RESUMEN
BACKGROUND: Electronic medical records can generate a wealth of information regarding compliance with perioperative clinical guidelines as well as patient outcomes. Utilizing this information to provide resident physicians with measures of their own clinical performance may positively impact residents' clinical performance. We hypothesize that providing residents with objective measures of their individual adherence to evidence based postoperative nausea and vomiting (PONV) management protocols will improve their compliance with standardized treatment methods. METHODS: We conducted a retrospective baseline analysis of junior anesthesiology residents' compliance with PONV prophylaxis guidelines for high-risk patients. This was followed by a prospective cohort study, before and after an educational intervention, a 15 minute lecture on PONV prophylaxis. The number of pharmacologic prophylactic interventions were tabulated for each operative case and reported back to individual residents in blind and anonymous fashion. The primary outcome was the use of two or more prophylactic interventions for a high-risk patient, while the secondary outcome was the use of three or more prophylactic interventions. A follow up survey was administered to participating residents regarding the use of their individualized clinical performance. RESULTS: After implementation of feedback, patients received a significantly higher amount of PONV prophylactic treatments (p=0.001, means of 1.35 vs. 1.99). Comparison of percentage compliance was 38% vs 73%, respectively (p<0.001). In a follow up survey, residents received the feedback intervention well and had no significant concern in the dissemination of deidentified performance outcomes publically. CONCLUSIONS: Resident compliance with PONV treatment guidelines was improved merely by auditing performance and providing individualized feedback. High-risk patients appear to receive more prophylactic agents after performance feedback and may be more effective than a more commonly used educational intervention to address the same topic. Providing direct performance feedback may be a useful tool for integration into graduate medical education programs.
RESUMEN
BACKGROUND: A number of prognostically relevant clinicopathological variables have been proposed for pancreatic neuroendocrine neoplasms. However, a standardized prognostication system has yet to be established for patients undergoing potentially curative tumour resection. METHODS: We examined a prospectively maintained, single-institution database to identify patients who underwent potentially curative resection of non-metastatic primary pancreatic neuroendocrine neoplasms. Patient, operative and pathological characteristics were analysed to identify variables associated with disease-specific and disease-free survival. RESULTS: Between 1991 and 2007, 43 patients met inclusion criteria. After a median follow-up of 68 months, 5-year disease-specific survival was 94% and 5-year disease-free survival was 72%. Tumours sized > or = 5 cm and vascular invasion were associated with worse disease-specific survival. Tumours sized > or = 5 cm, nodal metastases, positive resection margins and perineural invasion were associated with worse disease-free survival. A scoring system consisting of tumour size > or = 5 cm, histological grade, nodal metastases and resection margin positivity (SGNM) permitted stratification of disease-specific (P= 0.006) and disease-free (P= 0.0004) survival. This proposed scoring system demonstrated excellent discrimination of individual disease-specific and disease-free survival outcomes as reflected by concordance indices of 0.814 and 0.794, respectively. CONCLUSIONS: A simple scoring system utilizing tumour size, histological grade, nodal metastases and resection margin status can be used to stratify outcomes in patients undergoing resection of primary pancreatic neuroendocrine neoplasms.