A Bayesian Hierarchical Approach to Comparative Audit for Carotid Surgery

OBJECTIVES: the aim of this study was to illustrate how a Bayesian hierarchical modelling approach can aid the reliable comparison of outcome rates between surgeons. DESIGN: retrospective analysis of prospective and retrospective data. MATERIALS: binary outcome data (death/stroke within 30 days), together with information on 15 possible risk factors specific for CEA were available on 836 CEAs performed by four vascular surgeons from 1992-99. The median patient age was 68 (range 38-86) years and 60% were men. METHODS: the model was developed using the WinBUGS software. After adjusting for patient-level risk factors, a cross-validatory approach was adopted to identify "divergent" performance. A ranking exercise was also carried out. RESULTS: the overall observed 30-day stroke/death rate was 3.9% (33/836). The model found diabetes, stroke and heart disease to be significant risk factors. There was no significant difference between the predicted and observed outcome rates for any surgeon (Bayesian p -value>0.05). Each surgeon had a median rank of 3 with associated 95% CI 1.0-5.0, despite the variability of observed stroke/death rate from 2.9-4.4%. After risk adjustment, there was very little residual between-surgeon variability in outcome rate. CONCLUSIONS: Bayesian hierarchical models can help to accurately quantify the uncertainty associated with surgeons' performance and rank.     

Use of red blood cell transfusions in surgery

Background: Limited blood supplies necessitate the rational use of blood products. The aim of the present study was to provide a basis for audits of red cell usage in surgery by benchmarking common practice. Application of the data to the construction of a maximum surgical blood order schedule may be relevant for centres that perform a serological crossmatch or who collect autologous units. Methods: Data on surgical procedures identified by Commonwealth Medical Benefits Schedule item numbers, were collected retro­spectively from theatre and blood bank records at the Royal Melbourne and Melbourne Private hospitals from May 1997 to April 1998. The percentage of procedures for which red cells were transfused, and the mean, median and range of units transfused for procedures with ≥ 30% transfusion likelihood were identified. Results: Over 12 months, 266 surgical procedure codes were itemized ≥ 10 times each, contributing 12 300 data entries. Only 38 procedures demonstrated an incidence of transfusion of at least 30%. Most frequently transfused procedures included spinal fusion, total hip replacement, mandible/maxilla resection, prostatectomy and bladder excision. Conclusion: The number of common surgical procedures in which there is a 30% or greater likelihood that red cell transfusions will be given is limited. This benchmarking of common red cell usage is a first step in the process of determination of transfusion appropriateness.     

Issues of consent and privacy affecting the functioning of ASERNIP-S

The Australian Safety and Efficacy Register for New Interventional Procedures - Surgical (ASERNIP-S) undertakes horizon scanning, systematic reviews and audits. By disseminating information derived from these processes, ASERNIP-S aims to improve the quality of health care. In the present article, we discuss some of the legal and ethical issues surrounding the collection of identified data for the purposes of audit. The individual's right to privacy is considered as well as the benefits of improving the quality of surgical health care.     

Annual Scientific Meeting of The College of Surgeons of Hong Kong: A 5‐year audit

Objective : To examine the quality of surgical research in Hong Kong by auditing the results of abstracts submitted for annual scientific meetings held by The College of Surgeons of Hong Kong. Materials and Methods : From 1993 to 1998, all abstracts submitted for the meetings were evaluated and classified according to the hierarchy of evidence. The institutions of the presenting authors were recorded. Ovid MEDLINE search was then conducted to determine whether the abstracts were subsequently published in an indexed medical journal. Results : In total, 165 abstracts were submitted for the meeting in a 5‐year period. Randomized controlled trials constituted 12% of this research. Participation from community surgeons showed an encouraging trend from 17% in 1993 to 63% in 1998. In the first 4 years, 38% of abstracts were of publishable quality. More than half of the prospective randomized controlled trials were selected for presentation and subsequently published. Those abstracts selected for presentation have a higher chance of being published subsequently (P < 0.03). Conclusions : The randomized controlled trial remains a powerful research tool but is scarce in Hong Kong surgical research.      

医院伦理委员会的建设与临床试验的伦理审核

通过对卫生部北京医院伦理委员会建设和伦理审核工作的组织建设、制度建设、人员培训、工作状况等的分析，阐明伦理审核工作的意义、体会及需要进一步研究和探索的问题。     

网络环境下医院内部控制与审计

医院信息系统是一个存放着大量数据信息的准金融交易管理系统，其生成的数据信息和手工财务信息一样关系到经营安全。但有的并未把这部分信息像财务管理一样纳入内部审计的范畴，缺乏必要和有效的控制机制，使之成为控制的盲点。因此，建立完整、规范的内部控制与审计越来越重要。     

Burn mortality during 1982 to 1997 in Kuwait

The study group is comprised of 234 patients (6.4%) who died out of 3680 patients treated for burn injuries during the period January 1982 to December 1997 in Kuwait. There were 112 (47.9%) males and 122 (52.1%) females and their mean age was 30 years (range 1–93) when compared with 24 years among survivors. The high mortality amongst two age groups 0–5 years (39 deaths, 16.7%) and 16–35 years (109 deaths, 46.6%) shows their vulnerability in the society. In 190 patients (81.2%) the burn injuries occurred at home. A total of 216 patients (92.3%) sustained flame burns mainly due to clothes on fire (40.6%) and cooking gas accidents (25.2%), and in 18 patients (7.7%) the burns were due to scalds. The suicidal burns occurred in 22 female and 5 male patients mainly of younger age groups. The mean percentage of burns was 71% (range 9–100%) as against 20% amongst survivors, and 195 patients (83.3%) had 50% total body surface area (TBSA) burn. Four patients (1.7%) had superficial dermal burns, 94 (40.2%) had full thickness and 136 (58.1%) had mixed with full thickness burns predominance. The associated inhalation injury was diagnosed in 132 patients (56.4%). A total of 61 patients (26.1%) had either single or multiple pre-existing diseases and 51 of them sustained flame burns. The day of death varied from 1 to 103 days (mean 16 days) but 58 patients (24.8%) died within 48 hours of post burn. A total of 120 patients (51.3%) died due to septicaemia, 83 (35.5%) due to renal failure, 28 (10.2%) due to multi-organ failure, and 7 (3.0%) due to bronchopneumonia. The overall mortality rate was 6.4%, but this has significantly lowered to 4.4% (p= < 0.01) during last four years probably due to better burn care. The study thus shows that age group 0–5 and 16–35 years, domestic accidents, flame burn, inhalation injury, and pre-existing diseases are risk factors and septicaemia as the dominant cause of death in our patients.     

Performance and standards for the process of head and neck cancer care: South and West audit of head and neck cancer 1996-1997 (SWAHN I). South and West Regional Cancer Organisation Tumour Panel for Head and Neck Cancer

Evidence suggests wide variation in cancer care between different hospitals in the UK. To establish bench-marking data, we designed a prospective, 1 year regional study comparing key performance measures with established standards for the 28 hospital Trusts in the South and West of England involved in head and neck cancer care. 566 sequential patients with a newly-diagnosed head and neck cancer were included. Numbers referred and treated per hospital Trust were 1-58 and 1-65 respectively. 59% of patients received a pretreatment chest X-ray (standard 95%). 45% of patients were seen in a multidisciplinary clinic pretreatment (standard 95%), and this was proportional to the frequency of clinics held (P<0.0001). Median number of cases treated per surgeon was 4 (1-26), and by radiotherapist was 10 (1-51). Times between parts of the process of oral cancer care were closer to the standards than those for laryngeal cancer. Two patients were entered into a clinical trial. One had a quality-of-life score. Thus, in 1996-1997, in the South and West of England, there were major discrepancies between actual performance and established standards in many fundamental aspects of head and neck cancer care. Re-audit is essential to determine if the implementation of the Calman-Hine report has resulted in improvements.     

Air transport of the sick newborn infant: audit from a sparsely populated county in Norway

The aim of this study was to describe principal problems and to analyse transport times, stabilizing procedures, adverse events during transfer, outcome, effectiveness and the care of infants transferred by air from district general hospitals and maternity homes to a central hospital. Transfer times, equipment adverse events and clinical deterioration were recorded as they occurred. Data regarding clinical problems, diagnoses and outcome were collected retrospectively from hospital records. During the study period (1984-95) 275 infants (267 transports) were transferred by fixed-wing aircraft (233) or helicopter (34). Median time from request of transfer to arrival of the transport team (usually a neonatal nurse and a paediatrician) was 120 min, median stabilizing time 60 min. Ninety-six infants (35%) were intubated, 62 (22.5%) by the transport team. During 34 transports (12.7%), equipment-related adverse events occurred making six infants worse. Ten more infants deteriorated during transit. A significant correlation between birthweight and after-transfer temperature was recorded. After-transfer temperature for very low birthweight (<1500 g, VLBW) infants was significantly higher when the transport team attended the delivery than when they did not (35.9 degrees C vs 34.7 degrees C). All nine infants (3.2%) with after-transfer temperature <34.0 degrees C died, 15 infants (5.5%) died within 24 h after transfer and 20 (7.3%) died later. Adjusted OR for death among transported versus in utero transferred VLBW infants was 3.8 (1.4-10.4). Every effort should be taken to transfer VLBW infants in utero. If preterm deliveries at 26-28 weeks of gestation at district general hospitals is unavoidable, an early request for the neonatal transport team to be there at delivery is advisable. Transport of very immature infants <26 weeks gestational age is not recommended. An outreach educational program ("Team Pink Newborn") has been created. Staff training to combat hypothermia and regular inspection and control of the transport equipment by three neonatal intensive care nurses has now been implemented.