Case-mix Factors Research Articles

The management of rectal cancer in older patients in England - a retrospective population based study a patients diagnosed between April 2009 and December 2014

Background This study sought to examine the use of radical treatment for rectal cancer (neoadjuvant radiotherapy and major surgical resection) and the associated outcomes across the English National Health Service (NHS) in relation to age. Materials and Methods Data for all patients diagnosed with a first primary rectal cancer between 1st April 2009 and 31st December 2014 were included. Data from multiple sources including cancer registration data and Hospital Episode Statistics (HES) data, which were compiled as part of the Bowel Cancer Intelligence UK (BCI UK) hub, were used to obtain information about patient and tumour characteristics, treatments and outcomes. Patients were divided into three groups in relation to their age at the time of diagnosis; <70, 70-79 and ≥80. Descriptive analyses were undertaken to assess the variation in treatment and outcomes. Multilevel binary logistic regression models were used to assess the factors associated with the receipt of a major surgical resection, with patients clustered within NHS trusts. Results In total, 52,922 people were diagnosed with a first primary rectal cancer in England over the study period. Of these, 11,924 (22.4%) were aged 80 or over at the time of diagnosis. The proportion undergoing a major resection decreased with age, falling from 66.5% amongst those aged under 70 to 31.7% amongst those aged 80 and over. The use of neoadjuvant radiotherapy decreased with age, with 48.3% of those aged under 70 receiving pre-operative radiotherapy compared to 26.5% of those aged 80 and over. Stoma creation rates were similar across all age groups. However the proportion of patients having their stoma closed within 18 months fell with age, from 66.3% amongst those aged <70 to 32.4% amongst those aged ≥80. Deaths within 30 days of a major surgical resection increased with age, from 1.0% to 5.5%. The rate of returns to theatre were consistent between age groups (11.0%, 11.6% and 10.2% respectively). The rate of 30-day post-operative mortality was lower amongst those who received neoadjuvant radiotherapy than those who did not across all age groups (1.6% versus 2.6%). After adjustment for case-mix factors significant variation in operative rates for the oldest patients between NHS trusts in England remained. Results from adjusted logistic regression models showed no significant difference in 30-day post-operative mortality, length of stay or emergency readmission amongst those aged 80 and over between trusts with high and low operative rates. Conclusions This study demonstrates that older patients with rectal cancer were less likely than younger patients to receive potentially curative treatment. However those who did receive potentially curative treatment for rectal cancer demonstrated outcomes comparable to those of their younger counterparts, suggesting that they have been well selected.

Unlocking the potential of value-based health care by defining global standard sets of outcome measures that matter to patients with cardiovascular diseases.

As health systems around the world increasingly look to record and improve the value of care that they provide to patients, being able to measure the outcomes that matter most to patients is vital. Clinicians today gather more data than ever before, but what is measured often has little relationship to the results of care that matter most to patients. Through its working groups of global experts in particular diseases, the International Consortium for Health Outcomes Measurement aims to define minimum Standard Sets of outcomes, along with case-mix factors to support risk adjustment and meaningful comparison. These Standard Sets may then be implemented globally empowering patients to select providers with the best outcomes at the lowest cost, empowering providers that deliver superior outcomes at competitive costs to excel, and empowering payers to negotiate contracts based on results. The International Consortium for Health Outcomes Measurement has published 24 Standard Sets including coronary artery disease, heart failure, hypertension, and stroke and is nearing the completion of its work in atrial fibrillation.

Prediction of Arteriovenous Fistula Clinical Maturation from Postoperative Ultrasound Measurements: Findings from the Hemodialysis Fistula Maturation Study.

The utility of early postoperative ultrasound measurements in predicting arteriovenous fistula (AVF) clinical maturation is uncertain. We investigated the relationships of ultrasound parameters with AVF clinical maturation in newly created AVF, measured at 1 day and 2 and 6 weeks, in 602 participants of a multicenter, observational cohort study. A backward elimination algorithm identified ultrasound measurements that independently predicted unassisted and overall AVF maturation. Candidate variables included AVF blood flow, diameter, and depth, upper arm arterial diameter, presence of stenosis, presence of accessory veins, seven case-mix factors (age, sex, black race, AVF location, diabetes, dialysis status, and body mass index), and clinical center. We evaluated the accuracy of the resulting models for clinical prediction. At each ultrasound measurement time, AVF blood flow, diameter, and depth each predicted in a statistically significant manner both unassisted and overall clinical maturation. Moreover, neither the remaining ultrasound parameters nor case-mix factors were associated with clinical AVF maturation after accounting for blood flow, diameter, and depth, although maturation probabilities differed among clinical centers before and after accounting for these parameters. The crossvalidated area under the receiver operating characteristic curve for models constructed using these three ultrasound parameters was 0.69, 0.74, and 0.79 at 1 day and 2 and 6 weeks, respectively, for unassisted AVF clinical maturation and 0.69, 0.71, and 0.76, respectively, for overall AVF maturation. AVF blood flow, diameter, and depth moderately predicted unassisted and overall AVF clinical maturation. The other factors considered did not further improve AVF maturation prediction.

Vaginal birth after caesarean birth in Italy: variations among areas of residence and hospitals

BackgroundThe rates of caesarean section (CS) are increasing globally. CS rates are one of the most frequently used indicators of health care quality. Vaginal Birth After Caesarean (VBAC) could be considered a reasonable and safe option for most women with a previous CS. Despite this fact, in some European countries, many women who had a previous CS will have a routine CS subsequently and VBAC rates are extremely variable across countries. VBAC use is inversely related to caesarean use. The objective of the present study was to analyze VBAC rates with respect to caesarean rates and the variations among areas of residence, hospitals and hospital ownership types in Italy.MethodsThis study was based on information from the Hospital Information System (HIS). We collected data from all deliveries in Italy from January 1, 2010 to December 31, 2014 and we considered only deliveries with a previous caesarean section. Applying multivariate logistic regression analysis, the adjusted proportions of VBAC for each Local Health Units (LHU), each hospital and by hospital ownership types were calculated. Cross-classified logistic multilevel models were performed to analyze within geographic, hospitals and hospital ownership types variations.ResultsWe studied a total of 77,850 deliveries with a previous caesarean section in Italy between January 1, 2010 and December 31, 2014. The proportion of VBAC in Italy slightly increased in the last few years, from 5.8% in 2010 to 7.5% in 2014. Proportions of VBAC ranged from 0.29 to 50.05% in Italian LHUs. The LHUs with lower proportions of VBAC deliveries were characterized by higher values for primary caesarean deliveries. Private hospitals showed the lowest mean of crude VBAC proportions but the highest variation among hospitals, ranging from 0 to 47.1%.ConclusionsHospital rates of caesarean section for women with at least one previous caesarean section vary widely, and only some of the variation can be explained by case-mix and hospital-level factors, suggesting that additional factors influence practices. Identifying disparities in VBAC may have important implications for health services planning and targeted efforts to reduce overall rates of caesarean deliveries.

Risk-adjusted CPR Rates as a Measure of Quality During Interfacility Transports

Introduction Over the past decade, the health care industry has witnessed an unparalleled reporting of hospital-specific comparative outcomes. Clearly, there has been a growing consensus among a broad array of agencies and institutions around the importance of reporting quality measures, including those that measure clinical outcomes. Previous research suggests that there is substantial variability in care between hospitals, particularly in trauma centres. In 2006, the American College of Surgeons (ACS) Committee on Trauma launched the Trauma Quality Improvement Program (TQIP) to study the variability in outcomes between trauma centers to improve the quality of trauma care in North America. The primary goal of TQIP is to improve the quality of trauma care through outcomes-based, risk-adjusted benchmarking of trauma centers and feedback reports. However, differences in patient selection (selection bias), case mix, data quality, geography, and other factors inherent to different injured populations likely contribute in part to observed differences in outcome. Risk-adjustment is a methodology used to ensure that “like” patients are being compared, so that differences in outcome can be attributed solely to differences in the processes and quality of care provided. Transport services are beginning to use performance metrics to analyze for variations between ambulance and transport services in order to improve quality of care during transport. The “Ground Air Medical qUality Transport Quality Improvement” (GAMUT) Collaborative collects transport data in a large database to use as a free resource for transport teams to track, report, and analyze their performance on transport-specific quality metrics by comparing it to other program's. Because of the nature of transport, most of the metrics are process metrics or intermediate outcomes. Arguably, the only transport-related definitive outcome that GAMUT reports is rate of cardiac arrest during transport (Rate of CPR performed during transport). However, this rate is reported as an unadjusted rate: there is no risk-adjustment. We propose a simple methodology to allow for risk-adjustment of CPR rate during transport. Methods Ornge is the sole provider of Air Ambulance and Critical Care Transport Services to the province of Ontario, Canada. The province has a land mass of over 1 million square kilometers, and has a population of almost 14 million people. Ornge operates a fleet of Pilatus Next Generation PC-12 airplanes, Leonardo AW-139 helicopters, and Crestline Commander land ambulances, staffed with Critical Care and Advanced Care Paramedics. For low acuity patients requiring a lower level of care, Ornge uses a Standing Agreement to Chart Air Ambulance services from contract carriers, staffed by primary care paramedics. For interfacility transfer patients, we propose to compare CPR rates year over year for Ornge (2013-2017). SA transports will not be included, as they represent a very low-risk group. Risk adjustment will be done by adjusting for mechanical ventilation (yes/no), use of infusion(s) of vasopressors (yes/no), mechanical ventilation and pressors (yes/no), or none. Rates will be standardized to the distribution of cases during the reference year of 2013-14, and reported per thousand hours. Results Discussion Comparing variability in outcomes is helpful in improving quality of care. High performing centres can share their best practices to improve quality of care throughout the system. Risk adjustment is a methodology used to ensure that “apples” are being compared to “apples”, and that case selection is not affecting the analysis. Transport agencies are now reporting CPR rates during transports as an outcome measure, as part of their quality improvement programs. These rates are unadjusted, and are difficult to compare across groups. Air ambulances transport many different types of patients, such that standard risk adjustment methods may not be directly applicable. Risk adjustment for trauma patients is completely different than for post STEMI patients. As well, transport agencies only care for patients during a very short period of time. We presented a methodology of risk-adjustment for CPR rates during interfacility transports that have correlational validity with our changes in our quality processes over time.

National Comparison of Hospital Performances in Lung Cancer Surgery: The Role of Case Mix Adjustment

When comparing hospitals on outcome indicators, proper adjustment for case mix (a combination of patient and disease characteristics) is indispensable. This study examines the need for case mix adjustment in evaluating hospital outcomes for non-small cell lung cancer surgery. Data from the Dutch Lung Cancer Audit for Surgery were used to validate factors associated with postoperative 30-day mortality and complicated course with multivariable logistic regression models. Between-hospital variation in case mix was studied by calculating medians and interquartile ranges for separate factors on the hospital level and the "expected" outcomes per hospital as a composite measure. A total of 8,040 patients, distributed over 51 Dutch hospitals, were included for analysis. Mean observed postoperative mortality and complicated course were 2.2% and 13.6%, respectively. Age, American Society of Anesthesiologists classification, Eastern Cooperative Oncology Group performance score, lung function, extent of resection, tumor stage, and postoperative histopathologic findings were individual significant predictors for both outcomes of postoperative mortality and complicated course. A considerable variation of these case mix factors among hospital populations was observed, with the expected mortality and complicated course per hospital ranging from 1.4% to 3.2% and from 11.5% to 17.1%, respectively. The between-hospital variation in case mix of patients undergoing surgical treatment for non-small cell lung cancer emphasizes the importance of proper adjustment when comparing hospitals on outcome indicators.

Hospital and Intensive Care Unit Length of Stay for Injury Admissions: A Pan-Canadian Cohort Study.

To assess the variation in hospital and intensive care unit (ICU) length of stay (LOS) for injury admissions across Canadian provinces and to evaluate the relative contribution of patient case mix and treatment-related factors (intensity of care, complications, and discharge delays) to explaining observed variations. Identifying unjustified interprovider variations in resource use and the determinants of such variations is an important step towards optimizing health care. We conducted a multicenter, retrospective cohort study on admissions for major trauma (injury severity score >12) to level I and II trauma centers across Canada (2006-2012). We used data from the Canadian National Trauma Registry linked to hospital discharge data to compare risk-adjusted hospital and ICU LOS across provinces. Risk-adjusted hospital LOS was shortest in Ontario (10.0 days) and longest in Newfoundland and Labrador (16.1 days; P < 0.001). Risk-adjusted ICU LOS was shortest in Québec (4.4 days) and longest in Alberta (6.1 days; P < 0.001). Patient case-mix explained 32% and 8% of interhospital variations in hospital and ICU LOS, respectively, whereas treatment-related factors explained 63% and 22%. We observed significant variation in risk-adjusted hospital and ICU LOS across trauma systems in Canada. Provider ranks on hospital LOS were not related to those observed for ICU LOS. Treatment-related factors explained more interhospital variation in LOS than patient case-mix. Results suggest that interventions targeting reductions in low-value procedures, prevention of adverse events, and better discharge planning may be most effective for optimizing LOS for injury admissions.

928: Case mix and the utility of postpartum readmission rates as a marker of quality in obstetrics

Postpartum readmission rates have been discussed as a potential quality metric in obstetrics. The objective of this project was to determine the relative effects of case mix on a hospital's postpartum readmission rate. This retrospective cohort study was conducted using the State Inpatient Databases from CA, FL, and NY between 2004 and 2013. Women who delivered at hospitals with >100 deliveries/year were included. We compared patient and hospital characteristics among hospitals with low and high readmission rates using chi-squared tests. Risk-adjusted 30-day readmission rates were calculated for patient, delivery, and hospital characteristics to understand how case mix and hospital factors affect a patient’s risk for readmission using fixed and random effects models. The average 30-day readmission rates were 1.15%, 1.57%, and 1.42% in California, Florida, and New York from the 3,164,429, 1,890,802, and 2,257,360 deliveries included from each state, respectively. There were notable differences in the distributions of patients cared for at high readmission hospitals compared to low readmission hospitals. Patients were more likely to identify as white, have private insurance and higher incomes, and have fewer comorbidities at low readmission hospitals in all states. These characteristics were associated with a lower risk of readmission, as shown by the adjusted rates in Table 1. The patient characteristics with the highest risk-adjusted readmission rates varied by state, but included hypertension (range 2.14-3.04%), obesity (1.78-2.94%), preterm labor/delivery (2.50-2.60%), and seizure disorder (1.78-3.35%). Delivery complications were also associated with increased risk-adjusted readmission rates (Table 2), but overall occurred rarely. In comparison, hospital characteristics did not have a profound impact on readmission risk compared to the patient characteristics (Table 2). Postpartum readmissions are an overall uncommon event that are affected by unmodifiable factors, such as demographics, socioeconomic status, and underlying comorbidities. The use of unadjusted readmission rates as a quality metric in obstetrics would disproportionately affect hospitals caring for higher risk, sicker patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Major inpatient surgeries and in-hospital mortality in New South Wales public hospitals in Australia: A state-wide retrospective cohort study

BackgroundSurgical interventions save lives and are important focus for health services research worldwide. Investigating variation in postoperative mortality may improve understanding of unwarranted variations and promote safety and quality in surgical care. We aimed to evaluate trends of in-hospital mortality rates among adult inpatients receiving major elective surgeries and determine the variation in mortality among New South Wales (NSW) public hospitals. Materials and methodsIn this study, we used the all-inclusive population-based NSW Admitted Patient Data from July 2001 to June 2014. We retrospectively included adult patients aged 18+ years receiving Abdominal Aortic Aneurysm (AAA) repair, Peripheral bypass, Colorectal surgeries, Joint replacement, Spinal surgeries, or Cardiac surgeries. The primary outcome was in-hospital mortality for selected surgeries. Changes in mortality rates over time and hospital standardised mortality rates were modelled using multivariate logistic regression models adjusting for case-mix factors. ResultsOver 13-year study period, the in-hospital mortality rates declined annually by 6.4% (95% Confidence Interval (CI): 4.3, 8.4) for Colorectal surgery by 5.7% (95%CI: 2.0, 9.3) for Joint replacement and by 4.2% (95%CI: 1.9, 6.4) for Cardiac surgery. After controlling for patient-level factors, little variation was observed among hospitals for in-hospital mortality. There was a greater variability for cardiac surgery compared with the other surgical groups but no outlier hospital was consistently associated with significantly higher than expected mortality rate. ConclusionsMortality has declined for major surgeries in the past 15 years. There was some variation among hospitals regarding in-hospital mortality that was mostly explained by patients demographic and admission characteristics. Our findings are reassuring for patients and contribute to knowledge that can help further improve surgical care.

Factors contributing to variation in the use of multimodality treatment in patients with gastric cancer: A Dutch population based study

BackgroundSubstantial variation in the use of (neo) adjuvant treatment in patients with gastric cancer exists. The aim of this study was to identify underlying (organizational and process) factors associated with the use of perioperative therapy. Patients and methodsPatients with resectable gastric cancer who underwent surgery between 2012 and 2014 were selected from the Dutch Upper gastrointestinal Cancer Audit (DUCA). The proportion of perioperatively treated patients was defined per hospital. Five hospitals with the lowest percentage (LP group) and 5 hospitals with the highest percentage (HP group) of perioperative therapy were identified. In the selected hospitals additional information was obtained from patients' medical records using a structured list with predefined variables. ResultsIn total, 429 patients (231 in LP group, 198 in HP group) from 9 different hospitals were included. Perioperative therapy was given in 16.0% of patients in the LP group compared to 40.4% in the HP group. In the LP group, patients were enrolled in a clinical trial less frequently (10.8% versus 26.8%, P<.001), and a higher percentage grade III-IV toxicity was observed during neoadjuvant treatment (25.7% versus 46.3%, P=.007). Multivariable analysis showed that, besides known casemix factors, consultation with ≥3 upper GI specialists prior to treatment decision was positively associated with initiating perioperative therapy (OR 2.08, 95% CI 1.19–3.66). ConclusionResults of this study confirm considerable hospital variation in the use of perioperative therapy in patients with gastric cancer. Besides known casemix factors, use of perioperative therapy was associated with the level of involvement of multidisciplinary care.

Development of a core set of outcome measures for OAB treatment

Introduction and hypothesisStandardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB).MethodsThe International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input.ResultsThe standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included.ConclusionsThe standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research.

Nationwide prospective audit of pancreatic surgery: design, accuracy, and outcomes of the Dutch Pancreatic Cancer Audit

BackgroundAuditing is an important tool to identify practice variation and ‘best practices’. The Dutch Pancreatic Cancer Audit is mandatory in all 18 Dutch centers for pancreatic surgery. MethodsPerformance indicators and case-mix factors were identified by a PubMed search for randomized controlled trials (RCT's) and large series in pancreatic surgery. In addition, data dictionaries of two national audits, three institutional databases, and the Dutch national cancer registry were evaluated. Morbidity, mortality, and length of stay were analyzed of all pancreatic resections registered during the first two audit years. Case ascertainment was cross-checked with the Dutch healthcare inspectorate and key-variables validated in all centers. ResultsSixteen RCT's and three large series were found. Sixteen indicators and 20 case-mix factors were included in the audit. During 2014–2015, 1785 pancreatic resections were registered including 1345 pancreatoduodenectomies. Overall in-hospital mortality was 3.6%. Following pancreatoduodenectomy, mortality was 4.1%, Clavien–Dindo grade ≥ III morbidity was 29.9%, median (IQR) length of stay 12 (9–18) days, and readmission rate 16.0%. In total 97.2% of >40,000 variables validated were consistent with the medical charts. ConclusionsThe Dutch Pancreatic Cancer Audit, with high quality data, reports good outcomes of pancreatic surgery on a national level.

Adherence to Guidelines for Adult (Non-GIST) Soft Tissue Sarcoma in the Netherlands: A Plea for Dedicated Sarcoma Centers

IntroductionOptimal management of soft tissue sarcoma (STS) remains a challenge. A nationwide survey assessed the quality of STS care in the Netherlands, thereby aiming to identify potentialities for improvement through more centralized disease management.MethodsFrom the Netherlands Cancer Registry (NCR), data were obtained on 3317 adult STS patients (excluding gastrointestinal stromal tumor, GIST) diagnosed in 2006–2011. Logistic regression models were employed to compare outcomes on selected clinical indicators reflecting prevailing STS guidelines between high-volume (≥10 resections annually) and low-volume (<10 resections) hospitals, between academic and general hospitals, and between sarcoma research centers and other hospitals, adjusted for case mix. Analyses were performed on imputed datasets (m = 50), generated through multiple imputations by chained equations.ResultsOverall, 89% of patients underwent surgical resection. Resection status remained unknown in 24% (excluding those with metastasized disease), and grade was not documented for one-third of tumors. Microscopic residual disease was detected in 20% with an increased risk for older patients, larger and deeply located tumors, and those located in the (retro)peritoneum or upper extremity. Almost half of patients with an R1 resection received adjuvant radiotherapy. Following adjustment for case mix factors, patients treated in high-volume hospitals less often had macroscopic residual disease (R2 resection; adjusted odds ratio: 0.54). A strongly skewed distribution of surgical volumes was observed.ConclusionsThese survey results indicate a potential for improving Dutch STS care. More centralized sarcoma management should improve definitive pathology reporting on tumor characteristics, adherence to treatment guidelines and overall disease outcome.

Intimal Hyperplasia, Stenosis, and Arteriovenous Fistula Maturation Failure in the Hemodialysis Fistula Maturation Study.

Intimal hyperplasia and stenosis are often cited as causes of arteriovenous fistula maturation failure, but definitive evidence is lacking. We examined the associations among preexisting venous intimal hyperplasia, fistula venous stenosis after creation, and clinical maturation failure. The Hemodialysis Fistula Maturation Study prospectively observed 602 men and women through arteriovenous fistula creation surgery and their postoperative course. A segment of the vein used to create the fistula was collected intraoperatively for histomorphometric examination. On ultrasounds performed 1 day and 2 and 6 weeks after fistula creation, we assessed fistula venous stenosis using pre-specified criteria on the basis of ratios of luminal diameters and peak blood flow velocities at certain locations along the vessel. We determined fistula clinical maturation using criteria for usability during dialysis. Preexisting venous intimal hyperplasia, expressed per 10% increase in a hyperplasia index (range of 0%-100%), modestly associated with lower fistula blood flow rate (relative change, -2.5%; 95% confidence interval [95% CI], -4.6% to -0.4%; P=0.02) at 6 weeks but did not significantly associate with stenosis (odds ratio [OR], 1.07; 95% CI, 1.00 to 1.16; P=0.07) at 6 weeks or failure to mature clinically without procedural assistance (OR, 1.07; 95% CI, 0.99 to 1.15; P=0.07). Fistula venous stenosis at 6 weeks associated with maturation failure (OR, 1.98; 95% CI, 1.25 to 3.12; P=0.004) after controlling for case mix factors, dialysis status, and fistula location. These findings suggest that postoperative fistula venous stenosis associates with fistula maturation failure. Preoperative venous hyperplasia may associate with maturation failure but if so, only modestly.

Effect of day of the week on short- and long-term mortality after emergency general surgery.

The effect of day of the week on outcome after surgery is the subject of debate. The aim was to determine whether day of the week of emergency general surgery alters short- and long-term mortality. This was an observational study of all patients undergoing emergency general surgery in Scotland between 1 January 2005 and 31 December 2007, followed to 2012. Multilevel logistic and Cox proportional hazards regression were used to assess the effect of day of the week of surgery on outcome after adjustment for case mix and risk factors. The primary outcome was perioperative mortality; the secondary outcome was overall survival. A total of 50 844 patients were identified, of whom 31 499 had an emergency procedure on Monday to Thursday and 19 345 on Friday to Sunday. Patients undergoing surgery at the weekend were younger (mean 45·9 versus 47·5 years; P < 0·001) and had fewer co-morbidities, but underwent riskier and/or more complex procedures (P < 0·001). Patients who had surgery at the weekend were more likely to have been operated on sooner than those who had weekday surgery (mean time from admission to operation 1·2 versus 1·6 days; P < 0·001). No difference in perioperative mortality (odds ratio 1·00, 95 per cent c.i. 0·89 to 1·13; P = 0·989) or overall survival (hazard ratio 1·01, 0·97 to 1·06; P = 0·583) was observed when surgery was performed at the weekend. There was no difference in overall survival after surgery undertaken on any particular day compared with Wednesday; a borderline reduction in perioperative mortality was seen on Tuesday. There was no difference in short- or long-term mortality following emergency general surgery at the weekend, compared with mid-week.

Quality of Dutch integrated head and neck cancer care: Measurement and evaluation.

173 Background: Oncologic care is very complex, and delivery of integrated care with optimal alignment and collaboration of several disciplines is crucial. To monitor and effectively improve high-quality integrated oncologic care, a dashboard of valid and reliable quality indicators (QIs) is indispensable. A set of QIs is developed specifically for head and neck cancer (HNC) patients from three perspectives: patients (development of indicators from patient perspective, including the first results, are described in the abstract "PROMs and PREMs in Dutch integrated head and neck cancer care: Measurements and evaluation"), medical specialist and allied health professionals. This presentation concerns the first results from medical and allied health professional perspective. Methods: QIs on process, structure and outcome of care, were developed using an evidence based method: the Rand modified Delphi method. Data was collected in nine Dutch hospitals nearly 1,500 patients (November 2014 - December 2016). Indicators were calculated on national and hospital level and corrected for case-mix using SPSS. Results: The final set contained 5 outcome indicators from both perspectives, 13 and 18 process indicators from the perspective of medical specialists and allied health professionals respectively, and three structure indicators from the perspective of allied health professionals. Besides, 10 case-mix factors were selected. Current practice assessment, in 1263 patients, produced high scores on integrated care indicators, e.g., the percentage of patients discussed in multidisciplinary team meeting before start of the treatment (93%) and availability of a treatment plan (99%). However, involvement of dental teams (range 57 – 100%) and malnutrition screening (range 8-35%) could be improved in most hospitals. In addition, most hospitals did not meet the standard of 80% on patients starting with treatment within 30 days. Conclusions: The quality of integrated multidisciplinary care for patients with head and neck cancer in the Netherlands is already high on some aspects, but varied between hospitals and shows room for improvement. This study can be an example for other oncologic diseases where integrated care is necessary.

An international patient-centered outcome measurement set for colorectal cancer.

753 Background: While there are tools to measure outcomes relevant to patients with colorectal cancer, none is universally accepted and none incorporates components of long-term clinical outcomes, acute complications, and patient-reported outcomes (PROs). Methods: The International Consortium for Health Outcomes Measurement convened an international multidisciplinary working group to develop a comprehensive patient-centered outcome measurement set for patients with all stages of colorectal cancer. The working group utilized a literature review, patient focus group and their own clinical expertise to reach consensus on outcomes and case mix factors through a modified Delphi process. Measurement tools were selected by International Society of Quality of Life Research standards. The final list of PROs was validated through a patient survey. Results: The 29 members of the working group included patient representatives and palliative care, nursing, pathology, medical oncology, colorectal surgery and radiation oncology specialists from academic and nonacademic practices in Europe, Australia, Asia and the USA. The international focus group included 11 patients with colorectal cancer treated with palliative and curative intents. The working group defined four clinical outcomes applicable to all and eight specific to subgroups, such as presence of ostomy for patients with rectal cancer and hospital admission in the last 30 days of life for patients with advanced disease. An algorithm for documenting acute complications was developed. The working group defined 11 PROs applicable to all and eight specific to subgroups, such as erectile dysfunction for patients who received radiotherapy/surgery and neuropathy for those who received chemotherapy. 276 colorectal cancer patients completed the validation survey. Conclusions: Through use of extensive patient input, the international multidisciplinary group developed a patient-centered outcome measurement set incorporating clinical outcomes, acute complications and PROs for patients with colorectal cancer. This comprehensive measurement set allows for standardized international comparison on quality of care outcomes and will be revised annually.

Quality indicators of integrated care for patients with head and neck cancer.

Oncological care is very complex, and delivery of integrated care with optimal alignment and collaboration of several disciplines is crucial. To monitor and effectively improve high-quality integrated oncological care, a dashboard of valid and reliable quality indicators (QIs) is indispensable. The aim was to develop multidisciplinary QIs to measure quality of integrated oncological care, specifically for head and neck cancer (HNC) patients. The RAND-modified Delphi method was used to decide on the outcome, process and structure QIs form three different perspectives. In addition, case-mix factors were determined. Integrated HNC in the Netherlands. Head and neck cancer patients, chairmen of both patient organisations and medical specialists and allied health professionals involved in HNC care in the Netherlands. Outcome, process and structure indicators. Outcome indicators were assigned to healthcare status, tumour recurrence, complications, quality of life and patient experiences. The process indicators focused on the (allied health) care aspects during the diagnostic, treatment and follow-up phases, for example regarding waiting times, multidisciplinary team meetings and screening for the need of allied health care. This is the first set of multidisciplinary QIs for HNC care, to assess quality of integrated care agreed by patients and professionals. This set can be used to build other oncological quality dashboards for integrated care.

The Paediatric Admission Quality of Care (PAQC) score: designing a tool to measure the quality of early inpatient paediatric care in a low-income setting.

BackgroundEvaluating clinician compliance with recommended steps in clinical guidelines provides one measure of quality of process of care but can result in a multiplicity of indicators across illnesses, making it problematic to produce any summative picture of process quality, information that may be most useful to policy‐makers and managers.ObjectiveWe set out to develop a clinically logical summative measure of the quality of care provided to children admitted to hospital in Kenya spanning the three diagnoses present in 60% or more of admissions that would provide a patient‐level measure of quality of care in the face of comorbidity.MethodsWe developed a conceptual model of care based on three domains: assessment, diagnosis and treatment of illnesses. Individual items within domains correspond to recommended processes of care within national clinical practice guidelines. Summative scores were created to reduce redundancy and enable aggregation across illnesses while maintaining a clear link to clinical domains and our conceptual model. The potential application of the score was explored using data from more than 12 000 children from eight hospitals included in a prior intervention study in Kenya.ResultsSummative scores obtained from items representing discrete clinical decision points reduced redundancy, aided balance of score contribution across domains and enabled direct comparison of disease‐specific scores and the calculation of scores for children with comorbidity.ConclusionThis work describes the development of a summative Paediatric Admission Quality of Care score measured at the patient level that spans three common diseases. The score may be an efficient tool for assessing quality with an ability to adjust for case mix or other patient‐level factors if needed. The score principles may have applicability to multiple illnesses and settings. Future analysis will be needed to validate the score.

Does Admission to Hospital Affect Trends in Survival and Dependency After Stroke Using the South London Stroke Register?

Despite guidelines for specialist assessment in hospital for stroke, it is important to identify patient characteristics, trends, and outcome in patients not admitted to hospital compared with patients admitted to hospital. Population-based stroke register of first in a life time strokes between 1995 and 2012 were examined. Baseline data included admission or nonadmission, case mix, stroke subtype, and risk factors before stroke. Survival curves were estimated with Kaplan-Meier methods. Logistic regression was used to determine factors associated with poor outcome (dead and dependency: Barthel index, <15) at 3 months and 1 year. Three thousand four hundred sixty-four patients were admitted to hospital for stroke. Patients admitted were more likely have more severe impairments (P<0.001). There was a significant trend for increasing admission over time; 1995 to 2000 (82%), 2001 to 2006 (90%), and 2007 to 2012 (94%); P<0.001. When survival analysis was stratified according to Barthel index ≥15 at day 7, there were no significant differences in survival curves between admission and nonadmission groups in 1995 to 2000 (P=0.15) or 2001 to 2006 (P=0.06), but there was a significant trend for higher survival rates for nonadmission in the 2007 to 2012 cohort (P=0.025). Admission to hospital (stroke unit) compared with nonadmission was also associated with poor outcome in the 2001 to 2006 time period (odds ratio, 2.66; confidence interval, 1.17-6.04) and the 2007 to 2012 time period (odds ratio, 5.26; confidence interval, 1.27-21.81). There is a survival advantage from 2007 onward and lower levels of dependency from 2001 onward after adjusting for case mix for those patients who are not admitted to hospital, which requires further explanation.