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Ayala R, Gewehr DM, Godoi A, Velasquez C, Fernandez M, Carvalho PEP, Goebel N. Preoperative Levosimendan in Patients With Severe Left Ventricular Dysfunction Undergoing Isolated Coronary Artery Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2024; 38:649-659. [PMID: 38228424 DOI: 10.1053/j.jvca.2023.11.036] [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: 09/28/2023] [Revised: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To verify the impact of preoperative levosimendan on patients with severe left ventricular dysfunction (ejection fraction <35%) undergoing isolated coronary artery bypass grafting. DESIGN A meta-analysis. SETTING Hospitals. PARTICIPANTS The authors included 1,225 patients from 6 randomized controlled trials. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors performed a meta-analysis of trials that compared preoperative levosimendan with placebo or no therapy, reporting efficacy and safety endpoints. Statistical analyses used mean differences and risk ratios (RR), with a random effects model. Six studies were included, comprising 1,225 patients, of whom 615 (50.2%) received preoperative levosimendan, and 610 (49.8%) received placebo/no therapy. Preoperative levosimendan showed a lower risk of all-cause mortality (RR 0.31; 95% CI 0.16-0.60; p < 0.01; I2 = 0%), postoperative acute kidney injury (RR 0.44; 95% CI 0.25-0.77; p < 0.01; I2 = 0%), low-cardiac-output syndrome (RR 0.45; 95% CI 0.30-0.66; p < 0.001; I2 = 0%), and postoperative atrial fibrillation (RR 0.49; 95% CI 0.25-0.98; p = 0.04; I2 = 85%) compared to control. Moreover, levosimendan significantly reduced the need for postoperative inotropes and increased the cardiac index at 24 hours postoperatively. There were no differences between groups for perioperative myocardial infarction, hypotension, or any adverse events. CONCLUSION Preoperative levosimendan in patients with severe left ventricular dysfunction undergoing isolated coronary artery bypass grafting was associated with reduced all-cause mortality, low-cardiac-output syndrome, acute kidney injury, postoperative atrial fibrillation, and the need for circulatory support without compromising safety.
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Affiliation(s)
- Rafael Ayala
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany.
| | | | - Amanda Godoi
- Cardiff University School of Medicine, Wales, United Kingdom
| | | | - Miguel Fernandez
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Pedro E P Carvalho
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Nora Goebel
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Antonacci G, Whitney J, Harris M, Reed JE. How do healthcare providers use national audit data for improvement? BMC Health Serv Res 2023; 23:393. [PMID: 37095495 PMCID: PMC10123973 DOI: 10.1186/s12913-023-09334-6] [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: 10/03/2022] [Accepted: 03/23/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Substantial resources are invested by Health Departments worldwide in introducing National Clinical Audits (NCAs). Yet, there is variable evidence on the NCAs' effectiveness and little is known on factors underlying the successful use of NCAs to improve local practice. This study will focus on a single NCA (the National Audit of Inpatient Falls -NAIF 2017) to explore: (i) participants' perspectives on the NCA reports, local feedback characteristics and actions undertaken following the feedback underpinning the effective use of the NCA feedback to improve local practice; (ii) reported changes in local practice following the NCA feedback in England and Wales. METHODS Front-line staff perspectives were gathered through interviews. An inductive qualitative approach was used. Eighteen participants were purposefully sampled from 7 of the 85 participating hospitals in England and Wales. Analysis was guided by constant comparative techniques. RESULTS Regarding the NAIF annual report, interviewees valued performance benchmarking with other hospitals, the use of visual representations and the inclusion of case studies and recommendations. Participants stated that feedback should target front-line healthcare professionals, be straightforward and focused, and be delivered through an encouraging and honest discussion. Interviewees highlighted the value of using other relevant data sources alongside NAIF feedback and the importance of continuous data monitoring. Participants reported that engagement of front-line staff in the NAIF and following improvement activities was critical. Leadership, ownership, management support and communication at different organisational levels were perceived as enablers, while staffing level and turnover, and poor quality improvement (QI) skills, were perceived as barriers to improvement. Reported changes in practice included increased awareness and attention to patient safety issues and greater involvement of patients and staff in falls prevention activities. CONCLUSIONS There is scope to improve the use of NCAs by front-line staff. NCAs should not be seen as isolated interventions but should be fully embedded and integrated into the QI strategic and operational plans of NHS trusts. The use of NCAs could be optimised, but knowledge of them is poor and distributed unevenly across different disciplines. More research is needed to provide guidance on key elements to consider throughout the whole improvement process at different organisational levels.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Julie Whitney
- Department of Physiotherapy, King's College London, London, UK
| | - Matthew Harris
- Department of Primary Care and Public Health, Imperial College London, South Kensington, UK
| | - Julie E Reed
- School of Health and Welfare, Halmstad University, Halmstad, Sweden
- Julie Reed Consultancy Ltd, London, UK
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Treacy PJ, Toonson P, Blackadder H. Effective peer review audit and identification of the surgeon outlier. ANZ J Surg 2023; 93:1176-1180. [PMID: 36809578 DOI: 10.1111/ans.18343] [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: 01/18/2023] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit. METHODS All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT). RESULTS A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored. CONCLUSION The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.
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Affiliation(s)
- P John Treacy
- Northern Territory Medical School, Flinders University of South Australia, Adelaide, South Australia, Australia.,Department of Surgery, Royal Darwin Hospital, Northern Territory Department of Health, Darwin, Northern Territory, Australia
| | - Philip Toonson
- Department of Surgery, Royal Darwin Hospital, Northern Territory Department of Health, Darwin, Northern Territory, Australia
| | - Helen Blackadder
- Department of Surgery, Royal Darwin Hospital, Northern Territory Department of Health, Darwin, Northern Territory, Australia
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Patel A, Ngo L, Woodman RJ, Aliprandi-Costa B, Bennetts J, Psaltis PJ, Ranasinghe I. Institutional variation in early mortality following isolated coronary artery bypass graft surgery. Int J Cardiol 2022; 362:35-41. [PMID: 35504451 DOI: 10.1016/j.ijcard.2022.04.080] [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: 11/29/2021] [Revised: 04/04/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thirty-day mortality following coronary artery bypass grafting (CABG) is a widely accepted marker for quality of care. Although surgical mortality has declined, the utility of this measure to profile quality has not been questioned. We assessed the institutional variation in risk-standardised mortality rates (RSMR) following isolated CABG within Australia and New Zealand (ANZ). METHODS We used an administrative dataset from all public and most private hospitals across ANZ to capture all isolated CABG procedures recorded between 2010 and 2015. The primary outcome was all-cause death occurring in-hospital or within 30-days of discharge. Hospital-specific RSMRs and 95% CI were estimated using a hierarchical generalised linear model accounting for differences in patient characteristics. RESULTS Overall, 60,953 patients (mean age 66.1 ± 10.1y, 18.7% female) underwent an isolated CABG across 47 hospitals. The observed early mortality rate was 1.69% (n = 1029) with 81.8% of deaths recorded in-hospital. The risk-adjustment model was developed with good discrimination (C-statistic = 0.81). Following risk-adjustment, a 3.9-fold variation was observed in RSMRs among hospitals (median:1.72%, range:0.84-3.29%). Four hospitals had RSMRs significantly higher than average, and one hospital had RSMR lower than average. When in-hospital mortality alone was considered, the median in-hospital RSMR was 1.40% with a 5.6-fold variation across institutions (range:0.57-3.19%). CONCLUSIONS Average mortality following isolated CABG is low across ANZ. Nevertheless, in-hospital and 30-day mortality vary among hospitals, highlighting potential disparities in care quality and the enduring usefulness of 30-day mortality as an outcome measure. Clinical and policy intervention, including participating in clinical quality registries, are needed to standardise CABG care.
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Affiliation(s)
- Aayush Patel
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Linh Ngo
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Australia; Cardiovascular Centre, E Hospital, Hanoi, Viet Nam
| | - Richard J Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, South Australia, Australia
| | | | - Jayme Bennetts
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia; Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, Australia; Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Isuru Ranasinghe
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Australia.
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6576628. [DOI: 10.1093/ejcts/ezac284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/19/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
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Han A, Park J. Disparate Impacts of Two Public Reporting Initiatives on Clinical and Perceived Quality in Healthcare. Risk Manag Healthc Policy 2021; 14:5015-5025. [PMID: 34938137 PMCID: PMC8685764 DOI: 10.2147/rmhp.s337596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Transparency is increasingly viewed as a prerequisite for value-based health care that invites quality in the assessment of achieved value. However, nowadays the ability of transparency initiatives to enhance quality of care remains obscure, if not rejected. Thus, this study aims to investigate how transparency initiatives influence two types of quality of care: clinical and perceived quality. Methods First, factor analyses were conducted to construct three dependent variables: healthcare-associated infections (HAIs), 30-day readmission rates, and patient satisfaction. Then, the three quality models were compared by running ordinary least squares multiple regressions using STATA 14.1. The existence of heteroskedasticity was remedied by using robust standard errors. Results Examining general acute care hospitals in the US, the present study noted that the ability of public reporting to improve quality of care remains inconclusive and that the pursuit of transparency may lead to inadvertent results. The disclosure of all-payer claims data (APCD) was found to have the power to differentiate hospitals’ clinical and perceived quality, but it failed to reach the desired outcomes without market pressure. The impact of transparency on quality of care diverges depending on the unique characteristics of each transparency policy, even though they pursue the same ends through information dissemination. Furthermore, the same public policy showed starkly disparate impacts on clinical quality (eg, healthcare-associated infections (HAIs) and 30-day readmission rates) and perceived quality (eg, patient satisfaction). Conclusion Despite the theoretically acknowledged merits of transparency, the present study noted that its ability to enhance quality of care remains inconclusive, and the pursuit of transparency may even inadvertently harm quality of care. While hospitals may need to finetune their strategies for each quality measurement in order to cope with the new environmental pressure, it is health policymakers’ role to coordinate those quality metrics and improve the validity of patient experience measures and surveys.
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Affiliation(s)
- Ahreum Han
- Department of Health Care Administration, Trinity University, San Antonio, TX, USA
| | - Jongsun Park
- Department of Public Administration, Gachon University, Seongnam-si, Gyeonggi-do, South Korea
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Karhade AV, Sisodia RC, Bono CM, Fogel HA, Hershman SH, Cha TD, Doorly TP, Kang JD, Schwab JH, Tobert DG. Surgeon-level variance in achieving clinical improvement after lumbar decompression: the importance of adequate risk adjustment. Spine J 2021; 21:405-410. [PMID: 33039548 DOI: 10.1016/j.spinee.2020.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/23/2020] [Accepted: 10/05/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patient-Reported Outcome Measurement Information System (PROMIS) scores are increasingly utilized in clinical care. However, it is unclear if PROMIS can discriminate surgeon performance on an individual level. PURPOSE The purpose of this study was to examine surgeon-level variance in rates of achieving minimal clinically important difference (MCID) after lumbar decompression. PATIENT SAMPLE This is a prospective, observational cohort study performed across a healthcare enterprise (two academic medical centers and three community centers). Patients 18 years or older undergoing one- to two-level primary decompression for lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) were included. OUTCOME MEASURES The primary outcome was achievement of MCID, using a distribution-based method, on paired PROMIS physical function scores. METHODS Descriptive statistics were generated to examine the baseline characteristics of the study cohort. Bivariate analyses were used to examine the impact of surgeon-level variance on rates of MCID. Multivariable analyses were used to examine the risk-adjusted impact of surgeon-level variance on rates of MCID. RESULTS Overall, 636 patients treated by nine surgeons were included. The median patient age was 58 [interquartile range (IQR): 46-70] and 62.3% (n=396) were female. Among all patients, 56.9% (n=362) underwent surgery for LDH. The overall rate of achieving MCID was 75.8% (n=482). Of the surgeons, the median years in practice were 12 (range 4-31) and 55.6% (n=5) were in academic practice settings. On bivariate analysis, patients treated by one of the surgeons had lower rates of achieving MICD (odds ratio=0.37, 95% confidence interval: 0.15-0.91, p=.03). However, on multivariable analysis adjusting for operative indication (LDH vs. LSS), body mass index, number of comorbidities, percent unemployment in patient zip code, and preoperative PROMIS physical function scores, all surgeons were equally likely to obtain MCID. CONCLUSIONS In this cohort, variance in PROMIS scores after primary lumbar decompression is influenced by patient-related factors and not by individual surgeon. Adequate risk adjustment is needed if ascertaining clinical improvement on an individual surgeon basis. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Rachel C Sisodia
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Harold A Fogel
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Stuart H Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Terence P Doorly
- Department of Neurosurgery, North Shore Medical Center, Boston, MA 01923, USA
| | - James D Kang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA 02130, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA.
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Explaining health system responses to public reporting of cardiac surgery mortality in England and the USA. HEALTH ECONOMICS POLICY AND LAW 2021; 16:183-200. [PMID: 33455616 DOI: 10.1017/s1744133120000444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Public reporting of clinical performance is increasingly used in many countries to improve quality and enhance accountability of the health system. The assumption is that greater transparency will stimulate improvements by clinicians in response to peer pressure, patient choice or competition. The international diffusion of public reporting might suggest greater similarity between health systems. Alternatively, national and local contexts (including health system imperatives, professional power and organisational culture) might continue to shape its form and impact, implying continued divergence. The paper considers public reporting in the USA and England through the lens of Scott's 'pillars' institutional framework. The USA was arguably the first country to adopt public reporting systematically in the late 1980s. England is a more recent adopter; it is now being widely adopted through the National Health Service (NHS). Drawing on qualitative data from California and England, this paper compares the behavioural and policy responses to public reporting by health system stakeholders at micro, meso and macro levels and through the intersection of ideas, interests, institutions and individuals through. The interplay between the regulative, normative and cultural-cognitive pillars helps explain the observed patterns of on-going divergence.
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McCARTHY C, Spray D, Zilhani G, Fletcher N. Perioperative care in cardiac surgery. Minerva Anestesiol 2020; 87:591-603. [PMID: 33174405 DOI: 10.23736/s0375-9393.20.14690-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.
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Affiliation(s)
| | | | | | - Nick Fletcher
- St Georges University Hospitals, London, UK.,Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, UK
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Wilson T, Bevan G, Gray M, Day C, McManners J. Developing a culture of stewardship: how to prevent the Tragedy of the Commons in universal health systems. J R Soc Med 2020; 113:255-261. [PMID: 32663426 DOI: 10.1177/0141076820913421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Tim Wilson
- Nuffield Department of Primary Health Sciences, Oxford OX2 6GG, UK
| | - Gwyn Bevan
- London School Economics, London WC2A 2AE, UK
| | - Muir Gray
- Nuffield Department of Surgery, Oxford OX3 9DU, UK
| | - Clara Day
- University Hospitals Birmingham, Birmingham B15 2GW, UK
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Randell R, Alvarado N, McVey L, Ruddle RA, Doherty P, Gale C, Mamas M, Dowding D. Requirements for a quality dashboard: Lessons from National Clinical Audits. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2020; 2019:735-744. [PMID: 32308869 PMCID: PMC7153077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Healthcare organizations worldwide use quality dashboards to provide feedback to clinical teams and managers, in order to monitor care quality and stimulate quality improvement. However, there is limited evidence regarding the impact of quality dashboards and audit and feedback research focuses on feedback to individual clinicians, rather than to clinical and managerial teams. Consequently, we know little about what features a quality dashboard needs in order to provide benefit. We conducted 54 interviews across five healthcare organizations in the National Health Service in England, interviewing personnel at different levels of the organization, to understand how national (UK) clinical audit data are used for quality improvement and factors that support or constrain use of these data. The findings, organized around the themes of choosing performance indicators, assessing performance, identifying causes, communicating from ward to board, and data quality, have implications for the design of quality dashboards, which we have translated into a series of requirements.
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Randell R, Alvarado N, McVey L, Greenhalgh J, West RM, Farrin A, Gale C, Parslow R, Keen J, Elshehaly M, Ruddle RA, Lake J, Mamas M, Feltbower R, Dowding D. How, in what contexts, and why do quality dashboards lead to improvements in care quality in acute hospitals? Protocol for a realist feasibility evaluation. BMJ Open 2020; 10:e033208. [PMID: 32102812 PMCID: PMC7044920 DOI: 10.1136/bmjopen-2019-033208] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION National audits are used to monitor care quality and safety and are anticipated to reduce unexplained variations in quality by stimulating quality improvement (QI). However, variation within and between providers in the extent of engagement with national audits means that the potential for national audit data to inform QI is not being realised. This study will undertake a feasibility evaluation of QualDash, a quality dashboard designed to support clinical teams and managers to explore data from two national audits, the Myocardial Ischaemia National Audit Project (MINAP) and the Paediatric Intensive Care Audit Network (PICANet). METHODS AND ANALYSIS Realist evaluation, which involves building, testing and refining theories of how an intervention works, provides an overall framework for this feasibility study. Realist hypotheses that describe how, in what contexts, and why QualDash is expected to provide benefit will be tested across five hospitals. A controlled interrupted time series analysis, using key MINAP and PICANet measures, will provide preliminary evidence of the impact of QualDash, while ethnographic observations and interviews over 12 months will provide initial insight into contexts and mechanisms that lead to those impacts. Feasibility outcomes include the extent to which MINAP and PICANet data are used, data completeness in the audits, and the extent to which participants perceive QualDash to be useful and express the intention to continue using it after the study period. ETHICS AND DISSEMINATION The study has been approved by the University of Leeds School of Healthcare Research Ethics Committee. Study results will provide an initial understanding of how, in what contexts, and why quality dashboards lead to improvements in care quality. These will be disseminated to academic audiences, study participants, hospital IT departments and national audits. If the results show a trial is feasible, we will disseminate the QualDash software through a stepped wedge cluster randomised trial.
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Affiliation(s)
- Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, West Yorkshire, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Natasha Alvarado
- Wolfson Centre for Applied Health Research, Bradford, UK
- School of Healthcare, University of Leeds, Leeds, West Yorkshire, UK
| | - Lynn McVey
- Wolfson Centre for Applied Health Research, Bradford, UK
- School of Healthcare, University of Leeds, Leeds, West Yorkshire, UK
| | | | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Chris Gale
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Justin Keen
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Mai Elshehaly
- Faculty of Engineering & Informatics, University of Bradford, Bradford, UK
| | - Roy A Ruddle
- School of Computing, University of Leeds, Leeds, West Yorkshire, UK
| | - Julia Lake
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mamas Mamas
- Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
| | | | - Dawn Dowding
- School of Health Sciences, University of Manchester, Manchester, Greater Manchester, UK
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Soppa G, Theodoropoulos P, Bilkhu R, Harrison DA, Alam R, Beattie R, Bleetman D, Hussain A, Jones S, Kenny L, Khorsandi M, Lea A, Mensah K, Hici TN, Pinho-Gomes AC, Rogers L, Sepehripour A, Singh S, Steele D, Weaver H, Klein A, Fletcher N, Jahangiri M. Variation between hospitals in outcomes following cardiac surgery in the UK. Ann R Coll Surg Engl 2019; 101:333-341. [PMID: 30854865 PMCID: PMC6513373 DOI: 10.1308/rcsann.2019.0029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We examine the influence of variations in provision of cardiac surgery in the UK at hospital level on patient outcomes and also to assess whether there is an inequality of access and delivery of healthcare. Cardiothoracic surgery has pioneered the reporting of surgeon-specific outcomes, which other specialties have followed. We set out to identify factors other than the individual surgeon, which can affect outcomes and enable other surgical specialties to adopt a similar model. MATERIALS AND METHODS A retrospective analysis of prospectively collected data of patient and hospital level factors between 2013 and 2016 from 16 cardiac surgical units in the UK were analysed through the Society for Cardiothoracic Surgery of Great Britain and Ireland and the Royal College of Surgeons Research Collaborative. Patient demographic data, risks factors, postoperative complications and in-hospital mortality, as well as hospital-level factors such as number of beds and operating theatres, were collected. Correlation between outcome measures was assessed using Pearson's correlation coefficient. Associations between hospital-level factors and outcomes were assessed using univariable and multivariable regression models. RESULTS Of 50,871 patients (60.5% of UK caseload), 25% were older than 75 years and 29% were female. There was considerable variation between units in patient comorbidities, bed distribution and staffing. All hospitals had dedicated cardiothoracic intensive care beds and consultants. Median survival was 97.9% (range 96.3-98.6%). Postoperative complications included re-sternotomy for bleeding (median 4.8%; range 3.5-6.9%) and mediastinitis (0.4%; 0.1-1.0%), transient ischaemic attack/cerebrovascular accident (1.7%; range 0.3-3.0%), haemofiltration (3.7%; range 0.8-6.8%), intra-aortic balloon pump use (3.3%; range 0.4-7.4%), tracheostomy (1.6%; range 1.3-2.6%) and laparotomy (0.3%; range 0.2-0.6%). There was variation in outcomes between hospitals. Univariable analysis showed a small number of positive associations between hospital-level factors and outcomes but none remained significant in multivariable models. CONCLUSIONS Variations among hospital level factors exists in both delivery of, and outcomes, following cardiac surgery in the UK. However, there was no clear association between these factors and patient outcomes. This negative finding could be explained by differences in outcome definition, differences in risk factors between centres that are not captured by standard risk stratification scores or individual surgeon/team performance.
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Affiliation(s)
- G Soppa
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - P Theodoropoulos
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Bilkhu
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - DA Harrison
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Alam
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Beattie
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - D Bleetman
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Hussain
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - S Jones
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - L Kenny
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - M Khorsandi
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Lea
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - Ka Mensah
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - TN Hici
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - AC Pinho-Gomes
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - L Rogers
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Sepehripour
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - S Singh
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - D Steele
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - H Weaver
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Klein
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - N Fletcher
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - M Jahangiri
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
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Chancellor WZ, Mehaffey JH, Beller JP, Krebs ED, Hawkins RB, Yount K, Fonner CE, Speir AM, Quader MA, Rich JB, Yarboro LT, Teman NR, Ailawadi G. Current quality reporting methods are not adequate for salvage cardiac operations. J Thorac Cardiovasc Surg 2019; 159:194-200.e1. [PMID: 30826101 PMCID: PMC6660423 DOI: 10.1016/j.jtcvs.2019.01.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/19/2018] [Accepted: 01/15/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Outcomes in cardiac surgery are benchmarked against national Society of Thoracic Surgeons (STS) data and include patients undergoing elective, urgent, emergent, and salvage operations. This practice relies on accurate risk adjustment to avoid risk-averse behavior. We hypothesize that the STS risk calculator does not adequately characterize the risk of salvage operations because of their heterogeneity and infrequent occurrence. METHODS Data on all cardiac surgery patients with an STS predicted risk score (2002-2017) were extracted from a regional database of 19 cardiac surgery centers. Patients were stratified according to operative status for univariate analysis. Observed-to-expected (O:E) ratios for mortality and composite morbidity/mortality were calculated and compared among elective, urgent, emergent, and salvage patients. RESULTS A total of 76,498 patients met inclusion criteria. The O:E mortality ratios for elective, urgent, and emergent cases were 0.96, 0.98, and 0.93, respectively (all P values > .05). However, mortality rate was significantly higher than expected for salvage patients (O:E ratio, 1.41; P = .04). Composite morbidity/mortality rate was lower than expected in elective (O:E ratio, 0.81; P = .0001) and urgent (O:E ratio, 0.93; P = .0001) cases but higher for emergent (O:E ratio, 1.13; P = .0006) and salvage (O:E ratio, 1.24; P = .01). O:E ratios for salvage mortality were highly variable among each of the 19 centers. CONCLUSIONS The current STS risk models do not adequately predict outcomes for salvage cardiac surgery patients. On the basis of these results, we recommend more detailed reporting of salvage outcomes to avoid risk aversion in these potentially life-saving operations.
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Affiliation(s)
- William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va; Center for Health Policy, University of Virginia, Charlottesville, Va
| | - Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Elizabeth D Krebs
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va; Center for Health Policy, University of Virginia, Charlottesville, Va
| | - Kenan Yount
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | | | - Alan M Speir
- INOVA Heart and Vascular Institute, Falls Church, Va
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Va
| | - Jeffrey B Rich
- Virginia Cardiac Services Quality Initiative, Virginia Beach, Va
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
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Grant SW, Bittar MN, Rose D, Bose A, Duncan A, Zacharias J. Has Publishing Surgeon-Specific Outcomes Had an Impact on Training in Cardiac Surgery? Ann Thorac Surg 2018; 107:1552-1558. [PMID: 30579846 DOI: 10.1016/j.athoracsur.2018.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/07/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Surgeon-specific outcome data are now published for most surgical specialties in the United Kingdom. There are concerns that this initiative has had a negative impact on training. The primary objective of this study was to assess whether training activity has changed since the publication of surgeon-specific outcomes in cardiac surgery. METHODS Prospectively collected data for cardiac surgical procedures performed at a single center from 2004 to 2016 were analyzed. The cohort was split into two halves according to operation date. Multivariable logistic regression was used to assess whether training activity had increased from the first to the second part of the study and to identify whether trainee first operator was associated with adverse outcomes. RESULTS A total of 14,054 cardiac surgical procedures were included, of which 1,777 (12.6%) had a trainee as first operator. Despite an increase in the risk profile of patients undergoing surgical procedures, the proportion of cases performed by trainees increased from 11.7% (786 of 6,708) in the first half of the study to 13.5% (991 of 7,346) in the second half of the study (p = 0.002). This effect remained after adjustment for confounding variables. Trainee first operator was not significantly associated with an increased risk of any adverse short-term outcome. CONCLUSIONS Since surgeon-specific outcome publication began in United Kingdom, cardiac surgical training activity has significantly increased at the study center despite an increase in the risk profile of patients. This study demonstrates that it is possible to maintain or even increase training activity with good outcomes in the era of surgeon-specific outcome publication.
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Affiliation(s)
- Stuart W Grant
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom.
| | | | - David Rose
- Lancashire Cardiac Centre, Blackpool, United Kingdom
| | - Amal Bose
- Lancashire Cardiac Centre, Blackpool, United Kingdom
| | - Andrew Duncan
- Lancashire Cardiac Centre, Blackpool, United Kingdom
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Doubova SV, García-Saisó S, Pérez-Cuevas R, Sarabia-González O, Pacheco-Estrello P, Leslie HH, Santamaría C, Torres-Arreola LDP, Infante-Castañeda C. Barriers and opportunities to improve the foundations for high-quality healthcare in the Mexican Health System. Health Policy Plan 2018; 33:1073-1082. [PMID: 30544258 PMCID: PMC6415720 DOI: 10.1093/heapol/czy098] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2018] [Indexed: 11/15/2022] Open
Abstract
This study aimed to describe the foundations for quality of care (QoC) in the Mexican public health sector and identify barriers to quality evaluation and improvement from the perspective of the QoC leaders of the main public health sector institutions: Ministry of Health (MoH), the Mexican Institute of Social Security (IMSS) and the Institute of Social Security of State Workers (ISSSTE). We administered a semi-structured online questionnaire that gathered information on foundations (governance, health workforce, platforms, tools and population), evaluation and improvement activities for QoC; 320 leaders from MoH, IMSS and ISSSTE participated. We used thematic content and descriptive analyses to analyse the data. We found that QoC foundations, evaluation and improvement activities pose essential challenges for the Mexican health sector. Governance for QoC is weakly aligned across MoH, IMSS and ISSSTE. Each institution follows its own agenda of evaluation and improvement programmes and has distinct QoC indicators and information systems. The institutions share similar barriers to strengthening QoC: poor organizational structure at a facility level, scarcity of financial resources, lack of training in QoC for executive/managerial staff and health professionals and limited public participation. In conclusion, a stronger legal framework and policy dialogue is needed to foster governance by the MoH, to define and align health sector-wide QoC policies, and to set common goals and articulate QoC improvement actions among institutions. Robust QoC organizational structure with designated staff and clarity on their responsibilities should be established at all levels of healthcare. Investment is necessary to fund formal and in-service QoC training programmes for health professionals and to reinforce quality evaluation and improvement activities and quality information systems. QoC evaluation results should be available to healthcare providers and the population. Active public participation in the design and implementation of improvement initiatives should be strengthened.
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Affiliation(s)
- Svetlana V Doubova
- Epidemiology and Health Services Research Unit, CMN Siglo XXI, Mexican Institute of Social Security, Av. Cuauhtemoc 330, Col. Doctores, Del. Cuauhtemoc, Mexico City, Mexico
| | - Sebastián García-Saisó
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Mexico City, Mexico
| | - Ricardo Pérez-Cuevas
- Health System Research Center, National Institute of Public Health, Cuernavaca, Mexico
| | - Odet Sarabia-González
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Mexico City, Mexico
| | - Paulina Pacheco-Estrello
- General Directorate for Quality of Healthcare and Education, Ministry of Health, Mexico City, Mexico
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
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Williams MP, Modgil V, Drake MJ, Keeley F. The effect of consultant outcome publication on surgeon behaviour: a systematic review and narrative synthesis. Ann R Coll Surg Engl 2018; 100:428-435. [PMID: 29962298 PMCID: PMC6111901 DOI: 10.1308/rcsann.2018.0052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Surgeon-specific outcome data, or consultant outcome publication, refers to public access to named surgeon procedural outcomes. Consultant outcome publication originates from cardiothoracic surgery, having been introduced to US and UK surgery in 1991 and 2005, respectively. It has been associated with an improvement in patient outcomes. However, there is concern that it may also have led to changes in surgeon behaviour. This review assesses the literature for evidence of risk-averse behaviour, upgrading of patient risk factors and cessation of low-volume or poorly performing surgeons. Materials and methods A systematic literature review of Embase and Medline databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Original studies including data on consultant outcome publication and its potential effect on surgeon behaviour were included. Results Twenty-five studies were identified from the literature search. Studies suggesting the presence of risk-averse behaviour and upgrading of risk factors tended to be survey based, with studies contrary to these findings using recognised regional and national databases. Discussion and conclusion Our review includes instances of consultant outcome publication leading to risk-averse behaviour, upgrading of risk factors and cessation of low-volume or poorly performing surgeons. As UK data on consultant outcome publication matures, further research is essential to ensure that high-risk patients are not inappropriately turned down for surgery.
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Affiliation(s)
- MP Williams
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - V Modgil
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - MJ Drake
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - F Keeley
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
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Vallance AE, Fearnhead NS, Kuryba A, Hill J, Maxwell-Armstrong C, Braun M, van der Meulen J, Walker K. Effect of public reporting of surgeons' outcomes on patient selection, "gaming," and mortality in colorectal cancer surgery in England: population based cohort study. BMJ 2018; 361:k1581. [PMID: 29720371 PMCID: PMC5930269 DOI: 10.1136/bmj.k1581] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine the effect of surgeon specific outcome reporting in colorectal cancer surgery on risk averse clinical practice, "gaming" of clinical data, and 90 day postoperative mortality. DESIGN National cohort study. SETTING English National Health Service hospital trusts. POPULATION 111 431 patients diagnosed as having colorectal cancer from 1 April 2011 to 31 March 2015 included in the National Bowel Cancer Audit. INTERVENTION Public reporting of surgeon specific 90 day mortality in elective colorectal cancer surgery in England introduced in June 2013. MAIN OUTCOME MEASURES Proportion of patients with colorectal cancer who had an elective major resection, predicted 90 day mortality based on characteristics of patients and tumours, and observed 90 day mortality adjusted for differences in characteristics of patients and tumours, comparing patients who had surgery between April 2011 and June 2013 and between July 2013 and March 2015. RESULTS The proportion of patients with colorectal cancer undergoing major resection did not change after the introduction of surgeon specific public outcome reporting (39 792/62 854 (63.3%) before versus 30 706/48 577 (63.2%) after; P=0.8). The proportion of these major resections categorised as elective or scheduled also did not change (33 638/39 792 (84.5%) before versus 25 905/30 706 (84.4%) after; P=0.5). The predicted 90 day mortality remained the same (2.7% v 2.7%; P=0.3), but the observed 90 day mortality fell (952/33 638 (2.8%) v 552/25 905 (2.1%)). Change point analysis showed that this reduction was over and above the existing downward trend in mortality before the introduction of public outcome reporting (P=0.03). CONCLUSIONS This study did not find evidence that the introduction of public reporting of surgeon specific 90 day postoperative mortality in elective colorectal cancer surgery has led to risk averse clinical practice behaviour or "gaming" of data. However, its introduction coincided with a significant reduction in 90 day mortality.
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Affiliation(s)
- Abigail E Vallance
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
| | - Nicola S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
| | - James Hill
- Manchester Royal Infirmary, Manchester M13 9WL, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
| | - Charles Maxwell-Armstrong
- National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK
| | - Michael Braun
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Jan van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Kate Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
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Prang KH, Canaway R, Bismark M, Dunt D, Miller JA, Kelaher M. Public performance reporting and hospital choice: a cross-sectional study of patients undergoing cancer surgery in the Australian private healthcare sector. BMJ Open 2018; 8:e020644. [PMID: 29703855 PMCID: PMC5922515 DOI: 10.1136/bmjopen-2017-020644] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES National mandatory public performance reporting (PPR) for Australian public hospitals, including measures of cancer surgery waiting times, was introduced in 2011. PPR is voluntary for private hospitals. The aims of this study were to assess whether PPR of hospital data is used by patients with breast, bowel or lung cancer when selecting a hospital for elective surgery and how PPR could be improved to meet their information needs. DESIGN A national cross-sectional postal questionnaire. SETTING Australian private healthcare sector. PARTICIPANTS Private patients with breast, bowel or lung cancer who attended a public or private hospital for elective surgery (n=243) in 2016. OUTCOME MEASURES Patients' choice of hospital, use of PPR information and preferred areas of PPR information. Descriptive and conventional qualitative content analyses were conducted. RESULTS Two hundred and twenty-eight respondents (94%) attended a private hospital. Almost half could choose a hospital. Choice of hospital was not influenced by PPR data (92% unaware) but by their specialist (90%). Respondents considered PPR to be important (71%) but they did not want to see the information, preferring their general practitioners (GPs) to tell them about it (40%). Respondents considered surgery costs (59%), complications (58%) and recovery success rates (57%) to be important areas of information that should be publicly reported. Almost half suggested that quality indicators should be reported at the individual clinician level. Analysis of the open-ended questions identified four themes: (1) decision-making factors; (2) data credibility; (3) unmet information needs and (4) unintended consequences. CONCLUSIONS PPR of hospital data had no substantial impact on patients' choice of hospital. Nonetheless, many respondents expressed interest in using it in future. To increase PPR awareness and usability, personalised and integrated information on cost and quality of hospitals is required. Dissemination of PPR information via specialists and GPs could assist patients to interpret the data and support decision-making.
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Affiliation(s)
- Khic-Houy Prang
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel Canaway
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Bismark
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Julie A. Miller
- Endocrine Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Gutacker N, Bloor K, Bojke C, Walshe K. Should interventions to reduce variation in care quality target doctors or hospitals? Health Policy 2018; 122:660-666. [PMID: 29703654 PMCID: PMC6022214 DOI: 10.1016/j.healthpol.2018.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 10/16/2017] [Accepted: 04/06/2018] [Indexed: 11/29/2022]
Abstract
Performance management initiatives are increasingly targeting individual doctors as well as hospitals. Less than 25% of variation in clinical outcomes is attributable to providers. More variation in clinical outcomes is associated with doctors than with hospitals. Performance estimates for individual doctors are unreliable due to small samples.
Interventions to reduce variation in care quality are increasingly targeted at both individual doctors and the organisations in which they work. Concerns remain about the scope and consequences for such performance management, the relative contribution of individuals and organisations to observed variation, and whether performance can be measured reliably. This study explores these issues in the context of the English National Health Service by analysing comprehensive administrative data for all patients treated for four clinical conditions (acute myocardial infarction, hip fracture, pneumonia, ischemic stroke) and two surgical procedures (coronary artery bypass, hip replacement) during April 2010–February 2013. Performance indicators are defined as 30-day mortality, 28-day emergency readmission and inpatient length of stay. Three-level hierarchical generalised linear mixed models are estimated to attribute variation in case-mix adjusted indicators to individual doctors and hospital organisations. Except for length of stay after hip replacement, no more than 11% of variation in case-mix adjusted performance indicators can be attributed to doctors and organisations with the rest reflecting random chance and unobserved patient factors. Doctor variation exceeds hospital variation by a factor of 1.2 or more. However, identifying poor performance amongst doctors is hampered by insufficient numbers of cases per doctor to reliably estimate their individual performances. Policy makers and regulators should therefore be cautious when targeting individual doctors in performance improvement initiatives.
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Affiliation(s)
- Nils Gutacker
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - Karen Bloor
- Department of Health Sciences, University of York, United Kingdom.
| | - Chris Bojke
- Centre for Health Economics, University of York, United Kingdom.
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, United Kingdom.
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Michelotti M, de Korne DF, Weizer JS, Lee PP, Flanagan D, Kelly SP, Odergren A, Sandhu SS, Wai C, Klazinga N, Haripriya A, Stein JD, Hingorani M. Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals. BMC Ophthalmol 2017; 17:269. [PMID: 29284445 PMCID: PMC5747118 DOI: 10.1186/s12886-017-0667-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/20/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To determine alignment of proposed international standard outcomes sets for ophthalmic conditions to metrics currently reported by eye hospitals. METHODS Mixed methods comparative benchmark study, including eight eye hospitals in Australia, India, Singapore, Sweden, U.K., and U.S. All are major international tertiary care and training centers in ophthalmology. Main outcome measure is consistency of ophthalmic outcomes measures reported. RESULTS International agreed standard outcomes (ICHOM) sets are available for cataract surgery (10 metrics) and macular degeneration (7 metrics). The eight hospitals reported 22 different metrics for cataract surgery and 2 for macular degeneration, which showed only limited overlap with the proposed ICHOM metrics. None of the hospitals reported patient reported visual functioning or vision-related quality of life outcomes measures (PROMs). Three hospitals (38%) reported rates for uncomplicated cataract surgeries only. There was marked variation in how and at what point postoperatively visual outcomes following cataract, cornea, glaucoma, strabismus and oculoplastics procedures were reported. Seven (87.5%) measured post-operative infections and four (50%) measured 30 day unplanned reoperation rates. CONCLUSIONS Outcomes reporting for ophthalmic conditions currently widely varies across hospitals internationally and does not include patient-reported outcomes. Reaching consensus on measures and consistency in data collection will allow meaningful comparisons and provide an evidence base enabling improved sharing of "best practices" to improve eye care globally. Implementation of international standards is still a major challenge and practice-based knowledge on measures should be one of the inputs of the international standardization process.
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Affiliation(s)
- Monica Michelotti
- Casey Eye Institute, Oregon Health and Sciences University, Portland, OR USA
| | - Dirk F. de Korne
- Singapore National Eye Centre, SingHealth Duke-NUS Academic Medical Centre, 11 Third Hospital Avenue, Singapore, 168751 Singapore
- Medical Innovation & Care Transformation, KK Women’s & Children’s Hospital, Singapore, Singapore
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Jennifer S. Weizer
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, USA
| | - Paul P. Lee
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, USA
| | | | - Simon P. Kelly
- Department of Ophthalmology, Royal Bolton Hospital, Bolton, UK
| | | | - Sukhpal S. Sandhu
- The Royal Victorian Eye and Ear Hospital, Centre for Eye Research Australia, University of Melbourne, Melbourne, Victoria Australia
| | - Charity Wai
- Singapore National Eye Centre, SingHealth Duke-NUS Academic Medical Centre, 11 Third Hospital Avenue, Singapore, 168751 Singapore
| | - Niek Klazinga
- Department of Social Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Joshua D. Stein
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, USA
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23
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Risk Aversion and Public Reporting. Part 1: Observations From Cardiac Surgery and Interventional Cardiology. Ann Thorac Surg 2017; 104:2093-2101. [DOI: 10.1016/j.athoracsur.2017.06.077] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 06/25/2017] [Indexed: 11/17/2022]
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Gray AM, Fenn P, Rickman N, Vencappa D. Changing experience of adverse medical events in the National Health Service: Comparison of two population surveys in 2001 and 2013. Soc Sci Med 2017; 195:83-89. [PMID: 29156249 DOI: 10.1016/j.socscimed.2017.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 11/30/2022]
Abstract
Care quality is important to patients and providers, but is hard to measure. This study aimed to examine changes in the frequency and severity of one quality measure - adverse events associated with medical care - in Great Britain over a 12-year period when available resources initially expanded and were subsequently constrained. Data on perceived adverse events, collected from two representative population surveys in 2001 and 2013, were analysed and compared. The samples consisted of 8202 adults aged 15 and over in 2001 and 19,746 adults aged 15 and over in 2013. The main outcome measures were self-reported illness, injury or impairment caused in the opinion of the respondent by medical treatment or care. Respondents were also asked about the perceived severity of harm in terms of health and work, and any actions taken in response. The proportion of all respondents reporting that over the last three years they had suffered some illness, injury or impairment that in their opinion was caused by their medical treatment or care was 2.5% (497/19746) in 2013, compared with 4.8% (391/8202) in 2001, a reduction of 33% after adjusting for age, gender, income and social class differences between the two surveys. Perceived impact on health and work of these events was similar in both surveys, as was the proportion of injured respondents who pursued a legal claim for financial compensation, at 11% (53/497) in 2013 and 10.5% (41/391) in 2001. We also report multivariate analyses of perceived harm rates and severity, and propensity to seek, and accept, compensation. Our results suggest that the NHS became significantly safer over this period when measured by patient perceived harm from medical care. Our survey method could provide a valuable contribution to the monitoring of trends in health-care related adverse events and the impact of patient safety initiatives.
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Affiliation(s)
- Alastair M Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, United Kingdom.
| | - Paul Fenn
- Nottingham University Business School, Nottingham NG8 1BB, United Kingdom.
| | - Neil Rickman
- Department of Economics, University of Surrey, Guildford GU2 7XH, United Kingdom.
| | - Dev Vencappa
- Economics, Finance & Entrepreneurship Department, Aston Business School, Aston University, Aston Triangle, Birmingham B4 7ET, United Kingdom.
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Sanfilippo F, Knight JB, Scolletta S, Santonocito C, Pastore F, Lorini FL, Tritapepe L, Morelli A, Arcadipane A. Levosimendan for patients with severely reduced left ventricular systolic function and/or low cardiac output syndrome undergoing cardiac surgery: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:252. [PMID: 29047417 PMCID: PMC5648477 DOI: 10.1186/s13054-017-1849-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies have shown beneficial effects of levosimendan in high-risk patients undergoing cardiac surgery. Two large randomized controlled trials (RCTs), however, showed no advantages of levosimendan. METHODS We performed a systematic review and meta-analysis (MEDLINE and Embase from inception until March 30, 2017), investigating whether levosimendan offers advantages compared with placebo in high-risk cardiac surgery patients, as defined by preoperative left ventricular ejection fraction (LVEF) ≤ 35% and/or low cardiac output syndrome (LCOS). The primary outcomes were mortality at longest follow-up and need for postoperative renal replacement therapy (RRT). Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension during drug infusion. RESULTS Six RCTs were included in the meta-analysis, five of which investigated only patients with LVEF ≤ 35% and one of which included predominantly patients with LCOS. Mortality was similar overall (OR 0.64 [0.37, 1.11], p = 0.11) but lower in the subgroup with LVEF < 35% (OR 0.51 [0.32, 0.82], p = 0.005). Need for RRT was reduced by levosimendan both overall (OR 0.63 [0.42, 0.94], p = 0.02) and in patients with LVEF < 35% (OR 0.55 [0.31, 0.97], p = 0.04). Among secondary outcomes, we found lower postoperative LCOS in patients with LVEF < 35% receiving levosimendan (OR 0.49 [0.27, 0.89], p = 0.02), lower overall AKI (OR 0.62 [0.42, 0.92], p = 0.02), and a trend toward lower mechanical support, both overall (p = 0.07) and in patients with LVEF < 35% (p = 0.05). CONCLUSIONS Levosimendan reduces mortality in patients with preoperative severely reduced LVEF but does not affect overall mortality. Levosimendan reduces the need for RRT after high-risk cardiac surgery.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy.
| | - Joshua B Knight
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy.,Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sabino Scolletta
- Unit of Anesthesia and Critical Care Medicine, Department of Medical Biotechnologies, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
| | - Federico Pastore
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
| | - Ferdinando L Lorini
- Department of Anaesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luigi Tritapepe
- Department of Cardiovascular, Respiratory, Nephrological, Anaesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Morelli
- Department of Anesthesiology and Intensive Care, Policlinico Umberto 1, Sapienza University of Rome, Rome, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
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Burgers LT, Redekop WK, Al MJ, Lhachimi SK, Armstrong N, Walker S, Rothery C, Westwood M, Severens JL. Cost-effectiveness analysis of new generation coronary CT scanners for difficult-to-image patients. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:731-742. [PMID: 27650359 DOI: 10.1007/s10198-016-0824-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/04/2016] [Indexed: 06/06/2023]
Abstract
AIMS New generation dual-source coronary CT (NGCCT) scanners with more than 64 slices were evaluated for patients with (known) or suspected of coronary artery disease (CAD) who are difficult to image: obese, coronary calcium score > 400, arrhythmias, previous revascularization, heart rate > 65 beats per minute, and intolerance of betablocker. A cost-effectiveness analysis of NGCCT compared with invasive coronary angiography (ICA) was performed for these difficult-to-image patients for England and Wales. METHODS AND RESULTS Five models (diagnostic decision model, four Markov models for CAD progression, stroke, radiation and general population) were integrated to estimate the cost-effectiveness of NGCCT for both suspected and known CAD populations. The lifetime costs and effects from the National Health Service perspective were estimated for three strategies: (1) patients diagnosed using ICA, (2) using NGCCT, and (3) patients diagnosed using a combination of NGCCT and, if positive, followed by ICA. In the suspected population, the strategy where patients only undergo a NGCCT is a cost-effective option at accepted cost-effectiveness thresholds. The strategy of using NGCCT in combination with ICA is the most favourable strategy for patients with known CAD. The most influential factors behind these results are the percentage of patients being misclassified (a function of both diagnostic accuracy and the prior likelihood), the complication rates of the procedures, and the cost price of a NGCCT scan. CONCLUSION The use of NGCCT might be considered cost-effective in both populations since it is cost-saving compared to ICA and generates similar effects.
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Affiliation(s)
- L T Burgers
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - W K Redekop
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - M J Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - S K Lhachimi
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Research Group for Evidence-Based Public Health, BIPS -Leibniz-Institute für Prevention Research und Epidemiology, Bremen, Germany
| | | | - S Walker
- Centre for Health Economics, University of York, York, UK
| | - C Rothery
- Centre for Health Economics, University of York, York, UK
| | - M Westwood
- Kleijnen Systematic Reviews Ltd, York, UK
| | - J L Severens
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Mehta RH, Leimberger JD, van Diepen S, Meza J, Wang A, Jankowich R, Harrison RW, Hay D, Fremes S, Duncan A, Soltesz EG, Luber J, Park S, Argenziano M, Murphy E, Marcel R, Kalavrouziotis D, Nagpal D, Bozinovski J, Toller W, Heringlake M, Goodman SG, Levy JH, Harrington RA, Anstrom KJ, Alexander JH. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery. N Engl J Med 2017; 376:2032-2042. [PMID: 28316276 DOI: 10.1056/nejmoa1616218] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Levosimendan is an inotropic agent that has been shown in small studies to prevent or treat the low cardiac output syndrome after cardiac surgery. METHODS In a multicenter, randomized, placebo-controlled, phase 3 trial, we evaluated the efficacy and safety of levosimendan in patients with a left ventricular ejection fraction of 35% or less who were undergoing cardiac surgery with the use of cardiopulmonary bypass. Patients were randomly assigned to receive either intravenous levosimendan (at a dose of 0.2 μg per kilogram of body weight per minute for 1 hour, followed by a dose of 0.1 μg per kilogram per minute for 23 hours) or placebo, with the infusion started before surgery. The two primary end points were a four-component composite of death through day 30, renal-replacement therapy through day 30, perioperative myocardial infarction through day 5, or use of a mechanical cardiac assist device through day 5; and a two-component composite of death through day 30 or use of a mechanical cardiac assist device through day 5. RESULTS A total of 882 patients underwent randomization, 849 of whom received levosimendan or placebo and were included in the modified intention-to-treat population. The four-component primary end point occurred in 105 of 428 patients (24.5%) assigned to receive levosimendan and in 103 of 421 (24.5%) assigned to receive placebo (adjusted odds ratio, 1.00; 99% confidence interval [CI], 0.66 to 1.54; P=0.98). The two-component primary end point occurred in 56 patients (13.1%) assigned to receive levosimendan and in 48 (11.4%) assigned to receive placebo (adjusted odds ratio, 1.18; 96% CI, 0.76 to 1.82; P=0.45). The rate of adverse events did not differ significantly between the two groups. CONCLUSIONS Prophylactic levosimendan did not result in a rate of the short-term composite end point of death, renal-replacement therapy, perioperative myocardial infarction, or use of a mechanical cardiac assist device that was lower than the rate with placebo among patients with a reduced left ventricular ejection fraction who were undergoing cardiac surgery with the use of cardiopulmonary bypass. (Funded by Tenax Therapeutics; LEVO-CTS ClinicalTrials.gov number, NCT02025621 .).
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Affiliation(s)
- Rajendra H Mehta
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Jeffrey D Leimberger
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Sean van Diepen
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - James Meza
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Alice Wang
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Rachael Jankowich
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert W Harrison
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Douglas Hay
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Stephen Fremes
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Andra Duncan
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Edward G Soltesz
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John Luber
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Soon Park
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Michael Argenziano
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Edward Murphy
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Randy Marcel
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Dimitri Kalavrouziotis
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Dave Nagpal
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John Bozinovski
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Wolfgang Toller
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Matthias Heringlake
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Shaun G Goodman
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Jerrold H Levy
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert A Harrington
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John H Alexander
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
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Gutacker N, Bloor K, Cookson R, Gale CP, Maynard A, Pagano D, Pomar J, Bernal‐Delgado E. Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine a Safe Threshold. Health Serv Res 2017; 52:863-878. [PMID: 27198068 PMCID: PMC5346497 DOI: 10.1111/1475-6773.12508] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To estimate a safe minimum hospital volume for hospitals performing coronary artery bypass graft (CABG) surgery. DATA SOURCE Hospital data on all publicly funded CABG in five European countries, 2007-2009 (106,149 patients). DESIGN Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case mix. Segmented regression analysis to estimate a threshold. FINDINGS The 30-day in-hospital mortality rate was 3.0 percent overall, 5.2 percent (95 percent CI: 4.0-6.4) in low-volume hospitals, and 2.1 percent (95 percent CI: 1.8-2.3) in high-volume hospitals. There is a significant curvilinear relationship between volume and mortality, flatter above 415 cases per hospital per year. CONCLUSIONS There is a clear relationship between hospital CABG volume and mortality in Europe, implying a "safe" threshold volume of 415 cases per year.
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Affiliation(s)
| | - Karen Bloor
- Department of Health SciencesUniversity of YorkYorkUK
| | | | - Chris P. Gale
- Division of Epidemiology and BiostatisticsUniversity of LeedsUK
| | - Alan Maynard
- Department of Health SciencesUniversity of YorkYorkUK
| | - Domenico Pagano
- Department of Cardiothoracic SurgeryUniversity Hospital Birmingham Queen ElizabethEdgbastonUK
| | - José Pomar
- Department of Cardiovascular SurgeryHospital Clinic de BarcelonaBarcelonaSpain
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Saratzis A, Thatcher A, Bath MF, Sidloff DA, Bown MJ, Shakespeare J, Sayers RD, Imray C. Reporting individual surgeon outcomes does not lead to risk aversion in abdominal aortic aneurysm surgery. Ann R Coll Surg Engl 2017; 99:161-165. [PMID: 28071950 DOI: 10.1308/rcsann.2017.0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Reporting surgeons' outcomes has recently been introduced in the UK. This has the potential to result in surgeons becoming risk averse. The aim of this study was to investigate whether reporting outcomes for abdominal aortic aneurysm (AAA) surgery impacts on the number and risk profile (level of fitness) of patients offered elective treatment. METHODS Publically available National Vascular Registry data were used to compare the number of AAAs treated in those centres across the UK that reported outcomes for the periods 2008-2012, 2009-2013 and 2010-2014. Furthermore, the number and characteristics of patients referred for consideration of elective AAA repair at a single tertiary unit were analysed yearly between 2010 and 2014. Clinic, casualty and theatre event codes were searched to obtain all AAAs treated. The results of cardiopulmonary exercise testing (CPET) were assessed. RESULTS For the 85 centres that reported outcomes in all three five-year periods, the median number of AAAs treated per unit increased between the periods 2008-2012 and 2010-2014 from 192 to 214 per year (p=0.006). In the single centre cohort study, the proportion of patients offered elective AAA repair increased from 74% in 2009-2010 to 81% in 2013-2014, with a maximum of 84% in 2012-2013. The age, aneurysm size and CPET results (anaerobic threshold levels) for those eventually offered elective treatment did not differ significantly between 2010 and 2014. CONCLUSIONS The results do not support the assumption that reporting individual surgeon outcomes is associated with a risk averse strategy regarding patient selection in aneurysm surgery at present.
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Affiliation(s)
| | | | | | | | | | - J Shakespeare
- University Hospitals Coventry and Warwickshire NHS Trust , UK
| | | | - C Imray
- University Hospitals Coventry and Warwickshire NHS Trust , UK
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Greenhalgh J, Dalkin S, Gooding K, Gibbons E, Wright J, Meads D, Black N, Valderas JM, Pawson R. Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05020] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BackgroundThe feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.ObjectivesTo (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.DesignTwo separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.InterventionsAggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.Main outcome measuresAggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.Data sourcesSearches of electronic databases and forwards and backwards citation tracking.Review methodsRealist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.ResultsProviders were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.Strengths and limitationsThere was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.ConclusionsPROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.Future workFuture research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.Study registrationThis study is registered as PROSPERO CRD42013005938.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanne Greenhalgh
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Sonia Dalkin
- Department of Public Health, Northumbria University, Newcastle upon Tyne, UK
| | - Kate Gooding
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Elizabeth Gibbons
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Judy Wright
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - David Meads
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Nick Black
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Ray Pawson
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
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Bramesfeld A, Wensing M, Bartels P, Bobzin H, Grenier C, Heugren M, Hirschfield DJ, Langenegger M, Lindelius B, Lucet B, Manor O, Schneider T, Wardell F, Szecsenyi J. Mandatory national quality improvement systems using indicators: An initial assessment in Europe and Israel. Health Policy 2016; 120:1256-1269. [PMID: 27793361 DOI: 10.1016/j.healthpol.2016.09.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/27/2016] [Accepted: 09/30/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Quality improvement systems (QIS) that are based on empirical performance assessment have increasingly been implemented as a mandatory part of health systems across countries. This study aims to describe national mandatory QIS in Europe in 2014. MATERIALS AND METHODS Relevant national agencies for national mandatory QIS in Europe were identified through online searches and key informants. A questionnaire was compiled during a workshop with these agencies and filled out by representatives from these particular agencies. RESULTS Agencies in charge of national mandatory QIS in seven countries (Denmark, France, Germany, Israel, Scotland, Sweden and Switzerland) were included in the study. An analysis of QIS revealed similarities, such as the use of routine data for performance assessment and the aim to hold healthcare providers accountable. Differences relate to the different forms of feedback systems and improvement mechanisms used. Trends include the development towards greater implementation of QIS within health systems, the inclusion of the patient's perspective in performance assessment, and experiments with pay for performance-related measures. CONCLUSION On a country level, for health systems striving for newly implementing QIS it is recommended to start where routine data is available, add qualitative methodologies once the QIS is getting more complex, report performance data back to service providers and be patient centred. On the inter-country level exchange of information between agencies commissioned with implementing national QIS is very much needed for.
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Affiliation(s)
- Anke Bramesfeld
- AQUA-Institute for Applied Quality Improvement and Research in Health Care, Maschmühlenweg 8, 37073 Göttingen, Germany; Institute for Epidemiology, Social Medicine and Health System Research, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany.
| | - Michel Wensing
- Radboud University Medical Centre, Radboud Institute of Health Sciences, Geert Grooteplein 21, 6500 HB Nijmegen, The Netherlands
| | - Paul Bartels
- The Danish Clinical Registries-A National Quality Improvement Programme, Olof Palmes Allé 15, 8200 Aarhus, Denmark
| | - Henning Bobzin
- AQUA-Institute for Applied Quality Improvement and Research in Health Care, Maschmühlenweg 8, 37073 Göttingen, Germany
| | - Catherine Grenier
- Direction de l'Amélioration de la Qualité & de la Sécurité des Soins, Haute Autorité de Santé, 2, Avenue du Stade de France, 93218 Saint Denis La Plaine Cedex, France
| | - Mona Heugren
- National Board of Health and Welfare, Rålambsvägen 3, SE 10630 Stockholm, Sweden
| | - Dena Jaffe Hirschfield
- Braun School of Public Health & Community Medicine, Hebrew University-Hadassah, Jerusalem, Israel; Kantar Health, Health Outcomes Practice, Jerusalem, Israel
| | - Manfred Langenegger
- Bundesamt für Gesundheit BAG, Direktionsbereich Kranken- und Unfallversicherung, Schwarzenburgerstr. 175, 3003 Bern, Switzerland
| | - Birgitta Lindelius
- National Board of Health and Welfare, Rålambsvägen 3, SE 10630 Stockholm, Sweden
| | - Bruno Lucet
- Direction de l'Amélioration de la Qualité & de la Sécurité des Soins, Haute Autorité de Santé, 2, Avenue du Stade de France, 93218 Saint Denis La Plaine Cedex, France
| | - Orly Manor
- Direction de l'Amélioration de la Qualité & de la Sécurité des Soins, Haute Autorité de Santé, 2, Avenue du Stade de France, 93218 Saint Denis La Plaine Cedex, France
| | - Theres Schneider
- Bundesamt für Gesundheit BAG, Direktionsbereich Kranken- und Unfallversicherung, Schwarzenburgerstr. 175, 3003 Bern, Switzerland
| | - Fiona Wardell
- Healthcare Improvement Scotland, Delta House, 50 West Nile Street, Glasgow G1 2NP, United Kingdom
| | - Joachim Szecsenyi
- Healthcare Improvement Scotland, Delta House, 50 West Nile Street, Glasgow G1 2NP, United Kingdom; Department of General Practice and Health Services Research, Heidelberg University Hospital, Voßstr. 2, D-69115 Heidelberg, Germany
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Mechanisms and effects of public reporting of surgeon outcomes: A systematic review of the literature. Health Policy 2016; 120:1151-1161. [DOI: 10.1016/j.healthpol.2016.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 08/03/2016] [Accepted: 08/04/2016] [Indexed: 11/21/2022]
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Affiliation(s)
- N Fletcher
- Cardiothoracic Intensive Care and Cardiac Anaesthesia St Georges University Hospitals Foundation Trust, London, UK
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34
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Li MM, Shalhoub J, Davies AH, Maruthappu M. Guidance on feedback of outcome data to improve performance in vascular surgery. Br J Hosp Med (Lond) 2016; 77:476-80. [PMID: 27487059 DOI: 10.12968/hmed.2016.77.8.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Feedback of performance data is a well-established method of performance improvement in the health-care setting, although guidance has been limited in the context of surgical performance. This article outlines how optimal feedback can be achieved using surgeon outcome data.
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Affiliation(s)
- Mimi M Li
- Medical Student in the Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London W6 8RF
| | - Joseph Shalhoub
- Specialty Registrar in Vascular Surgery in the Section of Vascular Surgery, Imperial College Healthcare NHS Trust, London and Honorary Clinical Lecturer, Imperial College London, London
| | - Alun H Davies
- Professor of Vascular Surgery in the Section of Vascular Surgery, Imperial College London, London and Honorary Consultant Surgeon, Imperial College Healthcare NHS Trust, London
| | - Mahiben Maruthappu
- Academic Foundation Doctor in the Section of Vascular Surgery, Imperial College London, London
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35
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Burns EM, Pettengell C, Athanasiou T, Darzi A. Understanding The Strengths And Weaknesses Of Public Reporting Of Surgeon-Specific Outcome Data. Health Aff (Millwood) 2016; 35:415-21. [DOI: 10.1377/hlthaff.2015.0788] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Elaine M. Burns
- Elaine M. Burns is an honorary clinical lecturer in the Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, in the United Kingdom
| | - Chris Pettengell
- Chris Pettengell is a clinical research fellow in the Department of Surgery and Cancer, Faculty of Medicine, Imperial College London
| | - Thanos Athanasiou
- Thanos Athanasiou is a professor of cardiovascular sciences in the Department of Surgery and Cancer, Faculty of Medicine, Imperial College London
| | - Ara Darzi
- Ara Darzi is executive chair of the World Innovation Summit for Health (WISH), Qatar Foundation, and director of the Institute of Global Health Innovation, Imperial College London
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36
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Taylor A, Neuburger J, Walker K, Cromwell D, Groene O. How is feedback from national clinical audits used? Views from English National Health Service trust audit leads. J Health Serv Res Policy 2016; 21:91-100. [DOI: 10.1177/1355819615612826] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To explore how the output of national clinical audits in England is used by professionals and whether and how their impact could be enhanced. Methods A mixed-methods study with the primary recipients of four national clinical audits of cancer care of 607 local audit leads, 274 (45%) completed a questionnaire and 32 participated in an interview. Our questions focused on how the audits were used and whether barriers existed to using the audits for local service improvement. We described variation in questionnaire responses between the audits using chi-squared tests. Results are reported as percentages with their 95% confidence intervals. Qualitative data were analysed using Framework analysis. Results More than 90% of survey respondents believed that the audit findings were relevant to their clinical work, and interviewees described how they used the audits for a range of purposes. Forty-two percent of survey respondents said they had changed their clinical practice, and 56% had implemented service improvements in response to the audits. The degree of change differed between the four audits, evident in both the questionnaire and the interview data. In the interviews, two recurring barriers emerged: (1) the importance of data quality, which, in turn, influenced the perceived relevance and validity of the audit data and therefore the ability to make changes based on it and (2) the need for clear presentation of benchmarked local performance data. The perceived authority and credibility of the professional bodies supporting the audits was a key factor underpinning the use of the audit findings. Conclusion National cancer audit and feedback is used to improve services, but their impact could be enhanced by improving the data quality and relevance of feedback.
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Affiliation(s)
| | - Jenny Neuburger
- Lecturer in Statistics, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK
| | - Kate Walker
- Lecturer of Medical Statistics, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK
| | - David Cromwell
- Reader, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK
| | - Oliver Groene
- Previously Honorary Senior Lecturer in Health Services Research, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK
- Head of Research and Development, OptiMedis AG, Hamburg, Germany
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37
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Karthikesalingam A, Holt PJE, Loftus IM, Thompson MM. Risk Aversion in Vascular Intervention: The Consequences of Publishing Surgeon-specific Mortality for Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2015; 50:698-701. [PMID: 26411700 DOI: 10.1016/j.ejvs.2015.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
Affiliation(s)
- A Karthikesalingam
- St George's Vascular Institute, 4th Floor St James Wing, St George's Hospital, Blackshaw Road, London, UK.
| | - P J E Holt
- St George's Vascular Institute, 4th Floor St James Wing, St George's Hospital, Blackshaw Road, London, UK
| | - I M Loftus
- St George's Vascular Institute, 4th Floor St James Wing, St George's Hospital, Blackshaw Road, London, UK
| | - M M Thompson
- St George's Vascular Institute, 4th Floor St James Wing, St George's Hospital, Blackshaw Road, London, UK
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38
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Perioperative Letalität bei der Versorgung abdomineller Aortenaneurysmen in Deutschland. Chirurg 2015; 86:1041-50. [DOI: 10.1007/s00104-015-0087-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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39
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Affiliation(s)
- Tiit Mathiesen
- Department of Neurosurgery, Karolinska Hospital, Stockholm, Sweden
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40
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Abstract
This review examines the future of total hip arthroplasty, aiming to avoid past mistakes
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Affiliation(s)
- A. Manktelow
- Nottingham University NHS Hospitals Trust, Hucknall Road, Nottingham NG5 1BP, UK
| | - B. Bloch
- Nottingham University NHS Hospitals Trust, Hucknall Road, Nottingham NG5 1BP, UK
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41
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Radford PD, Derbyshire LF, Shalhoub J, Fitzgerald JEF. Publication of surgeon specific outcome data: a review of implementation, controversies and the potential impact on surgical training. Int J Surg 2014; 13:211-216. [PMID: 25498494 DOI: 10.1016/j.ijsu.2014.11.049] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 11/21/2014] [Accepted: 11/27/2014] [Indexed: 11/29/2022]
Abstract
Government-mandated publication of named surgeon-specific outcome data (SSD) has recently been introduced across nine surgical speciality areas in England. This move is the first time that such national data has been released in any country, and it promises to provide a significant advancement in health service transparency. Data is derived from nine preexisting national surgical audit databases. However, eight of these were not originally designed for this purpose, and there is considerable controversy surrounding data quality, risk adjustment, patient use and interpretation, and surgeons' subsequent case selection. Concerns also surround the degree to which these results truly reflect the individual consultant, or the wider hospital team and accompanying resources. The potential impact on surgical training has largely been overlooked. This paper investigated the background to SSD publication and controversies surrounding this, the potential impact on surgical training and the response to these concerns from medical and surgical leaders. As SSD collection continues to be refined, the most appropriate outcomes measurements need to be established, and risk adjustment requires ongoing improvement and validation. Prospective evaluation of changes in surgical training should be undertaken, as any degradation of will have both short and long-term consequences for patients and surgeons alike. It is important that the literature supporting the safety of supervised trainee practice is also promoted in order to counterbalance any potential concerns that might detract from trainee operating opportunities. Finally, it is important that outcomes data is communicated to patients in the most meaningful way in order to facilitate their understanding and interpretation given the complexities of the data and analysis involved.
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Affiliation(s)
- P D Radford
- Association of Surgeons in Training 35 - 43 Lincoln's Inn Fields, London, WC2A 3PE, United Kingdom
| | - L F Derbyshire
- Association of Surgeons in Training 35 - 43 Lincoln's Inn Fields, London, WC2A 3PE, United Kingdom
| | - J Shalhoub
- Association of Surgeons in Training 35 - 43 Lincoln's Inn Fields, London, WC2A 3PE, United Kingdom
| | - J E F Fitzgerald
- Association of Surgeons in Training 35 - 43 Lincoln's Inn Fields, London, WC2A 3PE, United Kingdom.
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- Association of Surgeons in Training 35 - 43 Lincoln's Inn Fields, London, WC2A 3PE, United Kingdom
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Fowler AJ, Agha RA, Sevdalis N. Surveillance and quality improvement in the United Kingdom: Is there a meeting point? Surgeon 2014; 12:177-80. [DOI: 10.1016/j.surge.2014.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/09/2014] [Accepted: 03/13/2014] [Indexed: 11/25/2022]
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Woodhead T, Lachman P, Mountford J, Botwinick L, Peden C, Stewart K. From harm to hope and purposeful action: what could we do after Francis? BMJ Qual Saf 2014; 23:619-23. [PMID: 24899635 DOI: 10.1136/bmjqs-2013-002581] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Responses to the reports on the inquiry into Mid Staffordshire have resulted in calls from politicians, NHS leaders and the public to improve care across the NHS in England. However, the substance of what needs to be done remains unclear. In this paper, we offer seven key 'ingredients' required to sustain improvement of care, supported by evidence drawn from published literature. We believe that empowering and upskilling the front-line workforce in understanding and implementing improvement techniques, supported by changes at system and policy level and reinforced by what leaders say and do, will result in sustainable benefit for patients and families, as well as greater satisfaction for staff.
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Affiliation(s)
| | - Peter Lachman
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | | - Laura Botwinick
- Graduate Program in Health Administration and Policy, The University of Chicago, Chicago, Illinois, USA
| | - Carol Peden
- Royal United Hospital, Bath and NHS England (South), Bath, UK
| | - Kevin Stewart
- Clinical Effectiveness & Evaluation Unit, Royal College of Physicians, London, UK
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Ranking and rankability of hospital postoperative mortality rates in colorectal cancer surgery. Ann Surg 2014; 259:844-9. [PMID: 24717374 DOI: 10.1097/sla.0000000000000561] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To examine to what extent random variation and variation in case-mix influence hospital rankings on the basis of mortality rates and to determine the suitability of mortality for ranking hospitals in colorectal surgery. BACKGROUND Comparing and ranking postoperative mortality rates between hospitals becomes increasingly popular. Differences in hospital case-mix, and chance variation related to caseload, may influence rankings. The suitability of mortality for rankings remains unclear. METHODS Data were derived from the Dutch Surgical Colorectal Audit. Hospital rankings based on fixed- and random-effects logistic regression models, unadjusted and adjusted for case-mix were compared with the percentile based on expected ranks (the chance that a hospital performs better than a random hospital). Rankability, measuring which part of variation between hospitals is not due to chance, was calculated. RESULTS Some 25,591 patients undergoing colorectal resections in 92 hospitals were evaluated. Postoperative mortality rates ranged between 0% and 8.8%. Adjustment for case-mix with a fixed-effects model caused large changes in rankings. A smaller additional effect on changes in rankings occurred after adjusting with a random-effects model, with lower volume hospitals moving toward the mean. Percentile based on expected ranks ranged between 10% and 85%. Rankability was 38%, meaning that 62% of hospital variation in mortality was due to chance. CONCLUSIONS Hospital ranks changed after case-mix adjustment and random-effects models, compared with unadjusted analysis. A large proportion of hospital variation in mortality was due to chance. Caution should be warranted when interpreting hospital rankings on the basis of postoperative mortality. Percentiles of expected ranks may help identify hospitals with exceptional performance.
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47
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Mukamel DB, Haeder SF, Weimer DL. Top-Down and Bottom-Up Approaches to Health Care Quality: The Impacts of Regulation and Report Cards. Annu Rev Public Health 2014; 35:477-97. [DOI: 10.1146/annurev-publhealth-082313-115826] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Dana B. Mukamel
- School of Medicine and Health Policy Research Institute (HPRI), University of California, Irvine, California 92697-5800;
| | | | - David L. Weimer
- Department of Political Science,
- The La Follette School of Public Affairs, University of Wisconsin, Madison, Wisconsin 53706; ,
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King D, Greaves F, Vlaev I, Darzi A. Approaches based on behavioral economics could help nudge patients and providers toward lower health spending growth. Health Aff (Millwood) 2014; 32:661-8. [PMID: 23569045 DOI: 10.1377/hlthaff.2012.1348] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Policies that change the environment or context in which decisions are made and "nudge" people toward particular choices have been relatively ignored in health care. This article examines the role that approaches based on behavioral economics could play in "nudging" providers and patients in ways that could slow health care spending growth. The basic insight of behavioral economics is that behavior is guided by the very fallible human brain and greatly influenced by the environment or context in which choices are made. In policy arenas such as pensions and personal savings, approaches based on behavioral economics have provided notable results. In health care, such approaches have been used successfully but in limited ways, as in the use of surgical checklists that have increased patient safety and reduced costs. With health care spending climbing at unsustainable rates, we review the role that approaches based on behavioral economics could play in offering policy makers a potential set of new tools to slow spending growth.
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Fowler AJ, Agha RA, Camm CF, Littlejohns P. The UK Freedom of Information Act (2000) in healthcare research: a systematic review. BMJ Open 2013; 3:e002967. [PMID: 24285626 PMCID: PMC3845048 DOI: 10.1136/bmjopen-2013-002967] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To assess the use and utility of the Freedom of Information Act (2000) in healthcare research since 2005 and to determine if any particular feature of studies found led to greater data acquisition. DESIGN PRISMA compliant systematic review. PARTICIPANTS An extensive literature search was performed of EMBASE, MEDLINE, CINAHL, psychINFO, BNI, AMED, HMIC and Health business elite databases from January 2005 to January 2013 using terms 'Freedom of information', 'Freedom of information act' and 'Freedom of information act 2000'. Papers were considered for publication if they described utilising the UK Freedom of information act to gather data for healthcare research. 16 articles met these criteria. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was the number and characteristics of studies utilising the Freedom of Information Act to collect the data for healthcare research. Secondary outcome measures were any features that improved data acquisition rates (including to whom the request was made, the number of questions asked per request, etc.) RESULTS 16 articles described utilising the Freedom of Information Act for healthcare research, and these investigated a broad range of topics. The median number of requests made was 86 (range 1-172), the total number of requests was 1732. A total of 15 817 pieces of data were retrieved by all studies. The amount of data collected was defined as the number of questions asked multiplied by the number of full responses. A median of five questions were asked per study (range 5-6.5) and the overall response rate was 86%. The National Health Service litigation authority responded to 100% of requests, while Primary Care Trusts had the lowest response rate of 81% for healthcare bodies. A positive correlation between number of requests made and data obtained (0.508, p<0.05) and number of requests made and increased response rate (0.737, p<0.01), both reached the statistical significance. CONCLUSIONS Researchers should make greater use of the Act to access the information they need that is not otherwise disclosed. We discuss the issues with the research utilising the Act and how future research of this type could be optimised.
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A Review of Recent Advances in Perioperative Patient Safety. Ann Med Surg (Lond) 2013; 2:10-4. [PMID: 26977290 PMCID: PMC4326122 DOI: 10.1016/s2049-0801(13)70020-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 12/29/2012] [Indexed: 12/02/2022] Open
Abstract
Major complications in surgery affect up to 16% of surgical procedures. Over the past 50 years, many patient safety initiatives have attempted to reduce such complications. Since the formation of the National Patient Safety Agency in 2001, there have been major advances in patient safety. Most recently, the production and implementation of the Surgical Safety Checklist by the World Health Organisation (WHO), a checklist ensuring that certain ‘never events’ (wrong-site surgery, wrong operation etc.) do not occur, irrespective of healthcare allowance. In this review, a summary of recent advances in patient safety are considered – including improvements in communication, understanding of human factors that cause mistakes, and strategies developed to minimise these. Additionally, the synthesis of best medical practice and harm minimisation is examined, with particular emphasis on communication and appreciation of human factors in the operating theatre. This is based on the resource management systems developed in other high risk industries (e.g. nuclear), and has also been adopted for other high risk medical areas. The WHO global movement to reduce surgical mortality has been highly successful, especially in the healthcare systems of developing nations where mortality reductions of up to 50% have been observed, and reductions in patient complications of 4%. Incident reporting has long been a key component of patient safety and continues to be so; allowing reflection and improved guideline formation. All patients are placed at risk in the surgical environment. It is crucial that this risk is minimised, whilst optimising the patient's outcome. In this review, recent advances in perioperative patient safety are examined and placed in context.
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