaires. Missing data occurred in less than 5% of responses to most questions. The attributable cost was 34.50 pounds per patient identified or 44 pounds for patients in whom either the treatment outcome or vital status was known three months after their prostatectomy. Conclusions--This multicentre audit of process and outcome of prostatectomy proved feasible in terms of surgeon participation, patient identification, and the quantity and quality of data collection. Whether the cost was warranted will depend on how surgeons use the audit data to modify their practice.

Coronary revascularisation: why do rates vary geographically in the UK?

OBJECTIVE

To explain the reasons for geographical variation in the use of coronary revascularisation in the United Kingdom.

DESIGN

This was a cross sectional ecological study.

SETTING

NHS and independent hospitals performing coronary revascularisation for the 11.6 million residents of the south east Thames, East Anglian and north western health regions in England plus Greater Glasgow, Lanarkshire, Ayr and Arran health boards in Scotland were included.

SUBJECTS

All residents aged > or = 25 years in 1992-93 who underwent coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) in either the public or private sector were included.

MAIN MEASURES

Crude and age-sex standardised intervention rates for residents of the 42 constituent districts and boards were determined. Variation was measured using the systematic component of variation.

RESULTS

Considerable systematic variations in district rates of CABG and PTCA existed. These variations mostly arose from differences in supply factors. Higher rate districts were characterised by being close to a regional revascularisation centre and having a local cardiologist. Demand factors such as the level of need in the population (measured by coronary heart disease mortality) and the lack of use of alternative treatments not only failed to explain the observed variation but were inversely associated with the rate of intervention--an example of the inverse care law. The finding that the residents of more socially deprived districts experienced higher intervention rates was probably subject to confounding due to their close proximity to specialist centres.

CONCLUSIONS

If greater geographical equity of use for the same level of need is to be achieved, attention must be paid to the supply factors that determine levels of utilisation. As responsibility for purchasing these procedures is decentralised, utilisation might become even more unequal.

Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study

OBJECTIVE

To describe the indications for total abdominal hysterectomy for women with nonmalignant disease and to determine the immediate (initial ten days) and medium term outcome.

DESIGN

A prospective cohort study.

SETTING

Three district general hospitals in shire counties, two in outer London and one London teaching hospital.

SUBJECTS

Three hundred and sixty-six women undergoing total abdominal hysterectomy (with or without other procedures) for nonmalignant disease.

INTERVENTIONS

Self-completed patient questionnaires before and ten days, six weeks and three months after surgery. Data extracted from patients' hospital case notes.

MAIN OUTCOME MEASURES

Complications plus change in symptoms, urinary and bowel function, general health status, sexual function, activities of daily living and quality of life.

RESULTS

The principal indications were bleeding, pain or both. Symptoms were severe enough to be socially debilitating and have a major impact on lifestyle. Otherwise, the women were in good health. During the first ten post-operative days the women suffered more pain, urinary discomfort, constipation and a reduction in their ability to perform activities of daily living. Urinary (25%) and wound (25%) infections were the commonest complications. At the same time, significant improvements in psychological health occurred. By six weeks, the principal symptoms had resolved for 95% of the women and early adverse effects on urinary and bowel function had settled. This was reflected in improvements in health status and quality of life including sexual activity. Despite this, these changes did not meet the pre-operative expectations of some women.

CONCLUSIONS

Most women reported substantial benefits from hysterectomy. However, women should be warned about early, transient adverse effects. These findings can serve as a benchmark for nonexperimental evaluations of the effectiveness of new treatment modalities.

Surgery for glue ear: the English epidemic wanes

OBJECTIVES

To describe the progress of the epidemic of surgery for glue ear since 1983 and trends in the use of different operative procedures.

DESIGN

Analysis of routine hospital data.

SETTING

Thirteen health districts in the Oxford and East Anglian regions.

MAIN MEASURES

Annual rates of surgery in children under 10 years of age.

RESULTS

The rate of surgery for glue ear reached a peak in 1986 since when it has declined by 12.6%. The rate peaked in all 13 districts but at different times over a six year period (1984-1989/90). Following the peak, district rates plateaued in eight districts and declined in five. These changes have been accompanied by: an increase in the proportion of operations confined to the tympanic membrane since 1983 (from 40% to 60%); an increase in the use of grommets after myringotomy (from 50% to 94% since 1980); and an increased use of day surgery for ear-only operations (from about 10% in the late 1970s to 50% in 1987/88).

CONCLUSIONS

The previously reported epidemic of surgery for glue ear is waning. This seems to be a result of changes in the clinical judgment of general practitioners and surgeons as to its use and possibly of a reduced demand from parents.

Recollected versus contemporary patient reports of pre-operative symptoms in men undergoing transurethral prostatic resection for benign disease

The objective of the study was to investigate the reliability of patients' recollected pre-intervention symptom status and the impact of those symptoms compared with contemporary pre-operative reports, and to test the stability of recollected views. In design (A) a self-completed symptom questionnaire was administered before (contemporary) and 3 months after (recollected) surgery. In design (B) a self-completed symptom questionnaire on recollected pre-operative symptoms was administered 12 and 14 weeks after surgery. Setting (A) comprised the twin consultant urological unit in the Chesterfield and North Derbyshire Royal Hospital NHS Trust, and setting (B) a sample from the National Prostatectomy Audit of 5281 patients. The subjects were 77 consecutive patients scheduled for transurethral resection of the prostate (TURP), and 170 consecutive respondents undergoing TURP. The main outcome measures were the difference in group mean scores for The American Urological Association (AUA) Symptom Index, Impact Index (a score of symptom impact), and 14 constituent questions; association assessed using Pearson's correlation coefficient; agreement assessed using weighted Kappa statistics. Complete paired data sets were available for 58 (75%) men for the Symptom Index, and for 61 (79%) men for the Impact Index. Pre-operative mean Symptom Index scores for contemporary and recollected were similar, as were mean scores for the Impact Index. However, only poor to fair levels of association and agreement were obtained for the Symptom Index (r = 0.6, kappa (w) = 0.3) and Impact Index (r = 0.6, kappa (w) = 0.3). Results for the constituent questions were similar.(ABSTRACT TRUNCATED AT 250 WORDS)