Effect of surgeon-specific feedback on surgical outcomes: a systematic review of the literature.

BACKGROUND: Surgeon-specific outcome reporting provides an opportunity for quality assurance and improved surgical results. It is becoming increasingly prevalent and remains contentious amongst surgeons. The purpose of this systematic review was to evaluate the extent to which published literature supports the concept that feedback of surgeon-level outcomes reduces morbidity and/or mortality. No systematic reviews have previously been completed on this subject. METHODS: Medline and Embase were systematically searched for studies published prior to the 1st of January 2022. Feedback was defined as a summary of clinical performance over a specified period of time provided in written, electronic or verbal format. Studies were required to provide surgeon-specific feedback to multiple individual consultant surgeons with the primary purpose being to determine if feedback improved outcomes. Primary outcome(s) needed to relate to surgical outcomes as opposed to process measures only. All surgical specialties and procedures were eligible for inclusion. RESULTS: Seventeen studies were included in the review, traversing a wide range of specialties and procedures. Sixteen were non-randominsed and one randomized. Fifteen were before and after studies. The balance of the non-randomized studies support the concept that provision of surgeon-specific feedback can improve surgical outcomes, while the single randomized study suggests feedback may not be effective. CONCLUSIONS: This systematic review supports the use of surgeon-level feedback to improve outcomes. The strength of this finding is limited by reliance on before and after studies, further randomized studies on this subject would be insightful.

Incorporating faecal haemoglobin measurement using the faecal immunochemical test (FIT) in the referral, triage and prioritisation pathway for patients with colorectal symptoms.

Incorporating faecal haemoglobin (FHb) measurement using the faecal immunochemical test (FIT) in the investigation pathway for patients with colorectal symptoms may improve access to colonoscopy for those at greatest risk of significant disease. AIM: To derive a colorectal symptom pathway incorporating standard clinical and FIT data to guide referral, triage, and prioritisation of cases in New Zealand. METHOD: Diagnostic accuracy of FIT to rule out colorectal cancer (CRC) was determined by meta-analysis. Thereafter, the risk of CRC after FIT was estimated for common clinical presentations by Bayesian methodology, using a specifically collated retrospective cohort of symptomatic cases. A symptom/FIT pathway was developed iteratively following multi-disciplinary engagement. RESULTS: Eighteen studies were included in meta-analysis. The sensitivity and specificity for CRC were 89.0% (95%CI 87.0-90.9%) and 80.1% (95%CI 77.7-82.4%) respectively, at a FHb threshold of >10mcg haemoglobin per gram stool, and 95.7% (95%CI 93.2-97.7%) and 60.5% (95%CI 53.8-67.0%) respectively, at the limit of detection. The final pathway was 97% sensitive for CRC, compared with 90% for the current direct access criteria, and requires 47% fewer colonoscopies. Estimated prevalence of CRC among those declined investigation was 0.23%. CONCLUSION: Incorporating FIT in the new patient symptomatic pathway as presented appears feasible, safe, and allows for resources to be targeted to those at greatest risk of disease. Further work is needed to ensure equity for Maori if this pathway were introduced nationally.

Transient elastography to assess liver stiffness in patients with inflammatory bowel disease.

BACKGROUND: Liver injury during inflammatory bowel disease (IBD) is primarily diagnosed by liver biopsy, which has a small but serious risk of severe complications. The aim of this study was to assess liver stiffness, and subsequently the prevalence and associations of liver fibrosis in IBD patients with thiopurine therapy and other clinical factors, by using transient elastography (TE). METHODS: In this prospective, international two-center study, included IBD-patients underwent TE measurements. Laboratory results and medication reports, radiology results and historical liver biopsy results were extracted from the patient charts. RESULTS: Transient elastography results of 168 patients were presented. Moderate and severe fibrosis were detected in 4% (7/168) and 1% (1/168) of the cohort, respectively. Factors contributing to lower liver stiffness were female gender and (historical) exposure to azathioprine. Further, there was a statistical trend towards lower liver stiffness in patients using thiopurines overall (4.7 vs. 5.2kPa, p=0.07). Liver stiffness correlated positively with waist circumference, liver enzyme tests, hemoglobin and 6-methylmercaptopurine concentration and negatively with platelet count. CONCLUSION: Exposure to thiopurine therapy was not associated with higher liver stiffness, although no clinical difference in severity of fibrosis was detected. Further research should robustly determine the accuracy of TE as an evaluation of liver fibrosis in IBD patients.

Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures.

BACKGROUND: Complex proximal humeral fractures may require prosthetic replacement of the humeral head. Surgical options include reverse shoulder arthroplasty (RSA) and shoulder hemiarthroplasty; however, the optimal technique remains controversial. The goal of this study was to compare functional outcomes and revision rates of RSA with hemiarthroplasty in patients with acute proximal humeral fractures. MATERIALS AND METHODS: Between January 1, 1999, and December 31, 2014, there were 218 patients who underwent RSA and 427 who underwent hemiarthroplasty for acute proximal humeral fractures identified through New Zealand Joint Registry records. Study groups were compared with regard to baseline characteristics, operative characteristics, and postoperative outcomes (Oxford Shoulder Score [OSS], revision rate, mortality rate) at 6 months and 5 years after surgery. RESULTS: RSA patients were significantly older (mean age, 78.2 vs. 71.6 years; P < .001), with a higher proportion of female patients (90% vs. 77%; P < .001) than in the hemiarthroplasty group. No statistically significant difference existed in revision rate per 100 component-years (0.58 [RSA] vs. 1.16 [hemiarthroplasty]; P = .137) or 1-year mortality (3.8% vs. 3.4%; P = .805) between both groups. There was no significant difference in 6-month OSS (29.6 vs. 28.4; P = .305). The RSA group demonstrated a superior mean 5-year OSS (37.6 vs. 32.7; P = .078); however, the difference did not achieve statistical significance. CONCLUSIONS: Although our results suggest that RSA patients may experience superior 5-year functional scores, we have identified no significant difference in functional outcomes and revision rates between RSA and hemiarthroplasty in the treatment of acute proximal humeral fractures.

Comparison of two plasma urate assays in patients receiving vitamin C supplementation.

The aim of this study was to compare plasma urate (PU) concentrations using two different assays in patients receiving vitamin C supplementation. PU was measured using two routinely available enzymatic uricase methods: (1) uric acid plus method (ascorbate oxidase assay), and (2) uric acid method (non-ascorbate oxidase assay). Twenty patients receiving allopurinol were randomised to an increase in allopurinol dose or commence vitamin C 500  mg/d on a 1:1 ratio. Twenty patients not receiving allopurinol were randomised to start allopurinol or vitamin C 500  mg/d on a 1:1 ratio. Trough fasting samples for plasma ascorbate and urate were measured weekly until week 8. There was no significant difference in the mean PU measured by the two assays. In patients not receiving supplemental vitamin C the mean PU concentrations were identical for both assays. For patients receiving supplemental vitamin C the mean PU concentrations for the ascorbate oxidase assay was 0.525  mmol/L (SE 0.034) and for the non-ascorbate oxidase assay 0.510  mmol/L (SE 0.033), p = 0.079.There is a small non-significant difference in measured PU in patients receiving supplemental vitamin C between the two assays. The assay which does not include ascorbate oxidase results in consistently lower PU concentrations compared to the assay which includes ascorbate oxidase.

Do larger femoral heads improve the functional outcome in total hip arthroplasty?

Use of larger diameter femoral heads has been popularised in total hip arthroplasty (THA). Recent studies have implicated larger femoral heads in early failure. We evaluated what effect the size of the femoral head had on the early functional outcome in order to determine the optimal head size for the maximal functional outcome. There were 726 patients who underwent elective THA and were divided into 3 groups according to head size then compared with respect to functional outcome scores and dislocation rates. This study failed to show that increasing the size of the femoral head significantly improved the functional outcome at 1 year after total hip arthroplasty but that the use of a 36 mm or greater femoral head did reduce the dislocation rate.

Effect of glenoid cementation on total shoulder arthroplasty for degenerative arthritis of the shoulder: a review of the New Zealand National Joint Registry.

BACKGROUND: Despite the lack of literature showing improved results compared with cemented designs, uncemented glenoid components are still commonly used in total shoulder arthroplasty (TSA). Most studies comparing cemented with uncemented glenoids involve small numbers or include patients with inflammatory arthritis. METHODS: New Zealand National Joint Registry data was used to compare the outcomes of uncemented and cemented glenoids in TSA performed for degenerative arthritis. Measured variables were the revision rate and the Oxford Shoulder Score (OSS). RESULTS: Data were retrieved on 1596 patients, with a mean follow-up 3.5 years (range 2-10.7 years), 1065 of whom had a cemented glenoid. There were no significant differences in any preoperative factors between the 2 groups. The revision rate for uncemented glenoids was 4.4 times higher than for cemented glenoids (1.92 vs. 0.44 revisions per 100 component-years, P < .001). Age <55 years was an independent risk factor for revision (P < .001). The most common reason for revision was rotator cuff wear (35.5%) in the uncemented glenoids and loosening (36.3%) in the cemented glenoids. The difference in the mean OSS between the 2 groups was less than 1 point at 6 months (P = .109) and at 5 years (P = .377). CONCLUSION: Uncemented glenoids had a markedly higher revision rate. Patients aged <55 years have the highest revision rate regardless of glenoid fixation method. The higher revision rate in the uncemented glenoid group persisted when the effect of young age was corrected for. There was no clinically or statistically significant difference in the OSS results for clinical outcome between the two groups. LEVEL OF EVIDENCE: Level III, retrospective cohort, treatment study.

Reliability of two-dimensional computed tomography for measuring hip anatomy.

PURPOSE: To evaluate the reliability (inter- and intra-observer variability) of 4 hip anatomies using 2-dimensional pelvic computed tomography (CT). METHODS: Two-dimensional pelvic CT of 10 men and 10 women aged 33 to 89 (mean, 69) years presenting with non-orthopaedic conditions within one month were evaluated by 3 observers. The centre-edge angle of Wiberg, the Sharp angle, the acetabular depth ratio of Murray, and the acetabular anteversion angle of every hip were measured by each observer. After 6 weeks, these measurements were repeated. Reliability was evaluated using intraclass correlation coefficient (ICC), which represents the variation between patients as a percentage of the variation from all 3 sources (patients, inter-observers, and intra-observers). The ICC was classified as poor (<0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), and excellent (0.81-1.00). RESULTS: Reliability was substantial for the Sharp angle (ICC=0.74), the acetabular anteversion angle (ICC=0.69), and the acetabular depth ratio of Murray (ICC=0.62), and was fair for the centre-edge angle of Wiberg (ICC=0.40). CONCLUSION: The Sharp angle, the acetabular anteversion angle, and the acetabular depth ratio of Murray could be reliably measured using 2-dimensional CT. These measurements are appropriate for population-based studies of hip anatomy.

Use and predictors of oral complementary and alternative medicine by patients with inflammatory bowel disease: a population-based, case-control study.

BACKGROUND: The use of complementary and alternative medicine (CAM) in the general population and in patients with chronic diseases has increased markedly in recent decades. We aimed to determine the prevalence, type, and predictors of oral CAM use among patients with inflammatory bowel disease (IBD) compared with the general population in a large, population-based, case-control study. METHODS: Overall, 1370 patients with IBD and 598 control subjects in Canterbury, New Zealand, were recruited. Environmental and phenotypic data were obtained through a questionnaire and case note review. Predictors of oral CAM use were identified using binary logistic regression. RESULTS: In the previous year, 44.1% of patients with IBD and 42.3% of control subjects used oral CAM (odds ratio [OR], 1.078; 95% confidence interval [CI], 0.885-1.312). The types of oral CAM used most frequently were vitamins (Crohn's disease [CD], 25.2%; ulcerative colitis, 23.7%; control subjects, 24.9%), followed by herbs (CD 15.1%, ulcerative colitis 15.2%, control subjects 12.8%), and dietary supplements (CD, 8.5%; ulcerative colitis 12.6%, control subjects 12.1%). Female gender (OR, 1.61; 95% CI, 1.25-2.08), younger age (P = 0.005), higher education (P = 0.002), higher income (P = 0.04), being a vegetarian (OR, 3.58; 95% CI, 1.97-6.48) and a middle social class at birth (P = 0.024) were independent predictors of oral CAM use in patients with IBD. Disease phenotype was not associated with oral CAM use. In control subjects, female gender (OR, 2.67; 95% CI, 1.85-3.86), higher education (P = 0.003) and a diagnosis of asthma (P = 0.017) predicted oral CAM use. CONCLUSIONS: Oral CAM use is common in, and does not differ between, patients with IBD and the general population in Canterbury, New Zealand. Socio-demographic factors, and not disease phenotype, predict oral CAM use in patients with IBD.

Functional response to total hip arthroplasty in patients with hip dysplasia.

BACKGROUND: While recent studies have shown patients with developmental dysplasia of the hip (DDH) undergoing total hip arthroplasty (THA) to achieve comparable post-operative outcomes to patients with primary osteoarthritis (OA), it is unclear whether DDH patients display better or worse preoperative function than the general THA population. We aimed to compare the preoperative function and functional response to THA of DDH patients with OA patients. METHODS: Through a retrospective review of prospectively collected regional joint registry data, we compared the preoperative, 1-year post-operative and post-operative change in disease-specific (Oxford hip score (OHS), Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC)) and general health (short form 12 physical health (SF-12 PH), mental health (SF-12 MH) scores) functional scores of 33 DDH patients and 968 OA patients undergoing primary THA. RESULTS: The DDH group displayed substantially worse preoperative function than the OA group (mean OHS 11.2 versus 16.3 (P = 0.001), WOMAC 72.7 versus 60.6 (P < 0.001), SF-12 PH 27.8 versus 28.9 (P = 0.433), SF-12 MH 35.5 versus 44.7 (P < 0.001)). Functional response to THA at 1 year was significantly better in the DDH group than the OA group (mean score improvements: OHS 31.1 versus 24.6 (P < 0.001), WOMAC 61.4 versus 47.2 (P < 0.001), SF-12 PH 22.3 versus 16.5 (P = 0.003), SF-12 MH 18.4 versus 8.4 (P < 0.001)). CONCLUSION: Despite experiencing significantly worse preoperative function, DDH patients undergoing THA demonstrated superior early functional response to OA patients, with substantially greater improvements observed in all disease-specific and general health outcome measures.

Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures.

BACKGROUND: Complex acute proximal humeral fractures may require prosthetic replacement of the proximal humerus. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative to hemiarthroplasty in the management of such fractures. This study compared the functional outcomes of RSA with hemiarthroplasty in patients with acute proximal humeral fractures. MATERIALS AND METHODS: All patients who underwent RSA or shoulder hemiarthroplasty for acute proximal humeral fractures between January 1, 1999, and December 31, 2010 were identified from The New Zealand Joint Registry. Baseline information, operative characteristics, and postoperative outcomes (Oxford Shoulder Score [OSS] at 6 months and 5 years, revision rate, and mortality rate) were examined and compared between the study groups. RESULTS: During the study period, 55 patients underwent RSA and 313 underwent shoulder hemiarthroplasty for acute proximal humeral fractures. Compared with hemiarthroplasty patients, RSA patients were significantly older (mean age, 79.6 vs 71.9 years; P < .001) and more often women (93% vs 78%, P = .013). The 6-month OSS was 28.1 for RSA and 27.9 for hemiarthroplasty, which was not significantly different (P = .923); however, the RSA group had a significantly better 5-year OSS than the hemiarthroplasty group (41.5 vs 32.3; P = .022). There was no significant difference between the RSA and hemiarthroplasty groups in revision rate per 100 component-years (1.7 vs 1.1; P = .747) or in 1-year mortality (3.5% vs 3.6%; P > .99). CONCLUSIONS: Patients with acute proximal humeral fractures who undergo RSA appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty.

Early results of total hip arthroplasty in patients with slipped upper femoral epiphysis compared with patients with osteoarthritis.

We have investigated the results of primary total hip arthroplasty (THA) performed in patients with slipped upper femoral epiphysis (SUFE). Through the New Zealand Joint Registry, we identified all patients with SUFE undergoing primary THA (n = 117) and all patients with primary osteoarthritis (OA) undergoing primary THA (n = 40 589) between January 1, 1999, and December 31, 2008. Baseline information, operative characteristics, and postoperative outcomes were analyzed and compared between the SUFE and the OA groups. There was no significant difference in postoperative Oxford Hip Score or revision rate between the 2 groups. Our results support THA as a successful surgical option in the management of degenerative arthritis in SUFE, with comparable functional outcomes and revision rates to THA performed for primary OA.

Early results of total hip arthroplasty in patients with developmental dysplasia of the hip compared with patients with osteoarthritis.

We have investigated the results of primary total hip arthroplasty (THA) performed in patients with developmental dysplasia of the hip (DDH). Through the New Zealand Joint Registry, we identified all patients with DDH undergoing primary THA (n = 1205) and all patients with primary osteoarthritis (OA) undergoing primary THA (n = 40 589) between January 1, 1999, and December 31, 2008. Postoperative outcomes, baseline information, and operative characteristics were analyzed and compared between the DDH and the OA groups. There was no significant difference in Oxford Hip Score or revision rate between the 2 groups. Our results support THA as a successful surgical option in the management of degenerative arthritis in DDH, with comparable functional outcomes and revision rates to THA performed for primary OA.

Perianal disease predicts changes in Crohn's disease phenotype-results of a population-based study of inflammatory bowel disease phenotype.

BACKGROUND: The Montreal classification system of inflammatory bowel disease (IBD) provides a framework for describing disease phenotype. OBJECTIVE: We aimed to describe changes in IBD phenotype using the Montreal system and determine predictors of phenotype change in a Caucasian population-based cohort. METHODS: Ninety-two percent of people with IBD in Canterbury, New Zealand were recruited. Clinical notes were reviewed to confirm diagnosis and phenotype. Determinants of phenotype change were analyzed using multivariate analysis. RESULTS: A total of 1,420 (715 Crohn's disease [CD], 668 ulcerative colitis [UC]) patients with IBD were included. Median follow-up was 6.5 and 10.9 yr for CD and UC, respectively. Disease location remained stable in 91% of those with CD. Seventy-three percent of CD patients had inflammatory disease at diagnosis with the proportion of patients with complicated disease increasing over time. Progression to complicated disease was more rapid in those with small bowel than colonic disease location, (P < 0.001). Perianal disease was a significant predictor of change in CD behavior (HR 1.62, P < 0.001). Younger UC patients were more likely to have extensive disease at diagnosis than older patients (P < 0.001). CONCLUSIONS: Although CD location remains relatively stable, behavior changes over time. Perianal disease is a strong predictor of developing more complicated CD. Proctitis is most common in UC patients at diagnosis although younger patients are more likely than older patients to have extensive disease. The Montreal classification provides a clinically useful framework for both researchers and clinicians.

High incidence of Crohn's disease in Canterbury, New Zealand: results of an epidemiologic study.

BACKGROUND: Inflammatory bowel disease (IBD) has increased exponentially in industrialized nations over the last 50 years. Previous New Zealand studies have shown that IBD is less common than in other countries; however, clinical observations suggested a high incidence and prevalence of IBD in Canterbury, particularly Crohn's disease (CD). AIM: This study aimed to determine the descriptive epidemiology of IBD in Canterbury. METHODS: Canterbury IBD patients, recruited using multiple strategies, gave informed consent, permission for clinical record review, completed a questionnaire, and were bled for DNA extraction as part of the Canterbury IBD Project. Cases were confirmed using standard criteria, and completeness of recruitment was validated using capture-recapture methods. Demographic and phenotypic data were extracted from case notes. One thousand four hundred twenty patients (715 CD, 668 ulcerative colitis [UC]) were recruited (> 91% of Canterbury IBD patients). RESULTS: In 2004, age-standardized (World Health Organization World Standard Population) IBD, CD, and UC incidence rates were 25.2, 16.5, and 7.6/100,000/year, respectively. The IBD, CD, and UC point prevalences on 1 June, 2005 were 308.3, 155.2, and 145.0/100,000, respectively. CD patients were more likely than UC patients to be female (61.4% vs. 47.1%) and to be younger (median age, 39.9 years vs. 43.7 years). The percent of IBD patients who were white was 97.5%. CONCLUSION: IBD is at least as common in Canterbury as in other western regions. CD incidence and prevalence are amongst the highest ever reported and are higher than for UC. IBD population characteristics are otherwise similar to other countries. The Canterbury IBD Project will be a valuable tool for future population-based IBD epidemiology and genetics research.

Screening and treatment for depression during pregnancy: a cautionary note.

OBJECTIVE: The aim of this study was to evaluate the recruitment and retention of depressed pregnant women, identified initially through screening, to a randomized controlled psychotherapy trial. METHOD: Consecutive pregnant women presenting for routine ultrasound scan were asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Women who scored greater than 12 on the EPDS and who agreed to contact were invited to attend an initial assessment to determine eligibility for the trial. Consenting, eligible women were randomized to either cognitive behaviour therapy (CBT) or routine clinical care (RCC). Follow-up assessments were conducted at mid (6 weeks following initial assessment), end (approximately 36 weeks gestation), and postpartum (approximately 4 months postdelivery) for all participants. RESULTS: 400 women were offered the EPDS, and 93% completed the questionnaire (370/400). Thirteen percent (49/370) of these women scored greater than 12, although only a minority of these women agreed to be contacted (15/49). Of those who agreed to be contacted, less than half attended initial interview (7/15 attended; 3/15 ineligible; 5/15 declined). Upon interview, all women except for one, were eligible and consenting (6/7). Three women were randomized to CBT and three to RCC. Only one woman randomized to CBT chose to commence treatment, and only one woman randomized to RCC was offered treatment for her low mood by her lead maternity provider. CONCLUSIONS: While the vast majority of pregnant women were willing to complete a depression screening questionnaire, most did not agree to additional contact or assessment, and either were not offered treatment or did not accept treatment. This was not an effective recruitment strategy for a randomized controlled psychotherapy trial.