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McLeod M, Leung K, Pramesh CS, Kingham P, Mutebi M, Torode J, Ilbawi A, Chakowa J, Sullivan R, Aggarwal A. Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals. BJS Open 2024; 8:zrae009. [PMID: 38513280 PMCID: PMC10957165 DOI: 10.1093/bjsopen/zrae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/16/2023] [Accepted: 12/17/2023] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups. METHODS A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level. RESULTS A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data. CONCLUSION Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.
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Affiliation(s)
- Megan McLeod
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Otolaryngology—Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kari Leung
- Department of Oncology, Guy’s & St Thomas’ NHS Trust, London, UK
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Julie Torode
- Institute of Cancer Policy, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Andre Ilbawi
- Department of Universal Health Coverage, World Health Organization, Geneva, Switzerland
| | | | - Richard Sullivan
- Institute of Cancer Policy, Global Oncology Group, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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2
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McLeod M, Torode J, Leung K, Bhoo-Pathy N, Booth C, Chakowa J, Gralow J, Ilbawi A, Jassem J, Parkes J, Mallafré-Larrosa M, Mutebi M, Pramesh CS, Sengar M, Tsunoda A, Unger-Saldaña K, Vanderpuye V, Yusuf A, Sullivan R, Aggarwal A. Quality indicators for evaluating cancer care in low-income and middle-income country settings: a multinational modified Delphi study. Lancet Oncol 2024; 25:e63-e72. [PMID: 38301704 DOI: 10.1016/s1470-2045(23)00568-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 02/03/2024]
Abstract
This Policy Review sourced opinions from experts in cancer care across low-income and middle-income countries (LMICs) to build consensus around high-priority measures of care quality. A comprehensive list of quality indicators in medical, radiation, and surgical oncology was identified from systematic literature reviews. A modified Delphi study consisting of three 90-min workshops and two international electronic surveys integrating a global range of key clinical, policy, and research leaders was used to derive consensus on cancer quality indicators that would be both feasible to collect and were high priority for cancer care systems in LMICs. Workshop participants narrowed the list of 216 quality indicators from the literature review to 34 for inclusion in the subsequent surveys. Experts' responses to the surveys showed consensus around nine high-priority quality indicators for measuring the quality of hospital-based cancer care in LMICs. These quality indicators focus on important processes of care delivery from accurate diagnosis (eg, histologic diagnosis via biopsy and TNM staging) to adequate, timely, and appropriate treatment (eg, completion of radiotherapy and appropriate surgical intervention). The core indicators selected could be used to implement systems of feedback and quality improvement.
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Affiliation(s)
- Megan McLeod
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Julie Torode
- Institute of Cancer Policy, Centre for Cancer, Society and Public Health, King's College London, London, UK
| | - Kari Leung
- Guy's and St Thomas' NHS Trust, London, UK
| | - Nirmala Bhoo-Pathy
- Department of Clinical Epidemiology, Universiti Malaya Medical Centre, Kuala Lampar, Malaysia
| | - Christopher Booth
- Department of Medical Oncology, Queen's University, Kingston, ON, Canada
| | | | - Julie Gralow
- American Society of Clinical Oncology, Alexandria, VA, USA
| | | | - Jacek Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland
| | - Jeannette Parkes
- Division of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Merixtell Mallafré-Larrosa
- City Cancer Challenge, Geneva, Switzerland; Department of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - C S Pramesh
- Department of Thoracic Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Audrey Tsunoda
- Department of Gynecologic Oncology, Pontifical Catholic University of Paraná, Curitiba, Brazil
| | | | - Verna Vanderpuye
- National Centre for Radiotherapy, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Aasim Yusuf
- Department of Gastroenterology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, Pakistan
| | - Richard Sullivan
- Institute of Cancer Policy, Centre for Cancer, Society and Public Health, King's College London, London, UK; Global Oncology Group, Centre for Cancer, Society and Public Health, King's College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Tan EJKW, Chen HLR, Chok AY, Tan IEH, Zhao Y, Lee RS, Ang KA, Au MKH, Ong HS, Ho HSS, Poopalalingam R, Tan HK, Kwek KYC. A reduction in hospital length of stay reduces costs for colorectal surgery: an economic evaluation of the National Surgical Quality Improvement Program in Singapore. Int J Colorectal Dis 2023; 38:257. [PMID: 37882868 DOI: 10.1007/s00384-023-04551-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE In 2017, the National Surgical Quality Improvement Program (NSQIP) was introduced in the Department of Colorectal Surgery at Singapore General Hospital as a pilot quality improvement initiative. This study aimed to examine the cost-effectiveness of NSQIP by evaluating its effects on surgical outcomes, length of stay (LOS), and costs. METHODS We retrospectively reviewed patients undergoing colorectal surgery (2017-2020). Patients were divided into two cohorts: pre-NSQIP (2017-2018) and post-NSQIP (2019-2020). Outcomes evaluated were 30-day postoperative complications, LOS, and costs. Total cost-savings from NSQIP intervention's impact on LOS were estimated using a decision model with a one-way sensitivity analysis. Multivariate logistic regression was performed to identify factors for prolonged LOS. RESULTS 1905 patients underwent colorectal surgery, with 996 in the pre-NSQIP cohort and 909 in the post-NSQIP cohort. A significant reduction in overall postoperative complications of 4.7% was observed in the post-NSQIP cohort (36.5% vs. 31.8%, p = 0.029). Patients in the post-NSQIP cohort had a shorter median LOS (8.0 vs. 6.0 days, p < 0.001). The implementation of NSQIP resulted in an 8.5% decrease in prolonged LOS > 6 days (p < 0.001), saving S$0.31 million on LOS. Total costs per case were reduced by 20.8% following NSQIP (S$39,539.05 vs. S$31,311.93, p < 0.001). CONCLUSION Implementing NSQIP has significantly reduced overall postoperative complications, LOS, and costs and achieved cost savings following colorectal surgery.
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Affiliation(s)
- Emile John Kwong Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Hui Lionel Raphael Chen
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Rachel Shiyi Lee
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Kwok Ann Ang
- Finance, Singapore General Hospital, Singapore, 169608, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
- Finance, Singhealth Community Hospitals, Singapore, 168582, Singapore
| | - Hock Soo Ong
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore, 169608, Singapore
| | - Henry Sun Sien Ho
- Department of Urology, Singapore General Hospital, Singapore, 169608, Singapore
| | - Ruban Poopalalingam
- Department of Anesthesiology, Singapore General Hospital, Singapore, 169608, Singapore
| | - Hiang Khoon Tan
- Singapore General Hospital, Singapore, 169608, Singapore
- SingHealth Duke-NUS Global Health Institute, Singapore, Singapore
| | - Kenneth Yung Chiang Kwek
- Singapore General Hospital, Singapore, 169608, Singapore
- Singapore Health Services, Singapore, 168582, Singapore
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4
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Celentano V, Manzo CA. Ten steps for ileoanal pouch anastomosis. Colorectal Dis 2023; 25:2093-2096. [PMID: 37583048 DOI: 10.1111/codi.16712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/17/2023]
Abstract
AIM Appropriate patient selection, surgical technique, and follow-up pathways can provide optimal functional outcomes and good quality of life in many patients undergoing ileoanal pouch surgery. The aim of this study was to demonstrate the standardised approach to ileoanal pouch formation that we have developed in our pouch surgery centre. METHODS We developed a structured approach to laparoscopic proctectomy with ileoanal pouch anastomosis formation, divided into 10 different steps. All patients referred to our centre from January 2020 to December 2022 for ulcerative colitis were included in the study. RESULTS A total of 38 consecutive patients underwent ileal pouch-anal anastomosis (IPAA) surgery. All procedures were completed laparoscopically with one conversion to open (2.6%). A total of 13 patients had postoperative complications within 30 days of surgery (34.2%), with six (15.8%) being Clavien Dindo class 3 or higher. Median follow-up length was 18 months (range 2-30). Median number of bowel movements in 24 h at 12 months post-surgery was 4 (range 1-11). CONCLUSIONS Our modular 10 steps approach could provide a standardised framework to surgeons in the learning curve. IPAA is a complex surgical procedure with significant postoperative morbidity. Our stepwise approach resulted in a high rate of minimally invasive surgery and could facilitate introduction of the technique.
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Affiliation(s)
- Valerio Celentano
- Inflammatory Bowel Disease and Ileoanal Pouch Surgery Centre, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Carlo Alberto Manzo
- Inflammatory Bowel Disease and Ileoanal Pouch Surgery Centre, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Coulman KD, Chalmers K, Blazeby J, Dixon J, Kow L, Liem R, Pournaras DJ, Ottosson J, Welbourn R, Brown W, Avery K. Development of a Bariatric Surgery Core Data Set for an International Registry. Obes Surg 2023; 33:1463-1475. [PMID: 36959437 PMCID: PMC10156789 DOI: 10.1007/s11695-023-06545-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE Bariatric and metabolic surgery is an effective treatment for severe and complex obesity; however, robust long-term data comparing operations is lacking. Clinical registries complement clinical trials in contributing to this evidence base. Agreement on standard data for bariatric registries is needed to facilitate comparisons. This study developed a Core Registry Set (CRS) - core data to include in bariatric surgery registries globally. MATERIALS AND METHODS Relevant items were identified from a bariatric surgery research core outcome set, a registry data dictionary project, systematic literature searches, and a patient advisory group. This comprehensive list informed a questionnaire for a two-round Delphi survey with international health professionals. Participants rated each item's importance and received anonymized feedback in round 2. Using pre-defined criteria, items were then categorized for voting at a consensus meeting to agree the CRS. RESULTS Items identified from all sources were grouped into 97 questionnaire items. Professionals (n = 272) from 56 countries participated in the round 1 survey of which 45% responded to round 2. Twenty-four professionals from 13 countries participated in the consensus meeting. Twelve items were voted into the CRS including demographic and bariatric procedure information, effectiveness, and safety outcomes. CONCLUSION This CRS is the first step towards unifying bariatric surgery registries internationally. We recommend the CRS is included as a minimum dataset in all bariatric registries worldwide. Adoption of the CRS will enable meaningful international comparisons of bariatric operations. Future work will agree definitions and measures for the CRS including incorporating quality-of-life measures defined in a parallel project.
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Affiliation(s)
- Karen D Coulman
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, BS8 2BN, UK.
- Bristol Centre for Surgical Research, University of Bristol, Bristol, BS8 2PS, UK.
- Obesity and Bariatric Surgery Service, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
| | - Katy Chalmers
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, BS8 2BN, UK
- Bristol Centre for Surgical Research, University of Bristol, Bristol, BS8 2PS, UK
| | - Jane Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, BS8 2BN, UK
- Bristol Centre for Surgical Research, University of Bristol, Bristol, BS8 2PS, UK
| | - John Dixon
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, 3122, Australia
| | - Lilian Kow
- College of Medicine and Public Health, Flinders University, Adelaide, 5042, Australia
| | - Ronald Liem
- Department of Surgery, Groene Hart Hospital, 2803 HH, Gouda, The Netherlands
| | - Dimitri J Pournaras
- Obesity and Bariatric Surgery Service, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Johan Ottosson
- School of Medical Sciences, Örebro University, 701 82, Örebro, Sweden
| | - Richard Welbourn
- Department of Upper GI and Bariatric Surgery, Somerset NHS Foundation Trust, Taunton, TA1 5DA, UK
| | - Wendy Brown
- Department of Surgery, Monash University, Melbourne, 3800, Australia
| | - Kerry Avery
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, BS8 2BN, UK
- Bristol Centre for Surgical Research, University of Bristol, Bristol, BS8 2PS, UK
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6
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Muirhead R, Aggarwal A. Real World Data - Does it Cut the Mustard or Should We Take it With a Pinch of Salt? Clin Oncol (R Coll Radiol) 2023; 35:15-19. [PMID: 36272863 DOI: 10.1016/j.clon.2022.09.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/16/2022] [Accepted: 09/26/2022] [Indexed: 01/05/2023]
Affiliation(s)
- R Muirhead
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - A Aggarwal
- Department of Clinical Oncology, Guy's & St Thomas' NHS Trust, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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7
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Celentano V, Rafique H, Jerome M, Lee YJ, Kontovounisious C, Warren O, MacDonald A, Wahed M, Mills S, Tekkis P. Development of a specialist ileoanal pouch surgery pathway: a multidisciplinary patient-centred approach. Frontline Gastroenterol 2022; 14:244-248. [PMID: 37056326 PMCID: PMC10086703 DOI: 10.1136/flgastro-2022-102267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
Background Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the gold standard procedure for ulcerative colitis refractory to medical treatment, as an alternative to permanent end ileostomy. Gaining experience in pouch surgery is difficult as the procedure is performed infrequently. This study presents an institutional initiative to promote standardisation of multidisciplinary care in IPAA surgery. Methods A dedicated pathway for patients who had an IPAA or are considering IPAA surgery was developed among colorectal surgeons, gastroenterologists, paediatric colorectal surgeons, inflammatory bowel disease (IBD) nurses, dietitians, stoma nurses, trainees in colorectal surgery. Pathway items were discussed and finalised via emails and videoconferences.The pathway included triaging of patients referred for IPAA surgery, preoperative IBD multidisciplinary team discussion and management plan for surgery, surgical review prior to surgery, peer to peer counselling, surgical technique, postoperative short-term and long-term follow-up, audit, research and training in IPAA surgery. Results A multidisciplinary preoperative pathway was developed and a stepwise approach to minimally invasive ileoanal pouch surgery was formalised. A dedicated one-stop ileoanal pouch clinic was established integrating endoscopy and imaging on the same day of the consultation with the surgical and gastroenterology team. The clinic reviewed 72 patients over 24 months, and during the same time 36 patients underwent IPAA surgery at our institution. Conclusions We have described our initial experience in establishing a specialist IPAA surgery pathway and have proposed outcome measures that we hope will support a subspecialty IPAA service.
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Affiliation(s)
- Valerio Celentano
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Henna Rafique
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Melanie Jerome
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Yu Jin Lee
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisious
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Oliver Warren
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alexander MacDonald
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mahmood Wahed
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sarah Mills
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paris Tekkis
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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8
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Parums DV. Editorial: Registries and Population Databases in Clinical Research and Practice. Med Sci Monit 2021; 27:e933554. [PMID: 34149048 PMCID: PMC8212698 DOI: 10.12659/msm.933554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Patient registries include data on patient diagnosis, demographics, treatment, and outcomes and are now fundamental to the provision of successful global health systems. Patient registries include mainly local, regional, and national patient data on general or specific patient groups. Global registries currently exist mainly for rare diseases. Some of the most studied registries include the national Surveillance, Epidemiology, and End Results (SEER) program and the hospital-based Medical Information Mart for Intensive Care (MIMIC-III) dataset. The limitations of registry databases have included lack of feedback from clinical studies to the clinical center, the lack of patient involvement, and limited findings on patient-reported outcomes (PROs). In September 2020, the European Medicines Agency (EMA) published its draft guidelines on registry-based clinical studies. Guidelines for the development and analysis of registry data will improve the quality and registry-based studies and increase the role of registry data to support clinical trials. This Editorial aims to present the current status of registries and population databases in clinical research and practice.
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Affiliation(s)
- Dinah V Parums
- Science Editor, Medical Science Monitor, International Scientific Information, Inc., Melville, NY, USA
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9
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Vicendese D, Marvelde LT, McNair PD, Whitfield K, English DR, Taieb SB, Hyndman RJ, Thomas R. Hospital characteristics, rather than surgical volume, predict length of stay following colorectal cancer surgery. Aust N Z J Public Health 2019; 44:73-82. [PMID: 31617657 DOI: 10.1111/1753-6405.12932] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/01/2019] [Accepted: 07/01/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Length of hospital stay (LOS) is considered a vital component for successful colorectal surgery treatment. Evidence of an association between hospital surgery volume and LOS has been mixed. Data modelling techniques may give inconsistent results that adversely impact conclusions. This study applied techniques to overcome possible modelling drawbacks. METHOD An additive quantile regression model formulated to isolate hospital contextual effects was applied to every colorectal surgery for cancer conducted in Victoria, Australia, between 2005 and 2015, involving 28,343 admissions in 90 Victorian hospitals. The model compared hospitals' operational efficiencies regarding LOS. RESULTS Hospital LOS operational efficiencies for colorectal cancer surgery varied markedly between the 90 hospitals and were independent of volume. This result was adjusted for pertinent patient and hospital characteristics. CONCLUSION No evidence was found that higher annual surgery volume was associated with lower LOS for patients undergoing colorectal cancer surgery. Our model showed strong evidence that differences in LOS efficiency between hospitals was driven by hospital contextual effects that were not predicted by provider volume. Further study is required to elucidate these inherent differences between hospitals. Implications for public health: Our model indicated improved efficiency would benefit the patient and medical system by lowering LOS and reducing expenditure by more than $3 million per year.
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Affiliation(s)
- Don Vicendese
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria.,Cancer Strategy and Development, Department of Health and Human Services, Victoria
| | - Luc Te Marvelde
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria.,Cancer Strategy and Development, Department of Health and Human Services, Victoria
| | - Peter D McNair
- The Victorian Agency for Health Information, The Department of Health and Human Services, Victoria.,The Melbourne School of Population and Global Health, The University of Melbourne, Victoria
| | - Kathryn Whitfield
- Cancer Strategy and Development, Department of Health and Human Services, Victoria
| | - Dallas R English
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria.,Centre for Epidemiology and Biostatistics, The University of Melbourne, Victoria
| | - Souhaib Ben Taieb
- Department of Econometrics and Business Statistics, Monash University, Victoria
| | - Rob J Hyndman
- Department of Econometrics and Business Statistics, Monash University, Victoria
| | - Robert Thomas
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria
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Chen YW, Ornstein MC, Wood LS, Allman KD, Martin A, Beach J, Gilligan T, Garcia JA, Rini BI. The association between facility case volume and overall survival in patients with metastatic renal cell carcinoma in the targeted therapy era. Urol Oncol 2018; 36:470.e19-470.e29. [DOI: 10.1016/j.urolonc.2018.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/27/2018] [Accepted: 06/27/2018] [Indexed: 12/25/2022]
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Nelson EC, Dixon-Woods M, Batalden PB, Homa K, Van Citters AD, Morgan TS, Eftimovska E, Fisher ES, Ovretveit J, Harrison W, Lind C, Lindblad S. Patient focused registries can improve health, care, and science. BMJ 2016; 354:i3319. [PMID: 27370543 PMCID: PMC5367618 DOI: 10.1136/bmj.i3319] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Eugene Nelson and colleagues call for registries of care data to be transformed into patient centred interactive learning systems
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Affiliation(s)
- Eugene C Nelson
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Mary Dixon-Woods
- Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Paul B Batalden
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Karen Homa
- Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Aricca D Van Citters
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Tamara S Morgan
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Elena Eftimovska
- Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Elliott S Fisher
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - John Ovretveit
- Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Wade Harrison
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Cristin Lind
- Quality Register Center Stockholm, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden
| | - Staffan Lindblad
- Medical Management Centre, Karolinska Institutet, Stockholm, Sweden Quality Register Center Stockholm, Karolinska Institutet and Stockholm County Council, Stockholm, Sweden
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Addressing unwarranted variations in colorectal cancer outcomes: a conceptual approach. Nat Rev Clin Oncol 2016; 13:706-712. [PMID: 27349194 DOI: 10.1038/nrclinonc.2016.94] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In the clinical setting, the term 'unwarranted variation' refers to variations in patient outcomes that cannot be explained by the patient's underlying illness or medical needs, or the dictates of evidence-based medicine. These types of variations persist even after adjusting for patient-specific factors. Unwarranted variation depends on a complex mix of disparities, including inequalities in access to appropriate care in a wide variety of geographical and cultural settings, in the uptake and application of clinical knowledge, in the prioritization and allocation of resources, and differences in organizational and professional culture. Nevertheless, unwarranted variation has been inexorably linked with clinical practice. Thus, awareness of the antecedents of unwarranted variations in clinical practice is strategically important. In this Perspective, we discuss these antecedents in colorectal cancer clinical care pathways with an emphasis upon the multidisciplinary team (MDT), and suggest pragmatic steps that could be taken to address latent unwarranted variation.
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Chen YW, Mahal BA, Muralidhar V, Nezolosky M, Beard CJ, Den RB, Feng FY, Hoffman KE, Martin NE, Orio PF, Nguyen PL. Association Between Treatment at a High-Volume Facility and Improved Survival for Radiation-Treated Men With High-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2016; 94:683-90. [DOI: 10.1016/j.ijrobp.2015.12.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/22/2015] [Accepted: 12/08/2015] [Indexed: 11/30/2022]
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de Cruppé W, Malik M, Geraedts M. Achieving minimum caseload requirements: an analysis of hospital quality control reports from 2004-2010. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:549-55. [PMID: 25220064 DOI: 10.3238/arztebl.2014.0549] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Legally mandated minimum hospital caseload requirements for certain invasive procedures, including pancreatectomy, esophagectomy, and some types of organ transplantation, have been in effect in Germany since 2004. The goal of such requirements is to improve patient care by ensuring that patients undergo certain procedures only in hospitals that have met the corresponding minimum caseload requirement. We used the case numbers published in legally mandated hospital quality control reports to determine whether the hospitals actually met the stipulated requirements. METHOD We performed a secondary analysis of data supplied by hospitals in their quality control reports for the years 2004, 2006, 2008, and 2010 with respect to six procedures that have a minimum caseload requirement: complex interventions on the esophagus and pancreas, total knee replacement, and hepatic, renal, and stem-cell transplantation. RESULTS The total case numbers for these six different procedures rose from 22 064 (0.1% of all procedures) in 2004 to 170 801 (0.9% of all procedures) in 2010. From 2006 onward, procedures to which minimum caseload requirements apply have been carried out in half of all hospitals studied. These procedures account for 0.9% of all inpatient cases in Germany. The percentage of hospitals that continue to perform certain procedures despite not having met the minimum caseload requirement ranged from 5% to 45%, depending on the type of procedure, and the percentage of cases carried out in such hospitals ranged from 1% to 15%. These values remained nearly constant for each of the six minimum caseload requirements over the 4 reporting years for which data were examined. CONCLUSION The establishment of minimum caseload requirements in Germany in 2004 did not lessen the number of cases performed in violation of these requirements over the period 2004 to 2010.
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Completeness and registration bias in PROCARE, a Belgian multidisciplinary project on cancer of the rectum with participation on a voluntary basis. Eur J Cancer 2015; 51:1099-108. [DOI: 10.1016/j.ejca.2014.02.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/27/2014] [Accepted: 02/27/2014] [Indexed: 12/14/2022]
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Liu CJ, Chou YJ, Teng CJ, Lin CC, Lee YT, Hu YW, Yeh CM, Chen TJ, Huang N. Association of surgeon volume and hospital volume with the outcome of patients receiving definitive surgery for colorectal cancer: A nationwide population-based study. Cancer 2015; 121:2782-90. [PMID: 25892632 DOI: 10.1002/cncr.29356] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 02/05/2015] [Accepted: 02/11/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with colorectal cancer (CRC) who undergo cancer surgeries with higher-volume providers may have better outcomes. The current debate focuses on whether it is hospital volume or surgeon volume that matters more. METHODS The authors conducted a nationwide population-based study in Taiwan that enrolled all patients who underwent definitive surgery for newly diagnosed CRC between 2005 and 2011. All patients were divided into 4 quartiles according to hospital and surgeon volume. The main outcome was the 5-year mortality rate, which was analyzed using a frailty model for Cox regression. The authors also conducted fixed and random effects multivariate regression models to examine short-term outcomes and resource use, including operative mortality, hospital stay, emergency department visits within 30 days, and medical expenses. Analyses were adjusted for patient and provider characteristics. RESULTS A total of 61,728 patients with CRC were included in the current study. The 5-year mortality rates were 38.7%, 32.8%, 32.0%, and 29.1% in descending order of hospital volume quartiles and were 41.4%, 34.1%, 29.8%, and 27.4% in descending order of surgeon volume quartiles. After adjustment for the individual and provider characteristics, surgeon volume, but not hospital volume, remained a significantly predictive factor of death (P<.001). In addition, those patients with CRC who underwent definitive surgeries performed by higher-volume surgeons had a relatively lower risk of operative mortality, shorter hospital length of stay, and lower medical expenses. CONCLUSIONS Patients with CRC who underwent definitive surgery performed by higher-volume providers were found to have better outcomes. Surgeon volume may play a more important role than hospital volume. Cancer 2015;121:2782-2790. © 2015 American Cancer Society.
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Affiliation(s)
- Chia-Jen Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Yiing-Jenq Chou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Jen Teng
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,Division of Oncology and Hematology, Department of Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chun-Chi Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Ting Lee
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wen Hu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chiu-Mei Yeh
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzeng-Ji Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
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Liu CJ, Huang N, Lin CC, Lee YT, Hu YW, Yeh CM, Chen TJ, Chou YJ. Outcome disparities between medical personnel and nonmedical personnel patients receiving definitive surgery for colorectal cancer: a nationwide population-based study. Medicine (Baltimore) 2015; 94:e402. [PMID: 25634168 PMCID: PMC4602941 DOI: 10.1097/md.0000000000000402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/04/2014] [Accepted: 12/05/2014] [Indexed: 11/25/2022] Open
Abstract
Disparities in quality of care have always been a major challenge in health care. Providing information to patients may help to narrow such disparities. However, the relationship between level of patient information and outcomes remains to be explored. More importantly, would better-informed patients have better outcomes through their choice of higher quality providers? We hypothesize that medical professionals may have better outcomes than nonmedical professionals following definitive surgery for colorectal cancer (CRC), and their choice of provider may mediate this relationship. We identified 61,728 patients with CRC receiving definitive surgery between 2005 and 2011 from the Taiwan National Health Insurance Research Database. Medical professionals were identified via the registry for medical personnel. Indicators for surgical outcome such as emergency room (ER) visits within 30 days, medical expenses, length of hospital stay (LOS), and 5-year mortality were analyzed by using fixed and random effects multivariate regression models. Compared with nonmedical personnel CRC patients, a greater proportion of medical personnel received definitive surgery from higher volume surgeons (median 390 vs 311 within the study period) and/or in higher volume hospitals (median 1527 vs 1312 within the study period). CRC patients who are medical personnel had a shorter median LOS (12 vs 14 days), lower median medical expenses (112,687 vs 121,332 New Taiwan dollars), a lower ER visit rate within 30 days (11.3% vs 13.0%), and lower 5-year mortality. After adjusting for patient characteristics, medical personnel had a significantly lower hazard of 5-year mortality, and were significantly more likely to have a LOS shorter than 14 days than their nonmedical personnel counterparts. However, after adjusting for patient and provider characteristics, while medical personnel were significantly less likely to have a long LOS, no significant difference was observed in 5-year mortality between the 2 groups. Medical personnel did have a significantly better survival outcome and a shorter length of stay following definitive surgery than nonmedical personnel patients. The outcome disparities can be partially explained by characteristics of their treatment providers. The findings may serve as an important reference for better understanding how information may narrow gaps in quality of care through better choice of providers.
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Affiliation(s)
- Chia-Jen Liu
- From the Division of Hematology and Oncology (C-JL, Y-TL), Department of Medicine, Taipei Veterans General Hospital; School of Medicine (C-JL, C-CL, Y-WH, T-JC); Institute of Public Health (C-JL, Y-JC); Institute of Hospital and Health Care Administration (NH), National Yang-Ming University; Division of Colon and Rectal Surgery (C-CL), Department of Surgery; Cancer Center (Y-WH); Department of Family Medicine (C-MY, T-JC), Taipei Veterans General Hospital, Taipei, Taiwan
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Voigt W, Hoellthaler J, Magnani T, Corrao V, Valdagni R. 'Act on oncology' as a new comprehensive approach to assess prostate cancer centres--method description and results of a pilot study. PLoS One 2014; 9:e106743. [PMID: 25192213 PMCID: PMC4156386 DOI: 10.1371/journal.pone.0106743] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 08/01/2014] [Indexed: 11/26/2022] Open
Abstract
Background Multidisciplinary care of prostate cancer is increasingly offered in specialised cancer centres. It requires the optimisation of medical and operational processes and the integration of the different medical and non-medical stakeholders. Objective To develop a standardised operational process assessment tool basing on the capability maturity model integration (CMMI) able to implement multidisciplinary care and improve process quality and efficiency. Design, Setting, and Participants Information for model development was derived from medical experts, clinical guidelines, best practice elements of renowned cancer centres, and scientific literature. Data were organised in a hierarchically structured model, consisting of 5 categories, 30 key process areas, 172 requirements, and more than 1500 criteria. Compliance with requirements was assessed through structured on-site surveys covering all relevant clinical and management processes. Comparison with best practice standards allowed to recommend improvements. ‘Act On Oncology’(AoO) was applied in a pilot study on a prostate cancer unit in Europe. Results and Limitations Several best practice elements such as multidisciplinary clinics or advanced organisational measures for patient scheduling were observed. Substantial opportunities were found in other areas such as centre management and infrastructure. As first improvements the evaluated centre administration described and formalised the organisation of the prostate cancer unit with defined personnel assignments and clinical activities and a formal agreement is being worked on to have structured access to First-Aid Posts. Conclusions In the pilot study, the AoO approach was feasible to identify opportunities for process improvements. Measures were derived that might increase the operational process quality and efficiency.
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Affiliation(s)
- Wieland Voigt
- Siemens AG, Healthcare Sector, Customer Solutions Division, H CX CRM-VA HCC ONC, Erlangen, Germany
- * E-mail:
| | - Josef Hoellthaler
- Siemens AG, Healthcare Sector, Customer Solutions Division, H CX CRM-VA HCC ONC, Erlangen, Germany
| | - Tiziana Magnani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Vito Corrao
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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The Dutch Surgical Colorectal Audit. Eur J Surg Oncol 2013; 39:1063-70. [DOI: 10.1016/j.ejso.2013.05.008] [Citation(s) in RCA: 223] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 04/01/2013] [Accepted: 05/08/2013] [Indexed: 01/02/2023] Open
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Shi HY, Chang HT, Culbertson R, Chen YJ, Liao YC, Hou MF. Breast cancer surgery volume-cost associations: Hierarchical linear regression and propensity score matching analysis in a nationwide Taiwan population. Surg Oncol 2013; 22:178-83. [DOI: 10.1016/j.suronc.2013.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 05/27/2013] [Accepted: 05/28/2013] [Indexed: 01/18/2023]
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Brisinda G, Vanella S, Maria G, Crocco A, Lombardi CP. Anastomotic leak and local recurrence in colorectal cancer. Ann Surg 2012; 256:e32-3; author reply e34. [PMID: 23108131 DOI: 10.1097/sla.0b013e31827693db] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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