Should systemic antibiotics be prescribed in periodontal abscesses and pericoronitis? A systematic review of the literature.

This study assessed whether systemic antibiotics are beneficial or harmful in patients who present with an acute periodontal abscess or pericoronitis, with or without systemic involvement, and, if antibiotics are beneficial, which type, dosage, and duration are the most effective. Medline, Embase, and the Cochrane Library were screened from 1948 up to 1 April 2022 for systematic reviews, randomised clinical trials (RCTs), and other studies. Dedicated websites were consulted for systematic reviews, clinical practice guidelines, and health technology assessments on the topic. Outcomes of interest comprised tooth survival, swelling, pain, tooth mobility, periodontal probing depth, suppuration, adverse effects, quality of life measurements, and medication required for pain relief. Overall, five guidelines, seven systematic reviews, 15 RCTs, and 34 other studies were identified and selected for full-text assessment, but none of them fulfilled the inclusion criteria. At present there is no single randomised or non-randomised controlled trial assessing the harms and clinical effectiveness of systemic antibiotics in adults with a periodontal abscess or pericoronitis.

Antibiotics at replantation of avulsed permanent teeth? A systematic review.

OBJECTIVES: At present there is no clear consensus whether systemic antibiotics should be administered at replantation of an avulsed permanent tooth. This systematic review and meta-analysis assessed the evidence on effectiveness and harms of the administration of systemic antibiotics at replantation of avulsed permanent teeth. METHODS: In August 2020 a systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, for systematic reviews, randomized controlled trials (RCT) and observational controlled studies in MEDLINE, PreMedline, Embase, and the Cochrane databases. The population of interest were medically fit patients with a replanted avulsed tooth. Main outcomes were tooth survival, periodontal healing, pulpal revascularization as well as (severe) adverse events. These outcomes were compared in patients who did and who did not receive systemic antibiotics. The GRADE methodology was used to assess the quality of evidence. RESULTS: The search yielded no RCTs, and none of the 7 included observational studies had the prime intent to investigate the effectiveness or harms of antibiotics. According to GRADE, the overall level of evidence was very low. The meta-analyses showed non-significant associations between the administration of systemic antibiotics on the one hand and tooth survival (1 study, RR = 3.70, 95% CI: 0.63-21.69), periodontal healing (meta-analysis of 6 studies RR: 1.07; 95% CI: 0.80-1.45), and pulpal revascularization (meta-analysis of 2 studies, RR: 0.36; 95% CI: 0.05-2.41) on the other hand. CONCLUSION: Currently there is no high-quality evidence to support the use of systemic antibiotics at replantation of avulsed permanent teeth. Hence, their routine use cannot be recommended in medically fit patients. Well-designed RCTs should be a priority on the research agenda.

Patterns and quality of care for head and neck cancer in Belgium: A population-based study.

OBJECTIVES: We evaluated the quality of care for patients with squamous cell carcinoma (SCC) of the oral cavity, oropharynx, hypopharynx or larynx in Belgium. METHODS: Data of the Belgian Cancer Registry were coupled with health insurance data and hospital discharge data. Quality of care and the association with hospital volume were evaluated based on six quality indicators. RESULTS: Half of the patients were treated with primary radiotherapy, with or without systemic therapy (49.7%) and 38.1% with surgery, with or without (neo)adjuvant therapy. Single-modality treatment was provided to 78.1% of early-disease patients. Of the patients with cN0 disease, 56.4% underwent neck dissection. Postoperative radiotherapy was completed timely in 48.5% of patients. Concomitant chemotherapy was administered to 58.2% of patients <70 years with locally advanced disease. Imaging of the neck after radiotherapy was performed appropriately in 32.7% of patients. Variability between centres was considerable. No clear relationship between hospital volume and results of the individual QIs was observed. CONCLUSIONS: Results show that for the measured QIs, targets are not met and variability between centres is considerable. Through individual feedback, centres are motivated to improve the quality of care for head and neck cancer patients in Belgium.

Are systemic antibiotics indicated in children presenting with an odontogenic abscess in the primary dentition? A systematic review of the literature.

OBJECTIVES: This systematic review aimed to assess (1) whether systemic antibiotics are beneficial or harmful in healthy children who present with an odontogenic abscess in the primary dentition with or without systemic involvement and (2) if antibiotics are beneficial, which type, dosage and duration are the most effective. MATERIALS AND METHODS: Electronic databases (Medline, Embase, and the Cochrane Library) were screened from 1948 up to August 2020. No filters with respect to study design were applied. Outcomes of interest included pain, swelling, pain relief, adverse effects, signs of infection, quality-of-life measurements and medication required for pain relief. RESULTS: Altogether, 352 titles and abstracts were screened for eligibility; of these, 19 were selected for full text assessment. All were excluded because none of them fulfilled the inclusion criteria and addressed the (adjunctive) use of antibiotics in children who present with an odontogenic abscess in the primary dentition. CONCLUSIONS: At present, there is no single randomised or non-randomised clinical study evaluating the effectiveness and harms of systemic antibiotics administered in children who present with an odontogenic abscess in the primary dentition. CLINICAL RELEVANCE: There is no clinical evidence to support nor to refute the use of antibiotics in children who present with an odontogenic abscess in the primary dentition without signs of local spread or systemic involvement. Given this lack of scientific evidence, the use of antibiotics cannot be recommended in these children. Well-designed clinical trials are indicated to fully understand the impact and necessity of antibiotics in these situations.

Effect evaluation of an oral health promotion intervention in preschool children.

OBJECTIVE: This study evaluates the effectiveness of a multi-component oral health intervention in preschool children in a non-randomized intervention study with a complementary baseline control. METHODS: Participants in the main study were 2137 children born between October 2003 and July 2004 in Flanders, Belgium. In the intervention group (50.5% of participants), an oral health education program was added to a standard preventive care program during the first 3 years of life. Oral health examinations were performed by trained dentists when the children were 3 (2007) and 5 (2009) years old. Data on dietary habits, oral hygiene habits and dental attendance were obtained through structured questionnaires. Regression analyses were applied to compare the results of the intervention and control group with baseline measurements obtained before the intervention (2003) in other cohorts of 3- (N = 1291) and 5-year-olds (N = 1325) living in the same regions. RESULTS: The prevalence of caries experience was generally lower in the main study compared with the baseline cohorts, with little differences between the intervention and control group. For the oral health-related behaviours, the control group scored mostly better. Nevertheless, compared with baseline, limited differences were observed in dental attendance, tooth brushing, helping with tooth brushing and consuming in-between drinks (P < 0.05). CONCLUSION: The study illustrates that a multi-component, theory-based intervention at community level had only a limited and temporary effect on oral health-related behaviours in the community under study. Further research is needed to determine how oral health in young children can be improved in the long term.

Quality of surgery and treatment and its association with hospital volume: A population-based study in more than 5000 Belgian ovarian cancer patients.

BACKGROUND: Different sets of quality indicators are used to identify areas for improvement in ovarian cancer care. This study reports transparently on how (surgical) indicators were measured and on the association between hospital volume and indicator results in Belgium, a country setting without any centralisation of ovarian cancer care. METHODS: From the population-based Belgian Cancer Registry, patients with a borderline malignant or invasive epithelial ovarian tumour diagnosed between 2014 and 2018 were selected and linked to health insurance and vital status data (n = 5119). Thirteen quality indicators on diagnosis and treatment were assessed and the association with hospital volume was analysed using logistic regression adjusted for case-mix. RESULTS: The national results for most quality indicators on diagnosis and systemic therapy were around the predefined target value. Other indicators showed results below the benchmark: genetic testing, completeness of staging surgery, lymphadenectomy with at least 20 pelvic/para-aortic lymph nodes removed, and timely start of chemotherapy after surgery (within 42 days). Ovarian cancer care in Belgium is dispersed over 100 hospitals. Lower volume hospitals showed poorer indicator results compared to higher volume hospitals for lymphadenectomy, staging, timely start of chemotherapy and genetic testing. In addition, surgery for advanced stage tumours was performed less often in lower volume hospitals. CONCLUSIONS: The indicators that showed poorer results on a national level were also those with poorer results in lower-volume hospitals compared to higher-volume hospitals, consequently supporting centralisation. International benchmarking is hampered by different (surgical) definitions between countries and studies.

Oral health-care utilization in adults with disabilities in Belgium.

Reports on oral health-service utilization among individuals with disabilities are very sparse. Nevertheless, such data are a prerequisite for the provision of proper care and for the development of optimal reimbursement schemes and may ultimately lead to better access to care. The objective of the present study was to provide data on oral health-care utilization in Belgian residents with disabilities and to compare these data with the utilization pattern of their peers without special needs. Data from the Permanent Sample of Socially Insured Persons, an anonymous representative sample of Belgian residents, were used. The database contained prospective data on oral and general health-care utilization and socio-demographic variables from 1,221 individuals with disabilities and from 131,877 individuals without disabilities, collected from 2002 to 2008. Overall, annual dental-attendance rates were very low and in those who attended, professional debridements, a cornerstone in preventive oral health care, were infrequently recorded. In adults with disabilities, significantly fewer radiographs, restorations, and endodontic treatments were recorded, whereas significantly more emergency visits were charged. Further research is indicated to evaluate whether this outcome points to high unmet oral-treatment needs.

Objective and subjective oral health care needs among adults with various disabilities.

OBJECTIVES: The present study explored the objective and subjective oral health care needs and the association between both among Belgian adults with disabilities. MATERIALS AND METHODS: A two-stage sampling methodology was used to select a sample of adults (22-65 years old) with disabilities, from various types of residential settings, day care centers, and sheltered workplaces and spread over the ten provinces. Oral screenings were performed by 28 trained dentists; subjective oral health care needs were collected through questionnaires. RESULTS: Seven hundred seven adults with disabilities were recruited; from 656 (93 %), permission was obtained for an oral examination. In 467 (78 %) and 407 (68 %) participants, dental plaque and calculus, respectively, were observed. In 343 (56 %) participants, untreated caries lesions (into dentine) were recorded; 203 (33 %) participants had 20 or less teeth. The prosthetic replacement of missing teeth was poor. Exactly 228 (40 %) participants stated that they had a problem in the oral region, and 264 (48 %) indicated that they were in need of an appointment with a dentist. Barriers to consult a dentist were reported by 244 (42 %); fear (n = 87; 37 %), followed by financial and transportation problems (both, n = 68; 29 %), was the most frequently reported barrier. CONCLUSIONS: The preventive as well as curative oral care needs in Belgian adults with various forms of disabilities are very high. CLINICAL RELEVANCE: Efforts to tackle these vast oral health care needs should take into account the differences in needs and demands between subgroups and should comprise the improvement of access to proper care.

Oral health care utilization in children with disabilities.

OBJECTIVES: The objectives of this report were to survey the utilization of oral health care in children and adolescents with disabilities over a 7-year period and to compare these data with the utilization pattern of their peers without disabilities. For most countries, these data have not been published in the international literature so far. MATERIAL AND METHODS: The cohort used was the Permanent Sample of Socially Insured Persons, an anonymous representative sample of Belgian residents. The database comprised prospective data on oral and general health care utilization and sociodemographic variables collected from 2002 up to 2008. RESULTS: Data were available from 326 children and adolescents with and 53,589 without disabilities. Dental attendance rates were low in both subgroups: only 50 % had a dental visit in four or more of the seven observation years. Emergency oral and medical care was recorded significantly more often in children with disabilities whereas radiographs, restorations, and orthodontic assessments and treatments more frequently in children without disabilities. CONCLUSION: The present study demonstrated that dental attendance rates in both subgroups were low and that in those who attended, preventive oral health care was only infrequently attested. Further research is needed to elucidate whether the lower number of radiographs and restorations and the higher number of emergency visits observed in the subgroup with disabilities reflect unmet oral treatment needs. CLINICAL RELEVANCE: Objective data on health care utilization are essential to enable governments and stakeholders to devise appropriate care and to optimize access to care for persons with disabilities.

Impact of caries onset on number and distribution of new lesions in preschool children.

BACKGROUND: Caries in preschool children remains an important public health issue. AIM: To determine (i) which teeth and tooth surfaces are most susceptible to dental caries by age 3, (ii) where do caries lesions develop during 2-year follow-up, and (iii) to evaluate the impact of caries onset on the distribution of new caries experience. DESIGN: One thousand and fifty seven consecutively born children were recruited in Flanders (Belgium). Parents completed validated questionnaires on oral health-related behaviour and trained dentists examined the children at ages 3 and 5. RESULTS: Children with visible caries experience at age 3 were significantly more vulnerable in developing additional caries during follow-up. In this group, new caries experience developed primarily in the occlusal and distal surfaces of the mandibular first molars and the occlusal surfaces of the maxillary second and first molars, whereas in the caries-free group, the occlusal surfaces of both mandibular and maxillary second molars ranked first. CONCLUSIONS: This paper confirms the higher vulnerability for further caries development in those children with caries experience at age 3. Visible caries develops most frequently in the occlusal surfaces of the second molars: in high-risk children already by age 3 and in children who were caries free at baseline by age 5.

Dental attendance in preschool children - a prospective study.

BACKGROUND: At present, our understanding of the use of dental care services is incomplete, certainly where preschool children are concerned. OBJECTIVES: To investigate what proportion of 3- and 5-year-olds living in Flanders (Belgium) have already visited the dentist, to describe parents' experience about their child's dental visit, and to explore factors that may have an impact on children's early dental visit. DESIGN: Data were collected from 1057 children; validated questionnaires were completed, and children were examined by trained dentist at ages 3 and 5. Logistic regression analyses were performed to explain dental attendance. RESULTS: At the age of 3, 62% and by 5 years, 21% had never visited the dentist. The first dental visit was considered a pleasant experience for the majority of children. Multivariable regression analyses revealed that children who were not first born, whose mothers had a higher educational level and whose parents had recently visited the dentist, had significantly higher odds for having visited the dentist at young age. CONCLUSIONS: Parents of young children need to be informed about and motivated for an early dental visit. Promotion campaigns should focus on firstborn children, children from less educated parents, and parents who do not regularly see a dentist.

Association between hospital volume and outcomes in invasive ovarian cancer in Belgium: A population-based study.

OBJECTIVES: To study the association between hospital volume and outcomes in patients with invasive epithelial ovarian cancer (EOC). METHODS: This study included 3988 patients diagnosed with invasive EOC between 2014 and 2018, selected from the population-based database of the Belgian Cancer Registry (BCR), and coupled with health insurance and vital status data. The associations between hospital volume and observed survival since diagnosis were assessed with Cox proportional hazard models, while volume associations with 30-day post-operative mortality and complicated recovery were evaluated using logistic regression models. RESULTS: Treatment for EOC was very dispersed with half of the 100 centres treating fewer than six patients per year. The median survival of patients treated in centres with the highest-volume quartile was 2.5 years longer than in those with the lowest-volume quartile (4.2 years versus 1.7 years). When taking the case-mix of hospitals into account, patients treated in the lowest volume centres had a 47% higher hazard to die than patients treated in the highest volume centres (HR: 1.47, 95% CI: 1.11-1.93, p = 0.006) over the first five years after incidence. A similar association was found when focussing on the surgical volume of the hospitals and considering only operated patients with invasive EOC. Lastly, the 30-day post-operative mortality decreased significantly with increasing surgical volume. CONCLUSIONS: The large dispersion of care and expertise within Belgium and the volume-outcome associations observed in this study support the implementation of the concentration of care for patients with invasive EOC in reference centres.

Risk factors for caries incidence in a cohort of Flemish preschool children.

The main objective of this study was to identify the risk factors for the incidence of visible caries experience in a cohort of preschool children living in Flanders. Data were collected from 1,057 children; validated questionnaires on oral health-related behaviour were completed by parents at birth (2003-2004), at age 3 (2007) and 5 years (2009). At ages 3 and 5, the children were examined by trained dentists. Logistic regression analyses were performed with the following as outcome variables: visible caries experience at age 3 and increment in visible caries experience between ages 3 and 5. At ages 3 and 5, enamel and/or dentinal caries experience was observed in 22% and 41% of the cohort, respectively. The multivariable logistic regression analyses revealed that the presence of visible plaque accumulation on at least one primary tooth was a significant risk factor for visible caries experience at age 3 and for an increment in caries experience between ages 3 and 5. Children with previous caries experience at age 3 had significantly higher odds for new caries lesions at age 5. Presence of visible plaque and previous caries experience are confirmed as significant risk factors for visible caries experience in preschool children. Interventions aimed at caries prevention should focus on very young children and on the control of plaque accumulation. The presence of visible plaque accumulation as a screening tool to identify young children at risk for future caries experience shows high potential.

Methodological issues in epidemiological studies of periodontitis--how can it be improved?

BACKGROUND: This position paper was commissioned by the European Association of Dental Public Health, which has established six working groups to investigate the current status of six topics related to oral public health. One of these areas is epidemiology of periodontal diseases. METHODS: Two theses "A systematic review of definitions of periodontitis and the methods that have been used to identify periodontitis" 1 and "Factors affecting community oral health care needs and provision" 2 formed the starting point for this position paper. Additional relevant and more recent publications were retrieved through a MEDLINE search. RESULTS: The literature reveals a distinct lack of consensus and uniformity in the definition of periodontitis within epidemiological studies. There are also numerous differences in the methods used. The consequence is that data from studies using differing case definitions and differing survey methods are not easily interpretable or comparable. The limitations of the widely used Community Periodontal Index of Treatment Need (CPITN) and its more recent derivatives are widely recognized. Against this background, this position paper reviews the current evidence base, outlines existing problems and suggests how epidemiology of periodontal diseases may be improved. CONCLUSIONS: The remit of this working group was to review and discuss the existing evidence base of epidemiology of periodontal diseases and to identify future areas of work to further enhance it.

Improved survival in patients with head and neck cancer treated in higher volume centres: A population-based study in Belgium.

OBJECTIVES: The study investigated the association between hospital volume and observed survival of patients with a head and neck squamous cell carcinoma (HNSCC). METHODS: Overall, 9245 patients diagnosed with HNSCC between 2009 and 2014, were identified in the population-based Belgian Cancer Registry. This database was coupled with other databases providing information on diagnostic and therapeutic procedures, vital status, and comorbidities. The overall and relative survival probabilities were estimated using the Kaplan-Meier and the Ederer II methods, respectively. The relation between hospital volume and observed survival since diagnosis was then assessed using Cox proportional hazard models adjusted for potential confounders. RESULTS: The care for patients with HNSCC in Belgium was dispersed over more than 99 centres with half of the centres treating four or less patients with HNSCC per year. Survival probabilities were significantly better for patients treated in higher volume centres (>20 patients/year): the median survival of patients treated in these centres was 1.1 year longer (5.1 versus 4.0 years) than in lower volume centres. This association was confirmed in analyses taking the case-mix between hospitals into account: the hazard to die of any cause decreased on average with 0.4% per increase of one additionally treated patient. Beyond 20 assigned patients per year, there was no further decrease in the hazard to die. CONCLUSIONS: Statistically significant and clinically relevant improved survival probabilities were obtained in patients treated in higher volume centres (>20 patients/year) compared with their peers treated in lower volume centres. This supports the recommendation to concentrate the care for patients with HNSCC in reference centres.

Comorbidity in head and neck cancer: Is it associated with therapeutic delay, post-treatment mortality and survival in a population-based study?

OBJECTIVES: This study aims to investigate the relationship between comorbidities and therapeutic delay, post-treatment mortality, overall and relative survival in patients diagnosed with squamous cell carcinoma of the head and neck (HNSCC). PATIENTS AND METHODS: 9245 patients with a single HNSCC diagnosed between 2009 and 2014 were identified in the Belgian Cancer Registry. The Charlson Comorbidity Index (CCI) was calculated for 8812 patients (95.3%), distinguishing patients having none (0), mild (1-2), moderate (3-4) or severe comorbidity (>4). The relationship between CCI and therapeutic delay was evaluated using the Spearman correlation. Post-treatment mortality was modelled with logistic regression, using death within 30 days as the event. The association between comorbidity and survival was assessed using Cox proportional hazard models. RESULTS: Among 8812 patients with a known CCI, 39.2% had at least one comorbidity. Therapeutic delay increased from 31 to 36 days when the CCI worsened from 0 to 4 (rho = 0.087). After case-mix adjustment, higher baseline comorbidity was associated with increased post-surgery mortality (mild, OR 3.52 [95% CI 1.91-6.49]; severe, OR 18.71 [95% CI 6.85-51.12]) and post-radiotherapy mortality (mild, OR 2.23 [95% CI 1.56-3.19]; severe, OR 9.33 [95% CI 4.83-18.01]) and with reduced overall survival (mild, HR 1.39, [95% CI 1.31-1.48]; severe, HR 2.41 [95% CI 2.00-2.90]). That was also the case for relative survival in unadjusted analyses (mild, EHR 1.77 [95% CI 1.64-1.92]; severe, EHR = 4.15 [95% CI 3.43-5.02]). CONCLUSION: Comorbidity is significantly related to therapeutic delay, post-treatment mortality, 5-year overall and relative survival in HNSCC patients. Therapeutic decision support tools should optimally integrate comorbidity.

Antimicrobial prescribing by Belgian dentists in ambulatory care, from 2010 to 2016.

OBJECTIVES: To describe antimicrobial prescribing by Belgian dentists in ambulatory care, from 2010 until 2016. MATERIALS AND METHODS: Reimbursement data from the Belgian National Institute for Health and Disability Insurance were analysed to evaluate antimicrobial prescribing (WHO ATC-codes J01/P01AB). Utilisation was expressed in defined daily doses (DDDs), and in DDDs and packages per 1000 inhabitants per day (DID and PID, respectively). Additionally, the number of DDD and packages per prescriber was calculated. RESULTS: In 2016, the dentistry-related prescribing rate of 'Antibacterials for systemic use' (J01) and 'Antiprotozoals' (P01AB) was 1.607 and 0.014 DID, respectively. From 2010 to 2016, the DID rate of J01 increased by 6.3%, while the PID rate declined by 6.7%. Amoxicillin and amoxicillin with an enzyme inhibitor were the most often prescribed products, followed by clindamycin, clarithromycin, doxycycline, azithromycin and metronidazole. The proportion of amoxicillin relative to amoxicillin with an enzyme inhibitor was low. The narrow-spectrum antibiotic penicillin V was almost never prescribed. CONCLUSIONS: Antibiotics typically classified as broad- or extended-spectrum were prescribed most often by Belgian dentists during the period 2000-2016. Although the DID rate of all 'Antibacterials for systemic use' (J01) increased over the years, the number of prescriptions per dentist decreased since 2013. The high prescription level of amoxicillin with an enzyme inhibitor is particularly worrying. It indicates that there is a need for comprehensive clinical practice guidelines for Belgian dentists.

Head and Neck Cancer in Belgium: Quality of Diagnostic Management and Variability Across Belgian Hospitals Between 2009 and 2014.

Aims: The study assessed the quality of diagnosis and staging offered to patients with a head and neck squamous cell carcinoma (HNSCC) and the variability across Belgian hospitals. Methods: In total, 9,245 patients diagnosed with HNSCC between 2009 and 2014, were identified in the population-based Belgian Cancer Registry (BCR). The BCR data were coupled with other databases providing information on diagnostic and therapeutic procedures reimbursed by the compulsory health insurance, vital status data, and comorbidities. The use of diagnosis and staging procedures was assessed by four quality indicators (QI) (i.e., use of dedicated head and neck imaging studies, use of PET-CT, TNM reporting and interval between diagnosis and start of treatment), for which a target was defined before the analysis. The association between the binary QIs and observed survival was assessed using Cox proportional hazard models adjusted for potential confounders. Results: Overall, 82.5% of patients received staging by MRI and/or CT of the head and neck region before the start of treatment. In 47.6% of stage III-IV patients eligible for treatment with curative intent, a whole-body FDG-PET(/CT) was performed. The proportion of patients whose cTNM and pTNM stage was reported to the BCR was 80.5 and 78.4%, respectively. The median interval from diagnosis to first treatment with curative intent was 32 days (IQR: 19-46). For none of these QIs the pre-set targets were reached and a substantial variability between centers was observed for all quality indicators. No binary QI was significantly associated with observed survival. Conclusions: The four quality indicators related to diagnosis and staging in HNSCC all showed substantial room for improvement. For none of them the pre-set targets were met at the national level and the variability between centers was substantial. Each Belgian hospital received an individual feedback report in order to stimulate reflection and quality improvement processes.

Variability in permanent tooth emergence sequences in Flemish children.

The aim of the present study was to investigate the variability in permanent tooth emergence sequences in Flemish children. Data were obtained in the Signal-Tandmobiel project, a 6-yr prospective longitudinal oral health screening survey in Belgium. Bayesian statistical analyses, taking into account the interval-censored character of the data, were performed. The analyses indicated that no sequence was common in a quadrant to more than 19% of the sample. When only those emergence sequences are considered with a prevalence of 1% or more, 21 variations can be expected in the maxilla and 15-22 variations in the mandible. These variations 'cover' 84-88% of all sequences. The presentation of emergence sequences solely based on means or medians should thus be regarded as misleading.

Variability in elective day-surgery rates between Belgian hospitals - Analyses of administrative data explained by surgical experts.

BACKGROUND: In the last decades, day surgery has steadily and significantly grown in many countries, yet the increase has been uneven. There are large variations in day-surgery activity between countries, but also within countries between hospitals and surgeons. This paper explores the variability in day-care activity for elective surgical procedures between Belgian hospitals. MATERIALS AND METHODS: The administrative hospital data of all patients formally admitted in a Belgian hospital for inpatient or day-care surgery between 2011 and 2013 were analysed and summarized in graphs. During 11 expert meetings with ad-hoc surgical expert groups the variability in day-surgery share between hospitals was discussed in depth. RESULTS: The variability in day-care share between Belgian hospitals is considerable. For 37 out of 486 elective surgical procedures, the variability ranged between 0 and 100%. High national day-care rates do not preclude room for improvement for certain hospitals as for the majority of these procedures there are "low performers". According to the consulted clinical experts, the high variability in day-care share may for the greater part be explained by medical team related factors, customs and traditions, the lack of clinical guidelines, financial factors, organisational factors and patient related factors. CONCLUSION: If a further expansion of day surgery is envisaged in Belgium the factors that contribute to the current variability in day-surgery rates between hospitals should be addressed. In addition, a feedback system in which hospitals and health care providers have the figures on their percentage of procedures carried out in day surgery compared to other hospitals and care providers (benchmarking) and the monitoring of a number of quality indicators (e.g. unplanned readmission, unplanned inpatient stay, emergency department visit) should be installed.