Morbidity and mortality (M&M) conferences are an acclaimed method for achieving case-based learning and improving surgical care1. Their educational value is acknowledged, but whether these... Show moreMorbidity and mortality (M&M) conferences are an acclaimed method for achieving case-based learning and improving surgical care1. Their educational value is acknowledged, but whether these conferences contribute to systemic improvement is unclear2. M&M formats vary widely3,4, and are mostly focused on severe adverse events and individual performance, thus lacking consideration of system-level issues or similar cases where successful outcomes were achieved3,5,6. To overcome these shortcomings, an adapted weekly M&M meeting was developed at the authors unit7. In the adapted meeting, the surgical team collectively reflects both on all recently discharged but also on planned procedures, which is consistent with existing frameworks8. Discussing all cases also directs attention to successful outcomes, rather than only the complicated ones. This allows the team to understand how to ensure safety for their patients continuously9,10.The aim of this qualitative study was to investigate how the novel weekly reflective team meeting affects the dynamics of a surgical team and improves the quality of care. Show less
Objective: To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).Design: Cluster... Show moreObjective: To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).Design: Cluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients.Setting: 20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands.Participants: 32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care). Intervention: The intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken. Main outcome measures: The primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS).The individual indicators were analysed as secondary outcomes. Changes in outcomes from preintervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII. Results: 16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 432% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95% CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95% CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95% CI 0.67-1.30). Conclusion: The multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes. Show less
Schie, P. van; Bodegom-Vos, L. van; Zijdeman, T.M.; Nelissen, R.G.H.H.; Mheen, P.J.M. van de 2022
Objective To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).Design Cluster... Show moreObjective To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).Design Cluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients.Setting 20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands.Participants 32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care).Intervention The intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken.Main outcome measures The primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS).The individual indicators were analysed as secondary outcomes. Changes in outcomes from preintervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII.Results 16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 432% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95% CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95% CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95% CI 0.67-1.30).Conclusion The multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes. Show less
OBJECTIVE:: To investigate the safety of laparoscopic colorectal cancer resections in a nationwide population-based study. BACKGROUND:: Although laparoscopic techniques are increasingly used in... Show moreOBJECTIVE:: To investigate the safety of laparoscopic colorectal cancer resections in a nationwide population-based study. BACKGROUND:: Although laparoscopic techniques are increasingly used in colorectal cancer surgery, little is known on results outside trials. With the fast introduction of laparoscopic resection (LR), questions were raised about safety. METHODS:: Of all patients who underwent an elective colorectal cancer resection in 2010 in the Netherlands, 93% were included in the Dutch Surgical Colorectal Audit. Short-term outcome after LR, open resection (OR), and converted LR were compared in a generalized linear mixed model. We further explored hospital differences in LR and conversion rates. RESULTS:: A total of 7350 patients, treated in 90 hospitals, were included. LR rate was 41% with a conversion rate of 15%. After adjustment for differences in case-mix, LR was associated with a lower risk of mortality (odds ratio 0.63, P < 0.01), major morbidity (odds ratio 0.72, P < 0.01), any complications (odds ratio 0.74, P < 0.01), hospital stay more than 14 days (odds ratio 0.71, P < 0.01), and irradical resections (odds ratio 0.68, P < 0.01), compared to OR. Outcome after conversion was similar to OR (P > 0.05). A large variation in LR and conversion rates among hospitals was found; however, the difference in outcome associated with operative techniques was not influenced by hospital of treatment. CONCLUSIONS:: Use of laparoscopic techniques in colorectal cancer surgery in the Netherlands is safe and results are better in short-term outcome than open surgery, irrespective of the hospital of treatment. Outcome after conversion was similar to OR. Show less
AIMS The purpose of this study was to determine how expected mortality based on case-mix varies between colorectal cancer patients treated in non-teaching, teaching and university hospitals, or... Show moreAIMS The purpose of this study was to determine how expected mortality based on case-mix varies between colorectal cancer patients treated in non-teaching, teaching and university hospitals, or high, intermediate and low-volume hospitals in the Netherlands. MATERIAL AND METHODS We used the database of the Dutch Surgical Colorectal Audit 2010. Factors predicting mortality after colon and rectum carcinoma resections were identified using logistic regression models. Using these models, expected mortality was calculated for each patient. RESULTS 8580 patients treated in 90 hospitals were included in the analysis. For colon carcinoma, hospitals' expected mortality ranged from 1.5 to 14%. Average expected mortality was lower in patients treated in high-volume hospitals than in low-volume hospitals (5.0 vs. 4.3%, p < 0.05). For rectum carcinoma, hospitals expected mortality varied from 0.5 to 7.5%. Average expected mortality was higher in patients treated in non-teaching and teaching hospitals than in university hospitals (2.7 and 2.3 vs. 1.3%, p < 0.01). Furthermore, rectum carcinoma patients treated in high-volume hospitals had a higher expected mortality than patients treated in low-volume hospitals (2.6 vs. 2.2% p < 0.05). We found no differences in risk-adjusted mortality. CONCLUSIONS High-risk patients are not evenly distributed between hospitals. Using the expected mortality as an integrated measure for case-mix can help to gain insight in where high-risk patients go. The large variation in expected mortality between individual hospitals, hospital types and volume groups underlines the need for risk-adjustment when comparing hospital performances. Show less
Kolfschoten, N.; Wouters, M.W.J.M.; Gooiker, G.A.; Eddes, E.H.; Kievit, J.; Tollenaar, R.A.E.M.; Mheen, P.J.M. van de 2011
