To test the hypothesis that complication rates for elective total hip replacement operations are related to surgeon and hospital volumes.
Retrospective population cohort study. STUDY COHORT: Patients who had undergone elective total hip replacement in Ontario during 1992 as captured in the Canadian Institute for Health Information database.
In-hospital complications, 1- and 3-year revision rates, 1- and 3-year infection rates, length of hospital stay, and 3-month and 1-year death rates.
Surgeons with patient volumes above the 80th percentile (more than 27 hip replacements annually) discharged patients approximately 2.4 days earlier (p 0.05).
There is no evidence to support regionalization of elective hip replacement surgery in Ontario based on adverse clinical outcomes. Surgeons who perform a large number of total hip replacements are discharging patients earlier than less experienced surgeons, without any-demonstrable increase in complications leading to hospital readmission. The explanation for this observation remains unknown and will require further study.
To test the feasibility of using a system for classification of surgical errors and of in-hospital deaths and long hospital stay as markers for errors in surgery we reviewed the hospital records of 273 patients with 285 admissions. During the one year study period there were in all 3767 patients admitted for surgical care. From these we selected the 131 who died in the department during the year, the 100 who had the longest stay (greater than 33 days) and the 91 patients were referred to the departments of internal medicine, infectious diseases or orthopedic surgery. Errors were classified as error of omission or commission, in diagnosis or in therapy. Possible or definitive errors were found in the care of 23% of the patients who died and in 10% of the ones with a long hospital stay. Only 3% of patients referred to other departments experienced errors. It is concluded, that "in-hospital death and "long hospital stay" can be used as markers to identify errors in surgery.
Research on adverse outcomes following common surgical procedures has suggested the importance of hospital and surgeon variables. Policy directions depend on which factors are important in influencing patient outcomes and what sorts of policies are feasible. Focusing on where a given procedure is performed highlights a concern for centralization; emphasizing who should perform a particular operation implies physician certification. Finally, monitoring involves identifying particular hospitals that appear to have relatively poor (or relatively good) results. This paper analyzes patient, surgeon, and hospital characteristics associated with serious postdischarge complications of hysterectomy, cholecystectomy, and prostatectomy in patients age 25 and over in Manitoba, Canada, following surgery during 1974 through 1976. The three procedures differ markedly in the ease of prediction of the probability of complications and in the predictive importance of patient, hospital, and physician variables. The predictors worked fairly well for cholecystectomy, somewhat less well for hysterectomy, and not well at all for prostatectomy. Hospital variables were not generally important in the multiple logistic regressions. After controlling for case mix and type of surgery, physician surgical experience was found to account for relatively large differences (almost two to one) in the probability of patient complications following cholecystectomy. Cholecystectomy might be a candidate for certification because of the epidemiology of the operation. As of the mid-1970s, a substantial proportion of the cholecystectomies were being performed by physicians with comparatively little ongoing experience with this type of procedure. Moreover, a monitoring perspective identified one hospital with a significantly higher postcholecystectomy complication rate, even after physician experience was taken into account. Both identifying which procedures should be attended to and focusing on problems following surgery are important beyond Manitoba and highly relevant to such American requirements as Peer Review Organizations. Methods of increasing the efficiency of using claims data for quality assurance studies are outlined.
Practical peer review by means of a clinical audit requires complete documentation, critical assessment and open discussion of difficulties or errors in patient management. The quality of care in a large surgical department was monitored using weekly on-the-ward capture of complications and immediate feedback to involved surgeons. Retrospective peer review of surgical deaths judged the process of patient care in three categories--treatment, investigation and documentation; feedback was also provided. Seven of the 10 surgical services each collected morbidity data for at least 40 weeks in 1976 and 44 weeks in 1977. In 1978, 8 of the 10 services collected data for 50 weeks or more. The number of patients reviewed was 3520 in 1978. Of these, 822 (23%) had complications in 1976, 703 (16%) in 1977 and 918 (17%) in 1978. In 1976, 260 patients died; the quality of care was considered to have been adequate in 67%. In 1977, 278 patients died; in 76% the management was considered adequate. In 1978, 231 patients died; in 68% management was satisfactory. This clinical audit system is suitable for computer programming and can provide a complete and accurate report of the entire spectrum of complications.
The study was partly based on a retrospective analysis of 408 hospital referrals and 261 discharge summary letters and partly on interviews with chief physicians/surgeons and general practitioners. The level of information in hospital referrals: patient history 87%, objective findings 94%, social medicine 31%, plan/expectations 21%. The diagnostic applicability of patient history/objective findings was 95% and social medicine 70%. The discharge summary letter was received 2-3 days after hospital discharge in 17% cases. In the discharge letters information about medication was described in 41%, information given to patient/relatives in 9%. When discharge summary letters from departments of internal medicine and surgery were compared the level of informations from departments of internal medicine to departments of surgery was superior e.g. descriptions of medication (62% against 26%), date of control (34% against 24%) and information to patient/relatives (12% against 5%). The conclusion was that the level of information and the diagnostic applicability showed variation with regard to quality. General practitioners and hospitals must develop guidelines for hospital referrals and discharge summary letters in order to improve the patient's course.
To validate completeness and accuracy of registry data reported from three randomly chosen departments contributing to The Danish National Registry of Laparoscopic Cholecystectomy, covering all departments offering chole cystectomy.
A total of 431 case reports representing cases of laparoscopic cholecystectomy in a 2-year period in three surgical departments.
Comparison of case reports with reported data in The Danish National Registry of Laparoscopic Cholecystectomy.
Rates of discrepancies, comparison of complication rates for cases in the registry and cases not reported to the registry.
Completeness of registration was 69%, 80% and 99% respectively. A significantly higher degree of completeness was found in the only department with a formalized registration procedure. Inaccuracies were found in 28-49% of the cases, but none regarding serious complications such as bile duct injury or perioperative death.
The information in the national registry may be accurate if the present findings can be extrapolated to the remaining departments in the country. The number of non-reported cases should be minimized by introducing a formalized procedure of handling and forwarding information to the registry. Continuous validation through external visits by registry staff to contributing departments may also be advisable.
The process of developing clinical guidelines and standards for cancer treatment and screening is well established in the Ontario health care system; however, the dissemination and implementation of such guidelines and standards are more recent undertakings. Traditional implementation strategies to improve surgical practice and the delivery of cancer care have not been consistently effective. There is a recognized need to develop integrated models that offer direct support for implementation strategies. Such a model should be feasible, adaptable, and open to evaluation across diverse surgical settings.
Research suggests that successful implementation should consider tools and expertise from other disciplines. This article considers a community of practice (COP) model to provide a supportive infrastructure for quality improvements in cancer surgery. The COP model was adapted for cancer surgeons. It is supported by 5 enablers referred to as tools: communication system, project development support, access to data, access to evidence review, and accreditation with continued medical education and continued professional development. These tools need to be part of an infrastructure that is both provided and supported by a team of administrators and health care professionals, who have active roles and responsibilities. Therefore, the primary objective of this article is to describe our COP model in cancer surgery including the key success factors necessary for providing the infrastructure and tools. The secondary objective is to offer the integrated COP model as a basis for future research and the evaluation of various collaborative improvement projects.
Building on knowledge management concepts, we identified the 4 essential processes that should be targeted by implementation strategies. A common COP evaluation framework uses the outcomes of 4 knowledge conversion modes-organizational memory, social capital, innovation, and knowledge transfer-as proxies for actual provider and organizational behavior. Insights from different collaborative improvement projects described in a consistent way could inform future research and assist in the collation of systematic reviews on this topic.