Tavs Folmer Andersen

The Challenges of Medical Practice Variations

Medical Practice Variations: Where Are We? T.Folmer Andersen & G.Mooney - Why Do Variations Occur? K.McPherson - Variations in Outcomes Research L.L.Roos et al - Medical Decision Making and Practice Variation A.G.Mulley, Jr. - Equity and Variability in Modern Health Care G.Bevan - Measuring Performance in the Health Care Sector: The Whys and the Hows A.McGuire - The Dog in the Night Time: Medical Practice Variations and Health Policy R.G.Evans - Variations from a Lay Perspective F.Vestergaard - On the Need for Outcomes Research and the Prospects for the Evaluative Clinical Sciences J.E.Wennberg - Promoting Clinical Policy Change: Using the Art to Promote the Science in Medicine J.Lomas - Challenges Facing Modern Health Care: A Need for Change G.Mooney & T.Folmer Andersen - Index

Risk of endophthalmitis after cataract extraction: results from the International Cataract Surgery Outcomes study.

AIM To estimate risk of infectious endophthalmitis after cataract extraction in Denmark and to compare results with the risk of this complication in the USA METHODS In the national Danish administrative hospital register, 19 426 patients were identified who underwent first eye cataract surgery from 1985 to 1987 and who were 50 years of age or older. Of these, 61 patients had postoperative endophthalmitis. RESULTS A 12 month cumulative risk of rehospitalisation for endophthalmitis was estimated at 0.18% (95% CI 0.09–0.26) after extracapsular cataract extraction with lens implant. Advanced age, male sex, intracapsular cataract extraction, and anterior vitrectomy were all associated independently with an increased risk of postoperative endophthalmitis. When restricting the sample to patients aged 65 years or older, in order to allow comparisons to be made with the US National Study of Cataract Outcomes, a 12 month risk of 0.17% (95% CI 0.08–0.25) was estimated. The previously reported US risk of 0.12% is included in the confidence interval of the risk estimated in the Danish sample. CONCLUSION Despite considerable differences in the healthcare systems, no statistically significant difference in outcome of surgery as measured by risk of endophthalmitis was shown between Denmark and the USA.

Risk of retinal detachment following cataract extraction: results from the International Cataract Surgery Outcomes Study.

AIMS: To estimate the risk of retinal detachment (RD) following cataract extraction in Denmark, and to compare the risk with that following cataract extraction in the USA, and with that in a sample of Danish patients who did not have ocular surgery. METHODS: A sample was created from the administrative Danish Hospital Register and included 19,252 patients who underwent first eye cataract surgery between 1985 and 1987, and who were 50 years of age or older. The patients were then followed for 4-6 years using the register data. The design and definition of events were identical to the US National Study of Cataract Outcomes. RESULTS: In Denmark a 4 year cumulative risk of hospitalisation for RD of 0.93% (95% confidence interval (CI) 0.71-1.16) was observed following an extracapsular cataract extraction with a lens implant. A similar cumulative risk of RD was reported from the US study. Thus, no difference in outcomes concerning risk of RD was shown between Denmark and the USA. In a multivariate analysis younger age, male sex, and intracapsular cataract extraction were all associated with higher risk of postoperative RD. A reference group of 7636 people not undergoing any ocular surgery was created and the incidence of RD in this group was calculated. During the sixth year following cataract surgery, the incidence of RD in the cataract group was still 7.5 (95% CI 1.6-22.0) times higher than that observed in the reference group.

Intraoperative clinical practice and risk of early complications after cataract extraction in the United States, Canada, Denmark, and Spain

OBJECTIVE To examine variation in intraoperative clinical practice and rates of adverse events after cataract surgery across four different healthcare systems. DESIGN Multicenter cohort study. PARTICIPANTS Patients were recruited from ophthalmic clinics in the United States (n = 75); in the Province of Manitoba, Canada (n = 12); in Denmark (n = 17); and the City of Barcelona, Spain (n = 10). In all, 1420 patients undergoing first eye cataract surgery were enrolled, with preoperative, perioperative, and postoperative clinical data collected on 1344 patients (95%). MAIN OUTCOME MEASURES Occurrence of 23 specified intraoperative and early postoperative adverse events was measured. Four-month postoperative visual acuity outcome also was measured. RESULTS Phacoemulsification was performed in two thirds of the extractions in the United States and Manitoba, in one third in Denmark, and in 3% in Barcelona (P < 0.001). More than 96% of extractions in North America and Denmark were performed with the patient under local anesthesia, whereas general anesthesia was used for 38% of extractions in Barcelona (P < 0.001). Rates of intraoperative adverse events were 11% to 12.8% in Manitoba, Denmark, and Barcelona and significantly lower in the United States (6%), mainly because of a lower rate of capsular rupture (P < 0.01). Significantly higher rates of early postoperative events were seen in the United States (18.8%) and Manitoba (20.4%) compared to Denmark (7.9%) and Barcelona (5%) (P < 0.001). The differences among sites in rates of events could not be explained by differences in recorded patient characteristics or surgical techniques. The occurrence of perioperative events was significantly associated with a worse 4-month visual outcome. CONCLUSION The observed variation in clinical practice might represent a general trend of a slower diffusion of new medical technology in Europe compared with that of North America. Rates of intraoperative and early postoperative events varied significantly across sites.

Variation in indications for cataract surgery in the United States, Denmark, Canada, and Spain: results from the International Cataract Surgery Outcomes Study

BACKGROUND/AIMS International comparisons of clinical practice may help in assessing the magnitude and possible causes of variation in cross national healthcare utilisation. With this aim, the indications for cataract surgery in the United States, Denmark, the province of Manitoba (Canada), and the city of Barcelona (Spain) were compared. METHODS In a prospective multicentre study, patients scheduled for first eye cataract surgery and aged 50 years or older were enrolled consecutively. From the United States 766 patients were enrolled; from Denmark 291; from Manitoba 152; and from Barcelona 200. Indication for surgery was measured as preoperative visual status of patients enlisted for cataract surgery. Main variables were preoperative visual acuity in operative eye, the VF-14 score (an index of functional impairment in patients with cataract) and ocular comorbidity. RESULTS Mean visual acuity were 0.23 (USA), 0.17 (Denmark), 0.15 (Manitoba), and 0.07 (Barcelona) (p<0.001). When restricting the sample to eyes with normal retina and macula, no significant difference between United States and Denmark was observed (p>0.05). Mean VF-14 scores were 76 (USA), 76 (Denmark), 71 (Manitoba), and 64 (Barcelona) (p<0.001). CONCLUSION Similar indications for cataract surgery were found in the United States and Denmark. Significantly more restricted indications were observed in Manitoba and Barcelona. Possible explanations for the results are discussed, including differences in sociodemographic characteristics, access to care, surgeons’ willingness to operate, and patient demand.

Early postoperative mortality following hysterectomy. A Danish population based study, 1977–1981

Summary. The main objective of this cohort study was to analyse the early postoperative mortality after ‘simple’ hysterectomy for benign indications and to compare it with that of a randomly selected reference group of women matched for age. Registry data covering the entire Danish female population were used. Included in the study were all patients operated in the period 1977–1981. Patients were only included if no cancer was diagnosed and if no major co‐surgery was performed (29 192 patients). Cancer patients were also excluded in the reference group (16182 women). Mortality was studied according to characteristics of patients, their residential area, the surgical approach and operating hospital. Overall 47 patients died within 30 days of admission for hysterectomy (overall mortality 16.1 per 10000). Only seven deaths were expected on the basis of the population sample, and adjusted for age, the relative risk (RR) for hysterectomy patients was 6.38 (95% CI 4.33–9.39). Early postoperative mortality increased with age, and the risk was elevated among emergency patients (RR = 3.22; 1.72–6.04). Patients with more than one diagnosis at discharge (RR = 4.53; 2.12–9.70) were at high risk, but early postoperative mortality was independent of surgical approach. Causes of death are discussed. Compared to the general population, patients who undergo ‘simple’ hysterectomy are faced with a sixfold risk of dying within 30 days, but a complete assessment of the risks and benefits of hysterectomy requires prospective studies of survival and morbidity, including quality of life for longer periods of time following operations.

Complications after hysterectomy : a Danish population based study 1978-1983

We studied complications after hysterectomy among all women in the Danish population who had a simple hysterectomy in the period 1978‐81 based on data obtained from the Danish National Hospital Registry. Among patients, with neither diagnosed cancer nor major co‐surgery (n = 23,386), we identified all the complications which occurred during hospital admission from the time of surgery up to six years from that point. Within 30 days of hysterectomy 2.6% of the patients had been diagnosed in hospitals as having complications according to our definition. The corresponding figures at 90 days and two years after the operation were 3.7% and 9.4%. The most frequently observed complications were post operative wound infections and bleeding, each affecting about 2% of all operated women. Logistic regression and Cox regression were used to identify prognostic indicators of readmission with complications. The probability of readmission with complications within six years after hysterectomy was estimated at 8% among low risk patients. The most pronounced increase in risk of readmission with complication occurred among women who had been admitted to psychiatric or somatic hospitals 0–12 months before they had their uterus removed (OR in the range 1.59 to 1.83). We discuss the prevailing difficulties of comparing observational evidence from different clinical settings reported in the literature, and emphasize the importance of developing a coordinated international strategy for non‐experimental assessment of medical technology.

Elevated mortality following transurethral resection of the prostate for benign hypertrophy! But why?

This paper reevaluates the recently reported excess mortality following transurethral resection of the prostate (TURP) for benign hypertrophy as compared with traditional open resection (OPEN). We studied survival through linkage of hospital discharge data with mortality data for the entire male population of Denmark (1977-85). For a maximum of 10.5 years 38,067 prostatectomy patients were followed. Adjusting for age and health status before surgery, TURP patients were subject to significantly higher levels of mortality than OPEN patients (RR = 1.19,95% confidence interval (1.15-1.24). The extent to which this difference is attributable to the surgical intervention itself remains an open question. The two groups of patients are quite different with regard to age and preoperative health status, and available data may not be sufficient to control such differences through statistical analysis. On the other hand, the difference in mortality persisted over calender time, even during periods when the pattern of utilization for the two procedures changed significantly (constant RR= 1.19, adjusting for age and comorbidity). The most important causes of death among Danish TURP patients differ from the causes suggested on the basis of previously reported Canadian data. The current evidence is thus ambiguous with regard to hypothetical biologic mechanismes behind the excess mortality over TURP patients. Further investigations are needed to evaluate the safety and effectiveness of prostate surgery.

Medical Practice Variations: Where Are We?

The existence of variations in modern medical practice has become a challenge for all health care systems in the industrialised world. To meet this challenge, major revisions have to be undertaken concerning many common practices in modern medicine. Practice variation may be seen primarily as a symptom, but it is a symptom which reveals the presence of a very fundamental syndrome, deeply rooted in all highly developed health care systems, a syndrome which will require radical therapy sooner or later.

Rash related to use of scented products. A questionnaire study in the Danish population. Is the problem increasing

Fragrances are used in many types of cosmetic and household products, which are an important part of everyday life in modern society. The aim of the current investigation was to describe the frequency of self‐reported rash due to scented products in a random sample of the adult Danish population. Further, it was determined whether risk of self‐reported 1st‐time rash from scented products had increased during the past 15 years compared to the preceding period. The sample consisted of 1537 persons, 801 female and 736 male, above the age of 15 years. The participants were interviewed person‐to‐person to obtain a general health profile, and in this connection, questions were asked concerning rash related to the use of scented products. 28.6% (440/1537) had on some occasion experienced rash from scented products, 10.6% had experienced rash within the year prior to interview. A multivariate analysis showed that women had a significantly increased risk of reporting rash from scented products compared to men (odds ratio: 1.56, p<0.0001). Furthermore, it was shown that individuals below the age of 40 years had a significantly increased risk of reporting rash from scented products compared to older age groups. The risk of reporting 1st‐time rash occurring after 1978 was significantly increased (odds ratio: 2.34, p<0.0001), as compared to the preceding period. This may be taken as indicative of an increasing problem with scented products, involving potentially severe public health implications.