Assessing the quality of surgical care in vascular surgery; moving from outcome towards structural and process measures.

OBJECTIVES: This study presents a review of studies reporting on quality of care in vascular surgery. The aim of this study was to provide insight in quality improvement initiatives in vascular surgery. DESIGN: Original data were collected from MEDLINE and EMBASE databases. Inclusion criteria were: description of one of the three factors of quality of care, e.g. process, outcome or structure and prospectively described. All articles identified were ascribed to a domain of quality of care. RESULTS: 57 prospective articles were included, drawn from 859 eligible reports. Structure as an indicator of quality of care was described in 19 reports, process in 7 reports and outcome in 31 reports. Most studies based on structural measures considered the introduction of a clinical pathway or a registration system. Reports based on process measures showed promising results. Outcome as clinical indicator mainly focussed on identifying risk factors for morbidity, mortality or failure of treatment. CONCLUSIONS: Structure and process indicators are evaluated scarcely in vascular surgery. Many studies in vascular surgery have been focussed on outcomes as indicator of quality of care, but a shift towards process measures should be considered as focus of attention in the future.

Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making.

OBJECTIVE: To evaluate the diagnostic accuracy of clinical evaluation and cross-sectional imaging modalities such as ultrasound and computed tomography for patients with suspected colonic diverticulitis and to determine the value of these examinations in clinical decision-making. METHOD: A prospective analysis was conducted of 802 consecutive patients that presented with abdominal pain at the emergency department. Initial clinical diagnoses and management proposals were compared to the final diagnoses and therapeutic strategies for all patients. RESULTS: Fifty-seven patients were identified with colonic diverticulitis as the final diagnosis. The positive and negative predictive values for the clinical diagnosis of colonic diverticulitis were 0.65 and 0.98 respectively. Additional cross-sectional imaging had a positive and negative predictive value of respectively 0.95 and 0.99 or higher. These additional examinations led to a correct change of the initial clinical diagnosis in 37% of the patients, and a change in management in only 7%. CONCLUSION: The accuracy of the clinical diagnosis for colonic diverticulitis is low. Ultrasound and computed tomography have superior diagnostic accuracy but these examinations rarely change the initial management proposal.

More than 25 years of surgical treatment of hydatid cysts in a nonendemic area using the "frozen seal" method.

BACKGROUND: Hydatid disease of the liver remains endemic in the world and is an imported disease in The Netherlands. The aim of this study was to evaluate the treatment and outcome of surgically treated patients for hydatid disease in a single center in The Netherlands. METHODS: This retrospective study included 112 consecutive patients surgically treated for hydatid disease between 1981 and 2007. The primary outcome was relapse of the disease. Secondary outcomes were infections, complications, reoperations, length of hospital stay, and mortality. RESULTS: In all cases, echinococcosis was diagnosed by computed tomography or ultrasonography (US). Serology (enzyme-linked immunosorbent assay, immunofluorescence) confirmed the diagnosis in 92.9%. Most of the cysts were seen only in the liver (73.5%). All cysts were operated on with the frozen seal technique. Relapse of disease was seen in 9 (8.0%) cases. Five (4.5%) required surgical treatment at a later stage. Twenty (17.9%) complications were recorded. Four (3.6%) needed radiological drainage and three (2.7%) a reoperation. Follow-up was performed with US and/or serology at a mean of 24 months (range 0.5-300 months). All but one complication were seen in the liver-operated group, this proved not to be of statistical significance (P = 0.477). Patients with complications stayed significantly longer in hospital than did the patients without complications (P < 0.001). No mortality was observed in this study. CONCLUSIONS: The present study suggests that the frozen seal method of surgery for hydatid disease is safe and effective. Future studies are needed to prove its position in the treatment of hydatid disease as new developments show promising results.

[Evaluation of the rate of autopsy and rate of disparity between autopsy results and clinical cause of death in a surgical ward, with the emphasis on necrological review]. / Een onderzoek naar het percentage obducties en naar discrepanties tussen obductiebevindingen en klinische doodsoorzaak op een heelkundige afdeling met extra aandacht voor necrologiebesprekingen.

OBJECTIVE: To determine the rate of autopsy and the rate of disparity between autopsy results and the clinically determined cause of death in a surgical ward. DESIGN: Descriptive. METHOD: A total of 12,000 patients were admitted to the surgical ward of the Red Cross Hospital, the Hague, the Netherlands, from January 1999 to December 2002. 305 (3%) died during their stay on the ward. By using our standard mortality registration system, it was possible to classify the causes of death, evaluate shortcomings in treatment, and determine the extent of agreement between pre- and post-mortem findings. RESULTS: Permission for an autopsy was obtained for 136 patients (45%). The autopsy rates in patients who died following abdominal aortic surgery, colonic surgery, peripheral artery bypass surgery, and hip surgery were 55%, 63%, 35% and 30%, respectively. In 37 patients (27%), the autopsy report revealed a disparity with the clinical cause of death. Patients who died after abdominal aortic surgery or colonic surgery had disparity rates of 33% and 21%, respectively. Patients who died after peripheral artery bypass surgery or hip surgery had disparity rates of 13% and 7%, respectively. CONCLUSION: The overall rate of autopsy was lower (45%) than in the period 1992-1998 (60%), but remained relatively high in patient groups who were previously found to have a high rate of disparity between pre- and post-mortem findings. Post-mortem examination remains an important tool that can be used to verify diagnosis and treatment and therefore assess the quality of care.

Cardiovascular determinants of carotid artery disease. The Rotterdam Elderly Study.

The objective of the present study was to assess the prevalence of moderate and severe stenosis of the right carotid artery in the elderly and its associations with smoking, blood pressure, serum lipid levels, and hemostatic factors. The Rotterdam Elderly Study is a recently started single-center prospective follow-up study of a cohort of 11,854 elderly people aged 55 years or more. In 1990, 954 participants of the Rotterdam Elderly Study underwent ultrasonic duplex examination of the right internal carotid artery. A reduction of the lumen diameter of 16-49% was found in 29 people (3.0%). Severe stenosis (50% or more) was observed in 13 people (1.4%). With differences in age, sex, and body mass index taken into account, subjects with moderate-to-severe carotid artery disease had, compared with participants without stenosis, lower mean high density lipoprotein cholesterol levels (mean difference, 0.10 mmol/l; 95% confidence interval, 0, 0.20) and higher mean fibrinogen levels (difference, 0.24 g/l; 0.04, 0.45). Among them were more people with hypertension (mean difference, 16%) and more current smokers (mean difference, 13%). Factor VIIc and factor VIIIc activity was higher in subjects with carotid artery disease, without, however, reaching statistical significance (mean difference, 0.06 IU/ml [-0.01, 0.12] and 0.21 IU/ml [-0.05, 0.47], respectively). Our data suggest that hypertension, smoking, and reduced serum high density lipoprotein cholesterol levels, combined with unfavorable increases in hemostatic factors, may be related to carotid artery disease in the elderly.

Clinical and rheological studies in patients with intermittent claudication.

While the resistance to flow offered by means of arterial narrowing and the collateral arteries are the major determinants affecting peripheral flow, there may be a contribution by those elements which affect the viscosity of the blood. To evaluate these factors, haematocrit, red blood cell aggregation and plasma viscosity were measured in 100 patients with occlusive arterial disease of the lower extremities. Disturbances in these parameters were noted and appeared to be related to the severity and extent of the occlusive disease. However, whether these factors contribute to the cause of intermittent claudication remains uncertain.

Carotid arterial disease in patients undergoing coronary artery bypass operations.

The occurrence of stroke associated with coronary artery bypass operations is approximately 2%. In an attempt to reduce this incidence some centers have proposed carotid thromboendarterectomy for symptomatic and asymptomatic carotid arterial disease in patients undergoing a coronary artery bypass operation. To obtain a better understanding of the incidence of carotid occlusive disease in candidates for the coronary bypass operation and to evaluate the practical use of a noninvasive method to screen patients preoperatively, we evaluated 102 patients preoperatively with an ultrasonic Duplex scanner; 24 studies were requested on the basis of either previous neurologic problems or the presence of a bruit and 78 patients were evaluated as part of a study protocol. In the unrequested group 6% (5/78) of the patients had a stenosis of 50% diameter reduction or more. In the requested group 54% (13/24) had a stenosis of 50% diameter reduction or more. In the postoperative phase one stroke and one transient ischemic attack were noted among the unrequested group and none in those suspected of having carotid disease on clinical grounds. Neither affected patient had a high-grade stenosis. There is little evidence to support the contention that noninvasive screening of patients free of symptoms or signs of carotid disease prior to coronary artery bypass operation is a valuable method of screening for patients who will sustain a focal neurologic event.

Nomenclature of Raynaud's phenomenon: a capillary microscopic and hemorheologic study.

Hemorheologic parameters and nailfold capillaries were investigated in 72 patients with ischemic hand phenomena and 25 normal subjects. Red blood cell (RBC) aggregation and plasma viscosity were normal in all groups except in patients with secondary Raynaud's phenomenon; in this group, these parameters were significantly increased (p less than 0.001). The capillary density in the nailfold was significantly lower in patients with secondary Raynaud's phenomenon or acrocyanosis (p less than 0.001). The capillary diameters were slightly increased in patients with primary Raynaud's phenomenon, moderately increased in patients with acrocyanosis (more than twofold), and markedly increased in patients with secondary Raynaud's phenomenon (fourfold to fivefold). Nailfold velocity, before and after cold provocation, was decreased in all patients (p less than 0.001). The findings in this study support the conclusion that patients with primary and secondary Raynaud's phenomenon, acrocyanosis, or asphyxia digitorum can be distinguished by combining hemorheologic observations with morphologic and functional microscopic investigations of the nailfold capillaries. The nomenclature currently employed in our clinic can be used to define these different phenomena.

Assessment of aortoiliac disease using hemodynamic measures.

To study the role of accurate hemodynamic assessment of aortoiliac disease, intra-arterial pressure measurements of 100 aortoiliac segments were compared with Doppler velocity waveform analysis and contrast arteriography. By applying the statistic kappa, we assessed the degree of agreement among the three methods corrected for chance. The agreement between pressure measurements and contrast arteriography provided a kappa of 0.41, as did the agreement between pressure measurements and velocity waveform analysis. Our results indicate that contrast arteriography and Doppler studies underestimate hemodynamically significant aortoiliac disease. Since the correlation is so poor, it is essential to use intra-arterial pressure measurements in every patient who is a candidate for surgery.

Evaluation of carotid bifurcation disease: the role of common carotid artery velocity patterns.

We evaluated duplex ultrasonographic velocity patterns from the common carotid artery in 156 patients with arteriographically verified internal carotid artery disease. Flow to zero during diastole in the common carotid was found in three groups of patients: (1) those with flow to zero in both common carotids not related to disease of the carotid bulb; (2) those with a tight (90% to 99%) stenosis in the internal carotid; and (3) those with total occlusion of the internal carotid. Although such flow to zero is commonly observed with total occlusion of the internal carotid artery, it may also be seen with high-grade stenosis. Thus, when found, it is essential to ascertain if flow is indeed present in the internal carotid artery; understanding changes in velocity patterns of the common carotid has improved our overall accuracy in detecting extracranial carotid artery disease.

Prevention of urinary retention after general surgery: a controlled trial of carbachol/diazepam versus alfusozine.

BACKGROUND: Postoperative urinary retention is a common complication after surgical procedures. It can cause bladder dilatation, infection, and even sepsis. Carbachol/diazepam and alfusozine have been reported to lower the incidence of postoperative urinary retention, but no study showed the benefits of these drugs in a randomized, placebo-controlled trial. STUDY DESIGN: We used a double blind, placebo-controlled trial in which 249 patients with postoperative urinary retention were randomly assigned to receive carbachol/diazepam (n = 72), alfusozine (n = 82), or placebo (n = 95). The primary endpoint was miction within 2 hours after taking the medication. RESULTS: There was no significant difference in miction frequency after taking the medication among the three groups (p = 0.31). The miction rate was 60% for patients in the alfusozine group, 61% in the carbachol/diazepam group, and 51% in the placebo group. CONCLUSIONS: Alfusozine and carbachol/diazepam had no apparent benefit on the incidence of postoperative urinary retention.

A series of carcinoid tumours of the breast.

Eight patients with a carcinoid tumour of the breast were treated between 1985 and 1992. All were reviewed for their history, physical examination, mammographic and ultrasound features. Staining methods according to Grimelius, with H&E and Neurone Specific Enolase were repeated, and all were positive. In only one patient was a positive axillary lymph node found. No recurrences were seen during follow-up. In agreement with the available literature there seems to be a less aggressive behaviour of carcinoid tumours of the breast in patients over 65 years of age. When a carcinoid tumour is suspected in this age group, the diagnosis can be confirmed by (immuno)histological analysis of a needle biopsy. If the diagnosis of carcinoid is confirmed, a limited operation, without an axillary lymph node dissection, may be considered.

Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial.

Pressure sores are a frequent problem, especially in elderly patients. Nutritional status may influence the incidence, progression and severity of pressure sores, data, however, are contradictory (1). The purpose of this study was to determine the effect of supplemental feeding on the nutritional status and the development and severity of pressure sores. The effect of supplemental feeding overnight (tube +) on patients with a fracture of the hip and a high pressure-sore risk score, was studied in a randomized clinical trial. The control group (tube -) had no supplemental feeding. After informed consent, 140 patients were randomized, and 129 of these took part in the trial (62 tube +, and 67 tube -). Protein and energy intake, haemoglobin, serum albumin, total serum protein and pressure-sore grade were measured at admission and after 1 and 2 weeks. Of the 62 patients randomized for tube feeding (tube +), only 25 tolerated their tube for more than 1 week and 16 for 2 weeks. Nevertheless, energy and protein intake was significantly higher in the tube + group (P < 0.001). This, however, did not significantly influence total serum protein, serum albumin and development and severity of pressure sores after 1 and 2 weeks. Comparison of the actually tube fed group (n=25 at 1 week, n = 16 at 2 weeks) and the control group showed a 2-3 times higher protein and energy intake (P < 0.0001), and a significantly higher total serum protein and serum albumin after 1 and 2 weeks in the actually tube fed group (all P < 0.001). Pressure-sore development and severity were not significantly influenced in the actually tube fed group. We conclude that we were not able to show a significant decrease in development and severity of pressure sores, because the nasogastric tube for supplemental feeding was not well tolerated in this patient group. Nevertheless, tube feeding overnight does result in a significant higher protein and energy intake, and has a significant effect on nutritional status in the actually tube-fed group. Other means of supplemental feeding will have to be used in order to answer the question of whether supplemental feeding can decrease development and severity of pressure sores.

More accurate assessment of stenotic lesions in percutaneous transluminal angioplasty.

Eighty patients underwent percutaneous transluminal dilatation and recanalisation of atheromatous lesions of the arteries of the lower extremities in the University Hospital of Maastricht in the period of 1980 to 1984. Out of 80 attempted procedures of the iliac and femoro-popliteal tract 71 (89%) were technically possible and were considered initially successful. In all cases of iliac artery lesions a retrograde arteriogram was performed prior to PTA. Intra-arterial pressure measurements at rest and after hyperemia were used for exact assessment of the hemodynamic significance of the stenosis before and after PTA. A follow-up of all patients successfully treated by angioplasty was performed. The early hemodynamic success rate of PTA for iliac lesions was 90 per cent and for femoral-popliteal segment 83 per cent. There was no morbidity or mortality. The cumulative 3-year patency rate for both segments was 74 per cent.

Comparative study of strain gauge plethysmography and Doppler ultrasound in patients with occlusive arterial disease of the lower extremities.

A series of 305 normal subjects and 77 patients with angiographically proven stenotic or occlusive arterial disease of the lower limbs was studied with Doppler ultrasound pressure measurements and strain gauge plethysmographic arterial flow measurements. The 2 techniques were compared singly and in combination at rest and after exercise or reactive hyperemia. Pressure-flow patterns were found to correlate well with the segment(s) and extent of involvement with arterial disease, especially in patients with superficial femoral artery disease. However, it was found that calf blood flow measurements were of little assistance in predicting the level and severity of involvement over and above the information obtained by pressure measurements alone.

Strain gauge plethsymography in ischemic handsyndromes.

In sixteen patients with ischemic handsyndromes, strain gauge plethysmography was used as a noninvasive diagnostic test. Contrast-arteriography was available for comparison. These patients demonstrate the role for a noninvasive test in selecting patients with Raynaud's phenomenon or asphyxia for arteriography.

[Myiasis caused by Dermatobia hominis]. / Myiasis door Dermatobia hominis.

In two patients, a woman of 35 and a man of 62 years old, myiasis caused by the larvae of the fly Dermatobia hominis was diagnosed. Both patients had recently returned from a visit to Central America. This ectoparasitosis is found in Central and South America. Patients present themselves with an insect bite which fails to heal. If the clinical presentation is unknown, the disease may well be mistaken for furunculosis. The condition may be easily treated by applying vaseline to the insect bite, which causes extrusion of the larva.

[Measurement of the quality of care for surgical patients in an intensive care unit in a peripheral hospital]. / Meting van de kwaliteit van de zorg voor chirurgiepatiënten op een intensive care-afdeling in een perifeer ziekenhuis.

OBJECTIVE: To determine the quality of care in an intensive care unit. DESIGN: Prospective investigation for one year. Comparison with results from the literature. SETTING: Surgical intensive care unit of a community hospital. PATIENTS: Measurement of the APACHE-II-score was performed on days 1, 3 and 7 in all surgical intensive care unit patients admitted during a one-year period. The predicted mortality from the literature was compared with the actual mortality in our hospital. RESULTS: A total of 301 patients were admitted to the intensive care unit. Overall mortality was 9%. All the patients with an APACHE II score above 25 on admission died. The actual mortality was comparable with the predicted mortality from the literature. CONCLUSION: The APACHE II score can be used to determine the quality of care in an intensive care unit. Early prediction of a bad prognosis makes transportation to a more specialized hospital possible, before irreversible organ damage develops.

[Good results 5 years after surgery for proximal femur fractures]. / Goede resultaten 5 jaar na operatieve behandeling van proximale femurfracturen.

OBJECTIVE: Determining the results 5 years after surgery for proximal femur fractures. DESIGN: Descriptive, retrospective. SETTING: Department of General Medicine, Red Cross Hospital, the Hague, the Netherlands. METHOD: In 1996, for all patients operated on for proximal femur fractures in 1991, data were collected from the patient records regarding the admission and situation at home, and from the municipal archives, the family physician, the patient or his or her family regarding survival. The 5-year survival was compared with that of a cohort matched for age and sex, according to data from the Central Bureau for Statistics. The level of function after 5 years was evaluated by means of a Broos checklist. RESULTS: Of the 117 patients operated, 69 had medical, 9 lateral and 39 pertrochanteric fractures. The average age of the 20 men and 97 women was 71 and 82 years, respectively. The average duration of hospitalisation was 31 days. Seven patients (6%) died while still in hospital. Of the 110 surviving patients, 61 (55%) returned to the situation in which they lived before. Starting 6 months postoperatively, the 5-year survival curves were parallel to those of the matched cohort. After 5 years, 53 patients (45%) were still alive. Of these, 37 patients (70%) functioned well. CONCLUSION: Most patients with proximal femur fracture belong to the category of patients in advanced old age. The survival after 5 years was 45%; most of the mortality occurred during the first 6 months after the operation. Of those surviving, 70% functioned well.

[Diagnostic surplus value of echography in children with acute abdominal pain]. / Diagnostische meerwaarde van echografie bij kinderen met acute buikklachten.

OBJECTIVE: To assess the role of echography in the diagnosis of acute abdominal symptoms in children. DESIGN: Prospective, descriptive. METHOD: During one year (1 June 1999-31 May 2000), abdominal ultrasonography was performed in all children with abdominal pain less than 2 weeks, who were referred to the emergency department of the Red Cross Hospital in The Hague (the Netherlands). An initial clinical diagnosis was made on the basis of the medical history, a physical examination and the results of laboratory tests. Subsequently, ultrasonography was performed by a radiologist who was unaware of the clinical diagnosis. A working hypothesis was reached on the basis of the clinical findings and the results of echography. The final diagnosis was made on the basis of either a histologic investigation after surgery or the condition at discharge. RESULTS: The study included 112 patients. The mean age was 9 years and 54% were boys. Acute appendicitis was ascertained in 48 children. The sensitivity of the clinical findings was 88% and the specificity 70%. The sensitivity of the clinical findings together with ultrasonography was 88% and the specificity 91%. The positive predictive value of the clinical findings alone was 69% and of the clinical findings together with ultrasonography 88%. CONCLUSION: Echography has added value in the diagnosis of acute abdominal pain in children; it increases the specificity of the physical examination. The number of negative laparotomies was decreased by the use of ultrasonography.