Perioperative Data (perioperative + data)

Distribution by Scientific Domains
Distribution within Medical Sciences


Selected Abstracts


Results from the International Cataract Surgery Outcomes Study

ACTA OPHTHALMOLOGICA, Issue thesis2 2007
Jens Christian Norregaard MD
Abstract It is widely accepted that cataract extraction with intraocular lens implantation is a highly effective and successful procedure. However, quality assessments and studies of effectiveness should still be undertaken. As with any surgical treatment modality, complications may occur, leading to suboptimal outcomes, additional health costs and deterioration in patients' functional capacity. International variation in clinical practice patterns and outcomes can serve as important pointers in the attempt to identify areas amenable to improvements in quality and cost-effectiveness. Once demonstrated, similar clinical results obtained in different health care systems can improve the level of confidence in a clinical standard against which the quality of care can be evaluated. The International Cataract Surgery Outcomes Study was established in 1992. The objective of this international comparative research project was to compare cataract management, outcomes of surgery and quality of care in four international sites. The study was conducted in the 1990s, since when many developments and refinements have emerged within cataract surgery. The actual figures reported in this thesis may no longer be of specific relevance as a decade has passed since their collection. However, the research questions and methods used in the study are still highly important and justify the publication of this report. The report deals with problems related to quality assessment, benchmarking, and the establishment and design of nationwide clinical databases , issues that are currently the focus of much attention. Moreover, the problems related to cross-national comparisons are increasingly relevant as more international databases are established. The study makes suggestions on how to report and compare objective as well as subjective criteria for surgery. The issue of how to report subjective criteria is a particular subject of current discussion. Four sites with high-quality health care systems were examined in this study: the USA, Denmark, the Province of Manitoba (Canada), and Barcelona (Spain). The design of the international research programme was based on methods developed by the US National Cataract Surgery Outcomes Study conducted by the US Cataract Patients Outcomes Research Team. The International Cataract Surgery Outcomes Study comprised three separate studies: a survey of ophthalmologists; a prospective cohort study, and a retrospective register-based cohort study. The survey study was based on data generated by a self-administered questionnaire completed by ophthalmologists in the four study areas. The questionnaire examined routine clinical practice involving patients considered for cataract surgery, and included questions on anaesthesia, monitoring and surgical techniques. The prospective cohort study was a large-scale, longitudinal observational study of patients undergoing first-eye cataract surgery in each study site. Patients were sampled consecutively from multiple clinics and followed for 4 months postoperatively. The retrospective cohort study was based on the Danish National Patient Register and claims data from the USA. This study could not be carried out in Barcelona or Manitoba as no suitable administrative databases were available. The papers based on register databases deal with retinal detachment and endophthalmitis but are not included in this thesis as the material was previously reported in my PhD thesis. The application of the studies was highly co-ordinated among the four sites and similar methods and instruments were used for data collection. The development of the data collection strategy, questionnaires, clinical data forms and data analyses were co-ordinated through weekly telephone conferences, annual in-person conferences, correspondence by mail or fax, and the exchange of sas programs and data files via the Internet. The survey study was based on responses from 1121 ophthalmologists in the four sites and results were presented in two papers. Within the previous year the participating ophthalmologists had performed a total of 212 428 cataract surgeries. With regard to preoperative ophthalmic testing, the present study reveals that refraction, fundus examination and A-scanning were performed routinely by most surgeons in all four sites. Other tests were reported to be performed routinely by some surgeons. It is unclear why any surgeon would use these other tests routinely in cataract patients with no ocular comorbidity. It appears that if this recommendation from the US Clinical Practice Guidelines Panel was broadly accepted, the use of these procedures and costs of care could be reduced, especially in Barcelona, the USA and Canada. Restricted use of medical screening tests was reported in Denmark. If this restricted screening were to be implemented in the USA, Canada and Barcelona, it would have significant resource implications. The most striking finding concerned the difference in monitoring practice between Denmark and each of the other three sites. In Denmark, monitoring equipment is seldom used and only occasionally is an anaesthesiologist present during cataract surgery. By contrast, in the other study sites, the presence of an anaesthesiologist using monitoring equipment is the norm. Adopting the Danish model in other sites would potentially yield significant cost savings. The results represent part of the background data used to inform the decision to conduct the two large-scale, multicentre Studies of Medical Testing for Cataract Surgery. The current study is an example of how surveys of clinical practice can pinpoint topics that need to be examined in randomized clinical trials. For the second study, 1422 patients were followed from prior to surgery until 4 months postoperatively. Preoperatively, a medical history was obtained and an ophthalmic examination of each patient performed. After consent had been obtained, patients were contacted for an in-depth telephone interview. The interview was repeated 4 months postoperatively. The interview included the VF-14, an index of functional impairment in patients with cataract. Perioperative data were available for 1344 patients (95%). The 4-month postoperative interview and clinical examination were completed by 1284 patients (91%). Main reasons for not re-evaluating patients were: surgery was cancelled (3%); refusal to participate (2%); lost to follow-up (1%), and death or being too sick (1%). The results have been presented in several papers, of which four are included in this thesis. One paper compared the preoperative clinical status of patients across the four sites and showed differences in both visual acuity (VA) and VF-14 measures. The VF-14 is a questionnaire scoring disability related to vision. The findings suggest that indications for surgery in comparable patients were similar in the USA and Denmark and were more liberal than in Manitoba and Barcelona. The results highlight the need to control for patient case mix when making comparisons among providers in a clinical database. This information is important when planning national databases that aim to compare quality of care. A feasible method may be to use one of the recently developed systems for case severity grading before cataract surgery. In another paper, perioperative clinical practice and rates of early complications following cataract surgery were compared across the four health care systems. Once again, the importance of controlling for case mix was demonstrated. Significant differences in clinical practice patterns were revealed, suggesting a general trend towards slower diffusion of new medical technology in Europe compared with North America. There were significant differences across sites in rates of intra- and early postoperative events. The most important differences were seen for rates of capsular rupture, hyphaema, corneal oedema and elevated pressure. Rates of these adverse events might potentially be minimized if factors responsible for the observed differences could be identified. Our results point towards the need for further research in this area. In a third paper, 4-month VA outcomes were compared across the four sites. When mean postoperative VA or crude proportions of patients with a visual outcome of <,0.67 were compared across sites, a much poorer outcome was seen in Barcelona. However, higher age, poorer general health status, lower preoperative VA and presence of ocular comorbidity were found to be significant risk factors associated with increased likelihood of poorer postoperative VA. The proportions of patients with these risk factors varied across sites. After controlling for the different distributions of these factors, no significant difference remained across the four sites regarding risk of a poor visual outcome. Once again the importance of controlling for case mix was demonstrated. In the fourth paper, we examined the postoperative VF-14 score as a measure of visual outcomes for cataract surgery in health care settings in four countries. Controlling for case mix was also necessary for this variable. After controlling for patient case mix, the odds for achieving an optimal visual function outcome were similar across the four sites. Age, gender and coexisting ocular pathology were important predictors of visual functional outcome. Despite what seemed to be an optimal surgical outcome, a third of patients still experienced visual disabilities in everyday life. A measure of the VF-14 might help to elucidate this issue, especially in any study evaluating the benefits of cataract surgery in a public health care context. [source]


Early Results of Photoselective Vaporization of the Prostate in Medical Control-failed Patients

LUTS, Issue 2 2009
Shen Kuang CHANG
Objectives: We present here our early results and learning curve for photoselective vaporization of the prostate (PVP) performed by an experienced urologist and we provide an analysis of the morbidity and early functional outcomes. Methods: Forty-four patients were selected, from May 2006 to January 2009, who had benign prostate hyperplasia (BPH) accompanied by lower urinary tract symptoms (LUTS). After undergoing PVP for BPH at our hospital, the patients were followed up for approximately 2 years. PVP was performed by the same experienced urologist using potassium-titanyl-phosphate (KTP) laser. Baseline characteristics, preoperative and perioperative data, and postoperative complications were evaluated. Regular outpatient department follow-up was conducted after patients were discharged from the hospital at 1, 4 and 12 weeks. Results: The mean age of the 44 patients was 71.6 years. The mean prostate volume was 47.52 mL. The mean PVP surgery time was 79.11 min. The mean urinary catheterization time was 23.41 h. Few complications arose after PVP, except that 47.7% of the patients developed pyuria after being discharged from hospital. The average hospital stay was 2.45 days. There were no significant differences in the efficiency of tissue vaporization among the patients. Conclusion: PVP for BPH has various advantages, including reducing postoperative complications. An experienced urologist can easily perform PVP. However, early results show no significant differences in the efficiency for the PVP technique. [source]


Is laparoscopic colectomy as cost beneficial as open colectomy?

ANZ JOURNAL OF SURGERY, Issue 4 2009
Asim Shabbir
Abstract Background:, Laparoscopic colectomy has yet to gain widespread acceptance in cost-conscious health-care institutions. The aim of the present study was to define the cost,benefit relationship of laparoscopic versus open colectomy. Methods:, Thirty-two consecutive patients undergoing elective laparoscopic colectomy (LC) by a single colorectal surgeon between August 2004 and September 2005 were reviewed. Cases were matched with a historical cohort undergoing elective open colectomy (OC) between June 2003 and July 2004. Demography, perioperative data, histopathology and cost were compared. Results:, Both groups had similar demographics. Most resections (90.6%) were for cancer. Operative time was significantly longer for LC compared to OC (180 min vs 110 min, P < 0.001). Four patients (12.5%) in the LC group required conversion. LC patients, however, had lower median pain scores (3, 2 and 1 vs 6, 4 and 2 at 24, 48 and 72 h postoperatively, P < 0.001), faster resolution of ileus (3 vs 4 days, P < 0.001) and earlier discharge (6 vs 9 days, P < 0.001) compared to the OC group. As a result, overall hospital cost for both procedures was not significantly different (US$7943 vs US$7253, P = 0.41). Conclusion:, Laparoscopic colectomy is as cost-beneficial in the short term as open colectomy. [source]


Factors influencing medical oncology referral in Dukes' C colonic cancer

ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, Issue 3 2010
Cu-Tai LU
Abstract Aim: Colorectal cancer (CRC) is one of the most common malignancies worldwide and adjuvant chemotherapy is proven to improve survival in patients with Dukes' C CRC. The purpose of this study was to analyze factors influencing referral to medical oncology in patients with Dukes' C colonic cancer in our institutions. Methods: Patients who underwent resection for Dukes' C colonic cancer were assessed for factors that influence the pattern of postoperative referral to the medical oncology department, including demographic and perioperative data. Results: Overall, 466 patients were identified to have Dukes' C colonic cancer, with 53.9% of these being female. Referral to medical oncology occurred for 58.4% patients. Multivariable logistic regression modeling identified age, elective admission and resection in private hospitals as factors. The likelihood of medical oncology referral in patients who had elective resection was 63% versus 41% in those who had emergency resection and resection in private hospitals was 69% versus 50% in public hospitals. Conclusion: Referral to a postoperative medical oncology clinic for adjuvant chemotherapy in Dukes' C colonic cancer was more likely in younger patients, those who underwent elective resection and those treated in private hospitals. [source]


Performance and functional outcome of endoscopic extraperitoneal radical prostatectomy in relation to obesity: an assessment of 500 patients

BJU INTERNATIONAL, Issue 6 2008
Evangelos Liatsikos
OBJECTIVE To investigate the impact of obesity on the performance and functional outcome of endoscopic extraperitoneal radical prostatectomy (EERPE). PATIENTS AND METHODS We retrospectively examined 500 patients treated with EERPE; they were categorized into three groups according to the World Health Organization classification of obesity: normal weight (body mass index, BMI, <25.0 kg/m2), overweight (25.0,29.9 kg/m2) and obese (30.0 kg/m2). The database of our institution was reviewed and perioperative data evaluated. The functional data were collected through questionnaires before and after EERPE and analysed statistically. RESULTS The age, prostate size and preoperative PSA level were similar in all three groups. The mean (sd) BMI was 27 (3.3) kg/m2, with 26.8%, 56.6% and 16.6% of the patients classed as normal, overweight and obese, respectively. A pelvic lymph node dissection and nerve-sparing was done in 218 and 123 patients, respectively. There was no statistically significance difference in the number of patients in each group who had previous procedures. Obese patients had a significantly higher American Society of Anesthesiologists score. The mean operative duration for all patients was 149 min; there was a statistically significant difference in duration among the three groups, with EERPE or nerve-sparing EERPE requiring a mean of 20 min more in obese patients. There was no conversion to open surgery. The estimated mean blood loss was 200 mL; four patients, none of them in the obese group, received a blood transfusion. At 3 months after EERPE there was a trend to worse continence in obese patients, but it was not statistically significant, and was not apparent at 6 months. There was no difference in transfusion rate and duration of catheterization. CONCLUSION EERPE seems to be a feasible and reproducible surgical technique in obese patients, although the operation takes longer. [source]


Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair,

BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 1 2004
S. Post
Background: Almost half the patients who undergo hernia repair with mesh report a feeling of stiffness and a foreign body in the groin. This study evaluated whether patients noticed any difference between lightweight and standard polypropylene mesh for the repair of inguinal hernia. Methods: Patients scheduled for elective repair of unilateral or bilateral, primary or recurrent inguinal hernia by the Lichtenstein technique were randomized to receive either a conventional densely woven polypropylene mesh (100,110 g/m2) or a lightweight composite multifilament mesh (polypropylene 27,30 g/m2). Quality of life was assessed using Short Form 36 before operation and 6 months after surgery. Pain was assessed by means of a visual analogue scale 2 days and 6 months after surgery. The primary outcome measure was the feeling of a foreign body in the groin at 6 months. Results: Some 122 hernias were randomized; 117 were included in the analysis of perioperative data, and 106 were re-examined after 6 months. There were no differences between the treatment groups with respect to early and late surgical complications. Use of lightweight mesh was associated with significantly less pain on exercise after 6 months (P = 0·042). In addition, fewer patients reported the feeling of a foreign body after repair with lightweight mesh (17·2 versus 43·8 per cent with conventional mesh; P = 0·003). Quality of life was improved significantly at 6 months compared with the preoperative assessment, and there were no differences between the treatment groups. Conclusion: Lightweight polypropylene mesh may be preferable for Lichtenstein repair of inguinal hernia. Larger cohorts with longer follow-up are needed before it can be recommended for routine use. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]