Alex M. Almoudaris

Mortality in high-risk emergency general surgical admissions

There is increasing evidence of variable standards of care for patients undergoing emergency general surgery in the National Health Service (NHS). The aim of this study was to quantify and explore variability in mortality amongst high‐risk emergency general surgery admissions to English NHS hospital Trusts.

Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection

Complication management appears to be of vital importance to differences in survival following surgery between surgical units. Failure‐to‐rescue (FTR) rates have not yet distinguished surgical from general medical complications. The aim of this study was to assess whether variability exists in FTR rates after reoperation for serious surgical complications following colorectal cancer resections in England.

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

Objective:To investigate the nature of process failures in postoperative care, to assess their frequency and preventability, and to explore their relationship to adverse events. Background:Adverse events are common and are frequently caused by failures in the process of care. These processes are often evaluated independently using clinical audit. There is little understanding of process failures in terms of their overall frequency, relative risk, and cumulative effect on the surgical patient. Methods:Patients were observed daily from the first postoperative day until discharge by an independent surgeon. Field notes on the circumstances surrounding any nonroutine or atypical event were recorded. Field notes were assessed by 2 surgeons to identify failures in the process of care. Preventability, the degree of harm caused to the patient, and the underlying etiology of process failures were evaluated by 2 independent surgeons. Results:Fifty patients undergoing major elective general surgery were observed for a total of 659 days of postoperative care. A total of 256 process failures were identified, of which 85% were preventable and 51% directly led to patient harm. Process failures occurred in all aspects of care, the most frequent being medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. Process failures accounted for 57% of all preventable adverse events. Communication failures and delays were the main etiologies, leading to 54% of process failures. Conclusions:Process failures are common in postoperative care, are highly preventable, and frequently cause harm to patients. Interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce hospital stay.

Poor 1-year survival in elderly patients undergoing nonelective colorectal resection.

BACKGROUND: Colorectal resection in elderly patients is associated with significant morbidity and mortality, especially in an emergency setting. OBJECTIVES: This study aims to quantify the risks associated with nonelective colorectal resection up to 1 year after surgery in elderly patients. DESIGN: This is a population-based observational study. SETTING: Data were obtained from the Hospital Episode Statistics database. POPULATION: All patients aged 70 years and older who underwent a nonelective colorectal resection in an English National Health Service Trust hospital between April 2001 and March 2008 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were 30-day in hospital mortality, 365-day mortality, unplanned readmission within 28 days of discharge, and duration of hospital stay. RESULTS: During the study period, 36,767 nonelective colorectal resections were performed in patients aged ≥70 years in England. Patients were classified into 3 age groups: A (70–75 years), B (76–80 years), and C (>80 years). Thirty-day mortality was 17.0%, 23.3%, and 31.0% in groups A, B, and C (p < 0.001). The overall 30-day medical complication rate was 33.7%, and the reoperation rate was 6.3%. Cardiac and respiratory complications were significantly higher in group C (22.2% and 18.2%, p < 0.001). Mortality in Group C was 51.2% at 1-year postsurgery. Advanced age was an independent determinant of mortality in risk-adjusted regression analyses. LIMITATIONS: This is a retrospective analysis of a prospective database. Stage of disease at presentation, severity of complications, and cause of death cannot be ascertained from this database. CONCLUSIONS: In this population-based study, half of all English patients aged over 80 years undergoing nonelective colorectal resection died within 1 year of surgery. Further research is required to identify perioperative and postdischarge strategies that may improve survival in this vulnerable cohort.

A colorectal perspective on voluntary submission of outcome data to clinical registries

The aim of the study was to identify outcome differences amongst patients undergoing resection of colorectal cancer at English National Health Service trusts using Hospital Episode Statistics (HES). A comparison was undertaken of trusts that submitted and those that did not submit, or submitted only poorly, voluntarily to a colorectal clinical registry, the National Bowel Cancer Audit Programme (NBOCAP).

Single measures of performance do not reflect overall institutional quality in colorectal cancer surgery

Objective To evaluate overall performance of English colorectal cancer surgical units identified as outliers for a single quality measure—30 day inhospital mortality. Design 144 542 patients that underwent primary major colorectal cancer resection between 2000/2001 and 2007/2008 in 149 English National Health Service units were included from hospital episodes statistics. Casemix adjusted funnel plots were constructed for 30 day inhospital mortality, length of stay, unplanned readmission within 28 days, reoperation, failure to rescue-surgical (FTR-S) and abdominoperineal excision (APE) rates. Institutional performance was evaluated across all other domains for institutions deemed outliers for 30 day mortality. Outliers were those that lay on or breached 3 SD control limits. ‘Acceptable’ performance was defined if units appeared under the upper 2 SD limit. Results 5 high mortality outlier (HMO) units and 15 low mortality outlier (LMO) units were identified. Of the five HMO units, two were substandard performance outliers (ie, above 3 SD) on another metric (both on high reoperation rates). A further two HMO institutions exceeded the second but not the third SD limits for substandard performance on other outcome metrics. One of the 15 LMO units exceeded 3 SD for substandard performance (APE rate). One LMO institution exceeded the second but not the third SD control limits for high reoperation rates. Institutional mortality correlated with FTR-S and reoperations (R=0.445, p<0.001 and R=0.191, p<0.020 respectively). Conclusions Performance appraisal in colorectal surgery is complex and dependent on stakeholder perspective. Benchmarking units solely on a single performance measure is over simplistic and potentially hazardous. A global appraisal of institutional outcome is required to contextualise performance.

Failure to Rescue Patients After Reintervention in Gastroesophageal Cancer Surgery in England

IMPORTANCE Gastroesophageal cancer resections are associated with significant reintervention and perioperative mortality rates. OBJECTIVE To compare outcomes following operative and nonoperative reinterventions between high- and low-mortality gastroesophageal cancer surgical units in England. DESIGN All elective esophageal and gastric resections for cancer between 2000 and 2010 in English public hospitals were identified from a national administrative database. Units were divided into low- and high-mortality units (LMUs and HMUs, respectively) using a threshold of 5% or less for 30-day adjusted mortality. The groups were compared for reoperations and nonoperative reinterventions following complications. SETTING Both LMUs and HMUs. PARTICIPANTS Patients who underwent esophageal and gastric resections for cancer. EXPOSURE Elective esophageal and gastric resections for cancer, with reoperations and nonoperative reinterventions following complications. MAIN OUTCOMES AND MEASURES Failure to rescue is defined as the death of a patient following a complication; failure to rescue-surgical is defined as the death of a patient following reoperation for a surgical complication. RESULTS There were 14 955 esophagectomies and 10 671 gastrectomies performed in 141 units. For gastroesophageal resections combined, adjusted mortality rates were 3.0% and 8.3% (P < .001) for LMUs and HMUs, respectively. Complications rates preceding reoperation were similar (5.4% for LMUs vs. 4.9% for HMUs; P = .11). The failure to rescue-surgical rates were lower in LMUs than in HMUs (15.3% vs. 24.1%; P < .001). The LMUs performed more nonoperative reinterventions than the HMUs did (6.7% vs. 4.7%; P < .001), with more patients surviving in LMUs than in HMUs (failure to rescue rate, 7.0% vs. 12.5%; P < .001). Overall, LMUs reintervened more than HMUs did (12.2% vs 9.6%; P < .001), and LMUs had lower failure to rescue rates following reintervention than HMUs did (9.0% vs. 18.3%; P = .001). All P values stated refer to 2-sided values. CONCLUSIONS AND RELEVANCE Overall, LMUs were more likely to reintervene and rescue patients following gastroesophageal cancer resections in England. Patients were more likely to survive following both reoperations and nonsurgical interventions in LMUs.

Is 30‐day mortality an appropriate measure of risk in elderly patients undergoing elective colorectal resection?

Aim  The study aimed to define mortality in the elderly following elective colorectal resection and to identify the most meaningful postoperative period to report mortality rates in this group of patients.

Measuring academic performance for healthcare researchers with the H index: which search tool should be used?

Objectives: To compare H index scores for healthcare researchers returned by Google Scholar, Web of Science and Scopus databases, and to assess whether a researcher’s age, country of institutional affiliation and physician status influences calculations. Subjects and Methods: One hundred and ninety-five Nobel laureates in Physiology and Medicine from 1901 to 2009 were considered. Year of first and last publications, total publications and citation counts, and the H index for each laureate were calculated from each database. Cronbach’s alpha statistics was used to measure the reliability of H index scores between the databases. Laureate characteristic influence on the H index was analysed using linear regression. Results: There was no concordance between the databases when considering the number of publications and citations count per laureate. The H index was the most reliably calculated bibliometric across the three databases (Cronbach’s alpha = 0.900). All databases returned significantly higher H index scores for younger laureates (p < 0.0001). Google Scholar and Web of Science returned significantly higher H index for physician laureates (p = 0.025 and p = 0.029, respectively). Country of institutional affiliation did not influence the H index in any database. Conclusion: The H index appeared to be the most consistently calculated bibliometric between the databases for Nobel laureates in Physiology and Medicine. Researcher-specific characteristics constituted an important component of objective research assessment. The findings of this study call to question the choice of current and future academic performance databases.

Hierarchical multilevel analysis of increased caseload volume and postoperative outcome after elective colorectal surgery

The study aimed to explore the impact of surgeon and institution volume on outcome following colorectal surgery in England using multilevel hierarchical analysis.