Improving quality through process change: a scoping review of process improvement tools in cancer surgery

Emergency general surgery: Impact of hospital and surgeon admission case volume on mortality

BACKGROUND

Emergency general surgery (EGS) is a high-volume and high-risk surgical service. Interhospital variation in EGS outcomes exists, but there is disagreement in the literature as to whether hospital admission volume affects in-hospital mortality. Scotland collects high-quality data on all admitted patients, whether managed operatively or nonoperatively. Our aim was to determine the relationship between hospital admission volume and in-hospital mortality of EGS patients in Scotland. Second, to investigate whether surgeon admission volume affects mortality.

METHODS

This national population-level cohort study included EGS patients aged 16 years and older, who were admitted to a Scottish hospital between 2014 and 2018 (inclusive). A logistic regression model was created, with in-hospital mortality as the dependent variable, and admission volume of hospital per year as a continuous covariate of interest, adjusted for age, sex, comorbidity, deprivation, surgeon admission volume, surgeon operative rate, transfer status, diagnosis, and operation category.

RESULTS

There were 376,076 admissions to 25 hospitals, which met our inclusion criteria. The EGS hospital admission rate per year had no effect on in-hospital mortality (odds ratio [OR], 1.000; 95% confidence interval [CI], 1.000-1.000). Higher average surgeon monthly admission volume increased the odds of in-hospital mortality (>35 admissions: OR, 1.139; 95% CI, 1.038-1.250; 25-35 admissions: OR, 1.091; 95% CI, 1.004-1.185; <25 admissions was the referent).

CONCLUSION

In Scotland, in contrast to other settings, EGS hospital admission volume did not influence in-hospital mortality. The finding of an association between individual surgeons' case volume and in-hospital mortality warrants further investigation.

LEVEL OF EVIDENCE

Care management, Level IV.

Lean Lobectomy: Streamlining Video-Assisted Lobectomy to Increase the Value of Lung Cancer Care

PURPOSE

A review of the outcomes of patients who received our video-assisted thoracic surgery (VATS) lung lobectomy in 2015 revealed long lengths of stay, inefficient care transitions, and overuse of resources. Focused process redesign offers a proven method for instituting improvement and changes in health care. We sought to use systems process improvement to streamline VATS lobectomies at our institution, and we targeted cost drivers to optimize quality of care and minimize overuse of resources.

METHODS

We performed a retrospective review of perioperative practices between January 2015 and March 2016 for patients undergoing VATS lobectomy that helped establish a value stream map, used a granular cost database, and performed real-time analysis. We used an outcomes database, which allowed us to identify cost drivers, practice variability, and rent seeking. We implemented process redesign with constant review and formal value stream reanalysis at 6-month intervals over a 2-year period.

RESULTS

We ultimately experienced an overall 187% reduction of time in the operating room (297 v 159 minutes). Our process redesign also resulted in significantly fewer chest x-rays per patient (mean, 6.7 v 2), laboratory draws (100% v 5.7%), and consultations (100% v 5.7%), which resulted in a 234% reduction in mean length of stay (4.4 v 1.88 days) and an overall cost reduction of 40%. These changes did not have a detrimental effect on patient outcomes: pulmonary complications (16.9% v 8.6%), cardiac complications (13.2% v 8.6%), and readmission rates (13.6% v 2.9%) all decreased.

CONCLUSION

By using value stream analysis and process redesign methodologies, closely paired with highly granular cost and outcomes data, we were able to achieve significant improvements in patient outcomes and use of resources.

The impact of a clinical pathway on patient postoperative recovery following pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomies (PD) are complex surgical procedures. Clinical pathways (CPW) are surgical process improvement tools that guide postoperative recovery and are associated with high quality care. Our objective was to report the quality of surgical care following implementation of a CPW.

METHODS

We developed and implemented a CPW for patients undergoing PD at a single high volume hepato-pancreato-biliary (HPB) centre. Patient outcomes were collected prospectively during the implementation period. A comparator cohort was selected by identifying patients that underwent a PD prior to CPW development.

RESULTS

122 patients underwent a PD during the CPW implementation period; 83 patients were initiated on the CPW. 74 patients underwent PD during the 12-month period prior to the CPW. The median hospital stay decreased after the implementation of the CPW (11 vs 8 days, p < 0.01) with no significant changes to mortality, morbidity, reoperation, or readmission rates. In-hospital complications were significantly higher in patients that were not initiated on the CPW (54% vs 74%, p = 0.03).

CONCLUSION

Results suggest the CPW reduced variability and allowed a greater proportion of patients to receive all elements of care, resulting in improved quality and efficiency of care based on current best evidence recommendations.

Applications and limitations of the concept of 'avoidable mortality' among immigrant groups in Europe: a scoping review

OBJECTIVES

Avoidable mortality is often used as a key indicator of broader health inequalities. Health inequalities refer to unfair differences in the quality of health and wellbeing, and health care across different populations. This includes differences in the presence of disease, health outcomes, or access to health care. Migrants represent a disadvantaged and growing demographic with special health risks. This study analyses the usages of the concept of avoidable mortality as applied in studies on migrants in Europe. In doing so, the study aims to identify the strengths and limitations of the concept of avoidable mortality for comparative work.

STUDY DESIGN

A scoping review was conducted for the period of 1990-2011.

METHODS

Publications were identified by a systematic search of PUBMED and WEB OF SCIENCE. An additional five publications were found through the search via references. A total number of 37 publications from 10 European countries were included in the analysis.

RESULTS

The authors divided studies according to direct versus indirect usage of the concept. Studies with direct usage of the concept established a correlation between patterns of avoidable mortality and health care system performance. Additionally, they searched studies which indirectly used avoidable mortality to examine further evidence for the strengths and weaknesses of the concept. These studies used indicators of amenable mortality (at times alongside other mortality indicators) without making direct reference to the concept. Findings using both approaches identified a similar trend in principal causes of premature death. The difference between the two types of studies concerned the more detailed analysis of the causes of death in studies with direct usage categorising into treatable versus preventable causes of death, or health policy versus medical intervention.

CONCLUSIONS

The results of this article highlight the role of health care systems in contributing to migrant health outcomes: whereas mixed outcomes across a number of indicators of avoidable mortality used indirectly do arise, the large number of studies - especially those using the concept directly - evidence a higher share of premature mortality for migrants compared to host populations. These findings can provide policy makers with important insights into targeted ways of improving the access and quality of health services for marginalised populations. However, the strength and depth of such insights stand to improve, as current research on avoidable mortality is often indirect (rather than overt and systematic), thereby limiting the potential for cross-national comparison, as well as a clearer understanding of the links between health outcomes and health care system performance for a disadvantaged group.