We studied complications after hysterectomy among all women in the Danish population who had a simple hysterectomy in the period 1978-81 based on data obtained from the Danish National Hospital Registry. Among patients, with neither diagnosed cancer nor major co-surgery (n = 23,386), we identified all the complications which occurred during hospital admission from the time of surgery up to six years from that point. Within 30 days of hysterectomy 2.6% of the patients had been diagnosed in hospitals as having complications according to our definition. The corresponding figures at 90 days and two years after the operation were 3.7% and 9.4%. The most frequently observed complications were post operative wound infections and bleeding, each affecting about 2% of all operated women. Logistic regression and Cox regression were used to identify prognostic indicators of readmission with complications. The probability of readmission with complications within six years after hysterectomy was estimated at 8% among low risk patients. The most pronounced increase in risk of readmission with complication occurred among women who had been admitted to psychiatric or somatic hospitals 0-12 months before they had their uterus removed (OR in the range 1.59 to 1.83). We discuss the prevailing difficulties of comparing observational evidence from different clinical settings reported in the literature, and emphasize the importance of developing a coordinated international strategy for non-experimental assessment of medical technology.
This article examines some of the key research and policy issues that are emerging as a result of recent analyses of regional variations in health care. The article presents a historical background to this important new field of health services' research, and indicates, using some Danish examples of research on hysterectomy, cholecystectomy, and prostatectomy, the relevance of this research to management and policy planning. Regional variations are not yet fully explained in terms of what causes them. What is clear and what is the primary focus of this article is that their very existence, whatever their explanation, creates a major challenge for the management and planning of future health services.
This paper assesses the risk of dying within 30 days of admission among 13,854 women who had a cholecystectomy performed as the principal operation from 1977 to 1981. The overall crude mortality rate was 1.2%. Women who had a simple elective cholecystectomy performed had a mortality rate similar to women who had a simple hysterectomy. The mortality was significantly higher than in the general female population (p less than 0.05). Increased age, acute admission, admissions to hospital within 3 months prior to the index admission, the number of discharge diagnoses, and the geographical region were significantly associated with increased mortality. Exploration of the common bile duct was associated with higher mortality in the bivariate analysis, but the association disappeared when the number of discharge diagnoses was taken into account. Type of hospital and the population based cholecystectomy rate of the patient's residential area was not associated with mortality. As regards early mortality, it is concluded that simple elective cholecystectomy is a safe procedure before the age of 50 to 60 years. Acute admissions and more than one diagnosis at discharge were associated with an increased mortality, whereas exploration of the common bile duct may not be as important an independent factor as previously assumed.
The main objective of this cohort study was to analyse the early postoperative mortality after 'simple' hysterectomy for benign indications and to compare it with that of a randomly selected reference group of women matched for age. Registry data covering the entire Danish female population were used. Included in the study were all patients operated in the period 1977-1981. Patients were only included if no cancer was diagnosed and if no major co-surgery was performed (29,192 patients). Cancer patients were also excluded in the reference group (16,182 women). Mortality was studied according to characteristics of patients, their residential area, the surgical approach and operating hospital. Overall 47 patients died within 30 days of admission for hysterectomy (overall mortality 16.1 per 10,000). Only seven deaths were expected on the basis of the population sample, and adjusted for age, the relative risk (RR) for hysterectomy patients was 6.38 (95% CI 4.33-9.39). Early postoperative mortality increased with age, and the risk was elevated among emergency patients (RR = 3.22; 1.72-6.04). Patients with more than one diagnosis at discharge (RR = 4.53; 2.12-9.70) were at high risk, but early postoperative mortality was independent of surgical approach. Causes of death are discussed. Compared to the general population, patients who undergo 'simple' hysterectomy are faced with a sixfold risk of dying within 30 days, but a complete assessment of the risks and benefits of hysterectomy requires prospective studies of survival and morbidity, including quality of life for longer periods of time following operations.
This paper assesses the risk of dying within thirty days of admission among 13,854 women who had a cholecystectomy performed as the principal operation during the period 1977-81. The overall crude mortality rate was 1.2%. Women who had a simple elective cholecystectomy performed had a mortality rate (0.2%) similar to women who had a simple hysterectomy, but significantly higher than in the general female population. High age, acute admission, admission to hospital in the three months prior to the index admission, the number of discharge diagnoses, and the geographical region were significantly associated with increased mortality. The higher mortality associated with exploration of the common bile duct disappeared when number of discharge diagnoses was taken into account. As regards early mortality, it is concluded that simple elective cholecystectomy is a safe procedure before the age of 50-60 years. Exploration of the common bile duct may not be as important an independent factor as previous assumed.
A large proportion of common medical practices are subject to substantial regional variation resulting in numerous natural experiments. Opportunities are thereby provided for outcome evaluation through quasi-experimental design. If patients treated in different regions were comparable a natural experiment involving alternative treatments could be regarded as 'pseudo randomised', but empirical investigations are needed to verify this prerequisite. This paper discusses the role of quasi-experimental designs in assessment of medical care with evaluation of outcomes after hysterectomy in Denmark as an example. The design is developed and the comparability of selected groups of patients is elucidated from administrative data, while the outcome results are not presented in this context. One indication for hysterectomy is carcinoma in situ of the cervix uteri which may be treated with either hysterectomy, or conisation. A study group of patients was selected from departments where hysterectomy was the treatment of choice for this indication while the reference group was drawn from departments in which conisation was generally preferred. The comparability of the populations, effects and information for the two groups are elicited from administrative data. We conclude that it is possible to establish a quasi-experimental design based on regional variations and that the comparability of the groups included may be assessed through registry data. The importance of technology diffusion for the prospects of performing quasi randomised studies is emphasised. In this attempt to evaluate hysterectomy, it was not possible to identify groups of patients, which were sufficiently comparable to justify a study of soft outcomes.
In a register-based study of all cholecystectomized patients in Denmark during the period from 1977-85 (37,048 patients) an account is given of the regional variations observed in connection with the intervention. The cholecystectomy operation is sub-divided into four types of operation dependent on whether the intervention is merely a matter of cholecystectomy or it involves the choledocus, the duodenum, the small intestine or other organs. The variation analysis is based on a division of the country into 75 areas, each primarily served by a single hospital. The method highly reflects the differences in clinical treatment strategies. The summarized rate of cholecystectomy for this period of time was 8.2 per 10,000 persons. In areas with the highest and the lowest rates of operation the figures were 12.3 per 10,000 and 5.1 per 10,000, respectively. In 18 areas, the rates of operation were significantly higher than average and in 18 other areas significantly higher than average and in 18 other areas significantly below average. SCV-score (X100) 2.19. There is no systematic correlation between the degree of specialisation in the operating department and the frequency in employing the operation. Areas with an operation index significantly above average had the same rate of more complicated operations than simple cholecystectomy as the other areas. Possible causes of national as well as international variations in the use of cholecystectomy are discussed, and the need for a radical evaluation of this kind of treatment is emphasized.
It has been a prevailing assumption that cholecystectomy patients by and large follow a pattern of survival similar to that of the normal population. This paper presents a population-based study of the long-term survival after cholecystectomy in order to reassess this assumption. Based on data available in the Danish National Hospital Register the records of all Danish women who were operated between 1977 and 1981 were examined and studied up to 6 years subsequent to surgery. Cholecystectomy patients who were free of diagnosed cancer and who had no major co-surgery (n = 11,123) were compared to both hysterectomy patients and a sample of the female population. Adjusting for age and other covariates, patients with psychiatric hospital admissions prior to surgery experienced a threefold risk of dying within 6 years after surgery. Patients with prior somatic admissions and patient with acute admissions had a relative risk (RR) of about 1.5. Cholecystectomy patients had a significantly increased mortality when compared to hysterectomy patients, RR = 1.3 (1.1-1.6), and to the population sample. Heart diseases and cancer occurred significantly more often as causes of death among cholecystectomy patients when compared to hysterectomy patients, but our data suggest that the occurrence of many other causes of death may be increased among cholecystectomy patients as well. The authors concluded that cholecystectomy patients are subject to relatively higher levels of mortality than previously assumed in parts of the literature. Furthermore, the increase seems to be attributable to a multitude of causes of death. The most likely explanation of the excess mortality among cholecystectomy patients is that gallbladder patients are relatively fragile.(ABSTRACT TRUNCATED AT 250 WORDS)