A fascinating paper just published in the Lancet, outlining rates of mortality up to 7 days post operatively across 28 European countries. Data on over 46000 patients was collected. Crude mortality ranged from 1.2% of all cases in Iceland to >20% in Latvia. When adjusted for confounding variables, e.g. smoking, COPD etc, there was a TEN FOLD difference between the best and worst performing systems.
"When compared with the UK, the recorded
mortality rates for Poland, Latvia, Romania, and Ireland
were higher even after adjustment for all identified
confounding variables. This pattern could relate to
cultural, demographic, socioeconomic, and political
differences between nations, which might affect
population health and health-care outcomes."
However there may be other explanations, including the size and volume of surgical units, availability and expertise of intensive care, staffing, training and use (or lack of use) of approaches known to reduce morbidity and mortality such as pre-operative briefings (Gawande and others), appropriate antimicrobial prophylaxis and VTE prophylaxis. Regardless of the cause, yet again we see evidence of huge variation. Time to start learning why this exists.
The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man. GB Shaw
Showing posts with label mortality. Show all posts
Showing posts with label mortality. Show all posts
Tuesday, September 25, 2012
Friday, April 1, 2011
Public Reporting of Surgical Outcomes
In this weeks Lancet, a discussion around public reporting of surgical outcomes. Specific mention is made of the Society for Cardiothoracic Surgery in Great Britain and Ireland. Since 2005, the society has made outcome data freely available to the public; this has been associated with a 50% reduction in risk adjusted mortality, i.e. half as many people have died as would have been expected to die.
In terms of cost savings, the program costs £1.5 million annually, but is estimated to save £5 million per year in reduced length of stay costs.
In terms of cost savings, the program costs £1.5 million annually, but is estimated to save £5 million per year in reduced length of stay costs.
While clinicians may be resistant to public reporting of data, it is inevitable. My opinion is that it is better to be proactive, seek to develop such databases and ensure the data represents as accurately as possible the reality, i.e. risk adjusted.
Trends in youth mortality around the world
Published in The Lancet today, an analysis of WHO data looking at mortality trends in children and young adults around the world over the last 50 years. There have been dramatic improvements in mortality reduction around the world, as much as a 93% reduction in children aged 1-4. The smallest reduction occurred in young men, aged 15-24. More focus should be directed on reducing mortality in this group. However, this is a very encouraging and optimistic paper, showing that greta work can be achieved.
Saturday, March 26, 2011
Are you better off flying with a trainee pilot, or being operated on by a trainee surgeon?
One of the concerns that some people have relates to the way we train our doctors, essentially an apprenticeship system, with a trainee learning from a senior doctor. While I have some concerns about other aspects of this system, one of the unavoidable consequences is that trainees have to practice upon a patient. Is this safe? Surely being operated on by someone with less expertise increases the risk of something going wrong?
A study has just been published seeking to answer that question. The American College of Surgeons examined patient outcomes in more than 600,000 operations. They found that having a resident, (junior surgeon in training) while associated with a slightly higher risk of developing (usually minor) complications, was also more likely to be associated with a slightly reduced risk of death. The reasons obviously are unclear, but this important paper does provide some reassurance.
A study has just been published seeking to answer that question. The American College of Surgeons examined patient outcomes in more than 600,000 operations. They found that having a resident, (junior surgeon in training) while associated with a slightly higher risk of developing (usually minor) complications, was also more likely to be associated with a slightly reduced risk of death. The reasons obviously are unclear, but this important paper does provide some reassurance.
Thursday, March 17, 2011
Culture eats strategy for lunch
The title of this post refers to an oft quoted piece in business and change literature; to paraphrase, you can have a great plan but if it doesn't take into account the culture of the organization, you will fail. This I think is the crux around which healthcare reform and quality improvement specifically will succeed or fail. This is the great intangible that must be isolated and measured, so that we can truly begin to determine how healthcare providers differ from one another in terms of the quality of the service they deliver. As doctors we believe that the keys to a great service are world class doctors, state of the art facilities, the latest in IT; basically the best that money can buy.
However a study just published in the Annals of Internal Medicine, link here, (subscription required), suggests that this credo is incorrect. Curry et al interviewed 158 staff members from 11 hospitals, which were either in the top or bottom 5% nationally in the US for mortality post heart attack. The factor most highly correlated with outcomes was a cohesive organizational vision that focused on communication and support of all efforts to improve care. In other words, it was the culture, the communication ethos, mutual respect, leadership and desire to improve that should determine where you want to be treated, not all the high tech stuff and big names. This is consistent with my own observations nationally and internationally. All hospitals have problems, the high performers are the ones that seek out the problems and respectfully engage all their staff and leadership to solve them. It is my strongly held belief that one can distinguish between the high and low performers within an hour of visiting them.
Previous studies have suggested that the traditional factors that underpin success include being an academic medical centre, having more beds, and being located in a large city. Curry found that these factors accounted for only 20% of the difference. This is a very significant study, and provides ammunition for those of us who believe the system can be dramatically improved without massive expenditure; the down side is that changing culture can be extremely difficult.
However a study just published in the Annals of Internal Medicine, link here, (subscription required), suggests that this credo is incorrect. Curry et al interviewed 158 staff members from 11 hospitals, which were either in the top or bottom 5% nationally in the US for mortality post heart attack. The factor most highly correlated with outcomes was a cohesive organizational vision that focused on communication and support of all efforts to improve care. In other words, it was the culture, the communication ethos, mutual respect, leadership and desire to improve that should determine where you want to be treated, not all the high tech stuff and big names. This is consistent with my own observations nationally and internationally. All hospitals have problems, the high performers are the ones that seek out the problems and respectfully engage all their staff and leadership to solve them. It is my strongly held belief that one can distinguish between the high and low performers within an hour of visiting them.
Previous studies have suggested that the traditional factors that underpin success include being an academic medical centre, having more beds, and being located in a large city. Curry found that these factors accounted for only 20% of the difference. This is a very significant study, and provides ammunition for those of us who believe the system can be dramatically improved without massive expenditure; the down side is that changing culture can be extremely difficult.
Thursday, December 2, 2010
Influenza; Is cure better than prevention?
At a time when healthcare systems around the world are facing severe financial strain, it is worth asking whether there are any quick and dirty solutions out there. Amazingly there are, chief amongst them the ability to reduce the morbidity and mortality attributable to seasonal flu by the simple expedient of administering flu vaccine. The evidence base is not just strong, but strongly impressive. To take one example, a Swedish study published in 2001 found that recipients (aged >65 years) were half as likely to die from any cause in the year of vaccination, compared to their unvaccinated peers.
One measure of the cost effectiveness of any intervention is the cost per Quality Adjusted Life Year (QALY) saved. One conventional measure suggests that a cost per QALY of up to $50,000 is economically worthwhile. The cost per QALY for flu vaccine is -$17, i.e. for every patient vaccinated, there is a saving to the funder of $17. A no brainer. So how are we doing in Ireland? Recent data suggest that only 50% of people > 65 receive the flu vaccine.
So in answer to the question above, prevention is better than cure.
One measure of the cost effectiveness of any intervention is the cost per Quality Adjusted Life Year (QALY) saved. One conventional measure suggests that a cost per QALY of up to $50,000 is economically worthwhile. The cost per QALY for flu vaccine is -$17, i.e. for every patient vaccinated, there is a saving to the funder of $17. A no brainer. So how are we doing in Ireland? Recent data suggest that only 50% of people > 65 receive the flu vaccine.
So in answer to the question above, prevention is better than cure.
Saturday, November 13, 2010
Checklists
Since the study published two years ago in the New England Journal of Medicine by Gawande, which showed the value of checklists in reducing surgical morbidity and mortality in a variety of care settings, developed and developing world, there has been increasing interest in the benefits of checklists in improving patient safety. However the Gawande study has been criticized on a number of fronts, with many people doubting the benefits. The cardinal message of that study was that each of us, no matter how brilliant, will make mistakes. The purpose of the checklist is to reduce the risk of each team member making a mistake. Importantly, two major studies have just been published, which support Gawande's contention that the use of checklists are associated with improved outcomes. De Vries et al writing in the NEJM report a dramatic reduction in mortality and complications.
Neily et al writing in JAMA last month report similarly impressive results. It would appear that the jury is in; the use of checklists as part of a comprehensive approach to reducing surgical complications appears to be proven. Let the checklist reign.
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