Thirty-day mortality after surgery for colorectal cancer in Denmark

Comparing colon cancer outcomes: The impact of low hospital case volume and case-mix adjustment

OBJECTIVE

When comparing performance across hospitals it is essential to consider the noise caused by low hospital case volume and to perform adequate case-mix adjustment. We aimed to quantify the role of noise and case-mix adjustment on standardized postoperative mortality and anastomotic leakage (AL) rates.

METHODS

We studied 13,120 patients who underwent colon cancer resection in 85 Dutch hospitals. We addressed differences between hospitals in postoperative mortality and AL, using fixed (ignoring noise) and random effects (incorporating noise) logistic regression models with general and additional, disease specific, case-mix adjustment.

RESULTS

Adding disease specific variables improved the performance of the case-mix adjustment models for postoperative mortality (c-statistic increased from 0.77 to 0.81). The overall variation in standardized mortality ratios was similar, but some individual hospitals changed considerably. For the standardized AL rates the performance of the adjustment models was poor (c-statistic 0.59 and 0.60) and overall variation was small. Most of the observed variation between hospitals was actually noise.

CONCLUSION

Noise had a larger effect on hospital performance than extended case-mix adjustment, although some individual hospital outcome rates were affected by more detailed case-mix adjustment. To compare outcomes between hospitals it is crucial to consider noise due to low hospital case volume with a random effects model.

Preliminary results of the first quality assurance project in rectal cancer in Poland

When compared with other EU countries, Poland is in the last place in terms of efficacy of rectal cancer treatment. In order to remedy this situation, in 2008 Polish centres were given the opportunity to participate in an international programme for evaluating the treatment efficacy.The aim of the study was to present the results obtained during the first two years of research.

MATERIAL AND METHODS

The study protocol covered 71 questions concerning demographic data, diagnostics, risk factors, peri- and post-operative complications, histopathology, and treatment plan at discharge. The patient and unit data were kept confidential.

RESULTS

From 1 January 2008 to 30 December 2009, there were 709 patients recorded, of which 55.9% were males. At least one risk factor was found in approx. 3/4 of patients, while approx. 1/3 of patients were classified to group 3 and 4 according to ASA. The mean distance of the tumour from the anal margin was 8.5 cm; approx. 70% of patients were in the clinical stages cT3 and cT4; metastases were observed in 18.8%. Transrectal endoscopic ultrasonography (TREUS) was performed in 23.7% of patients, magnetic resonance imaging (MRI) in 2.5% and computed tomography (CT) scan - in 48.1%. In close to half of the patients, anterior or low anterior resection of the rectum was performed, and abdominoperineal resection in 1/4 of the patients. Anastomotic leakage was seen in 3.8% of patients, while 1.8% died during hospitalisation.

CONCLUSIONS

It should be strived after that all the centres undertaking the treatment of rectal cancer should participate in the quality assurance programme. This should enable the achievement of good therapeutic results in patients with rectal cancer treated in Polish centres.

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.

Colorectal cancer prognosis twenty years later

AIM: To evaluate changes in colorectal cancer (CRC) survival over the last 20 years.

METHODS: We compared two groups of consecutive CRC patients that were prospectively recruited: Group I included 1990 patients diagnosed between 1980 and 1994. Group II included 871 patients diagnosed in 2001.

RESULTS: The average follow up time was 21 mo (1-229) for Group I and 50 mo (1-73.4) for Group II. Overall median survival was significantly longer in Group II than in Group I (73 mo vs 25 mo, P < 0.001) and the difference was significant for all tumor stages. Post surgical mortality was 8% for Group Iand 2% for Group II (P < 0.001). Only 17% of GroupI patients received chemotherapy compared with 50% of Group II patients (P < 0.001).

CONCLUSION: Survival in colorectal cancer patients has doubled over the past 20 years. This increase seems to be partly due to the generalization in the administration of chemotherapy and to the decrease of post surgical mortality.

[Postoperative mortality risk factors in colorectal cancer: follow up of a cohort in a specialised unit]

INTRODUCTION

The treatment of colorectal cancer (CRC) is usually surgical and involves morbidity-mortality. The aim of this study is to quantify the postoperative mortality in our hospital and to determine their risk factors.

MATERIALS AND METHODS

Prospective observational study from 1996 to 2007 included 1017 patients who underwent surgery for CRC in our hospital. Identification of independent risk factors for postoperative mortality by multivariate analysis.

RESULTS

The mean age was 67.8 years. The surgery was elective in 879 (86.5%) and was considered curative in 878 (86.1%). The postoperative mortality was 3.6% (37 patients), 2.5% in the elective surgery and 10.9% in the urgent. The independent risk factors identified were: type of surgery (odds ratio for urgent vs. elective=2.8), American Society of Anesthesiologists (ASA) grade (odds ratio for ASA III-IV vs. I-II=2.4), age (odds ratio for age > or = 85 vs. < or = 74=7.6 and age 75-84 vs. < or = 74=2.4).

CONCLUSIONS

We found a low postoperative mortality, which was mainly associated with age over 75 years, ASA III or IV stages and urgent surgery.

Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer

BACKGROUND

Only a few small studies have evaluated risk factors related to early death following emergency surgery for colonic cancer. The aim of this study was to identify risk factors for death within 30 days after such surgery.

METHODS

Some 2157 patients who underwent emergency treatment for colonic cancer from May 2001 to December 2005 were identified from the national colorectal cancer registry. Thirty-day mortality rates were calculated and risk factors for early death were identified using logistic regression analysis.

RESULTS

The overall 30-day mortality rate was 22.1 per cent. The strongest risk factor for early death was postoperative medical complications (cardiopulmonary, renal, thromboembolic and infectious), with an odds ratio of 11.7 (95 per cent confidence interval 8.8 to 15.5). Such complications occurred in 24.4 per cent of patients, of whom 57.8 per cent died. Other independent risk factors were age at least 71 years, male sex, American Society of Anesthesiologists grade III or more, palliative outcome, tumour perforation, splenectomy and adverse intraoperative surgical events. Postoperative surgical complications were noted in 20.4 per cent of the patients but had no statistically significant influence on mortality.

CONCLUSION

Emergency surgery for colonic cancer is still associated with an increased risk of death. There is a need for a system providing increased safety in the perioperative period.

How do patients with colorectal cancer perceive treatment and care compared with the treating health care professionals?

BACKGROUND

Patient evaluations are widely used in quality assessment of health services. It is widely recognized that patients and professionals provide a different perspective on quality. However, the extent to which they differ and the conceptual areas in which they differ is not well understood.

OBJECTIVES

We sought to examine how well professional and patient assessments of hospital health care correspond.

METHODS

We undertook a prospective study in which information from a national clinical register was combined with questionnaires to patients, surgeons, and nurses. The study included 527 patients after surgery for colorectal cancer. The patients and their professionals assessed the same questions. For 336 patients, all questionnaires and register information were available. The response rate was 64%. The main measures were assessments of technical, interpersonal, and organizational aspects of care. Agreement was analyzed by kappa statistic, kappa, and McNemar's test.

RESULTS

Comparing assessments of technical surgical care kappa statistic demonstrated moderate-to-almost perfect agreement (0.35 <or= kappa <or= 0.95). Assessments of technical nursing care demonstrated slight agreement (0.19 <or= kappa <or= 0.26). Comparing answers to questions on interpersonal or organizational care, kappa statistic revealed only slight or no more agreement than expected by chance (-0.06 <or= kappa <or= 0.30). For several items, McNemar's test revealed a significant difference in the distribution of answers.

CONCLUSIONS

Within a Danish population undergoing treatment of colorectal cancer, there were significant differences in perceptions of care between patients and health professionals. In particular, health professionals and readers of reports on patient evaluations ought to remember that patients' perspective is just one source of information in assessment of hospital health care.