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1.
Artículo en Inglés | MEDLINE | ID: mdl-32025806

RESUMEN

BACKGROUND: Chronic subdural haematoma (CSDH) is a pathology that is frequently encountered by neurosurgeons. Nevertheless, there is a lack of guidelines based on solid evidence. There has been a recent and considerable increase in the interest on management and outcomes for CSDH. Therefore, we systematically reviewed all currently running randomised controlled trials (RCTs) in chronic subdural haematoma to understand the areas under investigation and plan future collaborative trials. METHODS: Clinical trials databases (Cochrane Controlled Register of Trials, WHO ICTRP and clinical trials.gov) were searched for trials relevant to chronic subdural haematoma. It was then established which trials were currently running and fulfilled robust research methodology for a RCT. RESULTS: There are 26 currently running RCTs in CSDH, with the most common topics covering application of steroids (7), surgical techniques (5) and tranexamic acid (5). Further to this, there are trials running on other pharmacological agents (4), middle meningeal artery (MMA) embolisation (2) and peri-operative management (3). CONCLUSIONS: Pharmacological agents are a particular focus of CSDH management currently, and a wealth of studies on steroids will hopefully lead to more harmonised, evidence-based practice regarding this in the near future. Surgical techniques and new procedures such as MMA embolisation are also important focuses for improving patient outcomes. There is an on-going need for future RCTs and evidence-based guidelines in CSDH, particularly including low- and middle-income countries, and it is hoped that the establishment of the iCORIC (International COllaborative Research Initiative on Chronic Subdural Haematoma) will help address this.

2.
Anaesthesia ; 75(1): 45-53, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31520421

RESUMEN

Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER-TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed-effects multinomial regression to quantify the effects on pre-hospital or in-hospital tracheal intubation of the following: patient characteristics; injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre-hospital and 483 (13%) in-hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre-hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly chosen centres was 3.1 (95%CI 2.1-4.3) for pre-hospital intubation, and 2.7 (95%CI 1.9-3.5) for in-hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre-hospital intubation (OR 2.9, 95%CI 1.3-6.6), in contrast to the presence of ambulance personnel who are allowed to intubate (OR 0.5, 95%CI 0.3-0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between-centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.


Asunto(s)
Lesiones Traumáticas del Encéfalo/terapia , Intubación Intratraqueal/estadística & datos numéricos , Adulto , Factores de Edad , Anciano , Estudios de Cohortes , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad
3.
J Gastrointest Surg ; 2019 Nov 19.
Artículo en Inglés | MEDLINE | ID: mdl-31745899

RESUMEN

BACKGROUND: Socioeconomic status (SES) has been associated with early mortality in cancer patients. However, the association between SES and outcome in colorectal cancer patients is largely unknown. The aim of this study was to investigate whether SES is associated with short- and long-term outcome in patients undergoing curative surgery for colorectal cancer. METHODS: Patients who underwent curative surgery in the region of Rotterdam for stage I-III colorectal cancer between January 2007 and July 2014 were included. Gross household income and survival status were obtained from a national registry provided by Statistics Netherlands Centraal Bureau voor de Statistiek. Patients were assigned percentiles according to the national income distribution. Logistic regression and Cox proportional hazard regression were performed to assess the association of SES with 30-day postoperative complications, overall survival and cancer-specific survival, adjusted for known prognosticators. RESULTS: For 965 of the 975 eligible patients (99%), gross household income could be retrieved. Patients with a lower SES more often had diabetes, more often underwent an open surgical procedure, and had more comorbidities. In addition, patients with a lower SES were less likely to receive (neo) adjuvant treatment. Lower SES was independently associated with an increased risk of postoperative complications (Odds ratio per percent increase 0.99, 95%CI 0.99-0.998, p = 0.004) and lower cancer-specific mortality (Hazard ratio per percent increase 0.99, 95%CI 0.98-0.99, p = 0.009). CONCLUSION: This study shows that lower SES is associated with increased risk of postoperative complications, and poor cancer-specific survival in patients undergoing surgery for stage I-III colorectal cancer after correcting for known prognosticators.

4.
Acute Med ; 18(3): 171-183, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31536055

RESUMEN

We provide a systematic overview of literature on prediction models for mortality in the Emergency Department (ED). We searched various databases for observational studies in the ED or similar setting describing prediction models for short-term mortality (up to 30 days or in-hospital mortality) in a non-trauma population. We used the CHARMS-checklist for quality assessment. We found a total of 14.768 articles and included 17 articles, describing 22 models. Model performance ranged from AUC 0.63-0.93. Most articles had a moderate risk of bias in one or more domains. The full model and PARIS model performed best, but are not yet ready for implementation. There is a need for validation studies to compare multiple prediction models and to evaluate their accuracy.


Asunto(s)
Servicio de Urgencia en Hospital , Mortalidad Hospitalaria , Adulto , Predicción , Humanos , Pronóstico
5.
Br J Surg ; 2019 Sep 10.
Artículo en Inglés | MEDLINE | ID: mdl-31503341

RESUMEN

BACKGROUND: Patients with major trauma might benefit from treatment in a trauma centre, but early identification of major trauma (Injury Severity Score (ISS) over 15) remains difficult. The aim of this study was to undertake an external validation of existing prognostic models for injured patients to assess their ability to predict mortality and major trauma in the prehospital setting. METHODS: Prognostic models were identified through a systematic literature search up to October 2017. Injured patients transported by Emergency Medical Services to an English hospital from the Trauma Audit and Research Network between 2013 and 2016 were included. Outcome measures were major trauma (ISS over 15) and in-hospital mortality. The performance of the models was assessed in terms of discrimination (concordance index, C-statistic) and net benefit to assess the clinical usefulness. RESULTS: A total of 154 476 patients were included to validate six previously proposed prediction models. Discriminative ability ranged from a C-statistic value of 0·602 (95 per cent c.i. 0·596 to 0·608) for the Mechanism, Glasgow Coma Scale, Age and Arterial Pressure model to 0·793 (0·789 to 0·797) for the modified Rapid Emergency Medicine Score (mREMS) in predicting in-hospital mortality (11 882 patients). Major trauma was identified in 52 818 patients, with discrimination from a C-statistic value of 0·589 (0·586 to 0·592) for mREMS to 0·735 (0·733 to 0·737) for the Kampala Trauma Score in predicting major trauma. None of the prediction models met acceptable undertriage and overtriage rates. CONCLUSION: Currently available prehospital trauma models perform reasonably in predicting in-hospital mortality, but are inadequate in identifying patients with major trauma. Future research should focus on which patients would benefit from treatment in a major trauma centre.

6.
Ann Surg Oncol ; 25(12): 3563-3571, 2018 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-30178391

RESUMEN

PURPOSE: Considering the comparable prognosis in early-stage breast cancer after breast-conserving therapy (BCT) and mastectomy, quality of life should be a focus in treatment decision(s). We retrospectively collected PROs and analyzed differences per type of surgery delivered. We aimed to obtain reference values helpful in shared decision-making. PATIENTS AND METHODS: pTis-T3N0-3M0 patients operated between January 2005 and September 2016 were eligible if: (1) no chemotherapy was administered < 6 months prior to enrolment, and (2) identical surgeries were performed in case of bilateral surgery. After consent, EQ-5D-5L, EORTC-QLQ-C30/BR23, and BREAST-Q were administered. PROs were evaluated per baseline characteristics using multivariable linear regression models. Outcomes were compared for different surgeries as well as for primary (PBC) and second primary or recurrent (SBC) breast cancer patients using analyses of variance (ANOVAs). RESULTS: The response rate was 68%. PROs in 612 PBC patients were comparable to those in 152 SBC patients. Multivariable analyses showed increasing age to be associated with lower "physical functioning" [ß - 0.259, p < 0.001] and "sexual functioning" [ß - 0.427, p < 0.001], and increasing time since surgery with less "fatigue" [ß - 1.083, p < 0.001]. Mastectomy [ß - 13.596, p = 0.003] and implant reconstruction [ß - 13.040, p = 0.007] were associated with lower "satisfaction with breast" scores than BCT. Radiation therapy was associated with lower satisfaction scores than absence of radiotherapy. DISCUSSION: PRO scores were associated with age, time since surgery, type of surgery, and radiation therapy in breast cancer patients. The scores serve as a reference value for different types of surgery in the study population and enable prospective use of PROs in shared decision-making.


Asunto(s)
Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Carcinoma Lobular/cirugía , Mastectomía , Satisfacción del Paciente , Calidad de Vida , Neoplasias de la Mama/patología , Neoplasias de la Mama/radioterapia , Carcinoma Ductal de Mama/patología , Carcinoma Ductal de Mama/radioterapia , Carcinoma Lobular/patología , Carcinoma Lobular/radioterapia , Estudios Transversales , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Pronóstico , Radioterapia , Estudios Retrospectivos
7.
Eur J Surg Oncol ; 44(7): 963-968, 2018 07.
Artículo en Inglés | MEDLINE | ID: mdl-29678302

RESUMEN

INTRODUCTION: In the International Consortium for Health Outcome Measures (ICHOM) breast cancer outcome set Patient Reported Outcome Measurements (PROMs) form an important but rather innovative part. Few data exist on scores per type of breast surgery and how to use scores in surgical practice. We evaluated PROM scores as well as satisfaction with and expectations of the use of PROMs in breast cancer patients using the national and local patient advocate society. METHODS: Through an online survey patients were asked to report age, type of breast cancer surgery (whether Breast Conserving Therapy (BCT), mastectomy, autologous or implant breast reconstruction) and time since surgery. PROMs (EORTC-QLQ-C30/BR23 and BREAST-Q postoperative modules) were compared for the different surgeries. Additional comparison was made with literature normative and reference scores. Three questions evaluated satisfaction with PROMs and expectations. RESULTS: 496 patients completed all PROMs and 487 the satisfaction/expectation-questions. Significantly reduced physical functioning was reported following BCT as compared to other surgeries and literature reference values. Satisfaction scores were higher following autologous reconstruction and lower following implant reconstruction as compared to BCT. PRO scores were comparable to normative and references scores except for the 'physical functioning' (BREAST-Q) scores that reported lower in the present study. Ninety-four percent of the participants was (highly) satisfied with future PROM use. CONCLUSIONS: Statistical significant differences were found for PROMs following different types of breast surgery. The significance of these results should become clearer trough collection of future data. The great majority of participants considered PROMs as (highly) acceptable and reacted positively on their proposed future use.


Asunto(s)
Neoplasias de la Mama/cirugía , Mamoplastia/métodos , Mastectomía Segmentaria/métodos , Satisfacción del Paciente , Implantes de Mama , Femenino , Humanos , Mastectomía/métodos , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Factores de Tiempo
8.
AJNR Am J Neuroradiol ; 38(9): 1758-1764, 2017 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-28751519

RESUMEN

BACKGROUND AND PURPOSE: Thrombus CT characteristics might be useful for patient selection for intra-arterial treatment. Our objective was to study the association of thrombus CT characteristics with outcome and treatment effect in patients with acute ischemic stroke. MATERIALS AND METHODS: We included 199 patients for whom thin-section NCCT and CTA within 30 minutes from each other were available in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute ischemic stroke in the Netherlands (MR CLEAN) study. We assessed the following thrombus characteristics: location, distance from ICA terminus to thrombus, length, volume, absolute and relative density on NCCT, and perviousness. Associations of thrombus characteristics with outcome were estimated with univariable and multivariable ordinal logistic regression as an OR for a shift toward better outcome on the mRS. Interaction terms were used to investigate treatment-effect modification by thrombus characteristics. RESULTS: In univariate analysis, only the distance from the ICA terminus to the thrombus, length of >8 mm, and perviousness were associated with functional outcome. Relative thrombus density on CTA was independently associated with functional outcome with an adjusted common OR of 1.21 per 10% (95% CI, 1.02-1.43; P = .029). There was no treatment-effect modification by any of the thrombus CT characteristics. CONCLUSIONS: In our study on patients with large-vessel occlusion of the anterior circulation, CT thrombus characteristics appear useful for predicting functional outcome. However, in our study cohort, the effect of intra-arterial treatment was independent of the thrombus CT characteristics. Therefore, no arguments were provided to select patients for intra-arterial treatment using thrombus CT characteristics.


Asunto(s)
Isquemia Encefálica/diagnóstico por imagen , Accidente Cerebrovascular/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Procedimientos Endovasculares , Femenino , Humanos , Interpretación de Imagen Asistida por Computador , Masculino , Persona de Mediana Edad , Países Bajos , Selección de Paciente , Pronóstico , Accidente Cerebrovascular/terapia , Trombosis/complicaciones , Tomografía Computarizada por Rayos X , Resultado del Tratamiento
9.
J Neurol ; 264(1): 161-167, 2017 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-27878438

RESUMEN

Cognitive development in patients with tuberous sclerosis complex is highly variable. Predictors in the infant years would be valuable to counsel parents and to support development. The aim of this study was to confirm factors that have been reported to be independently correlated with cognitive development. 102 patients included in this study were treated at the ENCORE-TSC expertise center of the Erasmus Medical Center-Sophia Children's Hospital. Data from the first 24 months of life were used, including details on epilepsy, motor development and mutation status. Outcome was defined as cognitive development (intellectual equivalent, IE) as measured using tests appropriate to the patients age and cognitive abilities (median age at testing 8.2 years, IQR 4.7-12.0). Univariable and multivariable regression analyses were used. In a univariable analysis, predictors of lower IE were: the presence of infantile spasms (ß = -18.3, p = 0.000), a larger number of antiepileptic drugs used (ß = -6.3, p = 0.000), vigabatrin not used as first drug (ß = -14.6, p = 0.020), corticosteroid treatment (ß = -33.2, p = 0.005), and a later age at which the child could walk independently (ß = -2.1, p = 0.000). An older age at seizure onset predicted higher IE (ß = 1.7, p = 0.000). In a multivariable analysis, only age at seizure onset was significantly correlated to IE (ß = 1.2, p = 0.005), contributing to 28% of the variation in IE. In our cohort, age at seizure onset was the only variable that independently predicted IE. Factors predicting cognitive development could aid parents and physicians in finding the appropriate support and schooling for these patients.


Asunto(s)
Cognición , Inteligencia , Esclerosis Tuberosa/diagnóstico , Esclerosis Tuberosa/psicología , Edad de Inicio , Niño , Desarrollo Infantil , Preescolar , Epilepsia/diagnóstico , Epilepsia/epidemiología , Epilepsia/psicología , Epilepsia/terapia , Femenino , Estudios de Seguimiento , Humanos , Discapacidad Intelectual/diagnóstico , Discapacidad Intelectual/epidemiología , Discapacidad Intelectual/genética , Pruebas de Inteligencia , Masculino , Análisis Multivariante , Pronóstico , Psicología Infantil , Análisis de Regresión , Estudios Retrospectivos , Esclerosis Tuberosa/epidemiología , Esclerosis Tuberosa/terapia
10.
Eur J Trauma Emerg Surg ; 42(5): 627-633, 2016 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-26555726

RESUMEN

BACKGROUND: Base deficit provides a more objective indicator of physiological stress following injury as compared with vital signs constituting the revised trauma score (RTS). We have previously developed a base deficit-based trauma survival prediction model [base deficit and injury severity score model (BISS)], in which RTS was replaced by base deficit as a measurement of physiological imbalance. PURPOSE: To externally validate BISS in a large cohort of trauma patients and to compare its performance with established trauma survival prediction models including trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT). Moreover, we examined whether the predictive accuracy of BISS model could be improved by replacement of injury severity score (ISS) by new injury severity score (NISS) in the BISS model (BNISS). METHODS: In this retrospective, observational study, clinical data of 3737 trauma patients (age ≥15 years) admitted consecutively from 2003 to 2007 were obtained from a prospective trauma registry to calculate BISS, TRISS, and ASCOT models. The models were evaluated in terms of discrimination [area under curve (AUC)] and calibration. RESULTS: The in-hospital mortality rate was 8.1 %. The discriminative performance of BISS to predict survival was similar to that of TRISS and ASCOT [AUCs of 0.883, 95 % confidence interval (CI) 0.865-0.901 for BISS, 0.902, 95 % CI 0.858-0.946 for TRISS and 0.864, 95 % CI 0.816-0.913 for ASCOT]. Calibration tended to be optimistic in all three models. The updated BNISS had an AUC of 0.918 indicating that substitution of ISS with NISS improved model performance. CONCLUSIONS: The BISS model, a base deficit-based trauma model for survival prediction, showed equivalent performance as compared with that of TRISS and ASCOT and may offer a more simplified calculation method and a more objective assessment. Calibration of BISS model was, however, less good than that of other models. Replacing ISS by NISS can considerably improve model accuracy, but further confirmation is needed.


Asunto(s)
Mortalidad Hospitalaria , Heridas y Traumatismos/diagnóstico , Heridas y Traumatismos/mortalidad , Escala Resumida de Traumatismos , Adolescente , Anciano , Anciano de 80 o más Años , Área Bajo la Curva , Causas de Muerte , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Países Bajos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Análisis de Supervivencia , Centros Traumatológicos , Heridas y Traumatismos/fisiopatología , Heridas y Traumatismos/psicología
11.
Eur J Surg Oncol ; 41(8): 1045-53, 2015 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-26067372

RESUMEN

OBJECTIVE: When comparing performance across hospitals it is essential to consider the noise caused by low hospital case volume and to perform adequate case-mix adjustment. We aimed to quantify the role of noise and case-mix adjustment on standardized postoperative mortality and anastomotic leakage (AL) rates. METHODS: We studied 13,120 patients who underwent colon cancer resection in 85 Dutch hospitals. We addressed differences between hospitals in postoperative mortality and AL, using fixed (ignoring noise) and random effects (incorporating noise) logistic regression models with general and additional, disease specific, case-mix adjustment. RESULTS: Adding disease specific variables improved the performance of the case-mix adjustment models for postoperative mortality (c-statistic increased from 0.77 to 0.81). The overall variation in standardized mortality ratios was similar, but some individual hospitals changed considerably. For the standardized AL rates the performance of the adjustment models was poor (c-statistic 0.59 and 0.60) and overall variation was small. Most of the observed variation between hospitals was actually noise. CONCLUSION: Noise had a larger effect on hospital performance than extended case-mix adjustment, although some individual hospital outcome rates were affected by more detailed case-mix adjustment. To compare outcomes between hospitals it is crucial to consider noise due to low hospital case volume with a random effects model.


Asunto(s)
Neoplasias del Colon/terapia , Grupos Diagnósticos Relacionados/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Indicadores de Calidad de la Atención de Salud , Anciano , Neoplasias del Colon/mortalidad , Terapia Combinada , Femenino , Mortalidad Hospitalaria , Humanos , Incidencia , Masculino , Países Bajos/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias
12.
BMJ ; 347: f5913, 2013 Oct 21.
Artículo en Inglés | MEDLINE | ID: mdl-24144869

RESUMEN

OBJECTIVES: To assess the consequences of applying different mortality timeframes on standardised mortality ratios of individual hospitals and, secondarily, to evaluate the association between in-hospital standardised mortality ratios and early post-discharge mortality rate, length of hospital stay, and transfer rate. DESIGN: Retrospective analysis of routinely collected hospital data to compare observed deaths in 50 diagnostic categories with deaths predicted by a case mix adjustment method. SETTING: 60 Dutch hospitals. PARTICIPANTS: 1 228 815 patients discharged in the period 2008 to 2010. MAIN OUTCOME MEASURES: In-hospital standardised mortality ratio, 30 days post-admission standardised mortality ratio, and 30 days post-discharge standardised mortality ratio. RESULTS: Compared with the in-hospital standardised mortality ratio, 33% of the hospitals were categorised differently with the 30 days post-admission standardised mortality ratio and 22% were categorised differently with the 30 days post-discharge standardised mortality ratio. A positive association was found between in-hospital standardised mortality ratio and length of hospital stay (Pearson correlation coefficient 0.33; P=0.01), and an inverse association was found between in-hospital standardised mortality ratio and early post-discharge mortality (Pearson correlation coefficient -0.37; P=0.004). CONCLUSIONS: Applying different mortality timeframes resulted in differences in standardised mortality ratios and differences in judgment regarding the performance of individual hospitals. Furthermore, associations between in-hospital standardised mortality rates, length of stay, and early post-discharge mortality rates were found. Combining these findings suggests that standardised mortality ratios based on in-hospital mortality are subject to so-called "discharge bias." Hence, early post-discharge mortality should be included in the calculation of standardised mortality ratios.


Asunto(s)
Benchmarking/métodos , Mortalidad Hospitalaria , Hospitales/normas , Alta del Paciente , Bases de Datos Factuales , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Países Bajos , Transferencia de Pacientes/estadística & datos numéricos , Sistema de Registros , Estudios Retrospectivos , Ajuste de Riesgo , Factores de Tiempo
13.
Br J Surg ; 100(5): 628-36; discussion 637, 2013 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-23338243

RESUMEN

BACKGROUND: Comparing and ranking hospitals based on health outcomes is becoming increasingly popular, although case-mix differences between hospitals and random variation are known to distort interpretation. The aim of this study was to explore whether surgical-site infection (SSI) rates are suitable for comparing hospitals, taking into account case-mix differences and random variation. METHODS: Data from the national surveillance network in the Netherlands, on the eight most frequently registered types of surgery for the year 2009, were used to calculate SSI rates. The variation in SSI rate between hospitals was estimated with multivariable fixed- and random-effects logistic regression models to account for random variation and case mix. 'Rankability' (as the reliability of ranking) of the SSI rates was calculated by relating within-hospital variation to between-hospital variation. RESULTS: Thirty-four hospitals reported on 13 629 patients, with overall SSI rates per surgical procedure varying between 0 and 15·1 per cent. Statistically significant differences in SSI rate between hospitals were found for colonic resection, caesarean section and for all operations combined. Rankability was 80 per cent for colonic resection but 0 per cent for caesarean section. Rankability was 8 per cent in all operations combined, as the differences in SSI rates were explained mainly by case mix. CONCLUSION: When comparing SSI rates in all operations, differences between hospitals were explained by case mix. For individual types of surgery, case mix varied less between hospitals, and differences were explained largely by random variation. Although SSI rates may be used for monitoring quality improvement within hospitals, they should not be used for ranking hospitals.


Asunto(s)
Infección Hospitalaria/epidemiología , Hospitales/normas , Infección de la Herida Quirúrgica/epidemiología , Grupos Diagnósticos Relacionados/estadística & datos numéricos , Humanos , Persona de Mediana Edad , Países Bajos/epidemiología , Tempo Operativo , Indicadores de Calidad de la Atención de Salud , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Resultado del Tratamiento
14.
Neurology ; 76(11): 968-75, 2011 Mar 15.
Artículo en Inglés | MEDLINE | ID: mdl-21403108

RESUMEN

BACKGROUND: Guillain-Barré syndrome (GBS) has a highly diverse clinical course and outcome, yet patients are treated with a standard therapy. Patients with poor prognosis may benefit from additional treatment, provided they can be identified early, when nerve degeneration is potentially reversible and treatment is most effective. We developed a clinical prognostic model for early prediction of outcome in GBS, applicable for clinical practice and future therapeutic trials. METHODS: Data collected prospectively from a derivation cohort of 397 patients with GBS were used to identify risk factors of being unable to walk at 4 weeks, 3 months, and 6 months. Potential predictors of poor outcome (unable to walk unaided) were considered in univariable and multivariable logistic regression models. The clinical model was based on the multivariable logistic regression coefficients of selected predictors and externally validated in an independent cohort of 158 patients with GBS. RESULTS: High age, preceding diarrhea, and low Medical Research Council sumscore at hospital admission and at 1 week were independently associated with being unable to walk at 4 weeks, 3 months, and 6 months (all p 0.05-0.001). The model can be used at hospital admission and at day 7 of admission, the latter having a better predictive ability for the 3 endpoints; the area under the receiver operating characteristic curve (AUC) is 0.84-0.87 and at admission the AUC is 0.73-0.77. The model proved to be valid in the validation cohort. CONCLUSIONS: A clinical prediction model applicable early in the course of disease accurately predicts the first 6 months outcome in GBS.


Asunto(s)
Síndrome de Guillain-Barré/diagnóstico , Adulto , Factores de Edad , Área Bajo la Curva , Método Doble Ciego , Diagnóstico Precoz , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Curva ROC , Índice de Severidad de la Enfermedad
15.
Eur J Vasc Endovasc Surg ; 40(2): 147-54, 2010 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-20547077

RESUMEN

OBJECTIVES: The aim of this study is to investigate whether variation in mortality at hospital level reflects differences in quality of care of peripheral vascular surgery patients. DESIGN: Observational study. MATERIALS: In 11 hospitals in the Netherlands, 711 consecutive vascular surgery patients were enrolled. METHODS: Multilevel logistic regression models were used to relate patient characteristics, structure and process of care to mortality at 1 year. The models were constructed by consecutively adding age, sex and Lee index, then remaining risk factors, followed by structural measures for quality of care and finally, selected process of care parameters. RESULTS: Total 1-year mortality was 11%, ranging from 6% to 26% in different hospitals. Large differences in patient characteristics and quality indicators were observed between hospitals (e.g., age>70 years: 28-58%; beta-blocker therapy: 39-87%). Adjusted analyses showed that a large part of variation in mortality was explained by age, sex and the Lee index (Akaike's information criterion (AIC)=59, p<0.001). Another substantial part of the variation was explained by process of care (AIC=5, p=0.001). CONCLUSIONS: Differences between hospitals exist in patient characteristics, structure of care, process of care and mortality. Even after adjusting for the patient population at risk, a substantial part of the variation in mortality can be explained by differences in process measures of quality of care.


Asunto(s)
Mortalidad Hospitalaria , Procedimientos Quirúrgicos Vasculares/mortalidad , Procedimientos Quirúrgicos Vasculares/normas , Anciano , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/mortalidad , Comorbilidad , Endarterectomía Carotidea/mortalidad , Femenino , Humanos , Modelos Logísticos , Persona de Mediana Edad , Países Bajos , Indicadores de Calidad de la Atención de Salud , Calidad de la Atención de Salud , Medición de Riesgo , Enfermedades Vasculares/epidemiología , Enfermedades Vasculares/cirugía
16.
Eur J Epidemiol ; 25(4): 261-6, 2010 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-20155439

RESUMEN

Aneurysmal subarachnoid haemorrhage (aSAH) is a devastating event with substantial case-fatality. Our purpose was to examine which clinical and neuro-imaging characteristics, available on admission, predict 60 day case-fatality in aSAH and to evaluate performance of our prediction model. We performed a secondary analysis of patients enrolled in the International Subarachnoid Aneurysm Trial (ISAT), a randomised multicentre trial to compare coiling with clipping in aSAH patients. Multivariable logistic regression analysis was used to develop a prognostic model to estimate the risk of dying within 60 days from aSAH based on clinical and neuro-imaging characteristics. The model was internally validated with bootstrapping techniques. The study population comprised of 2,128 patients who had been randomised to either endovascular coiling or neurosurgical clipping. In this population 153 patients (7.2%) died within 60 days. World Federation of Neurosurgical Societies (WFNS) grade was the most important predictor of case-fatality, followed by age, lumen size of the aneurysm and Fisher grade. The model discriminated reasonably between those who died within 60 days and those who survived (c statistic = 0.73), with minor optimism according to bootstrap re-sampling (optimism corrected c statistic = 0.70). Several strong predictors are available to predict 60 day case-fatality in aSAH patients who survived the early stage up till a treatment decision; after external validation these predictors could eventually be used in clinical decision making.


Asunto(s)
Modelos Estadísticos , Hemorragia Subaracnoidea/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Estudios Multicéntricos como Asunto , Pronóstico , Radiografía , Ensayos Clínicos Controlados Aleatorios como Asunto , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/diagnóstico por imagen , Análisis de Supervivencia
17.
Acta Neurol Scand ; 122(1): 15-20, 2010 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-20047571

RESUMEN

AIM AND BACKGROUND: The benefit of statin treatment in patients with a previous ischemic stroke or transient ischemic attack (TIA) has been demonstrated in randomized clinical trials (RCT). However, the effectiveness in everyday clinical practice may be decreased because of a different patient population and less controlled setting. We aim to describe statin use in an unselected cohort of patients, identify factors related to statin use and test whether the effect of statins on recurrent vascular events and mortality observed in RCTs is also observed in everyday clinical practice. METHODS: In 10 centers in the Netherlands, patients admitted to the hospital or visiting the outpatient clinic with a recent TIA or ischemic stroke were prospectively and consecutively enrolled between October 2002 and May 2003. Statin use was determined at discharge and during follow-up. We used logistic regression models to estimate the effect of statins on the occurrence of vascular events (stroke or myocardial infarction) and mortality within 3 years. We adjusted for confounders with a propensity score that relates patient characteristics to the probability of using statins. RESULTS: Of the 751 patients in the study, 252 (34%) experienced a vascular event within 3 years. Age, elevated cholesterol levels and other cardiovascular risk factors were associated with statin use at discharge. After 3 years, 109 of 280 (39%) of the users at discharge had stopped using statins. Propensity score adjusted analyses showed a beneficial effect of statins on the occurrence of the primary outcome (odds ratio 0.8, 95% CI: 0.6-1.2). CONCLUSION: In our study, we found poor treatment adherence to statins. Nevertheless, after adjustment for the differences between statin users and non-statin users, the observed beneficial effect of statins on the occurrence of vascular events within 3 years, although not statistically significant, is compatible with the effect observed in clinical trials.


Asunto(s)
Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Ataque Isquémico Transitorio/prevención & control , Accidente Cerebrovascular/prevención & control , Anciano , Recolección de Datos , Femenino , Humanos , Ataque Isquémico Transitorio/mortalidad , Modelos Logísticos , Masculino , Países Bajos , Ensayos Clínicos Controlados Aleatorios como Asunto , Recurrencia , Factores de Riesgo , Accidente Cerebrovascular/mortalidad , Resultado del Tratamiento
18.
QJM ; 103(2): 99-108, 2010 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-20008321

RESUMEN

BACKGROUND: Measuring quality of care and ranking hospitals with outcome measures poses two major methodological challenges: case-mix adjustment and variation that exists by chance. AIM: To compare methods for comparing and ranking hospitals that considers these. METHODS: The Netherlands Stroke Survey was conducted in 10 hospitals in the Netherlands, between October 2002 and May 2003, with prospective and consecutive enrollment of patients with acute brain ischaemia. Poor outcome was defined as death or disability after 1 year (modified Rankin scale of > or =3). We calculated fixed and random hospital effects on poor outcome, unadjusted and adjusted for patient characteristics. We compared the hospitals using the expected rank, a novel statistical measure incorporating the magnitude and the uncertainty of differences in outcome. RESULTS: At 1 year after stroke, 268 of the total 505 patients (53%) had a poor outcome. There were substantial differences in outcome between hospitals in unadjusted analysis (chi(2) = 48, 9 df, P < 0.0001). Adjustment for 12 confounders led to halving of the chi(2) (chi(2) = 24). The same pattern was observed in random effects analysis. Estimated performance of individual hospitals changed considerably between unadjusted and adjusted analysis. Further changes were seen with random effect estimation, especially for smaller hospitals. Ordering by expected rank led to shrinkage of the original ranks of 1-10 towards the median rank of 5.5 and to a different order of the hospitals, compared to ranking based on fixed effects. CONCLUSION: In comparing and ranking hospitals, case-mix-adjusted random effect estimates and the expected ranks are more robust alternatives to traditional fixed effect estimates and simple rankings.


Asunto(s)
Hospitales/normas , Calidad de la Atención de Salud/normas , Accidente Cerebrovascular/terapia , Anciano , Femenino , Hospitales/clasificación , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Países Bajos
19.
Ned Tijdschr Geneeskd ; 152(39): 2126-32, 2008 Sep 27.
Artículo en Holandés | MEDLINE | ID: mdl-18856030

RESUMEN

OBJECTIVE: To determine the extent to which the outcome of stroke patients stroke is correlated with patient characteristics and care process parameters, and to determine whether outcome measures can be used to measure the quality of hospital care provided for these patients. DESIGN: Descriptive cohort study. METHODS: At 10 hospitals in the Netherlands, in the period October 2002-April 2003, patients with acute stroke were included in the study. Poor outcome was defined as dead or disabled at 1 year (a score on the modified Rankin scale > or = 3). Quality of the care was assessed by relating diagnostic, therapeutic and preventive procedures to indication. Multiple logistic regression models were used to compare observed numbers of patients with a poor outcome with expected numbers per hospital, after adjustment for patient characteristics and quality of care parameters. RESULTS: In total, 579 patients were included in the study, of which 271 (47%) were dead or disabled at 1 year. Poor outcome varied across the hospitals from 29 to 78%. The mean age was 70 years. There were large differences between hospitals with respect to patient characteristics and quality of care. Most of the differences in outcome between hospitals were explained by the differences in patient characteristics (Akaike's information criterion (AIC) = 134). Quality of care parameters explained just a small additional part of the variation in patient outcome (AIC = 5.5). CONCLUSIONS: Large differences between Dutch hospitals in the patient outcome after stroke could mostly be explained by differences in patient characteristics. Only a small part of the hospital variation in patient outcome was related to differences in quality of care. Therefore, outcome indicators cannot be regarded as valid performance indicators for care following a stroke.

20.
Acta Neurochir Suppl ; 101: 119-24, 2008.
Artículo en Inglés | MEDLINE | ID: mdl-18642645

RESUMEN

INTRODUCTION: None of the multi-centre phase III randomized controlled trials (RCTs) performed in TBI have convincingly demonstrated efficacy. Problems in clinical trial design and analysis may have contributed to these failures. Clinical trials in the TBI population pose several complicated methodological challenges, related especially to the heterogeneity of the population. In this paper we examine the issue of heterogeneity within the IMPACT (International Mission on Prognosis and Clinical Trial design in TBI) database and investigate the application of conventional and innovative methods for the statistical analysis of trials in TBI. METHODS AND RESULTS: Simulation studies in the IMPACT database (N = 9205) showed substantial gains in efficiency with covariate adjustment. Adjusting for 7 important predictors yielded up to a 28% potential reduction in trial size. Ongoing analyses on the potential benefit of ordinal analysis, such as proportional odds and sliding dichotomy, gave promising results with even larger potential reductions in trial size. CONCLUSION: The statistical power of RCTs in TBI can be considerably increased by applying covariate adjustment and by ordinal analysis methods of the GOS. These methods need to be considered for optimizing future TBI trials.


Asunto(s)
Lesiones Encefálicas/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto/estadística & datos numéricos , Proyectos de Investigación , Estadística como Asunto , Lesiones Encefálicas/epidemiología , Humanos
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