Does it matter what a hospital is "high volume" for? Specificity of hospital volume-outcome associations for surgical procedures: analysis of administrative data.
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OBJECTIVE: To determine whether the improved outcome of a surgical procedure in high volume hospitals is specific to the volume of the same procedure. DESIGN AND SETTING: Analysis of secondary data in Ontario, Canada. PARTICIPANTS: Patients having an oesophagectomy, colorectal resection for cancer, pancreaticoduodenectomy, major lung resection for cancer, or repair of an unruptured abdominal aortic aneurysm between 1994 and 1999. MAIN OUTCOME MEASURES: Odds ratio for death within 30 days of surgery in relation to the hospital volume of the same surgical procedure and the hospital volume of the other four procedures. Estimates were adjusted for age, sex, and comorbidity and accounted for hospital level clustering. RESULTS: With the exception of colorectal resection, 30 day mortality seemed to be inversely related not only to the hospital volume of the same procedure but also to the hospital volume of most of the other procedures. In some cases the effect of the volume of a different procedure was stronger than the effect of the volume of the same procedure. For example, the association of mortality from pancreaticoduodenectomy with hospital volume of lung resection (odds ratio for death in hospitals with a high volume of lung resection compared with low volume 0.36, 95% confidence interval 0.23 to 0.57) was much stronger than the association of mortality from pancreaticoduodenectomy with hospital volume of pancreaticoduodenectomy (0.76, 0.44 to 1.32). CONCLUSION: The inverse association between high volume of procedure and risk of operative death is not specific to the volume of the procedure being studied. (+info)
Regional availability of high-volume hospitals for major surgery.
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Despite evidence of increased risks, a large number of patients still have surgery in low-volume hospitals. To better understand why, we used Medicare data to study the regional availability of high-volume hospitals. More than half of patients undergoing three procedures in low-volume hospitals lived in regions lacking a high-volume hospital. Some regions simply lacked enough cases to support a high-volume hospital. Other regions had enough cases but too many hospitals performing them. Although consolidation of surgical services may be feasible in some settings, volume-based referral strategies are impractical for many U.S. regions. (+info)
The Patient Experiences Questionnaire: development, validity and reliability.
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OBJECTIVE: . To describe the development of the Patient Experiences Questionnaire (PEQ) and to evaluate reliability and validity of constructed summed rating scales. DESIGN: Literature review, focus groups and pilot surveys. Two national cross-sectional studies performed in 1996 and 1998. SETTING: Two postal surveys in a national sample of 14 hospitals stratified by geographical region and hospital size. Subjects. Patients consecutively discharged from surgical wards and wards of internal medicine. The surveys included 36 845 patients and 19 578 responded (53%). RESULTS: We constructed 10 summed rating scales based on factor analysis and theoretical considerations: Information on future complaints, Nursing services, Communication, Information examinations, Contact with next-of-kin, Doctor services, Hospital and equipment, Information medication, Organization and General satisfaction. Eight scales had a Cronbach alpha coefficient of >0.70, the remaining two were >0.60. Repeatability was >0.70 for five scales and >0.60 for the remaining scales. CONCLUSIONS: The PEQ is a self-report instrument covering the most important subjects of interest to hospital patients. Results are presented as 10 scales with good validity and reliability. It emphasizes practicability and comprehensibility while at the same time providing sufficient information about domains applicable to most patients admitted to medical and surgical wards. (+info)
The surgical assessment unit--effective strategy for improvement of the emergency surgical pathway?
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A special unit was set up in an associate teaching hospital to provide a fast-track route for the assessment of acute adult surgical and urological referrals. During an audit period of eight weeks, this surgical assessment unit had 550 referrals, of which 196 (36%) came via the accident and emergency (A&E) department; the other 354 came directly from general practitioners or other hospital departments. Mondays, Tuesdays and Fridays were the busiest days of the week; 57% of all patients arrived between 8 am and 5 pm. 68% were seen by a doctor within 1 hour of their arrival. 68% were either discharged or admitted to the main surgical wards within 4 hours. The study showed that, over the course of a year, the surgical assessment unit might divert some 2301 patients away from the A&E department. To achieve this total it would need to be open and appropriately staffed 24 hours a day. Such a unit offers a strategy for limiting the A&E workload and streamlining the assessment of patients with surgical and urological emergencies. (+info)
Waiting for orthopaedic surgery: factors associated with waiting times and patients' opinion.
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OBJECTIVE: To assess waiting times for three groups of orthopaedic patients in Sweden and to identify factors explaining variations in waiting time. Also examined were factors associated with patients' perceptions that waiting times were too long. DESIGN: Retrospective study. SETTING AND STUDY PARTICIPANTS: Patients from orthopaedic units at 10 Swedish hospitals participated in the study. A questionnaire was sent to 1336 surgical patients (517 hip replacement, 321 back surgery, and 498 arthroscopic knee surgery) 3 months after surgery. Information extracted from the hospitals' patient administrative systems was also used. Outcome measures. Length of waiting time, socio-economic variables, hospital type, health-related quality of life, and opinion about waiting time. The data were analysed mainly using regression analyses. RESULTS: The overall response rate was 79%. In all pre-operative stages, waiting times were longest in the hip replacement group. Socio-economic variables were not consistent determinants of variation in waiting times except for working status in the back surgery group where working patients had shorter waiting times than non-working patients irrespective of phase of waiting time. Admission to a county/district county hospital, compared with a university/regional hospital, was associated with shorter time on the waiting list. Patients with better health-related quality of life had significantly longer waiting times for arthroscopic knee surgery by all waiting time measures. The length of wait was a significant predictor of the patients' acceptance of waiting time. Patients' influence over the date of surgery also appeared to affect their opinion about the waiting time. CONCLUSIONS: Hospital-related factors are more important than patient characteristics as explanations of variations in waiting times for orthopaedic surgery. Patients value short waiting times and the possibility of influencing the date of surgery. (+info)
Hospital use of systemic antifungal drugs.
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BACKGROUND: Sales data indicate a major increase in the prescription of antifungal drugs in the last two decades. Many new agents for systemic use that only recently have become available are likely to be prescribed intensively in acute care hospitals. Sales data do not adequately describe the developments of drug use density. Given the concerns about the potential emergence of antifungal drug resistance, data on drug use density, however, may be valuable and are needed for analyses of the relationship between drug use and antifungal resistance. METHODS: Hospital pharmacy records for the years 2001 to 2003 were evaluated, and the number of prescribed daily doses (PDD, defined according to locally used doses) per 100 patient days were calculated to compare systemic antifungal drug use density in different medical and surgical service areas between five state university hospitals. RESULTS: The 3-year averages in recent antifungal drug use for the five hospitals ranged between 8.6 and 29.3 PDD/100 patient days in the medical services (including subspecialties and intensive care), and between 1.1 and 4.0 PDD/100 patient days in the surgical services, respectively. In all five hospitals, systemic antifungal drug use was higher in the hematology-oncology service areas (mean, 48.4, range, 24 to 101 PDD/100 patient days, data for the year 2003) than in the medical intensive care units (mean, 18.3, range, 10 to 33 PDD/100) or in the surgical intensive care units (mean, 10.7, range, 6 to 18 PDD/100). Fluconazole was the most prescribed antifungal drug in all areas. In 2003, amphotericin B consumption had declined to 3 PDD/100 in the hematology-oncology areas while voriconazole use had increased to 10 PDD/100 in 2003. CONCLUSION: Hematology-oncology services are intense antifungal drug prescribing areas. Fluconazole and other azol antifungal drugs are the most prescribed drugs in all patient care areas while amphotericin B use has considerably decreased. The data may be useful as a benchmark for focused interventions to improve prescribing quality. (+info)
Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis.
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OBJECTIVE: To qualitatively describe patient, hospital care, and critical pathway characteristics that may be associated with pathway effectiveness in reducing length of stay. DATA SOURCES/STUDY SETTING: Administrative data and review of pathway documentation and a sample of medical records for each of 26 surgical critical pathways in a tertiary care center's department of surgery, 1988-1998. STUDY DESIGN: Retrospective qualitative study. DATA COLLECTION/ABSTRACTION METHODS: Using information from a literature review and consultation with experts, we developed a list of characteristics that might impact critical pathway effectiveness. We used hypothesis-driven qualitative comparative analysis to describe key primary and secondary characteristics that might differentiate effective from ineffective critical pathways. PRINCIPAL FINDINGS: " All 7 of the 26 pathways associated with a reduced length of stay had at least one of the following characteristics: (1) no preexisting trend toward lower length of stay for the procedure (71 percent), and/or (2) it was the first pathway implemented in its surgical service (71 percent). In addition, pathways effective in reducing length of stay tended to be for procedures with lower patient severity of illness, as indicated by fewer intensive care days and lower mortality. Effective pathways tended to be used more frequently than ineffective pathways (77 versus 59 percent of medical records with pathway documents present), but high rates of documented pathway use were not necessary for pathway effectiveness. CONCLUSIONS: Critical pathway programs may have limited effectiveness, and may be effective only in certain situations. Because pathway utilization was not a strong predictor of pathway effectiveness, the mechanism by which critical pathways may reduce length of stay is unclear. (+info)
Cost effectiveness of minor surgery in general practice: a prospective comparison with hospital practice.
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The cost effectiveness of general practitioners undertaking minor surgery in their practices was determined in a prospective comparison of patients having minor surgery undertaken in five general practices over a 12 week period in 1989, and in the departments of dermatology and general surgery in Rotherham District General Hospital over a contemporaneous eight week period. There were no differences between the settings in the reported rates of wound infection or other complications and only one general practice patient was subsequently referred to hospital for specialist treatment. General practitioners sent a smaller proportion of specimens to a histopathology laboratory than hospital doctors (61% versus 90%, P less than 0.001); incorrectly diagnosed a larger proportion of malignant conditions as benign (10% versus 1%, P less than 0.05) and inadequately excised 5% of lesions where this never happened in hospital (difference not significant). General practice patients had shorter waiting times between referral and treatment, spent less time and money attending for treatment and more of them were satisfied with their treatment. The cost of a procedure undertaken in general practice was less than in hospital--pounds 33.53 versus pounds 45.54 for the excision of a lesion and pounds 3.00 versus pounds 3.22 for cryotherapy of a wart (1989-90 prices). Performing minor surgery in general practice would seem cost effective compared with a hospital setting. However, the risk of general practitioners inadequately excising a malignancy and not sending it to a histopathology laboratory must be addressed and the conclusion regarding cost effectiveness only applies where general practice is a substitute for the hospital setting and not an additional activity. (+info)