Patient perspectives on key symptoms and preferences for follow-up after upper gastro-intestinal cancer surgery.

PURPOSE: Long-lasting symptoms and reductions in quality of life are common after oesophago-gastric surgery. Post-operative follow-up has traditionally focussed on tumour recurrence and survival, but there is a growing need to also identify and treat functional sequelae to improve patients' recovery. METHODS: An electronic survey was circulated via a British national charity for patients undergoing oesophago-gastric surgery and their families. Patients were asked about post-operative symptoms they deemed important to their quality of life, as well as satisfaction and preferences for post-operative follow-up. Differences between satisfied and dissatisfied patients with reference to follow-up were assessed. RESULTS: Among 362 respondents with a median follow-up of 58 months since surgery (range 3-412), 36 different symptoms were reported as being important to recovery and quality of life after surgery, with a median of 13 symptoms per patient. Most (84%) respondents indicated satisfaction with follow-up. Satisfied patients were more likely to have received longer follow-up (5-year or longer follow-up 60% among satisfied patients vs 27% among unsatisfied, p < 0.001). These were also less likely to have seen a dietitian as part of routine follow-up (37% vs 58%, p = 0.005). CONCLUSION: This patient survey highlights preferences regarding follow-up after oesophago-gastrectomy. Longer follow-up and dietician involvement improved patient satisfaction. Patients reported being concerned by a large number of gastrointestinal and non-gastrointestinal symptoms, highlighting the need for multidisciplinary input and a consensus on how to manage the poly-symptomatic patient.

A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay After Colorectal Surgery.

BACKGROUND: Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes. METHODS: A cross-sectional questionnaire was administered to surgeons and nurses in August-October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013-15. RESULTS: 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management. CONCLUSIONS: Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.

Endoscopic tumour morphology impacts survival in adenocarcinoma of the oesophagus.

BACKGROUND: Prognostication in oesophageal cancer on the basis of preoperative variables is challenging. Many of the accepted predictors of survival are only derived after surgical treatment and may be influenced by neoadjuvant therapy. This study aims to explore the relationship between pre-treatment endoscopic tumour morphology and postoperative survival. METHODS: Patients with endoscopic descriptions of tumours were identified from the prospectively managed databases including the OCCAMS database. Tumours were classified as exophytic, ulcerating or stenosing. Kaplan Meier survival analysis and multivariable Cox regression analyses were performed to determine hazard ratios (HR) with 95% confidence intervals. RESULTS: 262 patients with oesophageal adenocarcinoma undergoing potentially curative resection were pooled from St Thomas' Hospital (161) and the OCCAMS database (101). There were 70 ulcerating, 114 exophytic and 78 stenosing oesophageal adenocarcinomas. Initial tumour staging was similar across all groups (T3/4 tumours 71.4%, 70.2%, 74.4%). Median survival was 55 months, 51 months and 36 months respectively (p < 0.001). Rates of lymphovascular invasion (P = 0.0176), pathological nodal status (P = 0.0195) and pathological T stage (P = 0.0007) increased from ulcerating to exophytic to stenosing lesions. Resection margin positivity was 21.4% in ulcerating tumours compared to 54% in stenosing tumours (p < 0.001). When compared to stenosing lesions, exophytic and ulcerating lesions demonstrated a significant survival advantage on multivariable analysis (HR 0.56 95% CI 0.31-0.93, HR 0.42 95% CI 0.21-0.82). CONCLUSION: This study demonstrates that endoscopic morphology may be an important pre-treatment prognostic factor in oesophageal cancer. Ulcerating, exophytic and stenosing tumours may represent different pathological processes and tumour biology.

A mixed methods case study investigating how randomised controlled trials (RCTs) are reported, understood and interpreted in practice.

BACKGROUND: While randomised controlled trials (RCTs) provide high-quality evidence to guide practice, much routine care is not based upon available RCTs. This disconnect between evidence and practice is not sufficiently well understood. This case study explores this relationship using a novel approach. Better understanding may improve trial design, conduct, reporting and implementation, helping patients benefit from the best available evidence. METHODS: We employed a case-study approach, comprising mixed methods to examine the case of interest: the primary outcome paper of a surgical RCT (the TIME trial). Letters and editorials citing the TIME trial's primary report underwent qualitative thematic analysis, and the RCT was critically appraised using validated tools. These analyses were compared to provide insight into how the TIME trial findings were interpreted and appraised by the clinical community. RESULTS: 23 letters and editorials were studied. Most authorship included at least one academic (20/23) and one surgeon (21/23). Authors identified wide-ranging issues including confounding variables or outcome selection. Clear descriptions of bias or generalisability were lacking. Structured appraisal identified risks of bias. Non-RCT evidence was less critically appraised. Authors reached varying conclusions about the trial without consistent justification. Authors discussed aspects of internal and external validity covered by appraisal tools but did not use these methodological terms in their articles. CONCLUSIONS: This novel method for examining interpretation of an RCT in the clinical community showed that published responses identified limited issues with trial design. Responses did not provide coherent rationales for accepting (or not) trial results. Findings may suggest that authors lacked skills in appraisal of RCT design and conduct. Multiple case studies with cross-case analysis of other trials are needed.

Do patients with gastrointestinal cancer want to decide where they have tests and surgery? A questionnaire study of provider choice.

BACKGROUNDS: Choice of provider has been an important strategy among policy makers, intended, in part, to drive improvements in quality and efficiency of healthcare. This study examined the information requirements, and decision-making experiences and preferences of patients who have had surgery for gastrointestinal cancer, to assess the status of provider choice in current practice. METHODS: The single-item Control Preferences Scale was used to determine patients' experiences and preferences when being referred for tests, and choosing where to have surgery. Participants used a Likert scale to rate the importance of 23 information items covering a variety of structures, processes and outcomes at the hospital level and the department level. Participants were recruited by post and online. RESULTS: 463 responses were analysed. Patients reported very low levels of involvement in provider choice, with their doctor deciding where they underwent tests or surgery in 77.0% and 81.8% of cases, respectively. Over two-thirds of participants would have preferred greater involvement in provider choice than they experienced. Of note, patient age and education were not associated with reported preferences. Information on how long patients with cancer wait for treatment, annual operative volume and postoperative mortality rate, as well as retained foreign bodies and infection rates were considered very important. CONCLUSIONS: There was a substantial unmet desire for greater involvement in provider choice among study participants. Respondents attached particular importance to surgery-specific information. Efforts should be made to increase involvement of patients with gastrointestinal cancer in provider decisions, across primary and secondary care, to deliver more patient-centred care. The reported lack of patient involvement in provider choice suggests it is unlikely to be working as an effective lever to drive quality improvement at present.

Effects of Interdisciplinary Team Care Interventions on General Medical Wards: A Systematic Review.

IMPORTANCE: Improving the quality of health care for general medical patients is a priority, but the organization of general medical ward care receives less scrutiny than the management of specific diseases. Optimizing teams' performance improves patient outcomes in other settings, and interdisciplinary practice is a major target for improvement efforts. However, the effect of interdisciplinary team interventions on general medical ward care has not been systematically reviewed. OBJECTIVES: To describe the range of objective patient outcomes used in studies of general medical ward interdisciplinary team care, and to evaluate the performance of interdisciplinary interventions against them. EVIDENCE REVIEW: We searched EMBASE, MEDLINE, and PsycINFO from January 1, 1998, through December 31, 2013, for interdisciplinary team care interventions in adult general medical wards using an objective patient outcome measure. Reference lists of included articles were also searched. The last search was conducted on January 29, 2014, and the narrative and statistical analysis was conducted through December 1, 2014. Study quality was assessed using the Cochrane Effective Practice and Organization of Care group's tool. FINDINGS: Thirty of 6934 articles met the selection criteria. The studies included 66,548 patients, with a mean age of 63 years. Nineteen of 30 (63%) studies reported length of stay, readmission, or mortality rate as their primary outcome, or did not specify the primacy of their outcomes. The most commonly reported objective patient outcomes were length of stay (23 of 30 [77%]), complications of care (10 of 30 [33%]), in-hospital mortality rate (8 of 30 [27%]), and 30-day readmission rate (8 of 30 [27%]). Of 23 interventions, 16 (70%) had no effect on length of stay, 12 of 15 (80%) did not reduce readmissions, and 14 of 15 (93%) did not affect mortality. Five of 10 (50%) interventions reduced complications of care. In an exploratory quantitative analysis, the interventions did not consistently reduce the relative risk of early readmission or early mortality, or the weighted mean difference in length of stay. All studies had a medium or high risk of bias. CONCLUSIONS AND RELEVANCE: Current evidence suggests that interdisciplinary team care interventions on general medical wards have little effect on traditional measures of health care quality. Complications of care or preventable adverse events may merit inclusion as quality indicators for general medical wards. Future study should clarify how best to implement interdisciplinary team care interventions and establish quality metrics that are credible to both health care professionals and patients in this setting.

Understanding how colorectal units achieve short length of stay: an interview survey among representative hospitals in England.

BACKGROUND: Wide variation in the outcomes of colorectal surgery persists, despite a well-established evidence-base to inform clinical practice. This variation may be attributed to differences in quality of care, but we do not know what this means in practical terms of care delivery. This telephone interview study aimed to identify distinguishing characteristics in the organisation of care among colorectal units with the best length of stay results in England. METHODS: Ten English National Health Service hospitals were identified with the shortest length of stay after elective colonic surgery between January 2011 and December 2012. Semi-structured telephone interviews were conducted with a senior colorectal surgeon and ward nurse, who were not informed of their performance, at each site. Audio recordings were professionally transcribed and thematically analysed for similarities and differences in practice between units. RESULTS: All ten short length of stay units approached agreed to participate, and 19 of 20 interviews were recorded. These units standardised clinical care based upon an Enhanced Recovery Program. Beyond this, they organised the clinical team to efficiently and reliably deliver this package of care, with the majority of day-to-day care delivered by consultants and nurses. Patients were closely monitored for postoperative deterioration, using a combination of early warning scores, nurses' clinical judgement and regular senior medical review. Of note, operative volume and laparoscopy rates in these units were not statistically significantly different from the national average (p = 0.509 and p = 0.131, respectively). The postoperative analgesic strategy varied widely between units, from routine epidural use to local anaesthetic infiltration or patient-controlled analgesia. CONCLUSIONS: The Enhanced Recovery Program may be seen as necessary but not sufficient to achieve the best length of stay results. In the study units, consultants and nurses led and delivered the majority of patient care on the ward. High quality teamwork helped detect and resolve clinical issues promptly, with nurses empowered to contact consultants directly if needed. Other units may learn from these teams by adopting protocol-based, consultant- or nurse-delivered care, and by improving coordination and communication between consultants and ward nurses.

Outlier identification in colorectal surgery should separate elective and nonelective service components.

BACKGROUND: The identification of health care institutions with outlying outcomes is of great importance for reporting health care results and for quality improvement. Historically, elective surgical outcomes have received greater attention than nonelective results, although some studies have examined both. Differences in outlier identification between these patient groups have not been adequately explored. OBJECTIVE: The aim of this study was to compare the identification of institutional outliers for mortality after elective and nonelective colorectal resection in England. DESIGN: This was a cohort study using routine administrative data. Ninety-day mortality was determined by using statutory records of death. Adjusted Trust-level mortality rates were calculated by using multiple logistic regression. High and low mortality outliers were identified and compared across funnel plots for elective and nonelective surgery. SETTINGS: All English National Health Service Trusts providing colorectal surgery to an unrestricted patient population were studied. PATIENTS: Adults admitted for colorectal surgery between April 2006 and March 2012 were included. INTERVENTION(S): Segmental colonic or rectal resection was performed. MAIN OUTCOME MEASURES: The primary outcome measured was 90-day mortality. RESULTS: Included were 195,118 patients, treated at 147 Trusts. Ninety-day mortality rates after elective and nonelective surgery were 4% and 18%. No unit with high outlying mortality for elective surgery was a high outlier for nonelective mortality and vice versa. Trust level, observed-to-expected mortality for elective and nonelective surgery, was moderately correlated (Spearman ρ = 0.50, p< 0.001). LIMITATIONS: This study relied on administrative data and may be limited by potential flaws in the quality of coding of clinical information. CONCLUSIONS: Status as an institutional mortality outlier after elective and nonelective colorectal surgery was not closely related. Therefore, mortality rates should be reported for both patient cohorts separately. This would provide a broad picture of the state of colorectal services and help direct research and quality improvement activities.

Spinal cord ischemia following external iliac artery angioplasty: a case report.

Spinal cord ischemia (SCI) is a rare disease that leads to variable degrees of neurological deficit including permanent paraplegia. It has been reported after open and endovascular interventions of the thoracic and abdominal aorta, but it is extremely rare after interventions involving peripheral vessels. We present a case of permanent paraplegia after iliac angioplasty and stenting for critical limb ischemia and a related review of the literature.