In-hospital mortality and associated complications after bowel surgery in Victorian public hospitals.

BACKGROUND: The purpose of the present paper was to determine the mortality rate and associated complications after large bowel resection and anastomosis in Victorian public hospitals. METHODS: A retrospective analysis of data from the Victorian Inpatient Minimum Database (VIMD) was undertaken. The data were collected from all Victorian public hospitals performing hemicolectomy and anterior resection (resection of the rectum with anastomosis) from 1987/88 to 1995/96. RESULTS: A total of 11036 patients underwent hemicolectomy or anterior resection in the time period studied, there being a 7% increase in the rate of operations performed over the 9 years. Two-thirds of these operations were for carcinoma of the large bowel. The anastomotic leak rate of 4.5% fell slightly but the in-hospital mortality rate of 6.5% did not change over the study period. The total morbidity recorded (mainly major complications) was 24.6%. The patients most at risk of death were the elderly with pre-existing cardiac or respiratory disease undergoing an emergency operation. CONCLUSIONS: Notwithstanding some inaccuracies of coding and reporting, the morbidity and mortality for surgery of the large intestine remains high, largely due to the comorbidities of the patients, although certain technical complications such as leakage of an anastomosis after anterior resection are still associated with a significantly increased risk of death. Consideration should be given to the routine use of high-dependency nursing units for these high-risk patients after major colorectal surgery, and support from physicians to reduce morbidity and mortality from associated medical conditions worsened by surgery.

Predictors of length of stay for transurethral prostatectomy in Victoria.

BACKGROUND: Transurethral resection of prostate (TURP) is among the top 10 surgical conditions that account for hospital admission in Victoria. Bed utilization for TURP is an increasing concern in current times. This paper describes trends in length of stay (LOS) and identifies predictors of LOS for TURP in Victoria. METHODS: Trends in TURP were studied using ICD-9-CM coded Victorian hospital morbidity data from public hospitals from 1987/88 to 1994/95. Detailed morbidity data from the same source for the financial year 1995/96 were used to study predictors of LOS by logistic regression. RESULTS: Length of stay decreased significantly between 1987 and 1995 from 10.6 to 6.1 days. The strongest predictor of increased LOS was admission through the emergency room (odds ratio (OR) 14.7; 95% confidence interval (CI) 11.8-18.3). Other significant predictors were older age, lower socio-economic status, presence of comorbid conditions, occurrence of procedural morbidity, and hospital type and location. CONCLUSIONS: The trend in decreasing LOS may be explained by increasingly efficient bed management in hospitals who are faced with an increasing need for cost control. Advances in surgical techniques and peri-operative care have also contributed to the decrease in LOS. Other factors that influence LOS can be divided into three categories: intrinsic patient factors, such as co-morbid conditions; procedure-specific factors such as peri-operative morbidity; and intrinsic hospital factors relating to capacity and resources. Such determinants of LOS may be of value to policy makers when considering the effective application of newer methods for treatment of benign prostatic hyperplasia.

Changes in bed resources and admission patterns in acute public hospitals in Victoria, 1987-1995.

OBJECTIVE: To describe changes in admission patterns, bed resources and hospital use in acute public hospitals and their relationship with early readmissions and interhospital transfers in Victoria between 1987 and 1995. DESIGN: Descriptive study of longitudinal trends using data from the Victorian inpatient Minimum Database and the Acute Health Services Branch of the Department of Human Services, Victoria. SETTING: State of Victoria. MAIN OUTCOME MEASURES: Acute public hospital beds and hospital separations per 1000 population; separation type (same-day or longer); mean length of stay; interhospital transfers; and readmissions to the same hospital within 28 days. RESULTS: Between 1987-88 and 1994-95, public hospital beds in Victoria decreased from 3.2 to 2.8/1000 population, and mean length of hospital stay decreased from 6.4 to 4.2 days. There was a significant direct correlation between number of beds/1000 and length of stay (r = 0.90; 95% confidence interval [CI], 0.52-0.98). Bed occupancy remained constant at 80%. Over the same period, same-day admissions increased from 22% to 42% of hospital separations, interhospital transfers increased from 2.7% to 4% of separations, and readmissions to the same hospital within 28 days for any reason increased from 12.4% to 15% of separations (21% increase). Beds/1000 were inversely correlated with interhospital transfers (r = -0.83; 95% CI, -0.31 to -0.97), while readmission rates were inversely correlated with beds/1000 (r = -0.89; 95% CI, -0.98 to -0.50) and length of hospital stay (r = -0.95; 95% CI, -0.99 to -0.74). CONCLUSIONS: There were significant changes in the patterns of use of public hospitals between 1987 and 1995, possibly reflecting technological advances and changes in clinical practice, as well as policy to improve efficiency. Early readmission rates may be a useful proxy measure of potentially avoidable adverse outcomes.

Accuracy of ICD-9-CM codes in hospital morbidity data, Victoria: implications for public health research.

Hospital morbidity data in the form of International classification of diseases, 9th revision, clinical modification codes are often used for epidemiological studies and disease surveillance. We aimed to evaluate the reliability of the Victorian In-patient Minimum Database for use in epidemiological studies and disease surveillance. Data from 1993-94 were collected, as part of a coding audit of public hospitals in Victoria, from 7052 randomly selected records. The frequency of discrepancy in any coding field was 53 per cent, and of discrepancy in the principal diagnosis, 22 per cent. New Australian national diagnosis-related group (ANDRG) codes were assigned as a result of discrepancy in 13.6 per cent of cases. Discrepancy rates increased with increasing rarity of ANDRG, from 50 per cent to 56 per cent. Predictors of change in ANDRG assignment were discrepancy in the principal diagnosis, ANDRG frequency of over 0.6 per cent, more than three diagnoses, medical ANDRGs, length of stay over five days and rural hospitals. Rates of any discrepancy increased from 36 per cent in patients with one diagnosis to 94 per cent in patients with 12 diagnoses. The discrepancy rates were consistent with those of other studies. Coding discrepancy is likely to be caused by universal difficulties associated with the coding of hospital records, rather than any unique local problems. The predictors of discrepancy suggest that more complex cases are more prone to coding discrepancy. In areas where the database is less reliable, use of a supplementary data source, such as link-age studies, would improve reliability.

Accuracy of injury coding in Victorian hospital morbidity data.

In Victoria injury surveillance data are drawn from hospital morbidity data. The accuracy and reliability of these data are often questioned. We aimed to ascertain the reliability of injury data in the Victorian inpatient minimum database. A random sample of 546 public hospital separations with principal diagnosis ICD-9-CM codes 800-999 was selected from four metropolitan hospitals. Medical records were reviewed, and the hospital coding was compared with the record content. The frequency of error in any coding field was 73 per cent (349/480); of diagnosis error, 61 per cent (292/480); of procedure error, 45 per cent (168/370); of error in the principal diagnosis, 19 per cent (93/480); and of error in external-cause codes (E-codes), 16 per cent (75/480). Ninety-four per cent of errors (87/93) in the principal diagnosis involved recoding within the same group of codes. Only 6 per cent (6/93) were recoded to principal diagnoses other than injury. Sixty-two per cent (181/292) were errors of omission of codes for comorbid conditions. Nearly half the errors in the principal diagnosis were minor, involving the last two digits. E-codes were more complete than diagnosis codes. The best predictors of error in the principal diagnosis were greater length of stay, type of injury code (poisonings and toxic effects were associated with lower error rates) and death as the outcome. While selection of data from secondary diagnosis fields may not provide complete data, the use of the principal-diagnosis code and E-codes for injury surveillance is feasible and reliable. The database is a valuable source of injury surveillance data, bearing in mind the limitations of coded hospital morbidity data.