Benchmarking of abdominal surgery: a study evaluating the HARM score in a European national cohort.

BACKGROUND: Reliable, easily accessible metrics of surgical quality are currently lacking. The HARM (HospitAl length of stay, Readmission and Mortality) score is a composite measure that has been validated across diverse surgical cohorts. The aim of this study was to validate the HARM score in a national population of patients undergoing abdominal surgery. METHODS: Data on all abdominal surgery in Norwegian hospitals from 2011 to 2017 were obtained from the Norwegian Patient Registry. Readmissions and 30-day postoperative complications as well as deaths in and out of hospital were evaluated. The HARM scoring algorithm was tested after adjustment by establishing a newly proposed length of stay score. The correlation between the HARM score and complications, as well as the ability of aggregated HARM scores to discriminate between hospitals, were analysed. Risk adjustment models were developed for nationwide hospital comparisons. RESULTS: The data consisted of 407 113 primary operations on 295 999 patients in 85 hospitals. The HARM score was associated with complications and complication severity (Goodman-Kruskal γ value 0·59). Surgical specialty was the dominating variable for risk adjustment. Based on 1-year data, the risk-adjusted score classified 16 hospitals as low HARM score and 16 as high HARM score of the 53 hospitals that had at least 30 operations. CONCLUSION: The HARM score correlates with major outcomes and is associated with the presence and severity of complications. After risk adjustment, the HARM score discriminated strongly between hospitals in a European population of abdominal surgery.

ANTECEDENTES: En la actualidad no se dispone de un sistema de cuantificación numérica confiable y accesible para evaluar la calidad quirúrgica. La puntuación HARM es una medida compuesta basada en la duración de la estancia hospitalaria, los reingresos y la mortalidad postoperatoria que se ha validado en varias cohortes quirúrgicas. El objetivo de este estudio fue validar la puntuación HARM en una población nacional de pacientes sometidos a cirugía abdominal. MÉTODOS: Se obtuvieron los datos de todas las cirugías abdominales realizadas en hospitales noruegos entre 2011 y 2017 a través del registro noruego de pacientes. Se evaluaron los reingresos y las complicaciones postoperatorias a los 30 días, así como la mortalidad intra- y extra-hospitalaria. Se utilizó el algoritmo de puntuación HARM tras el ajuste con la nueva propuesta de puntuación para la duración de la estancia hospitalaria. Se analizó la correlación entre HARM y complicaciones, así como la capacidad de las puntuaciones HARM agregadas para discriminar entre hospitales. Se desarrollaron modelos de ajuste de riesgo para las comparar hospitales en todo el país. RESULTADOS: Se incluyeron 407.113 intervenciones primarias llevadas a cabo en 295.999 pacientes en 85 hospitales. La puntuación HARM se asoció con las complicaciones y la gravedad de la complicación (Goodman-Kruskal γ de 0,59). La especialidad quirúrgica fue la variable dominante para el ajuste del riesgo. Utilizando los datos de un período anual, la puntuación ajustada al riesgo clasificó a 16 hospitales como de baja puntuación y a 16 de alta puntuación de los 53 hospitales en los que se habían realizado al menos 30 intervenciones. CONCLUSIÓN: La puntuación HARM se correlaciona con los resultados principales y con la presencia y la gravedad de las complicaciones. La puntuación HARM, después del ajuste de riesgo, discrimina de forma sólida entre hospitales en una población europea de cirugía abdominal. This article is protected by copyright. All rights reserved.

Telemedicine in postoperative follow-up of STOMa PAtients: a randomized clinical trial (the STOMPA trial).

BACKGROUND: A stoma has severe impact on the patient's quality of life (QoL). Postoperative home community follow-up by teleconsultation (TC) and stoma nurses may reduce the burden of travel and improve QoL. METHODS: A university hospital and five district medical centres participated. Patients with a stoma were randomized to follow-up by either TC (intervention) or hospital (control). Stoma nurses performed the clinical examination at the TC studio, aided remotely by hospital nurses and surgeons. The primary endpoint was the EQ-5D™ index score; secondary endpoints were the Stoma Quality-of-Life Scale, the OutPatient Experiences Questionnaire, and use of hospital resources. RESULTS: A total of 110 patients were randomized to hospital (58 patients) or TC (52) follow-up; 64 patients (hospital 38, TC 26) were followed for more than 12 months and 246 consultations (hospital 151, TC 95) were performed. There were no differences in QoL: EQ-5D™ index score (P = 0·301) and EQ-5D™ visual analogue scale (VAS) score (P = 0·775); Work/Social Function (P = 0·822); Sexuality/Body Image (P = 0·253) and Stoma Function (P = 0·074). Hospital follow-up performed better for organization of care (staff collaboration, P = 0·004; met same persons, P = 0·003) and communication (surgeon understandable, P < 0·001; surgeon caring P = 0·003). TC did not increase the number of hospital consultations (P = 0·684) and reduced the number of journeys of more than 8 h (P = 0·007). CONCLUSION: Telemedicine follow-up by stoma nurses did not improve the QoL of patients, but decreased the readmission rate and burden of travel. Registration number NCT01600508 ( https://www.clinicaltrials.gov).

ANTECEDENTES: Un estoma tiene un gran impacto en la calidad de vida (quality of life, QoL) del paciente. El seguimiento postoperatorio comunitario a nivel del hogar del paciente por Tele Consulta (TC) y enfermeras especializadas en estomas puede reducir la carga de viaje y mejorar la calidad de vida. MÉTODOS: Un hospital universitario y cinco centros médicos de distrito participaron en el estudio. Los pacientes con estoma fueron asignados al azar para el seguimiento mediante TC (intervención) o en el hospital (control). Las enfermeras de estomas realizaron el examen clínico en el estudio de TC, con la ayuda remota de enfermeras y cirujanos del hospital. El objetivo final primario fue la puntuación del índice EQ-5D, los objetivos finales secundarios fueron la Escala de Calidad de Vida del Estoma, el Cuestionario de Experiencias Ambulatorias y la utilización de recursos hospitalarios. Se utilizaron análisis de la varianza (ANOVA) para comparar los grupos. RESULTADOS: Un total de 110 pacientes fueron asignados al azar para el seguimiento en el hospital (n = 58) o por TC (n = 52), 54 pacientes (hospital n = 38, TC n = 26) fueron seguidos durante > 12 meses; se realizaron 245 consultas (hospital n = 151; TC n = 94). No hubo diferencias en la QoL; puntuación del índice EQ-5D (P = 0,30); escala analógica visual (P = 0,77); trabajo y función social (P = 0,82); sexualidad y cuerpo (P = 0,25) y función del estoma (P = 0,07). El seguimiento hospitalario funcionó mejor en la organización de la atención (colaboración del personal P < 0,01; seguimiento por la misma persona P < 0,01), comunicación (cirujano comprensible/afectuoso, P < 0,01). La TC no aumentó las consultas hospitalarias (P = 0,68) y redujo > 8 horas de viaje (P < 0,01). CONCLUSIÓN: El seguimiento por telemedicina realizado por enfermeras especializadas en estomas no mejoró la QoL de los pacientes, pero disminuyó los reingresos y la carga de los viajes.

Educational implications for surgical telementoring: a current review with recommendations for future practice, policy, and research.

BACKGROUND: Surgical telementoring (ST) was introduced in the sixties, promoting videoconferencing to enhance surgical education across large distances. Widespread use of ST in the surgical community is lacking. Despite numerous surveys assessing ST, there remains a lack of high-level scientific evidence demonstrating its impact on mentorship and surgical education. Despite this, there is an ongoing paradigm shift involving remote presence technologies and their application to skill development and technique dissemination in the international surgical community. Factors facilitating this include improved access to ST technology, including ease of use and data transmission, and affordability. Several international research initiatives have commenced to strengthen the scientific foundation documenting the impact of ST in surgical education and performance. METHODS: International experts on ST were invited to the SAGES Project Six Summit in August 2015. Two experts in surgical education prepared relevant questions for discussion and organized the meeting (JP and HH). The questions were open-ended, and the discussion continued until no new item appeared. The transcripts of interviews were recorded by a secretary from SAGES. RESULTS: In this paper, we present a summary of the work performed by the SAGES Project 6 Education Working Group. We summarize the existing evidence regarding education in ST, identify and detail conceptual educational frameworks that may be used during ST, and present a structured framework for an educational curriculum in ST. CONCLUSIONS: The educational impact and optimal curricular organization of ST programs are largely unexplored. We outline the critical components of a structured ST curriculum, including prerequisites, teaching modalities, and key curricular components. We also detail research strategies critical to its continued evolution as an educational tool, including randomized controlled trials, establishment of a quality registry, qualitative research, learning analytics, and development of a standardized taxonomy.

Metastatic spread pattern after curative colorectal cancer surgery. A retrospective, longitudinal analysis.

OBJECTIVE: The most common sites of colorectal cancer (CRC) recurrence are the local tissues, liver or lungs. The objective was to identify risk factors associated with the primary CRC tumor and cancer recurrence in these anatomical sites. METHODS: Retrospective, longitudinal analyses of data on CRC survivors. Multivariable Cox regression analysis was performed to examine the association between possible cofounders with recurrence to various anatomical sites. RESULTS: Data for 10,398CRC survivors (tumor location right colon=3870, left colon=2898, high rectum=2569, low rectum=1061) were analyzed; follow up time was up to five years. Mean age at curative surgery was 71.5 (SD 11.8) years, 20.2% received radio-chemotherapy, stage T3 (64.4%) and N0 (65.1%) were most common. Overall 1632 (15.7%) had cancer recurrence (Isolated liver n=412, 3,8%; isolated lung n=252, 2,4%; isolated local n=223, 2.1%). Risk factors associated with recurrent CRC were identified, i.e. isolated liver metastases (male: Adjusted Hazard Ratio (AHR) 1,45; colon left: AHR 1,63; N2 disease: AHR 3,35; T2 disease: AHR 2,82), isolated lung metastases (colon left: AHR 1,53; rectum high: AHR 2,48; rectum low: AHR 2,65; N2 disease 3,76), and local recurrence (glands examined<12: AHR 1,51; CRM <3mm: AHR 1,60; rectum high: AHR 2,15; N2 disease: AHR 2,58) (all p values <0001). CONCLUSION: Our study finds that the site of the primary CRC tumor is associated with location of subsequent metastasis. Left sided colon cancers have increased risk of metastatic spread to the liver, whereas rectal cancers have increased risk of local recurrence and metastatic spread to the lungs. These results, in combination with other risk factors for CRC recurrence, should be taken into consideration when designing risk adapted post-treatment CRC surveillance programs.

System-based factors influencing intraoperative decision-making in rectal cancer by surgeons: an international assessment.

AIM: Sound surgical judgement is the goal of training and experience; however, system-based factors may also colour selection of options by a surgeon. We analysed potential organizational characteristics that might influence rectal cancer decision-making by an experienced surgeon. METHOD: One hundred and seventy-three international centres treating rectal cancer were invited to participate in a survey assessment of key treatment options for patients undergoing curative rectal-cancer surgery. The key organizational characteristics were analysed using multivariate methods for association with intra-operative surgical decision-making. RESULTS: The response rate was 71% (123 centres). Sphincter-saving surgery was more likely to be performed at university hospitals (OR=3.63, P=0.01) and by high-caseload surgeons (OR=2.77 P=0.05). A diverting stoma was performed more frequently in departments with clinical audits (OR=3.06, P=0.02), and a diverting stoma with coloanal anastomosis was more likely in European centres (OR=4.14, P=0.004). One-stage surgery was less likely where there was assessment by a multidisciplinary team (OR=0.24, P=0.02). Multivariate analysis showed that university hospital, clinical audit, European centre, multidisciplinary team and high caseload significantly impacted on surgical decision-making. CONCLUSION: Treatment variance of rectal cancer surgeons appears to be significantly influenced by organizational characteristics and complex team-based decision-making. System-based factors may need to be considered as a source of outcome variation that may impact on quality metrics.

Standards for reporting randomized controlled trials in medical informatics: a systematic review of CONSORT adherence in RCTs on clinical decision support.

INTRODUCTION: The Consolidated Standards for Reporting Trials (CONSORT) were published to standardize reporting and improve the quality of clinical trials. The objective of this study is to assess CONSORT adherence in randomized clinical trials (RCT) of disease specific clinical decision support (CDS). METHODS: A systematic search was conducted of the Medline, EMBASE, and Cochrane databases. RCTs on CDS were assessed against CONSORT guidelines and the Jadad score. RESULT: 32 of 3784 papers identified in the primary search were included in the final review. 181 702 patients and 7315 physicians participated in the selected trials. Most trials were performed in primary care (22), including 897 general practitioner offices. RCTs assessing CDS for asthma (4), diabetes (4), and hyperlipidemia (3) were the most common. Thirteen CDS systems (40%) were implemented in electronic medical records, and 14 (43%) provided automatic alerts. CONSORT and Jadad scores were generally low; the mean CONSORT score was 30.75 (95% CI 27.0 to 34.5), median score 32, range 21-38. Fourteen trials (43%) did not clearly define the study objective, and 11 studies (34%) did not include a sample size calculation. Outcome measures were adequately identified and defined in 23 (71%) trials; adverse events or side effects were not reported in 20 trials (62%). Thirteen trials (40%) were of superior quality according to the Jadad score (≥3 points). Six trials (18%) reported on long-term implementation of CDS. CONCLUSION: The overall quality of reporting RCTs was low. There is a need to develop standards for reporting RCTs in medical informatics.

Assessment of comparative skills between hand-assisted and straight laparoscopic colorectal training on an augmented reality simulator.

PURPOSE: The aim of this study was to compare skills sets during a hand-assisted and straight laparoscopic colectomy on an augmented reality simulator. METHODS: Twenty-nine surgeons, assigned randomly in 2 groups, performed laparoscopic sigmoid colectomies on a simulator: group A (n = 15) performed hand-assisted then straight procedures; group B (n = 14) performed straight then hand-assisted procedures. Groups were compared according to prior laparoscopic colorectal experience, performance (time, instrument path length, and instrument velocity changes), technical skills, and operative error. RESULTS: Prior laparoscopic colorectal experience was similar in both groups. Both groups had better performances with the hand-assisted approach, although technical skill scores were similar between approaches. The error rate was higher with the hand-assisted approach in group A, but similar between both approaches in group B. CONCLUSIONS: These data define the metrics of performance for hand-assisted and straight laparoscopic colectomy on an augmented reality simulator. The improved scores with the hand-assisted approach suggest that with this simulator a hand-assisted model may be technically easier to perform, although it is associated with increased intraoperative errors.

Single incision laparoscopic colectomy: technical aspects, feasibility, and expected benefits.

Background. This paper studied technical aspects and feasibility of single incision laparoscopic colectomy (SILC). Methods. Bibliographic search was carried out up to October 2009 including original articles, case reports, and technical notes. Assessed criteria were techniques, operative time, scar length, conversion, complications, and hospitalization duration. Results. The review analyzed seventeen SILCs by seven surgical teams. A single port system was used by four teams. No team used the same laparoscope. Two teams used two laparoscopes. All teams used curved instruments. SILC time was 116 +/- 34 minutes. Final scar was longer than port incision (31 +/- 7 versus 24 +/- 8 mm; P = .036). No conversion was reported. The only complication was a bacteremia. Hospitalization was 5 +/- 2 days. Conclusion. SILC is feasible. A single incision around the umbilical scar represents cosmetic progress. Comparative studies are needed to assess potential abdominal wall and recovery benefits to justify the increased cost of SILC.

Closed mitral commissurotomy in Archangel, Northern Russia, 1965-1993. Operative assessment of 367 patients operated on for rheumatic mitral stenosis.

OBJECTIVE: Preoperative and operative assessment of the 367 patients operated on for rheumatic mitral stenosis with closed mitral commissurotomy (CMC) at the regional hospital in Archangel, northwest Russia, between 1965 and 1993. DESIGN: Retrospective survey. RESULTS: Mean age at first attack of rheumatic fever was 15 years +/- 1.09 years. Mean age at time of surgery was 33.4 years +/- 0.92. Preoperatively, most patients (67%, n = 245) were in New York Heart Association stage III; 29% (n = 107) in stage IV. Digital commissurotomy alone was performed in 16% (n = 57) and a transventricular dilator was used in 84% (n = 310). Operative blood loss was average (384.4 ml +/- 34 ml); 20% (n = 73) developed wound infection, 21% (n = 77) pericarditis. In-hospital stay was above 50 days for both sexes. In-hospital mortality was 1.6% (n = 6). CONCLUSION: Rheumatic heart disease developed rapidly in these patients. CMC has a place as a low cost treatment of mitral stenosis when a heart lung machine is not available.

[Rheumatic fever and rheumatic heart disease in Northwest Russia]. / Reumatisk feber og reumatisk hjertesykdom i Nordvest-Russland.

296 patients who were operated between 1965 and 1993 with mitral commissurotomy, were included in this retrospective study of rheumatic heart disease in North-West Russia. There were 117 (39.5%) reported cases of acute rheumatic fever, with either polyarthritis (n = 88), carditis (n = 23), or Sydenham's chorea (n = 6). There were no reported cases of erythema marginatum and subcutaneous nodules. The first case of acute rheumatic fever in our patients was in 1924. More than 50% of the patients (164) did not get the diagnosis acute rheumatic fever, and became aware of their rheumatic heart disease only when symptoms of mitral stenosis appeared. 15 patients had a subclinical attack of rheumatic fever, i.e. not all of Jones' criteria were fulfilled. At onset of acute rheumatic fever, the mean age was 15 years, when valvular disease was confirmed 24 years, and 33 years at mitral surgery. Dyspnea (n = 293) was the most common symptom of mitral stenosis, followed by atrial fibrillation (n = 105). 15 patients developed cerebral stroke. The Archangel Health Region has one of the highest prevalences of rheumatic heart disease in Europe (3.7/1,000 in those above 16 years of age, 1993). There is high mortality and the disease develops rapidly.