Appraising the quality of care in surgery

Patients' subjective well-being: Determinants and its usage as a metric of healthcare service quality

It is commonly suggested that patients' subjective well-being (SWB) can be affected by pre-treatment conditions and treatment experiences, and hence SWB can be used to measure and improve healthcare quality. With data collected in a hospital in the UK (N = 446), we investigated the determinants of patients' SWB and evaluated its use in healthcare research. Our findings showed strong relationships between pre-treatment conditions and patients' SWB: anxiety and depression negatively predicted SWB across all three domains, mobility positively predicted the life satisfaction and happiness domains, while the ability to self care and pain and discomfort also predicted SWB in some domains. In contrast, patients' satisfaction with the treatment only played minor roles in determining SWB, much less so the characteristics of their nurses. The general lack of associations between treatment experiences and patient's SWB highlighted the challenges of using SWB to measure healthcare quality and inform policy making.

A Sustainable and Scalable Approach to the Provision of Cleft Care: A Focus on Safety and Quality

BACKGROUND

A global health model based on partnering with local hospitals and surgical teams, providing education and training for local providers, and mandating adherence to safety and quality standards to ensure safe surgery and anesthesia care can build local surgical capacity and strengthen existing health care systems in low- and middle-income countries. Smile Train uses this sustainable partnership model to provide responsible humanitarian aid while maintaining a bidirectional exchange with its international partners.

METHODS

A voluntary online survey is administered annually to Smile Train's global partners. One portion of this survey focuses on how Smile Train can best support providers' adherence to the Smile Train Safety and Quality Protocol and Anesthesia Guidelines for cleft care.

RESULTS

In 2014 and 2015, 1132 health care providers responded to Smile Train's annual partner survey (77 percent response rate). When asked how Smile Train could best support partners to continually meet the safety and quality standards, most partners reported that they could benefit from additional financial support (59.6 percent) and medical professional education and training opportunities (59.2 percent).

CONCLUSIONS

The results from the partner survey yield important insights into the programmatic needs of Smile Train partners. Smile Train uses this information to efficiently allocate and distribute resources and to strategically plan and implement training opportunities where needed. The partner survey helps to ensure that Smile Train patients around the world consistently receive safe and high-quality cleft surgery and anesthesia care.

Variation in access to pediatric surgical care among coexisting public and private providers: inguinal hernia as a model

BACKGROUND

Faced with growing healthcare demand, the Saudi government is increasingly relying on privatization as a tool to improve patient access to care. Variation in children's access to surgical care between public (PB) and private providers (PV) has not been previously analyzed.

OBJECTIVES

To compare access to pediatric surgical services between two coexisting PB and PV.

DESIGN

Retrospective comparative study.

SETTINGS

A major teaching hospital and the largest PV group in Saudi Arabia.

PATIENTS AND METHODS

The outcomes for children who underwent inguinal herniotomy (IH) between May 2010 and December 2014 at both providers were with IH serving as the model. Data collected included patient demographics, insurance coverage, referral pattern and access parameters including time-to-surgery (TTS), surgery wait time (SWT) and duration of symptoms (DOS).

MAIN OUTCOME MEASURE(S)

TTS, SWT and DOS.

RESULTS

Of 574 IH cases, 56 cases of in-hospital referrals were excluded leaving 290 PB and 228 PV cases. PV patients were younger (12.0 vs 16.4 months, P=.043) and more likely to be male (81.6% vs 72.8%, P=.019), expatriates (18% vs 3.4%, P < .001) and insured (47.4% vs 0%, P < .001). The emergency department was more frequently the source for PB referrals (35.2% vs 12.7%, P < .001) while most PV patients were self-referred (72.8% vs 16.7%, P < .001). Access parameters were remarkably better at PV: TTS (21 vs 66 days, P < .001), SWT (4 vs 31 days, P < .001) and DOS (33 vs 114 days, P < .001).

CONCLUSION

When coexisting, PV offers significantly better access to pediatric surgical services compared to PB. Diverting public funds to expand children's access to PV can be a valid choice to improve access to care in case when outcomes with the two providers are similar.

LIMITATIONS

Although it is the first and largest comparison in the pediatric population, the sample may not represent the whole population since it is confined to a single selected surgical condition.

Implementation of a visceral surgery clinical pathway: Evaluating patient satisfaction with information, safety and involvement in care

Background

Care pathways are essential to ensure continuity, quality, efficient use of resources and positive patient outcomes. Although patient satisfaction is widely considered a major indicator of care quality, it remains largely unexamined in the context of care pathway implementation. The aim of this study was to assess patient satisfaction during implementation of a care pathway for recurrent surgeries.

Method

A newly designed questionnaire was utilized to examine patient satisfaction among adult patients hospitalized for visceral surgery at the University Hospital of Lausanne (CHUV). Analysis was conducted through nine care pathways frequently performed in visceral surgeries.

Results

Of the 280 patients surveyed, 258/280 (92%) of patients were satisfied with information received, 255/280 (91%) with the safety and 210/280 (75%) with their involvement in decision-making and care.

Conclusion

Patient satisfaction ratings of the care received during the care pathway were high. Complete and personalized information seems to be the key element for patients’ sense of safety and involvement in decision making and care.

Using a hybrid electronic medical record system for the surveillance of adverse surgical events and human error in a developing world surgical service

INTRODUCTION

The quantification and analysis of adverse events is essential to benchmark surgical outcomes and establish a foundation for quality improvement interventions. We developed a hybrid electronic medical record (HEMR) system for the accurate collection and integration of data into a structured morbidity and mortality (M&M) meeting.

METHODOLOGY

The HEMR system was implemented on January 1, 2013. It included a mechanism to capture and classify adverse events using the ICD-10 coding system. This was achieved by both prospective reporting by clients and by retrospective sentinel-event-trawling performed by administrators.

RESULTS

From January 1, 2013 to March 20, 2014, 6,217 patients were admitted within the tertiary surgical service of Greys Hospital. A total of 1,314 (21.1 %) adverse events and 315 (5.1 %) deaths were recorded. The adverse events were divided into 875 "pathology-related" morbidities and 439 "error-related" morbidities. Pathology-related morbidities included 725 systemic complications and 150 operative complications. Error-related morbidities included 257 cognitive errors, 158 (2.5 %) iatrogenic injuries, and 24 (1.3 %) missed injuries. Error accounted for 439 (33 %) of the total number of adverse events. A total of 938 (71.4 %) adverse events were captured prospectively, whereas the remaining 376 (28.6 %) were captured retrospectively. The ICD-10 coding system was found to have some limitations in its classification of adverse events.

CONCLUSIONS

The HEMR system has provided the necessary platform within our service to benchmark the incidence of adverse events. The use of the international ICD-10 coding system has identified some limitations in its ability to classify and categorise adverse events in surgery.

Factors Implicated for Delay of Adjuvant Chemotherapy in Colorectal Cancer: A Meta-analysis of Observational Studies

BACKGROUND

The survival benefit of administering adjuvant chemotherapy (AC) in colorectal cancer is well established, as is the impact of its timing. Although various factors have been associated with treatment delay, their implications remain controversial. We determined clinicopathological factors associated with delay in transition to AC via systematic review and meta-analysis.

METHODS

Studies assessing factors for delay in initiating AC were identified from MEDLINE, EMBASE, and Cochrane Databases. Studies were included only if relevant clinicopathological factors were adequately described and appropriate comparative groups were balanced. For each study, the odds ratio (OR) and 95 % confidence interval (CI) were estimated, regarding response to early versus delayed AC initiation.

RESULTS

We identified 15 eligible studies involving 67,537 patients. Twelve studies were multicentre studies and three were single-center cohort studies. Meta-analysis demonstrated age >75 years [4 studies, OR = 1.44 (95 % CI 1.32-1.58)], marital status-single [3 studies, OR = 1.32 (95 % CI 1.20-1.44)], low socioeconomic status (SES) [7 studies, OR = 1.67 (95 % CI 1.32-2.12)], worse comorbidity status [5 studies, OR = 1.47 (95 % CI 1.14-1.90)], low tumour grade [7 studies, OR = 1.06 (95 % CI 1.02-1.11)], prolonged length of stay [3 studies, OR 2.37 (95 % CI 2.10-2.68)], and readmission [3 studies, OR = 3.23 (95 % CI 1.66-6.26)] were significant predictors of delayed initiation of AC. Laparoscopy compared to an open surgical approach was a significant predictor of earlier AC initiation [5 studies, OR = 0.70 (95 % CI 0.51-0.97)].

CONCLUSIONS

Laparoscopy is associated with earlier initiation of AC, encouraging its increased adoption. Social isolation and low SES merit consideration of approaches that counter the lack of social support and deprivation to improve cancer outcomes.

Laparoscopic vs. open surgery for treating benign liver lesions: assessing quality of life in the first year after surgery

Laparoscopic liver surgery has not yet gained widespread acceptance among liver surgeons. Some questions remain regarding indications to surgery and health related quality of life (HRQOL) after surgery, especially for the treatment of benign lesions, has so far not yet been investigated. The aim of this study is to evaluate HRQOL at 1 month, 6 months and 1 year after surgery in two groups of patients undergoing liver resections for benign liver lesions either by laparoscopic or open surgery. From January 2004 to September 2010 75 patients underwent surgery (29 laparoscopic, 46 open) for benign liver lesions.We retrospectively compared surgical results of the two groups and evaluated HRQOL with the SF-36 test. A personal or telephonic interview was administrated for the assessment of HRQOL before surgical treatment and at1 month, 6 months and 1 year after surgery. Sixty six patients (88%) were available for the study. The length of stay (4.7 vs. 8.2 days, p = 0.0002), the reprisal of oral intake (II post-op vs. III post-op, p = 0.02) the number of transfused patients (2 vs. 8, p = 0.1) and the overall rate of morbidity (p = 0.06) were lower in the laparoscopic group.HRQOL was significantly better in the laparoscopic group in the first year after surgery. Surgical treatment for benign liver lesions, when indicated, should be laparoscopic. This approach shows a lower rate of surgical complications with a better quality of life after surgery and a faster reprisal of social and job activities.

The impact of variation in access to care on the management of Hirschsprung disease

INTRODUCTION

Variation in access to care has a significant impact on the disease management process and outcomes. Variable access to care might have similar effects on the management of Hirschsprung disease (HD). However, such variation has not been highlighted.

MATERIALS AND METHODS

All patients referred to 3 academic centers (ACs) with HD were reviewed. Patient presentations, referral patterns, timing, and type of surgical intervention were compared between patients born in AC and those born in non-AC. Babies born with major congenital anomalies (MCAs) or total colonic HD were excluded.

RESULTS

Between 1998 and 2011, 129 patients were identified. After excluding 30 patients, 99 were split into 20 inborn patients (AC) and 79 outborn patients. Outborn patients more often presented with constipation (95% vs 65%, P = .001), whereas inborn patients presented with feeding intolerance or vomiting (75% vs 39%, P = .004). Outborn patients were diagnosed and had their pull-through (PT) at an older median age (in days) of 186 (1-2621) vs 4.5 (1-451) (P = .001) and 345 (11-2757) vs 92 (3-928) (P = .001), respectively. Moreover, inborn patients were more likely to undergo primary PT (75% vs 46%, P = .02) and avoid bowel diversion (95% vs 66%, P = .02).

CONCLUSION

Variation in access to care can have a significant impact on the quality of care delivery in HD. Limited access to AC is associated with staged PT in addition to delay in the diagnosis and management.

Patient reported outcomes and their importance in the development of novel surgical techniques

INTRODUCTION

Although traditional quality measures such as morbidity and mortality outcomes still pay an important role in the assessment of health care quality, greater emphasis is now being placed on patient-reported outcome measures such as patient satisfaction. This area is especially important for novel surgical technologies such as single-incision laparoscopic surgery (SILS) and natural orifice translumenal endoscopic surgery (NOTES). These new innovations are able to minimize or abolish surgical scarring and are likely to have most benefit in the area of patient satisfaction as opposed to traditional outcome measures. Therefore, it is important to gauge the public opinion regarding these new techniques, as continued public interest can help support further research in this up-and-coming field.

METHODS

A questionnaire study was carried out with members of the general public. Questions were asked regarding preference for surgical techniques, including open surgery, laparoscopic surgery, NOTES, and SILS, in the situation of acute appendicitis.

RESULTS

The questionnaire was completed by 1006 individuals. Results indicated that an established safety profile was necessary before the introduction of these new techniques into general practice. The concept of scarless surgery did appeal to the public, with SILS being the treatment of choice in the scenario of acute appendicitis.

DISCUSSION

The patient perspective on health care is an important aspect of health care quality assessment. This is especially important with regard to the development of novel surgical techniques such as SILS and NOTES. With these techniques, the potential benefits are most likely to be found in the realms of reduced scarring and improved patient satisfaction. The findings from this study demonstrate the public's interest in these new techniques and thus give further support to continued research and development in this area.

Establishing quality in colorectal surgery

AIM

The review aimed to offer a contemporary perspective of the quality of current colorectal surgery.

METHOD

A literature search was undertaken to identify relevant indicators. Citations were included if they related to quality in colorectal surgery. The search terms used included the Medical Subject Heading terms and Boolean characters: 'colon' OR 'colorectal', OR 'rectal' OR 'rectum' AND 'Quality Indicators', OR 'Quality Assurance', OR 'Quality of healthcare', OR 'Reference Standards', OR 'Quality' plus a variable floating term. A two-person independent review was undertaken from resulting citations and their consequent reference lists. The search was limited to citations from 2000 to 2010 in humans and to the English language.

RESULTS

Metrics identified as potential quality indicators in colorectal surgery are discussed according to the structure, process and outcome framework.

CONCLUSION

A clear appreciation of the scope of individual metrics for quality appraisal purposes is necessary if they are to be used meaningfully for performance benchmarking.