Chris Sherlaw-Johnson

Monitoring the results of cardiac surgery by variable life-adjusted display

BACKGROUND Conventional assessment of the outcome of cardiac surgery usually takes the form of retrospective mortality figures and, at best, indicates an average performance over time. Summary tables conceal good and bad runs, and without risk adjustment they are difficult to interpret. We developed a refinement of the cumulative sum method that weights death and survival by each patients risk status and provides a display of surgical performance over time. METHODS The variable life-adjusted (VLAD) plot shows the difference between expected and actual cumulative mortality. VLAD shows whether a surgeons performance is above or below what might be expected. This mortality-scoring system accumulates penalties for each death and rewards for every survivor, based on the inherent risk of perioperative death of each case concerned. FINDINGS We illustrate the results of three performance reviews, displayed as VLADs. The first shows the results of an individual surgeon for 547 consecutive cardiac-surgical cases. The overall mortality was 36% less than that predicted by the Parsonnet scoring system. The second displays the results for 5000 consecutive patients who underwent cardiopulmonary bypass between 1992 and 1996, divided into six contemporaneous series. The predicted mortality was 9% compared with 6% actual mortality. The third is a plot for a trainee surgeon and clearly shows how a period of poor performance was identified and then substantially improved, which would not have been revealed by conventional tables of summary statistics. INTERPRETATION VLAD provides a graphical display of risk-adjusted survival figures for individual surgeons or units over time and could be modified to monitor performance over a range of treatments and outcomes.

Can papilloma virus testing be used to improve cervical cancer screening

This report investigates different options for using human papillomavirus (HPV) testing in cervical cancer prevention. These options are evaluated by a stochastic model of the progression of pre‐malignancy and its relationship to HPV infection. Three screening policies are compared: 2 based on cytological screening, with or without HPV testing, and I in which HPV testing is the primary screening method. A policy of HPV testing for women with mildly abnormal smears would have little effect on the overall incidence of invasive cancer when compared with a policy of repeat cytology, provided follow‐up is efficient. Moreover, the potential value of HPV testing as a primary screening method is strongly dependent on the proportion of neoplasias that are HPV‐negative. Important factors in assessing the future role of HPV testing would be cost‐effectiveness and benefits from improved compliance.

Evaluating cervical cancer screening programmes for developing countries

This study evaluates cervical screening programmes for regions of the world where resources are scarce and little screening currently takes place. It investigates infrequent screening and programmes in which as many women as possible are screened just once in their lifetime. It also compares the effectiveness of cytology and human papillomavirus (HPV) testing for primary screening. Different programmes are evaluated by a stochastic model of the progression of pre‐cancer, its relationship to papillomavirus infection and the diagnostic accuracy of alternative screening methods. These are compared in terms of the impact on the incidence of invasive cancer and resource use. Important factors that determine the suitability of different screening programmes are the available resources and the expected population coverage. Blanket screening for women aged 30–59 years, with the aim of covering all just once in their lifetime, could reduce the incidence of invasive cancer by up to 30%. A 10‐year programme would require about 50% more routine screening tests to bring about the same reduction in incidence and a 5‐year programme about 2.5–3 times as many. With either approach it would be more effective for resource use to concentrate on screening women aged 30–59 than a wider age group. Whether HPV testing would be more effective as a primary screening method than cytology depends on the underlying prevalence of HPV infection, the accuracy of cytology, the cost and the suitability of the testing procedure under field conditions. Int. J. Cancer 72:210–216, 1997.

Surgical Performance Measurement

The need for effective surgical performance measurement has gained an increasingly high profile in recent years, particularly since events at Bristol Royal Infirmary, where apparent poor performance has prompted the UK Department of Health to instigate a major Public Inquiry. This paper describes issues that concern the measuring and monitoring of surgical performance, and methods that have been devised for judging a good surgeon from the less competent. The authors are a collaborative team composed of specialists in Cardiothoracic surgery and Operational Research analysts with experience of monitoring performance in cardiac surgery. This paper describes concrete examples from that knowledge base.

Comparative indicators for cancer network management in England: availability, characteristics and presentation.

BackgroundIn 2000, the national cancer plan for England created 34 cancer networks, new organisational structures to coordinate services across populations varying between a half and three million people. We investigated the availability of data sets reflecting measures of structure, process and outcome that could be used to support network management.MethodsWe investigated the properties of national data sets relating to four common cancers – breast, colorectal, lung and prostate. We reviewed the availability and completeness of these data sets, identified leading items within each set and put them into tables of the 34 cancer networks. We also investigated methods of presentation.ResultsAcute Hospitals Portfolio and the National Cancer Peer Review recorded structural characteristics at hospital and cancer service level. Process measures included Hospital Episode Statistics, recording admissions, and Cancer Waiting List data. Patient outcome measures included the National Survey: Cancer Patients, and Cancer Survival, drawn from cancer registration.ConclusionWhile not as yet used together in practice, comparative indicators are available within the National Health Service in England for use in performance assessment by cancer networks.

The planning of cervical cancer screening programmes in Eastern Europe: is viral testing a suitable alternative to smear testing?

Cervical cancer screening with human papillomavirus (HPV) DNA testing has potential advantages over conventional smear testing in that it can predict cases in which invasive cancers are more likely to develop, may be cheaper to implement and improve compliance. In areas of the world where little formalised cervical cancer screening takes place, or where health resources are limited, HPV testing has been suggested as a possible alternative for primary screening.In this paper we demonstrate the use of mathematical modelling to evaluate the effects of setting up screening programmes in Eastern Europe with HPV DNA testing as the primary screening tool and compare it with conventional smear testing. The impact of screening is measured in terms of the life years gained and the resulting resource usage and cost. We investigate several screening options with different screening intervals and age ranges for the target population.

Organizational determinants of patients' experiences of care for breast, lung and colorectal cancers

Organizational characteristics in English NHS hospitals and the experiences of patients with three common cancers – breast, colorectal and lung – were examined using secondary data analyses. Two specific measures of satisfaction, Respect and Dignity, reflecting inpatient care, and Communication reflecting hospital outpatient care, were drawn from a national survey of cancer patients after first hospital treatment. They were compared at hospital level with hospital cancer service standards, and measures of hospital provision, each drawn from national surveys. Respect and Dignity was greater in hospitals with fewer complaints, slower admission procedures and a greater proportion of medicine consultants, for breast and colorectal cancers only. For breast cancer alone, Respect and Dignity was greater in hospitals achieving more participation in meetings by lead team members at the cancer unit level. For lung cancer alone, there were tumour-specific team organizational measures (relating to outpatient assessment) associated with Communication. However, the majority of recorded standards did not show associations, and there were occasional negative associations (dissatisfaction). The impact of organizational factors on patients may be examined through observational studies when experimental designs are not possible. Understanding how organizational factors affect quality of care for cancer patients can contribute to planning and management of cancer services.

Monitoring Surgical Performance

OR is ultimately dependent on the implementation of improved methods. This paper describes a project which has been successful in this, and illustrates how close collaboration with clinicians was necessary.