1
|
van der Graaf SH, Hagens MJ, Veerman H, Roeleveld TA, Nieuwenhuijzen JA, Wit EMK, W J M Wouters M, van der Mierden S, van Moorselaar RJA, Beerlage HP, Vis AN, van Leeuwen PJ, van der Poel HG. A Systematic Review on the Impact of Quality Assurance Programs on Outcomes after Radical Prostatectomy. Eur Urol Focus 2024:S2405-4569(24)00048-8. [PMID: 38631992 DOI: 10.1016/j.euf.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/23/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND OBJECTIVE The implementation of quality assurance programs (QAPs) within urological practice has gained prominence; yet, their impact on outcomes after radical prostatectomy (RP) remains uncertain. This paper aims to systematically review the current literature regarding the implementation of QAPs and their impact on outcomes after robot-assisted RP, laparoscopic RP, and open prostatectomy, collectively referred to as RP. METHODS A systematic Embase, Medline (OvidSP), and Scopus search was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) process, on January 12, 2024. Studies were identified and included if these covered implementation of QAPs and their impact on outcomes after RP. QAPs were defined as any intervention seeking quality improvement through critically reviewing, analyzing, and discussing outcomes. Included studies were assessed critically using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool, with results summarized narratively. KEY FINDINGS AND LIMITATIONS Ten included studies revealed two methodological strategies: periodic performance feedback and surgical video assessments. Despite conceptual variability, QAPs improved outcomes consistently (ie, surgical margins, urine continence, erectile function, and hospital readmissions). Of the two strategies, video assessments better identified suboptimal surgical practice and technical errors. Although the extent of quality improvements did not appear to correlate with the frequency of QAPs, there was an apparent correlation with whether or not outcomes were evaluated collectively. CONCLUSIONS AND CLINICAL IMPLICATIONS Current findings suggest that QAPs have a positive impact on outcomes after RP. Caution in interpretation due to limited data is advised. More extensive research is required to explore how conceptual differences impact the extent of quality improvements. PATIENT SUMMARY In this paper, we review the available scientific literature regarding the implementation of quality assurance programs and their impact on outcomes after radical prostatectomy. The included studies offered substantial support for the implementation of quality assurance programs as an incentive to improve the quality of care continuously.
Collapse
Affiliation(s)
- Sophia H van der Graaf
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands.
| | - Marinus J Hagens
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Hans Veerman
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Ton A Roeleveld
- Prostate Cancer Network Netherlands, Amsterdam, The Netherlands; Department of Urology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Jakko A Nieuwenhuijzen
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Esther M K Wit
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Michel W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Stevie van der Mierden
- Scientific Information Service, Netherlands Cancer Institute- Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - R Jeroen A van Moorselaar
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Harrie P Beerlage
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - André N Vis
- Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands; Prostate Cancer Network Netherlands, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Nikolian VC, Camacho D, Earle D, Lehmann R, Nau P, Ramshaw B, Stulberg J. Development and preliminary validation of a new task-based objective procedure-specific assessment of inguinal hernia repair procedural safety. Surg Endosc 2024; 38:1583-1591. [PMID: 38332173 DOI: 10.1007/s00464-024-10677-2] [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: 03/29/2023] [Accepted: 12/30/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND Surgical videos coupled with structured assessments enable surgical training programs to provide independent competency evaluations and align with the American Board of Surgery's entrustable professional activities initiative. Existing assessment instruments for minimally invasive inguinal hernia repair (IHR) have limitations with regards to reliability, validity, and usability. A cross-sectional study of six surgeons using a novel objective, procedure-specific, 8-item competency assessment for minimally invasive inguinal hernia repair (IHR-OPSA) was performed to assess inter-rater reliability using a "safe" vs. "unsafe" scoring rubric. METHODS The IHR-OPSA was developed by three expert IHR surgeons, field tested with five IHR surgeons, and revised based upon feedback. The final instrument included: (1) incision/port placement; (2) dissection of peritoneal flap (TAPP) or dissection of peritoneal flap (TEP); (3) exposure; (4) reducing the sac; (5) full dissection of the myopectineal orifice; (6) mesh insertion; (7) mesh fixation; and (8) operation flow. The IHR-OPSA was applied by six expert IHR surgeons to 20 IHR surgical videos selected to include a spectrum of hernia procedures (15 laparoscopic, 5 robotic), anatomy (14 indirect, 5 direct, 1 femoral), and Global Case Difficulty (easy, average, hard). Inter-rater reliability was assessed against Gwet's AC2. RESULTS The IHR-OPSA inter-rater reliability was good to excellent, ranging from 0.65 to 0.97 across the eight items. Assessments of robotic procedures had higher reliability with near perfect agreement for 7 of 8 items. In general, assessments of easier cases had higher levels of agreement than harder cases. CONCLUSIONS A novel 8-item minimally invasive IHR assessment tool was developed and tested for inter-rater reliability using a "safe" vs. "unsafe" rating system with promising results. To promote instrument validity the IHR-OPSA was designed and evaluated within the context of intended use with iterative engagement with experts and testing of constructs against real-world operative videos.
Collapse
Affiliation(s)
- Vahagn C Nikolian
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA.
| | - Diego Camacho
- Minimally Invasive and Endoscopic Surgery at Montefiore Medical Center, New York, NY, USA
| | - David Earle
- New England Hernia Center, Lowell, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Ryan Lehmann
- Department of Surgery, Section of Bariatric Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Peter Nau
- Department of Surgery, Section of Bariatric Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Bruce Ramshaw
- CQInsights PBC, Knoxville, TN, USA
- Caresyntax Corporation, Boston, MA, USA
| | - Jonah Stulberg
- Department of Surgery, McGovern Medical School University of Texas Health Science Center at Houston, Houston, TX, USA
| |
Collapse
|
3
|
Balvardi S, Kammili A, Hanson M, Mueller C, Vassiliou M, Lee L, Schwartzman K, Fiore JF, Feldman LS. The association between video-based assessment of intraoperative technical performance and patient outcomes: a systematic review. Surg Endosc 2022; 36:7938-7948. [PMID: 35556166 DOI: 10.1007/s00464-022-09296-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/18/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Efforts to improve surgical safety and outcomes have traditionally placed little emphasis on intraoperative performance, partly due to difficulties in measurement. Video-based assessment (VBA) provides an opportunity for blinded and unbiased appraisal of surgeon performance. Therefore, we aimed to systematically review the existing literature on the association between intraoperative technical performance, measured using VBA, and patient outcomes. METHODS Major databases (Medline, Embase, Cochrane Database, and Web of Science) were systematically searched for studies assessing the association of intraoperative technical performance measured by tools supported by validity evidence with short-term (≤ 30 days) and/or long-term postoperative outcomes. Study quality was assessed using the Newcastle-Ottawa Scale. Results were appraised descriptively as study heterogeneity precluded meta-analysis. RESULTS A total of 11 observational studies were identified involving 8 different procedures in foregut/bariatric (n = 4), colorectal (n = 4), urologic (n = 2), and hepatobiliary surgery (n = 1). The number of surgeons assessed ranged from 1 to 34; patient sample size ranged from 47 to 10,242. High risk of bias was present in 5 of 8 studies assessing short-term outcomes and 2 of 6 studies assessing long-term outcomes. Short-term outcomes were reported in 8 studies (i.e., morbidity, mortality, and readmission), while 6 reported long-term outcomes (i.e., cancer outcomes, weight loss, and urinary continence). Better intraoperative performance was associated with fewer postoperative complications (6 of 7 studies), reoperations (3 of 4 studies), and readmissions (1 of 4 studies). Long-term outcomes were less commonly investigated, with mixed results. CONCLUSION Current evidence supports an association between superior intraoperative technical performance measured using surgical videos and improved short-term postoperative outcomes. Intraoperative performance analysis using video-based assessment represents a promising approach to surgical quality-improvement.
Collapse
Affiliation(s)
- Saba Balvardi
- Department of Surgery, McGill University, 1650 Cedar Ave, D6-136, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Anitha Kammili
- Department of Surgery, McGill University, 1650 Cedar Ave, D6-136, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Melissa Hanson
- Department of Surgery, McGill University, 1650 Cedar Ave, D6-136, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Carmen Mueller
- Department of Surgery, McGill University, 1650 Cedar Ave, D6-136, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Melina Vassiliou
- Department of Surgery, McGill University, 1650 Cedar Ave, D6-136, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University, 1650 Cedar Ave, D6-136, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Kevin Schwartzman
- Respiratory Division, Department of Medicine, McGill University, Montreal, QC, Canada
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, McGill University, 1650 Cedar Ave, D6-136, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, 1650 Cedar Ave, D6-136, Montreal, QC, H3G 1A4, Canada.
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
| |
Collapse
|
4
|
Prebay ZJ, Peabody JO, Miller DC, Ghani KR. Video review for measuring and improving skill in urological surgery. Nat Rev Urol 2020; 16:261-267. [PMID: 30622365 DOI: 10.1038/s41585-018-0138-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Interest is growing within the urological surgery community for objective assessments of technical skill. Surgical video review relies on the use of objective assessment tools to evaluate both global and procedure-specific skill. These evaluations provide structured feedback to surgeons with the aim of improving technique, which has been associated with patient outcomes. Currently, skill assessments can be performed by using expert peer-review, crowdsourcing or computer-based methods. Given the relationship between skill and patient outcomes, surgeons might be required in the future to provide empirical evidence of their technical skill for certification, employment, credentialing and quality improvement. Interventions such as coaching and skills workshops incorporating video review might help surgeons improve their skill, with the ultimate goal of improving patient outcomes.
Collapse
Affiliation(s)
- Zachary J Prebay
- School of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James O Peabody
- Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - David C Miller
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Khurshid R Ghani
- Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
5
|
Permpongkosol S, Aramay S, Vattanakul T, Phongkitkarun S. The association between the outcomes of extraperitoneal laparoscopic radical prostatectomy and the anthropometric measurements of the prostate by magnetic resonance imaging. Int Braz J Urol 2018; 44:238-247. [PMID: 29064657 PMCID: PMC6050549 DOI: 10.1590/s1677-5538.ibju.2017.0260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/29/2017] [Indexed: 11/24/2022] Open
Abstract
Introduction and objective To determine the association between the anthropometric measurements by magnetic resonance imaging (MRI) and perioperative outcomes of extraperitoneal laparoscopic radical prostatectomy (ELRP). Materials and Methods From 2008 to June 2016, 86 patients underwent preoperative MRI prior to undergoing ELRP for localized prostate cancer. We analyzed the associations between anthropometric measurements of MRI and the perioperative outcomes of patients who underwent ELRP. Results The mean patient age was 69.61±8.30 years. The medians of operating time and blood loss were 2.30 hours and 725.30ml, respectively. The total post-surgical complication rate was 1.16%. The median hospital stay was 6.50 days. The pathological stages for T2 and T3 were 45.74% and 34.04%, respectively. The rate as positive surgical margins (PSMs) was 18.09% (pT2 and pT3; 6.38% and 9.57%). The angles between pubic bone and prostate gland (angle 1&2), were significantly associated with operative time and hospital stay, respectively (p<0.05). There was no correlation between the pelvimetry and positive surgical margin. Conclusions The findings of the present study suggest that anthropometric measurements of the MRI are related to operative difficulties in ELRP. This study confirmed that MRI planning is the key to preventing complications in ELRP.
Collapse
Affiliation(s)
- Sompol Permpongkosol
- Division of Urology, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Supanun Aramay
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thawanrat Vattanakul
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sith Phongkitkarun
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
6
|
Goldenberg MG, Goldenberg L, Grantcharov TP. Surgeon Performance Predicts Early Continence After Robot-Assisted Radical Prostatectomy. J Endourol 2017; 31:858-863. [PMID: 28557582 DOI: 10.1089/end.2017.0284] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION There is limited, yet compelling evidence supporting the role of surgeon technical performance in influencing patient outcomes. To date, this concept has been underexplored in endourologic procedures. We hypothesized that a surgeon's technical performance plays a role in predicting an early return to continence after robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS We conducted a retrospective, matched case-control analysis of prospectively collected unedited RARP endoscopic videos performed by a single surgeon. A blinded observer with expertise in intraoperative video analysis evaluated clinically relevant steps of RARP using the global evaluative assessment of robotic skill (GEARS) and the generic error rating tool (GERT). The primary outcome was continence status at 3 months postoperatively, defined as patient use of less than or equal to a single precautionary pad. Mann-Whitney U tests examined differences in predictor variables between cases and controls, and multivariate analysis was conducted using binary logistic regression models. RESULTS Twenty-four incontinent patients were matched for age, body mass index, preoperative International Prostate Symptoms Score, use of posterior/anterior hitch, prostate weight, and learning curve position. No statistically significant difference in errors between groups was observed using the GERT. On multivariate analysis, overall case GEARS score was independently predictive of 3-month continence status (odds ratios [OR] = 0.55, 95% confidence interval [CI] 0.33-0.91), as were urethrovesical anastomosis (OR = 0.70, 95% CI 0.50-0.97) and bladder neck GEARS scores (OR = 0.69, 95% CI 0.51-0.94). CONCLUSIONS Our study generates the hypothesis that there may be a link between surgeon technical performance and functional outcomes in RARP. This relationship may have implications for the accreditation and training of future urologists and warrants further investigation.
Collapse
Affiliation(s)
- Mitchell G Goldenberg
- 1 Division of Urology, University of Toronto , Toronto, Canada .,2 Department of Urologic Sciences, University of British Columbia , Vancouver, Canada
| | - Larry Goldenberg
- 3 Department of Surgery, University of Toronto , Toronto, Canada
| | - Teodor P Grantcharov
- 2 Department of Urologic Sciences, University of British Columbia , Vancouver, Canada
| |
Collapse
|