Surgeon Volume and Cancer Esophagectomy, Gastrectomy, and Pancreatectomy: A Population-based Study in England.

OBJECTIVE: The aim of the study was to assess whether there is a proficiency curve-like relationship between surgeon volume and operative mortality and determine the minimum surgeon volume for optimum operative mortality. BACKGROUND: The inverse relationship between hospital volume and operative mortality is well-established for esophageal, gastric, and pancreatic cancer. The recommended minimum surgeon volumes are however uncertain. METHODS: We retrieved data on esophagectomies, gastrectomies, and pancreatectomies for cancer from the NHS Hospital Episodes Statistics database from April 2000 to March 2010. We defined mortality as in-hospital death within 30 days of surgery. We determined whether there was a proficiency curve relationship by inspecting surgeon volume-mortality graphs after adjusting for patient age, sex, socioeconomic, and comorbidity indices. We then statistically determined the minimum surgeon volume that produced a mortality rate insignificantly different from the optimum of the curve. RESULTS: Sixteen thousand five hundred seventy-two esophagectomies, 12,622 gastrectomies, and 9116 pancreatectomies were examined. Surgeon volume ranged from 2 to 29 esophagectomies, from 1 to 14 gastrectomies, and from 2 to 31 pancreatectomies per surgeon per year. We demonstrated a proficiency relationship between surgeon volume and mortality in esophageal, gastric, and pancreatic cancer surgery. Each additional case of esophagectomy, gastrectomy, and pancreatectomy would reduce 30-day mortality odds by 3.4%, 7.2%, and 4.1%, respectively. However, as surgeon volume increased, mortality rate continued to improve. Therefore, we were unable to recommend minimum surgeon volume. CONCLUSIONS: Mortality after resections for esophageal, gastric, and pancreatic cancer falls as surgeon volume rises up to 30 cases. Within this range, we did not demonstrate any statistical threshold that could be recommended as a minimum volume target.

Development and implementation of the Structured Training Trainer Assessment Report (STTAR) in the English National Training Programme for laparoscopic colorectal surgery.

BACKGROUND: There is a lack of educational tools available for surgical teaching critique, particularly for advanced laparoscopic surgery. The aim was to develop and implement a tool that assesses training quality and structures feedback for trainers in the English National Training Programme for laparoscopic colorectal surgery. METHODS: Semi-structured interviews were performed and analysed, and items were extracted. Through the Delphi process, essential items pertaining to desirable trainer characteristics, training structure and feedback were determined. An assessment tool (Structured Training Trainer Assessment Report-STTAR) was developed and tested for feasibility, acceptability and educational impact. RESULTS: Interview transcripts (29 surgical trainers, 10 trainees, four educationalists) were analysed, and item lists created and distributed for consensus opinion (11 trainers and seven trainees). The STTAR consisted of 64 factors, and its web-based version, the mini-STTAR, included 21 factors that were categorised into four groups (training structure, training behaviour, trainer attributes and role modelling) and structured around a training session timeline (beginning, middle and end). The STTAR (six trainers, 48 different assessments) demonstrated good internal consistency (α = 0.88) and inter-rater reliability (ICC = 0.75). The mini-STTAR demonstrated good inter-item reliability (α = 0.79) and intra-observer reliability on comparison of 85 different trainer/trainee combinations (r = 0.701, p = <0.001). Both were found to be feasible and acceptable. The educational report for trainers was found to be useful (4.4 out of 5). CONCLUSIONS: An assessment tool that evaluates training quality was developed and shown to be reliable, acceptable and of educational value. It has been successfully implemented into the English National Training Programme for laparoscopic colorectal surgery.

Analysis of laboratory-based laparoscopic colorectal surgery workshops within the English National Training Programme.

BACKGROUND: This study aimed to determine and compare the opinions of trainees and trainers attending courses using two simulation models (fresh frozen cadavers or anaesthetized pigs) and to assess trainees' degree of insight into both the difficulty of different procedures and their operative performance in the simulated environment. METHODS: Trainers and trainees attending the training courses completed questionnaires. Performance was evaluated using the Global Assessment Score (GAS). RESULTS: Data were collected over a 12-month period from 26 trainers and 77 trainees. The overall satisfaction was high after attendance at either course (4.50 vs. 4.49; p=0.83). When the opinions of the trainees and trainers in cadaveric and animal courses were compared, the findings rated the animal model as superior in terms of tissue quality (3.97 vs. 3.55; p=0.02), persistence of air leak (1.43 vs. 2.40; p<0.001), and lack of disturbance by odor (4.24 vs. 3.41; p<0.001). The cadaveric model provided more realistic simulation for port placement (4.02 vs. 3.11; p<0.001) and anatomy (4.25 vs. 3.00; p<0.001) and was perceived to be superior as a training model (4.53 vs. 3.61; p=0.001). The trainees demonstrated good insight into procedure difficulty and their operative performance. The trainees and trainers were shown to have a good concordance of scores. The trainees were more inclined to underrate and the peers to overrate their performance. CONCLUSIONS: Trainees appear to have a good insight into procedure difficulty and their ability. Both training models have advantages and disadvantages, but overall, the cadaveric model is perceived to have a higher fidelity and greater educational value.

Utilisation of remote capillary blood testing in an outpatient clinic setting to improve shared decision making and patient and clinician experience: a validation and pilot study.

BACKGROUND: In a tertiary respiratory centre, large cohorts of patients are managed in an outpatient setting and require blood tests to monitor disease activity and organ toxicity. This requires either visits to tertiary centres for phlebotomy and physician review or utilisation of primary care services. OBJECTIVES: This study aims to validate remote capillary blood testing in an outpatient setting and analyse impact on clinical pathways. METHODS: A single-centre prospective cross-sectional validation and parallel observational study was performed. Remote finger prick capillary blood testing was validated compared with local standard venesection using comparative statistical analysis: paired t-test, correlation and Bland-Altman. Capillary was considered interchangeable with venous samples if all three criteria were met: non-significant paired t-test (ie, p>0.05), Pearson's correlation coefficient (r)>0.8% and 95% of tests within 10% difference through Bland-Altman (limits of agreement). In parallel, current clinical pathways including phlebotomy practice were analysed over 4 weeks to review test predictability. A subsequent pilot cohort study analysed potential impact of remote capillary blood sampling on shared decision making. A final implementation phase ensued to embed the service into clinical pathways within the institution. RESULTS: 117 paired capillary and venous blood samples were prospectively analysed. Interchangeability with venous blood was seen with glycated haemoglobin (%), total protein and C reactive protein. Further tests, although not interchangeable, are likely useful to enable longitudinal remote monitoring (eg, liver function and total IgE). 65% of outpatient clinic blood tests were predictable with 16% of patients requiring further follow-up. Patient and clinician-reported improvement in shared decision making given contemporaneous blood test results was observed. CONCLUSIONS: Remote capillary blood sampling can be used accurately for specific tests to monitor chronic disease, and when incorporated into an outpatient clinical pathway can improve shared decision making and patient experience. Further research is required to determine health economic impact and applicability within telemedicine-based outpatient care.

Designing medical technology for resilience: integrating health economics and human factors approaches.

INTRODUCTION: The slow adoption of innovation into healthcare calls into question the manner of evidence generation for medical technology. This paper identifies potential reasons for this including a lack of attention to human factors, poor evaluation of economic benefits, lack of understanding of the existing healthcare system and a failure to recognise the need to generate resilient products. Areas covered: Recognising a cross-disciplinary need to enhance evidence generation early in a technology's life cycle, the present paper proposes a new approach that integrates human factors and health economic evaluation as part of a wider systems approach to the design of technology. This approach (Human and Economic Resilience Design for Medical Technology or HERD MedTech) supports early stages of product development and is based on the recent experiences of the National Institute for Health Research London Diagnostic Evidence Co-operative in the UK. Expert commentary: HERD MedTech i) proposes a shift from design for usability to design for resilience, ii) aspires to reduce the need for service adaptation to technological constraints iii) ensures value of innovation at the time of product development, and iv) aims to stimulate discussion around the integration of pre- and post-market methods of assessment of medical technology.

Usability study of pH strips for nasogastric tube placement.

AIMS: (1) To model the process of use and usability of pH strips (2) to identify, through simulation studies, the likelihood of misreading pH strips, and to assess professional's acceptance, trust and perceived usability of pH strips. METHODS: This study was undertaken in four phases and used a mixed method approach (an audit, a semi-structured interview, a survey and simulation study). The three months audit was of 24 patients, the semi-structured interview was performed with 19 health professionals and informed the process of use of pH strips. A survey of 134 professionals and novices explored the likelihood of misinterpreting pH strips. Standardised questionnaires were used to assess professionals perceived usability, trust and acceptance of pH strip use in a simulated study. RESULTS: The audit found that in 45.7% of the cases aspiration could not be achieved, and that 54% of the NG-tube insertions required x-ray confirmation. None of those interviewed had received formal training on pH strips use. In the simulated study, participants made up to 11.15% errors in reading the strips with important implications for decision making regarding NG tube placement. No difference was identified between professionals and novices in their likelihood of misinterpreting the pH value of the strips. Whilst the overall experience of usage is poor (47.3%), health professionals gave a positive level of trust in both the interview (62.6%) and the survey (68.7%) and acceptance (interview group 65.1%, survey group 74.7%). They also reported anxiety in the use of strips (interview group 29.7%, survey group 49.7%). CONCLUSIONS: Significant errors occur when using pH strips in a simulated study. Manufacturers should consider developing new pH strips, specifically designed for bedside use, that are more usable and less likely to be misread.

Hospital volume and survival in oesophagectomy and gastrectomy for cancer.

BACKGROUND: High volume upper gastrointestinal cancer hospitals demonstrate improved postoperative mortality rates, but the impact on survival is unclear. This population-based cohort study explores the effect of hospital volume on survival following upper gastrointestinal cancer surgery. PATIENTS AND METHODS: This study used a population-based cohort of 3866 patients who underwent surgery for oesophageal or gastric cancer between 1998 and 2008 with follow-up until December 2008. RESULTS: Hospital volume ranged from 1 to 68 cases/year. Overall, 5-year survival was 27%. Increasing age and advanced stage of disease were independently correlated with shorter survival. High hospital volume was significantly and independently correlated with improved 30-day mortality postoperatively (P<0.001), but not with survival beyond 30 days. CONCLUSION: The correlation between hospital volume and improved 30-day mortality following oesophageal and gastric cancer surgery supports the centralisation of upper gastrointestinal cancer surgery services. The low survival in both high and low volume hospitals beyond 30 days highlights the need for increasing earlier diagnosis and optimising approaches to radical treatment.

Is minimally invasive harvesting of the great saphenous vein for coronary artery bypass surgery a cost-effective technique?

OBJECTIVE: In this study we aim to assess the cost-effectiveness analysis of minimally invasive vein harvesting. The great saphenous vein is the most commonly used conduit in coronary artery bypass surgery. In the past decade minimally invasive techniques have been developed to reduce the surgical trauma associated with the conventional open vein-harvesting technique. There is strong evidence to suggest that minimally invasive harvesting can reduce postoperative wound healing complications, pain, mobility restriction, and hospital stay. Despite the increasingly widespread use of this technique, formal cost-effectiveness analysis has never been performed. METHODS: Economic analysis was performed according to the National Institute of Healthcare and Clinical Excellence guidelines on the evaluation of technology by using published data on postoperative pain and mobility restriction, locally collected data, National Health Service reference costs, and manufacturer's data. Probabilistic sensitivity analysis was performed to investigate and quantify the uncertainty associated with the results of our analysis. RESULTS: The results of our analysis demonstrate that minimally invasive vein harvesting was more cost-effective, with an incremental cost-effectiveness ratio of $19,858.87/quality-adjusted life year (QALY), comparing favorably with other health care interventions. Probabilistic sensitivity analysis demonstrated with 95.6% certainty that endoscopic harvesting was more cost-effective at a willingness-to-pay threshold of $50,000/quality-adjusted life year. Alternative analysis suggested that even with considerable uncertainty associated with quality of life after vein harvesting, minimally invasive harvesting was more cost-effective than conventional vein harvesting. CONCLUSION: Minimally invasive harvesting is the most cost-effective method of harvesting the great saphenous vein and can significantly improve a patient's quality of life.