P J Marang-van de Mheen

The Relative Importance of Quality of Care Information When Choosing a Hospital for Surgical Treatment: A Hospital Choice Experiment

Objective: To assess the impact of quality of care and other hospital information on patients’ choices between hospitals. Methods: 665 former surgical patients were invited to respond to an Internet-based questionnaire including a choice-based conjoint analysis. Each patient was presented with 12 different comparisons of 2 hospitals, with each hospital characterized by 6 attributes containing 2 levels. Hospital attributes were included if frequently reported by patients as most important for future hospital choices. These included both general hospital information (e.g., atmosphere), information on quality of care (e.g., percentage of patients with “textbook outcome”), and surgery-specific information (e.g., possibility for minimally invasive procedure). Hierarchial Bayes estimation was used to estimate the utilities for each attribute level for each patient. Based on the ranges of these utilities, the relative importance of each hospital attribute was determined for each participant as a measure of the impact on patients’ choices. Results: 308 (46.3%) questionnaires were available for analysis. Of the hospital attributes that patients considered, surgery-specific information on average had the highest relative importance (25.7 [23.9–27.5]), regardless of gender, age, and education. Waiting time and hospital atmosphere were considered least important. The attribute concerning the percentage of patients with “textbook outcomes” had the second greatest impact (18.3 [16.9–19.6]), which was similar for patients with different adverse outcome experience. Conclusions: Surgery-specific and quality of care information are more important than general information when patients choose between hospitals.

Adverse outcomes in surgical patients: implementation of a nationwide reporting system

Problem: Lack of comparable data on adverse outcomes in hospitalised surgical patients. Design: A Plan-Do-Study-Act (PDSA) cycle to implement and evaluate nationwide uniform reporting of adverse outcomes in surgical patients. Evaluation was done within the Reach Efficacy-Adoption Implementation Maintenance (RE-AIM) framework. Setting: All 109 surgical departments in The Netherlands. Key measures for improvement: Increase in the number of departments implementing the reporting system and exporting data to the national database. Strategies for change: The intervention included (1) a coordinator who could mediate in case of problems; (2) participation of an opinion leader; (3) a predefined plan of action communicated to all departments (including feedback of results during implementation); (4) connection with existing hospital databases; (5) provision of software and a helpdesk; and (6) an instrument based on nationwide standards. Effects of change: Implementation increased from 18% to 34% in 1.5 years. The main reason for not implementing the system was that the Information Computer Technology (ICT) department did not link data with the hospital information system (lack of time, finances, low priority). Only 5% of the departments exported data to the national database. Export of data was hindered mainly by slow implementation of the reporting system (so that departments did not have data to export) and by concerns regarding data quality and public availability of data from individual hospitals. Lessons learned: Hospitals need incentives to realise implementation. Important factors are financial support, sufficient manpower, adequate ICT linkage of data, and clarity with respect to public availability of data.

Choosing between Hospitals: The Influence of the Experiences of Other Patients

Objective. Publicly available information on hospital performance is increasing, with the aim to support consumers when choosing a hospital. Besides general hospital information and information on outcomes of care, there is increasing availability of systematically collected information on experiences of other patients. The aim of this study was to assess the influence of previous patients’ experiences relative to other information when choosing a hospital for surgical treatment. Methods. Three hundred thirty-seven patient volunteers and 280 healthy volunteers (response rate of 52.4% and 93.3%, respectively) filled out an Internet-based questionnaire that included an adaptive choice-based conjoint analysis. They were asked to select hospital characteristics they would use for future hospital choice, compare hospitals, and choose the overall best hospital. Based on the respondents’ choices, the relative importance (RI) of each hospital characteristic for each respondent was estimated using hierarchical Bayes estimation. Results. Information based on previous patients’ experience was considered at least as important as information provided by hospitals. “Report card regarding physician’s expertise” had the highest RI (16.83 [15.37–18.30]) followed by “waiting time for outpatient clinic appointment” (14.88 [13.42–16.34]) and “waiting time for surgery” (7.95 [7.12–8.78]). Patient and healthy volunteers considered the same hospital attributes to be important, except that patient volunteers assigned greater importance to “positive judgment about physician communication” (7.65 v. 5.80, P < 0.05) and lower importance to “complications” (2.56 v. 4.22, P < 0.05). Conclusion. Consumers consider patient experience–based information at least as important as hospital-based information. They rely most on information regarding physicians’ expertise, waiting time, and physicians’ communication when choosing a hospital.

Nonelective colon cancer resections in elderly patients: results from the dutch surgical colorectal audit.

Aims: The aim of the study was to assess which factors contribute to postoperative mortality, especially in elderly patients who undergo emergency colon cancer resections, using a nationwide population-based database. Methods: 6,161 patients (1,172 nonelective) who underwent a colon cancer resection in 2010 in the Netherlands were included. Risk factors for postoperative mortality were investigated using a multivariate logistic regression model for different age groups, elective and nonelective patients separately. Results: For both elective and nonelective patients, mortality risk increased with increasing age. For nonelective elderly patients (80+ years), each additional risk factor increased the mortality risk. For a nonelective patient of 80+ years with an American Society of Anesthesiologists score of III+ and a left hemicolectomy or extended resection, postoperative mortality rate was 41% compared with 7% in patients without additional risk factors. Conclusions: For elderly patients with two or more additional risk factors, a nonelective resection should be considered a high-risk procedure with a mortality risk of up to 41%. The results of this study could be used to adequately inform patient and family and should have consequences for composing an operative team.

Adverse outcomes after discharge: occurrence, treatment and determinants

Objective: (1) to estimate the occurrence of postdischarge adverse outcomes in surgical patients and their treatment; (2) to explore determinants during admission that may influence the occurrence of postdischarge adverse outcomes. Design: Four weeks after discharge, patients were contacted by telephone and interviewed about: (1) the occurrence of adverse health outcomes after discharge; (2) their treatment and whether readmission or additional surgery was required. Data on the type of surgery and the occurrence of in-hospital adverse outcomes were taken from the routine reporting system. Setting: Dutch university hospital Study sample: All 2145 surgical patient admissions in 2003, of whom 1960 (91%) agreed to participate. Main outcome measures: Percentage of patient admissions with postdischarge adverse outcomes, by type of treatment. Results: Postdischarge adverse outcomes occurred in 487 patients (25%). Most (76%) of the 554 adverse outcomes were treated by a specialist: 165 (30%) during readmission and 257 (46%) at the outpatient clinic. Postdischarge adverse outcomes were mostly infections (39%). In-hospital adverse outcomes and complex surgical procedures increased the probability for both postdischarge adverse outcomes (odds ratio 1.43 (1.05 to 1.94) and 1.36 (1.02 to 1.82) respectively) and postdischarge adverse outcomes that require readmission (odds ratio 1.59 (1.01 to 2.52) and 1.73 (1.09 to 2.74) respectively). Conclusions: Patients should be informed at discharge that postdischarge adverse outcomes may occur, in particular if the patient had complex surgical procedures or adverse outcomes during hospitalisation. Since infections were the main type of postdischarge adverse outcomes, more attention should be given on wound treatment by patients and infection prevention after discharge.

Surgical adverse outcomes and patients’ evaluation of quality of care: inherent risk or reduced quality of care?

Background: Previous research has shown that sicker patients are less satisfied with their healthcare, but specific effects of adverse health outcomes have not been investigated. The present study aimed to assess whether patients who experience adverse outcomes, in hospital or after discharge, differ in their evaluation of quality of care compared with patients without adverse outcomes. Method: Inhospital adverse outcomes were prospectively recorded by surgeons and surgical residents as part of routine care. Four weeks after discharge, patients were interviewed by telephone about the occurrence of post-discharge adverse outcomes, and their overall evaluation of quality of hospital care and specific suggestions for improvements in the healthcare provided. Results: Of 2145 surgical patients admitted to the Leiden University Medical Center in 2003, 1876 (88%) agreed to be interviewed. Overall evaluation was less favourable by patients who experienced post-discharge adverse outcomes only (average 19% lower). These patients were also more often dissatisfied (OR 2.02, 95% CI 1.24 to 3.31) than patients without adverse outcomes, and they more often suggested that improvements were needed in medical care (OR 2.07, 1.45 to 2.95) and that patients were discharged too early (OR 3.26, 1.72 to 6.20). The effect of inhospital adverse outcomes alone was not statistically significant. Patients with both inhospital and post-discharge adverse outcomes also found the quality of care to be lower (on average 33% lower) than patients without adverse outcomes. Conclusions: Post-discharge adverse outcomes negatively influence patients’ overall evaluation of quality of care and are perceived as being discharged too early, suggesting that patients need better information at discharge.

Surgical adverse outcome reporting as part of routine clinical care

Background In The Netherlands, health professionals have created a doctor-driven standardised system to report and analyse adverse outcomes (AO). The aim is to improve healthcare by learning from past experiences. The key elements of this system are (1) an unequivocal definition of an adverse outcome, (2) appropriate contextual information and (3) a three-dimensional hierarchical classification system. Objectives First, to assess whether routine doctor-driven AO reporting is feasible. Second, to investigate how doctors can learn from AO reporting and analysis to improve the quality of care. Methods Feasibility was assessed by how well doctors reported AO in the surgical department of a Dutch university hospital over a period of 9 years. AO incidence was analysed per patient subgroup and over time, in a time-trend analysis of three equal 3-year periods. AO were analysed case by case and statistically, to learn lessons from past events. Results In 19 907 surgical admissions, 9189 AOs were reported: one or more AO in 18.2% of admissions. On average, 55 lessons were learnt each year (in 4.3% of AO). More AO were reported in P3 than P1 (OR 1.39 (1.23–1.57)). Although minor AO increased, fatal AO decreased over time (OR 0.59 (0.45–0.77)). Conclusions Doctor-driven AO reporting is shown to be feasible. Lessons can be learnt from case-by-case analyses of individual AO, as well as by statistical analysis of AO groups and subgroups (illustrated by time-trend analysis), thus contributing to the improvement of the quality of care. Moreover, by standardising AO reporting, data can be compared across departments or hospitals, to generate (confidential) mirror information for professionals cooperating in a peer-review setting.

Erythropoietin to reduce allogeneic red blood cell transfusion in patients undergoing total hip or knee arthroplasty

To determine the value of erythropoietin in reducing allogeneic transfusions, it is important to assess the effects, safety and costs for individual indications. Previous studies neither compared the effects of erythropoietin between total hip and total knee arthroplasty, nor evaluated the safety or costs. We performed a meta‐analysis to assess the effects of erythropoietin in total hip and knee arthroplasty separately. Safety and costs were evaluated as secondary outcomes.

Combining process indicators to evaluate quality of care for surgical patients with colorectal cancer: are scores consistent with short-term outcome?

Objective To determine if composite measures based on process indicators are consistent with short-term outcome indicators in surgical colorectal cancer care. Design Longitudinal analysis of consistency between composite measures based on process indicators and outcome indicators for 85 Dutch hospitals. Setting The Dutch Surgical Colorectal Audit database, the Netherlands. Participants 4732 elective patients with colon carcinoma and 2239 with rectum carcinoma treated in 85 hospitals were included in the analyses. Main outcome measures All available process indicators were aggregated into five different composite measures. The association of the different composite measures with risk-adjusted postoperative mortality and morbidity was analysed at the patient and hospital level. Results At the patient level, only one of the composite measures was negatively associated with morbidity for rectum carcinoma. At the hospital level, a strong negative association was found between composite measures and hospital mortality and morbidity rates for rectum carcinoma (p<0.05), and hospital morbidity rates for colon carcinoma. Conclusions For individual patients, a high score on the composite measures based on process indicators is not associated with better short-term outcome. However, at the hospital level, a good score on the composite measures based on process indicators was consistent with more favourable risk-adjusted short-term outcome rates.

The importance of experienced adverse outcomes on patients' future choice of a hospital for surgery

Objective To assess whether patients who experience adverse outcomes during hospitalisation or after discharge differ in the information they would use for future choices of a hospital for surgery compared with patients without any adverse outcomes. Design Cross-sectional questionnaire study, including questions on (1) adverse outcome occurrence during hospitalisation and after discharge, (2) information patients would use for future hospital choice and (3) priority of information. Setting Three hospitals in the western part of The Netherlands. Study sample All 2122 patients who underwent elective aorta reconstruction (for treatment of aneurysm), cholecystectomy, colon resection, inguinal hernia repair, oesophageal resection or thyroid surgery in the period 2005–2006, of whom 1329 (62.6%) responded. Results Patients who experienced postdischarge adverse outcomes intend to use more information items to choose a future hospital (on average 1.6 items more). They more often would use the item on information provision during hospitalisation (OR 2.35 (1.37 to 4.03)) and information on various quality-of-care measures, compared with patients without adverse outcomes. Patients who experienced in-hospital adverse outcomes would not use more information items but more often would use the item on mortality after surgery (OR 1.93 (1.27 to 2.94)) and extended hospital stay (OR 1.61 (1.10 to 2.36)). However, when asked for priority of information, previous treatment in that hospital is mentioned as the most important item by most patients (32%), regardless of adverse outcome occurrence, followed by hospital reputation and waiting time. Conclusions Adverse outcome experience may change the information patients use (on quality of care) to choose a future hospital.