I. S. Benjamin

Mortality control charts for comparing performance of surgical units: validation study using hospital mortality data

Abstract Objective: To design and validate a statistical method for evaluating the performance of surgical units that adjusts for case volume and case mix. Design: Validation study using routinely collected data on in-hospital mortality. Data sources: Two UK databases, the ASCOT prospective database and the risk scoring collaborative (RISC) database, covering 1042 patients undergoing surgery in 29 hospitals for gastro-oesophageal cancer between 1995 and 2000. Statistical analysis: A two level hierarchical logistic regression model was used to adjust each units operative mortality for case mix. Crude or adjusted operative mortality was plotted on mortality control charts (a graphical representation of surgical performance) as a function of number of operations. Control limits defined as 90%, 95%, and 99% confidence intervals identified units whose performance diverged significantly from the mean. Results: The mean in-hospital mortality was 12% (range 0% to 50%). The case volume of the units ranged from one to 55 cases a year. When crude figures were plotted on the mortality control chart, four units lay outside the 90% control limit, including two outside the 95% limit. When operative mortality was adjusted for risk, three units lay outside the 90% limit and one outside the 95% limit. The model fitted the data well and had adequate discrimination (area under the receiver operating characteristics curve 0.78). Conclusions: The mortality control chart is an accurate, risk adjusted means of identifying units whose surgical performance, in terms of operative mortality, diverges significantly from the population mean. It gives an early warning of divergent performance. It could be adapted to monitor performance across various specialties. What is already known on this topic League tables are an established technique for ranking the performance of organisations such as healthcare providers Mortality control charts are another way to compare the performance of healthcare providers, particularly for outcomes of surgery What this study adds Mortality control charts can be adjusted for case mix and case volume and are better than league tables for monitoring surgical performance Mortality control charts have a “buffer zone” for indicating divergence from the mean mortality and are particularly useful for specialties with a low volume of surgery

Meta-analysis suggests antibiotic prophylaxis is not warranted in low-risk patients undergoing laparoscopic cholecystectomy.

Although laparoscopic cholecystectomy is associated with a low incidence of wound infection antibiotic prophylaxis is still commonly used in low-risk patients undergoing this procedure. A review of the available evidence on infective complications in laparoscopic surgery concluded that antibiotic prophylaxis could be omitted1. A meta-analysis was performed to assess whether antibiotic prophylaxis reduced the risk of wound infection and other septic complications.

ABC of the upper gastrointestinal tract: Cancer of the stomach and pancreas

Cancers of the stomach and the pancreas share similarly poor prognoses. However, long term survival is possible if patients present at an early stage. In England and Wales carcinoma of the stomach and pancreas cause about 7% and 4% of all cancer deaths respectively. In women they are the fourth and fifth most common causes of cancer death; in men their respective rankings are third equal (with colonic cancer) and seventh. Endoscopic appearance of gastric carcinoma on the lesser curve of the stomach The incidence of distal gastric carcinoma has fallen in the West, probably because of decreasing rates of infection with Helicobacter pylori , but it remains one of the main causes of death from malignancy worldwide. The incidence of proximal gastric cancer seems to be rising. These two gastric cancers depend on the distribution and severity of H pylori gastritis, as discussed in the earlier chapter on the pathophysiology of duodenal and gastric ulcers and gastric cancer.1 Gastric adenocarcinoma is rare below the age of 40 years, and its incidence peaks at about 60 years of age. Men are affected twice as often as women. Chronic atrophic pangastritis associated with H pylori infection is one of the most important risk factors for distal gastric cancer. #### Risk factors for gastric cancer ### Clinical presentation Symptoms may not occur until local disease is advanced. Patients may have symptoms and signs related to secondary spread (principally to the liver) and to the general effects of advanced malignancy, such as weight loss, anorexia, or nausea. Epigastric pain is present in about 80% of patients and may be similar to that from a benign gastric ulcer. If caused by obstruction of the gastric lumen, it is relieved by …