Lynn P. Copley

The national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis

Objectives: This study summarises the results of a National Audit of sino‐nasal surgery carried out in England and Wales. It describes patient and operative characteristics as well as patient outcomes up to 36 months after surgery.

Key messages from the National Prospective Tonsillectomy Audit.

Objectives: Investigation of the occurrence of postoperative hemorrhage after tonsillectomy and risk factors for these complications.

Pretransplant MELD score and post liver transplantation survival in the UK and Ireland

It has been shown that the model for end‐stage liver disease (MELD) score is an accurate predictor of survival in patients with liver disease without transplantation. Four recent studies carried out in the United States have demonstrated that the MELD score obtained immediately prior to transplantation is also associated with post‐transplant patient survival. Our aim was to evaluate how accurately the MELD score predicts 90‐day post‐transplant survival in adult patients with chronic liver disease in the UK and Ireland. The UK and Ireland Liver Transplant Audit has data on all liver transplants since 1994. We studied survival of 3838 adult patients after first elective liver transplantation according to United Network for Organ Sharing categories of their MELD scores (≤ 10, 11–18, 19–24, 25–35, ≥36). The overall survival at 90‐days was 90.2%. The 90‐day survival varied according to the United Network for Organ Sharing MELD categories (92.6%, 91.9%, 89.7%, 89.7%, and 70.8%, respectively; P < 0.01). Therefore, only those patients with a MELD score of 36 or higher (3% of the patients) had a survival that was markedly lower than the rest. As a consequence, the ability of the MELD score to discriminate between patients who were dead or alive was poor (c‐statistic 0.58). Re‐estimating the coefficients in the MELD regression model, even allowing for nonlinear relationships, did not improve its discriminatory ability. In conclusion, in the UK and Ireland the MELD score is significantly associated with post‐transplant survival, but its predictive ability is poor. These results are in agreement with results found in the United States. Therefore, the most appropriate system to support patient selection for transplantation will be one that combines a pretransplant survival model (e.g., MELD score) with a properly developed post‐transplant survival model. (Liver Transpl 2004;10:903–907.)

Long-term outcomes from the English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis

We present a large, prospective cohort study following patients who underwent surgery for chronic rhinosinusitis (CRS), with or without nasal polyps, in hospitals in England and Wales. Five‐year outcomes will be reported, and we will revisit a previous analysis of the effectiveness of extensive surgery in the treatment of nasal polyposis.

Complications of surgery for nasal polyposis and chronic rhinosinusitis : The results of a national audit in England and Wales

Objective: The objective of this study was to determine the rate of complications of surgery for nasal polyposis and chronic rhinosinusitis as well as their risk factors.

Variation in Outcome After Subarachnoid Hemorrhage A Study of Neurosurgical Units in UK and Ireland

Backgrounds and Purpose— The purpose of the study was to describe the characteristics, management, and outcomes of patients with confirmed aneurysmal subarachnoid hemorrhage and to compare outcomes across neurosurgical units (NSUs) in the UK and Ireland. Methods— A cohort of patients admitted to NSUs with subarachnoid hemorrhage between September 14, 2001 and September 13, 2002 was studied longitudinally. Information was collected to characterize clinical condition on admission and treatment. Death or severe disability, defined by the Glasgow Outcome Score–Extended, was ascertained at 6 months. Results— Data for 2397 patients with a confirmed aneurysm and no coexisting neurological pathology were collected by all 34 NSUs in the UK and Ireland. Aneurysm repair was attempted in 2198 (91.7%) patients (surgical clipping, 57.7%; endovascular coiling, 41.2%; other repair, 1.0%). Most patients (65.0%) were admitted to the NSU on the same day or the day after their hemorrhage; 32.0% of treated patients had the aneurysm repaired on the day of admission to the NSU (day 0), day 1 or day 2 and a further 39.3% by day 7. Glasgow Outcome Score–Extended at 6 months was obtained for 90.6% of patients (2172), of whom 38.5% had an unfavorable outcome. The median risk of an unfavorable outcome for all patients was 31% (5th and 95th percentiles, 12% and 83%), depending on prerepair prognostic factors. After adjustment for case-mix, the percentage of patients with an unfavorable outcome in each NSU did not differ significantly from the overall mean. Conclusions— In this study that collected representative data from the UK and Ireland, there was no evidence that the performance of any NSU differed from the average.

Survival after liver transplantation in the United Kingdom and Ireland compared with the United States

Background and objective: Surgical mortality in the US is widely perceived to be superior to that in the UK. However, previous comparisons of surgical outcome in the two countries have often failed to take sufficient account of case-mix or examine long-term outcome. The standardised nature of liver transplantation practice makes it uniquely placed for undertaking reliable international comparisons of surgical outcome. The objective of this study is to undertake a risk-adjusted disease-specific comparison of both short- and long-term survival of liver transplant recipients in the UK and Ireland with that in the US. Methods: A multicentre cohort study using two high quality national databases including all adults who underwent a first single organ liver transplant in the UK and Ireland (n = 5925) and the US (n = 41 866) between March 1994 and March 2005. The main outcome measures were post-transplant mortality during the first 90 days, 90 days to 1 year and beyond the first year, adjusted for recipient and donor characteristics. Results: Risk-adjusted mortality in the UK and Ireland was generally higher than in the US during the first 90 days (HR 1.17; 95% CI 1.07 to 1.29), both for patients transplanted for acute liver failure (HR 1.27; 95% CI 1.01 to 1.60) and those transplanted for chronic liver disease (HR 1.18; 95% CI 1.07 to 1.31). Between 90 days and 1 year post-transplantation, no statistically significant differences in overall risk-adjusted mortality were noted between the two cohorts. Survivors of the first post-transplant year in the UK and Ireland had lower overall risk-adjusted mortality than those transplanted in the US (HR 0.88; 95% CI 0.81 to 0.96). This difference was observed among patients transplanted for chronic liver disease (HR 0.88; 95% CI 0.81 to 0.96), but not those transplanted for acute liver failure (HR 1.02; 95% CI 0.70 to 1.50). Conclusions: Whilst risk-adjusted mortality is higher in the UK and Ireland during the first 90 days following liver transplantation, it is higher in the US among those liver transplant recipients who survived the first post-transplant year. Our results are consistent with the notion that the US has superior acute perioperative care whereas the UK appears to provide better quality chronic care following liver transplantation surgery.

Health-related quality of life after polypectomy with and without additional surgery

Objective: The objective of this study was to compare the health‐related quality of life of patients undergoing simple polypectomy with that of patients undergoing polypectomy with additional surgery.

Is there overutilisation of cataract surgery in England

Objectives: Following a 3.7-fold increase in the rate of cataract surgery in the UK between 1989 and 2004, concern has been raised as to whether this has been accompanied by an excessive decline in the threshold such that some operations are inappropriate. The objective was to measure the impact of surgery on a representative sample of patients so as to determine whether or not overutilisation of surgery is occurring. Design: Prospective cohort assessed before and 3 months after surgery. Setting: Ten providers (four NHS hospitals, three NHS treatment centres, three independent sector treatment centres) from across England. Participants: 861 patients undergoing first eye (569) or second eye (292) cataract surgery provided preoperative data of whom 745 (87%) completed postoperative questionnaires. Main outcome measures: Patient-reported visual function (VF-14); general health status and quality of life (EQ5D); postoperative complications; overall view of the operation and its impact. Results: Overall, visual function improved (mean VF-14 score increased from 83.2 (SD 17.3) to 93.7 (SD 13.2)). Self-reported general health status deteriorated (20.3% fair or poor before surgery compared with 25% afterwards) which was reflected in the mean EQ5D score (0.82 vs 0.79; p = 0.003). At least one complication was reported by 66 (8.9%) patients, though this probably overestimated the true incidence. If the appropriateness of surgery is based on an increase in VF-14 score of 5.5 (that corresponds to patients’ reporting being “a little better”), 30% of operations would be deemed inappropriate. If an increase of 12.2 (patients’ reports of being “much better”) is adopted, the proportion inappropriate is 49%. Using a different approach to determining a minimally important difference, the proportion inappropriate would be closer to 20%. Although visual function (VF-14) scores were unchanged or deteriorated in 25% of patients, 93.1% rated the results of the operation as “good,” “very good” or “excellent,” and 93.5% felt their eye problem was “better.” This partly reflects inadequacies in the validity of the VF-14. Conclusions: Improvement in the provision of cataract surgery has been accompanied by a reduction in the visual function threshold. However, methodological difficulties in measuring the impact of cataract surgery on visual function and quality of life mean it is impossible to determine whether or not overutilisation of cataract surgery is occurring.

Variation in recording of child maltreatment in administrative records of hospital admissions for injury in England, 1997–2009

Background Information on variation in the recording of child maltreatment in administrative healthcare data can help to improve recognition and ensure that services are able to respond appropriately. Objective To examine variation in the recording of child maltreatment and related diagnoses. Design Cross-sectional analyses of administrative healthcare records (Hospital Episode Statistics). Setting and participants Acute injury admissions to the National Health Service in England of children under 5 years of age (1997–2009). Outcome measure Annual incidence of admission for injury recorded by International Classifications of Diseases 10 codes for maltreatment syndrome (child abuse or neglect) or maltreatment-related features (assault, undetermined cause or adverse social circumstances). Proportion of all admissions for injury coded for maltreatment syndrome or maltreatment-related features. Results From 1997 to 2009, the annual incidence of injury admissions coded for maltreatment syndrome declined in infants and in 1–3-year-old children while admissions coded for maltreatment-related features increased in all age groups. The combined incidence of these categories remained stable. Overall, 2.6% of injury admissions in infants, and 0.4–0.6% in older age groups, had maltreatment syndrome recorded. This prevalence more than doubled when maltreatment-related codes were added (6.4% in infants, 1.5–2.1% in older age groups). Conclusion Despite a shift from maltreatment syndrome to codes for maltreatment-related features, the overall burden has remained stable. In combination, the cluster of codes related to maltreatment identify children likely to meet thresholds for suspecting or considering maltreatment and taking further action, as recommended in recent National Institute of Health and Clinical Excellence guidance, and indicate a considerable burden to which hospitals should respond.