Benchmarking clinical outcomes in elective colorectal cancer surgery: The interplay between institutional reoperation- and mortality rates

Background

“Unplanned reoperations” has been advocated as a quality measure in colorectal cancer surgery as it is correlated with complications and postoperative mortality at a patient level. However, little is known about the relation between reoperation rates and postoperative mortality rates at a hospital level.

Methods

Data were derived from the Dutch Surgical Colorectal Audit 2009–2012 database. Hospitals with significantly higher and lower reoperation rates than average were identified and grouped accordingly. Postoperative mortality rates were compared between the groups.

Results

Some 28,667 patients who underwent elective colorectal cancer resections in 92 hospitals were analyzed. Fourteen hospitals had significantly higher (mean 14.6%) adjusted reoperation rates than average (10%), 20 had lower (5.3%) rates than average. Adjusted mortality rates were similar in groups with high reoperation rates and the majority cohort (3.5–3.2%) and significantly lower in hospitals with low reoperation rates (2.3%). However, individual hospitals with relatively high reoperation rates had low mortality rates and vice versa.

Conclusions

Reoperation rates after elective colorectal cancer resections varied. Hospitals with significantly higher reoperation rates than average did not have higher mortality rates. The group with lowest reoperation rates also had lower postoperative mortality rates; however, this did not apply to all hospitals in the group. In conclusion, ‘reoperations’ seems suitable as benchmark information to hospitals but less suitable to detect poor performers. Best practices should be identified as hospitals with both low reoperation- and mortality rates.     

Cancer in Aboriginal and Torres Strait Islander People of Australia

Aboriginal and Torres Strait Islander Australians have a cancer incidence for all sites combined equivalentto or slightly lower than for other Australians. They have a higher incidence of cancers of the cervix, liver andgallbladder, oesophagus, unknown primary site, mouth and throat, lung and pancreas, but a lower incidence ofcancers of the prostate, female breast, colon/rectum and skin (melanoma). Case survivals are lower for Aboriginaland Torres Strait Islander patients, partly due to an excess of cancer types with a high case fatality, relativelylow numbers with a low case fatality, and due to more advanced cancer stages at diagnosis. After accounting forthese factors, Aboriginal and Torres Strait Islander Australians still fare worse, probably due to elevated comorbidityand less complete care resulting from geographic remoteness, limited access to transport andaccommodation services, and sometimes a cultural disconnect with mainstream services.     

Mortality patterns among very preterm babies: a comparative analysis of two European regions in France and England

OBJECTIVE: To explore the differences in outcome of very preterm pregnancies between two geographically defined populations in Europe with similar socioeconomic characteristics and healthcare provision but different organisational arrangements for perinatal care. DESIGN: Prospective cohort study. SETTING: Nord Pas-de-Calais (NPC), France, and Trent, UK. PARTICIPANTS: All pregnancy outcomes 22(+0) to 32(+6) weeks' gestational age for resident mothers. OUTCOME MEASURES: Mortality patterns (antepartum death, intrapartum death, labour ward death and neonatal unit death) among very preterm babies were analysed by region. Multinomial logistic regression was used to model regional differences for a variety of pregnancy outcomes and to adjust for regional differences in the organisation of perinatal care. RESULTS: Delivery of very preterm infants was significantly higher in Trent compared with NPC (1.9% v 1.5% of all births, respectively (p<0.001)). Stillbirth rate was significantly higher in NPC than in Trent (23.0%, 95% CI 20.0% to 26.5% v 14.4%, 95% CI 12.3% to 16.6%, respectively (p<0.001)) and survival to discharge was higher in Trent than in NPC (74.6%, 95% CI 71.9% to 77.1% v 66.7%, 95% CI 63.3% to 69.9%, respectively (p<0.001)). Probability of intrapartum and labour ward death in NPC was more than five times higher than Trent (relative risk 5.3, 95% CI 2.2 to 13.1 (p<0.001)). CONCLUSION: The high rate of very preterm deliveries and the larger proportion of these infants recorded as live born in Trent appear to be the cause of the excess neonatal mortality seen in the routine statistics. Information about very preterm babies (not usually included in routine statistics) is vital to avoid inappropriate interpretation of international perinatal and infant data. This study highlights the importance of including deaths before transfer to neonatal care and emphasises the need to include the outcome of all pregnancies in a population in any comparative analysis.     

指背逆行岛状皮瓣修复指端缺损的治疗体会

目的探讨Ⅰ期指背逆行岛状皮瓣修复指端缺损的疗效及治疗体会。方法自2000年2月至2009年2月,对46例(52指)手指皮肤缺损的患者,采用指背逆行筋膜岛状皮瓣旋转180°转移修复。结果除2例皮瓣远端部分坏死外,余均成活,经6个月~5年随访,功能及外观良好。按TAM法评定,优36例,良7例,可3例,优良率达93%。结论该术式操作简单、疗程短、成功率高,对手指功能影响小,皮瓣血运良好,指端外形感觉效果好,是理想的修复方法。     

Treatment sequence network meta-analysis in Crohn’s disease: a methodological case study

Objective: Several biologic therapies are available for the treatment of mild-to-moderate Crohn’s disease (CD). This network meta-analysis (NMA) aimed to assess the comparative efficacy of ustekinumab, adalimumab, vedolizumab and infliximab in the maintenance of clinical response and remission after 1?year of treatment.

Methods: A systematic literature search was performed to identify relevant randomized controlled trials (RCTs). Key outcomes of interest were clinical response (CD activity index [CDAI] reduction of 100 points; CDAI-100) and remission (CDAI score under 150 points; CDAI < 150). A treatment sequence Bayesian NMA was conducted to account for the re-randomization of patients based on different clinical definitions, the lack of similarity of the common comparator for each trial and the full treatment pathway from the induction phase onwards.

Results: Thirteen RCTs were identified. Ustekinumab 90?mg q8w was associated with statistically significant improvement in clinical response relative to placebo and vedolizumab 300?mg. For clinical remission, ustekinumab 90?mg q8w was associated with statistically significant improvement relative to placebo and vedolizumab 300?mg q8w. Findings from sub-population analyses had similar results but were not statistically significant.

Conclusions: The NMA suggest that ustekinumab is associated with the highest likelihood of reaching response or remission at 1?year compared with placebo, adalimumab and vedolizumab. Results should be interpreted with caution because this is a novel methodology; however, the treatment sequence analysis may be the most methodologically sound analysis to derive estimates of comparative efficacy in CD in the absence of head-to-head evidence.     

Admissible multiarm stepped-wedge cluster randomized trial designs

Numerous publications have now addressed the principles of designing, analyzing, and reporting the results of stepped-wedge cluster randomized trials. In contrast, there is little research available pertaining to the design and analysis of multiarm stepped-wedge cluster randomized trials, utilized to evaluate the effectiveness of multiple experimental interventions. In this paper, we address this by explaining how the required sample size in these multiarm trials can be ascertained when data are to be analyzed using a linear mixed model. We then go on to describe how the design of such trials can be optimized to balance between minimizing the cost of the trial and minimizing some function of the covariance matrix of the treatment effect estimates. Using a recently commenced trial that will evaluate the effectiveness of sensor monitoring in an occupational therapy rehabilitation program for older persons after hip fracture as an example, we demonstrate that our designs could reduce the number of observations required for a fixed power level by up to 58%. Consequently, when logistical constraints permit the utilization of any one of a range of possible multiarm stepped-wedge cluster randomized trial designs, researchers should consider employing our approach to optimize their trials efficiency.     

Comparing groups of time dependent data using locally weighted scatterplot smoothing alpha-adjusted serial T-tests

BackgroundIn statistical analysis of time series researchers often pick key points from curves and run the venerable analysis of variance (ANOVA) to determine if a difference exists between groups. However, this approach fails to compare most of the data across time and thereby may throw out potentially valuable inferences.Research questionThis study illustrates a novel method termed LOESS alpha-adjusted serial t-testing (LAAST). LAAST employs locally weighted scatterplot smoothing (LOESS) on the data, serial correlation to make alpha adjustments, and point-wise Welch's t-tests to determine regional significance when comparing groups of time dependent data. It was expected that LAAST gives similar results to random field theory (RFT) based inferences while overcoming its shortcomings with respect to longitudinal data analysis.MethodsTwo data sets were analyzed with LAAST and RFT. The first contained two groups of five simulated random sinusoidal waveforms such that both inline time-series and equivalent time-offset longitudinal conditions were represented. The second data set was comprised of publicly available medial gastrocnemius forces from individuals with (N = 27) and without (N = 16) pain.ResultsResults for both data sets indicated similar corrected alpha levels regardless of analysis type, but the applied alpha level corrections were less conservative for LAAST than RFT or Holm-Bonferroni corrections, but often more conservative than Hochberg corrections.SignificanceAnalysis methods employing functional ANOVA and RFT have enabled researchers to effectively run comparisons between groups at all points within the time series and are gaining popularity. However, in some correction methods for multiple comparisons the alpha level correction can in turn lead to inflation of type II error. These results suggest that LAAST is comparable to RFT while also being appropriate for longitudinal type time series data analysis. Additionally, its use of Welch’s t-tests improves its validity on non-normally distributed data.     

Potential stock differences in the social behavior of rats in a situation of restricted access to food

The social behavior of outbred Long-Evans (LE) and Wistar (WI) rats was compared in a situation where access to food was particularly difficult (clearing an aquatic barrier, plus the necessity of carrying the food back to the home cage). In groups of either six WI or LE rats, only about 50% of individuals carried the food, and the others survived by attacking those that did. However, behavioral profiles associated with these acts were different in the two cases: LE carriers, contrary to WI carriers, restole some food, and LE noncarriers expressed more agonistic behavior and were more often attacked than were the WI noncarriers. Food flow and all associated, interactive behaviors were more complex in the LE than in the WI rats, indicating the likelihood of potential genetic differences in this testing situation.