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 estimate a safe minimum hospital volume for hospitals performing coronary artery bypass graft (CABG) surgery.
Hospital data on all publicly funded CABG in five European countries, 2007-2009 (106,149 patients).
Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case mix. Segmented regression analysis to estimate a threshold.
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.
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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Two consecutive bedside prevalence studies of 455 surgical patients were made by the same infection control nurse in 15 surgical and gynaecological departments in eight Danish hospitals. Four point six percent had a deep and another 4.6% a superficial surgical wound infection (SWI). Two months after the second survey only one third of the infections were correctly recorded by the hospital routine surveillance of surgical wound infections (SWI). Registration systems that are simpler and more valid than the existing ones need to be developed. A follow-up was carried out with self-administered questionnaires in 2976 patients, of whom 1447 (48.6%) responded. A patient-diagnosed SWI was defined as an antibiotic treatment of a wound and/or a wound reopening by a health care professional. A total of 311 patients were treated for a SWI, 42% with antibiotics, 27% with wound reopening and 31% received both these treatments. Post-discharge surveillance cannot be recommended as a routine.
A study among day-case and inpatients on an orthopaedic ward has been carried out to assess patient satisfaction. A single-page questionnaire were mailed to 445 patients, 388 (87.2%) returned the questionnaire. Three hundred and fifty five (79.8%) answers were usable. We found an overall rate of satisfaction with the given treatment of 71.3%, 20.3% were dissatisfied. We found the group of day-case patients more satisfied than the group of inpatients. The group of patients who underwent arthroscopic surgery were identified as being the most dissatisfied. There were among all patients a large group who were dissatisfied with the amount of perioperative information and especially the amount of postoperative out-patient control. We recommend a higher degree of written information including information about risk of complications and failures.
There are few good methods of evaluating efficiency in the operating theatres. Data from four operating theatres (gynaecology, gastroenterology, thoracic/vascular-surgery and orthopaedics) during regular working hours (0730-1530) were evaluated for a period of 37 weeks in 1993. A record was made of duration of surgery and the time that elapsed from when the nurses received the patient until he or she was delivered to the postoperative ward. We also registered the time elapsing from the end of one operation to the start of the next. On average 2.2 (thoracic/vascular) to 3.2 (gynaecology) patients were operated on each day. The surgeons spent about 40% of their normal working hours actually operating. Preparations before start of anaesthesia took about 30 minutes, and before surgery 30-40 minutes. Another 30 minutes elapsed from the end of the operation until the patient was delivered to the postoperative ward. We conclude that there may still be a potential for increasing productivity in these operating theatres.
Comment In: Tidsskr Nor Laegeforen. 1995 Nov 20;115(28):35497491611
INTRODUCTION: The number of operations performed by a surgeon is a predictor of the outcome of colon/rectum resection. Therefore it is relevant to monitor the surgeons' volume of work and the number of patients' complications in order to secure both an adequate number and high quality. MATERIALS AND METHODS: Using data from the Danish National Patient Registry and Danish Colon Cancer Group's database, we located hospital departments that had performed colon/rectum surgery in 2003 and asked them whether they monitored surgeons' volume of work and the number of patients' complications and whether they considered those data relevant to the patients or their GPs. RESULTS: Thirty-nine departments had performed colon/rectum resection; 27 of them responded. Eight departments (36%) had defined a standard for the number of operations per surgeon, while only four used the data to determine the surgeons' volume of work. 68% found data concerning the department's volume of operations relevant to both GPs and patients, while 23% thought that those data were not relevant to GPs or patients. 64% found the data concerning surgeons' volume to be irrelevant to both GPs and patients. None of the departments had informed the GPs or the patients about their results. DISCUSSION: It is remarkable that very few hospital departments actually collect and use data to secure adequate volume and quality. It is necessary to increase the focus on surgeons' volume of operations in order to secure high quality.
At the Department of General Surgery, Hillerød Hospital, the quality of data from a continuous registration of post-operative wound infection was evaluated. Data registered over a six-month period were compared with data available in caserecords and data from a questionnaire sent to the patients. During the period 1.2-31.7.1990 924 operations were registered in 864 patients. Eight hundred and ninety-five patient records could be traced and 770 questionnaires were sent. The remaining 125 were dead or had unknown addresses. Six hundred eighty-seven questionnaires were returned. The data-registered overall infection rate was 3.0%. The actual infection rate was 8.9%. Fifty-eight percent of the infections noted in the records were registered. Approximately 40% of the infections were diagnosed and treated in general practice only. It is concluded that in order to compare infection rates between departments, it is necessary to ensure that equal definitions and equal quality of the data are used. Strict routines in the department and a close contact to the general practitioners are essential to achieve a satisfactory quality of data.
The factors which could influence the selection of cases for post-mortem examination were analysed during a 6-month period. The variables studied included the age and sex of the patients, the length of terminal hospitalization, the principal disease, the certainty of the clinical diagnostics and the extent of the clinical investigation. Both clinical and autopsy records were reviewed. Seventy-four patients died at the Department of Surgery during this period of whom 50 (68% autopsy rate) were autopsied. The autopsy rate was influenced by (a) the length of the terminal hospitalization, (b) the diagnosis of the principal disease and, to a certain degree, (c) the extent of the clinical investigation. Thus, patients who were hospitalized for a shorter period, had no clinically diagnosed malignant tumours and were not investigated with more sophisticated methods were more frequently autopsied. The discrepancy rate between principal clinical and post-mortem diagnoses was 28% and was not influenced by the use of modern investigative methods.