Clinical indicators in orthopaedic surgery

Risk-adjusted rates for potentially avoidable reoperations were computed from routine hospital data

OBJECTIVES

Reoperations may reflect a suboptimal initial surgical treatment. The study aimed to develop a screening algorithm for those potentially avoidable, using only routinely collected hospital data and a prediction model to adjust rates for case-mix.

STUDY DESIGN AND SETTING

Data of a 3-year random sample of 7,370 therapeutic operations on inpatients, among which 833 were followed-up by a reoperation during the same stay. A review of medical records identified clearly avoidable and other potentially avoidable reoperations to develop and test the screening algorithm. A logistic prediction model of potentially avoidable reoperations was developed on one randomly chosen half of the data (about 9,000 interventions) and tested on the other half (cross-validation).

RESULTS

Two hundred thirty-seven interventions (3%) were followed by a potentially avoidable reoperation, among which 144 were clearly avoidable. The screening algorithm had a sensitivity of 75% and a specificity of 72%. Predictors of potentially avoidable reoperations were surgery categories, diagnosis related conditions, and experiencing prior surgery. The risk score, based on these variables, showed at once a satisfactory discriminative performance (C-statistic=0.76) and goodness-of-fit measure on the validation set.

CONCLUSION

The adjusted rate of potentially avoidable reoperations should be included in internal reporting of hospital quality indicators, but further validated in various settings.

Accuracy of mandatory surgeon recording of unplanned return to theatre

BACKGROUND

Unplanned return to theatre (URTT) is a common performance indicator in surgery. The aim of this study is to determine the accuracy of recording URTT in orthopaedic surgery, and whether it is improved when recorded by the operating surgeon.

METHODS

All orthopaedic URTT at St. George Hospital (Kogarah, Australia), as recorded by nursing staff, from 1 January 2001 to 31 December 2001 were reviewed. The results were compared to a similar review for the period from 1 June 2002 to 31 May 2003, when data was entered by the operating surgeon.

RESULTS

In 2001, the true URTT rate was 68 out of a total of 2250 cases. Only 39 of these were recorded as URTT (sensitivity = 57%). Of the 2182 remaining cases, 34 were incorrectly reported as URTT (specificity = 98.4%). In the period June 2002-May 2003, the true URTT rate was 25 out of 2119 cases. Of these, 22 were correctly recorded (sensitivity = 88%). Of the 2094 remaining cases, 16 were incorrectly recorded as URTT (specificity = 99.2%). The differences in sensitivity and specificity between the two periods were statistically significant.

CONCLUSIONS

Unplanned return to theatre cases need to be reviewed individually to assess clinical significance. Mandatory surgeon reporting significantly increases the accuracy of data.

Early experience with clinical indicators in surgery

BACKGROUND

In 1997 a set of 53 clinical indicators developed by the Royal Australasian College of Surgeons (RACS) and the Australian Council on Healthcare Standards (ACHS) Care Evaluation Programme (CEP), was introduced into the ACHS Evaluation and Quality Improvement Programme (EQuIP). The clinical indicators covered 20 different conditions or procedures for eight specialty groups and were designed to act as flags to possible problems in surgical care.

METHODS

The development process took several years and included a literature review, field testing, and revision of the indicators prior to approval by the College council. In their first year 155 health-care organizations (HCO) addressed the indicators and this rose to 210 in 1998. Data were received from all states and both public and private facilities.

RESULTS

The collected data for 1997 and 1998 for some of the indicators revealed rates which were comparable with those reported in the international literature. For example, the rates of bile duct injury in laparoscopic cholecystectomy were 0.7 and 0.53%, respectively; the mortality rates for coronary artery graft surgery were 2.5 and 2.1%, respectively; the mortality rates after elective abdominal aortic aneurysm repair were 2.5 and 3.7%, respectively; and the post-tonsillectomy reactionary haemorrhage rates were 0.9 and 1.3%, respectively. Results for some indicators differed appreciably from other reports, flagging the need for further investigation; for example, the negative histology rates for appendectomy in children were 18.6 and 21.2%, respectively, and the rates for completeness of excision of malignant skin tumours were 90.7 and 90%, respectively. The significance of these figures, however, depends upon validation of the data and their reliability and reproducibility. Because reliability can be finally determined only at the hospital level they are of limited value for broader comparison.

CONCLUSION

The process of review established for the indicator set has led to refinement of some indicators through improvement of definitions, and to a considerable reduction in the number of indicators to 29 (covering 18 procedures), for the second version of the indicators (which was introduced for use from January 1999). The clinical indicator programme, as it has with other disciplines, hopefully will provide a stimulus to the modification and improvement of surgical practice. Clinician ownership should enhance the collection of reliable data and hence their usefulness.