Background: Emergency colon cancer surgery is associated with increased mortality and complication risk, which can be due to differences in the organization of hospital care. This study aimed... Show moreBackground: Emergency colon cancer surgery is associated with increased mortality and complication risk, which can be due to differences in the organization of hospital care. This study aimed.Objective: To explore which structural factors in the preoperative, perioperative and postoperative periods influence outcomes after emergency colon cancer surgery.Methods: An observational study was performed in 30 Dutch hospitals. Medical records from 1738 patients operated in the period 2012 till 2015 were reviewed on the type of referral, intensive care unit (ICU) level, surgeon specialization and experience, duration of surgery and operating room time, blood loss, stay on specialized postoperative ward, complication occurrence, reintervention and day of surgery and linked to case-mix data available in the Dutch Colorectal Audit. Multivariate logistic regression analysis was used to estimate the influence of these factors on 30-day mortality, severe complication and failure to rescue (FTR), after adjustment for case-mix.Results: Patients operated by a non-Gastro intestinal/oncology specialized surgeon have significantly increased mortality (Odds Ratio (OR) 2.28 [95% confidence interval (95% CI) 1.23-4.23]) and severe complication risk (OR 1.61 [95% CI 1.08-2.39]). Also, duration of stay in the operating room was significantly associated with increased risk on severe complication (OR 1.03 [95% CI 1.01-1.06]). Patients admitted to a non-specialized ward have significantly increased mortality (OR 2.25 [95% CI 1.46-3.47]) and FTR risk (OR 2.39 [95% CI 1.52-3.75]). A low ICU level (basic ICU) was associated with a lower severe complication risk (OR 0.72 [95% CI 0.52-1.00]). Surgery on Tuesday was associated with a higher mortality risk (OR 2.82 [95% CI 1.24-6.40]) and a severe complication risk (OR 1.77, [95% CI 1.19-2.65]).Conclusion: This study identified a non-specialized surgeon and ward, operating room, time and day of surgery to be risk factors for worse outcomes in emergency colon cancer surgery. Show less
Groningen, J.T. van; Ceyisakar, I.E.; Gietelink, L.; Henneman, D.; Harst, E. van der; Westerterp, M.; ... ; Dutch Surg Colorectal Audit Grp 2020
Background: Comparing outcomes across hospitals to learn from best performing hospitals can be valuable. However, reliably identifying best performance is challenging. This study assesses the... Show moreBackground: Comparing outcomes across hospitals to learn from best performing hospitals can be valuable. However, reliably identifying best performance is challenging. This study assesses the possibility to distinguish best performing hospitals on single outcomes and consistency of performance on different outcomes.Methods: Data were derived from the Dutch ColoRectal Audit 2013-2015. Outcomes considered were textbook outcome (colon), (circumferential) resection margins, (serious) complications, mortality, and 'failure to rescue'. To include uncertainty in rankings, random effect logistic regression models were used to calculate expected ranks (ERs), for each hospital and outcome. Rankability was calculated for each outcome, as a measure of reliability of ranking. Furthermore, correlation between ERs on different outcomes was assessed. Correlation was considered weak <0.40, moderate between 0.40 - 0.59 and strong >0.60.Results: The study included 32 143 patients; of whom 11 373 were treated in 2015 across 84 hospitals, 8181 colon and 3192 rectal cancer patients. In this one-year period 'Postoperative complications' had the highest rankability for colon (57%) and rectal (41%) surgery. No (group of) hospital(s) had the highest ER(s) on all outcomes. Correlation between ERs of outcomes was moderate in 2 (of 25) and strong in 4 (of 25) combinations. Rankability of colorectal mortality increased from 14% in 2015 to 35% when data over 2013-2015 were used.Conclusion: The highest reliability of identifying best performance based on an outcome was 57%. However, the balance between reliability and relevance of outcomes is vulnerable. No (group of) hospital(s) could be identified as best performer on all outcomes. Performance was not consistent on outcomes. (C) 2020 Published by Elsevier Ltd. Show less
To evaluate and improve quality of colorectal cancer surgery clinical audit systems were introduced in several countries. One of the goals of a clinical audit is learning from ‘best practice’. The... Show moreTo evaluate and improve quality of colorectal cancer surgery clinical audit systems were introduced in several countries. One of the goals of a clinical audit is learning from ‘best practice’. The aim of this thesis was to learn about ‘best practice’ in colorectal cancer surgery. This was done by first identifying best performing hospitals and then investigate which structural, procedural and contextual factors are correlated with best performance in these hospitals.This thesis shows that the concept of best performance and ‘best practice’ may be too simplistic in everyday practice. It was not possible to reliably define a best performing (group of) hospitals on a combination of outcomes. However, specific outcomes could be helpful to identify starting points for improvement. Furthermore, it was not possible to identify a combination of structural or process measures necessary for good performance. To reach good outcomes, specialization and dedication of the ward and the team seem to be important. To reach best performance, ‘best practice’ seems to be: a specialized team with the right attitude and culture, effective teamwork and dedication to continuous improvement supported by continuous learning from reliable national and hospital specific data. Show less
Objectives Hospital variation in risk-adjusted outcomes after colorectal cancer surgery has been shown. However, explanatory factors are not sufficiently clear. The objective of this study was to... Show moreObjectives Hospital variation in risk-adjusted outcomes after colorectal cancer surgery has been shown. However, explanatory factors are not sufficiently clear. The objective of this study was to identify factors perceived by gastrointestinal surgeons as important to achieve excellent casemix-adjusted outcomes after colorectal cancer surgery.Design Based on literature and experts' opinion, 86 factors associated with serious complications, failure to rescue and mortality were listed. These were presented to gastrointestinal surgeons through two web-based surveys and an expert meeting. Participants were asked to choose their top 10 of most important factors.Participants Dutch gastrointestinal surgeons (n=52) of different hospitals and different hospital types (general/teaching/academic).Results Of 31 invited experts for the first survey and meeting, 71% responded. Of 130 invited surgeons, 34 responded to the second survey. Factors deemed important were: procedural hospital volume (46% in top 10), specialised surgeons performing surgery, (elective 87%, emergency 60% and reoperations 62% in top 10), accessibility of, and daily ward rounds by specialised surgeons (41% and 38% in top 10), preoperative screening for malnutrition (57% in top 10), a protocol for recognition of anastomotic leakage and rapid reintervention (54% and 49% in top 10).Conclusion Procedural hospital volume, specialisation of surgeons, screening for malnutrition, early recognition of complications followed by rapid action were perceived as most important factors to achieve good outcomes by gastrointestinal surgeons. Show less
