Variation In Surgical Rates Research Articles

Editors' Introduction: Artificial Intelligence and Predictive Analytics, Present and Future.

An evidence-based approach to the management of patients with spinal disorders is complex, and it requires consideration of several factors, including spinal pathology, anatomy, patient comorbidities, and goals of both the patient and the surgeon. The presence of high variation in surgical rates and

Association of Variation in US County-Level Rates of Liver Surgical Resection for Colorectal Liver Metastasis With Poverty Rates in 2010

Among patients with colorectal liver metastasis (CRLM) who are eligible for curative-intent liver surgical resection, only half undergo liver metastasectomy. It is currently unclear how rates of liver metastasectomy vary geographically in the US. Geographic differences in county-level socioeconomic characteristics may, in part, explain variability in the receipt of liver metastasectomy for CRLM. To describe county-level variation in the receipt of liver metastasectomy for CRLM in the US and its association with poverty rates. This ecological, cross-sectional, and county-level analysis was conducted using data from the Surveillance, Epidemiology, and End Results Research Plus database. The study included the county-level proportion of patients who had colorectal adenocarcinoma diagnosed between January 1, 2010, and December 31, 2018, underwent primary surgical resection, and had liver metastasis without extrahepatic metastasis. The county-level proportion of patients with stage I colorectal cancer (CRC) was used as a comparator. Data analysis was performed on March 2, 2022. County-level poverty in 2010 obtained from the US Census (proportion of county population below the federal poverty level). The primary outcome was county-level odds of liver metastasectomy for CRLM. The comparator outcome was county-level odds of surgical resection for stage I CRC. Multivariable binomial logistic regression accounting for clustering of outcomes within a county via an overdispersion parameter was used to estimate the county-level odds of receiving a liver metastasectomy for CRLM associated with a 10% increase in poverty rate. In the 194 US counties included in this study, there were 11 348 patients. At the county level, the majority of the population was male (mean [SD], 56.9% [10.2%]), White (71.9% [20.0%]), and aged between 50 and 64 (38.1% [11.0%]) or 65 and 79 (33.6% [11.4%]) years. The adjusted odds of undergoing a liver metastasectomy was lower in counties with higher poverty in 2010 (per 10% increase; odds ratio, 0.82 [95% CI, 0.69-0.96]; P = .02). County-level poverty was not associated with receipt of surgery for stage I CRC. Despite the difference in rates of surgery (mean county-level rates were 0.24 for liver metastasectomy for CRLM and 0.75 for surgery for stage I CRC), the variance at the county-level for these 2 surgical procedures was similar (F370, 193 = 0.81; P = .08). The findings of this study suggest that higher poverty was associated with lower receipt of liver metastasectomy among US patients with CRLM. Surgery for a more common and less complex cancer comparator (ie, stage I CRC) was not observed to be associated with county-level poverty rates. However, county-level variation in surgical rates was similar for CRLM and stage I CRC. These findings further suggest that access to surgical care for complex gastrointestinal cancers such as CRLM may be partially influenced by where patients live.

Changes in healthcare utilisation for paediatric tonsillectomy and adenoidectomy in the Netherlands: a population-based study.

ObjectivesTonsillectomy and adenoidectomy in children are controversial subjects with large regional variation in surgical rates, partly explained by cultural differences and lack of high‐quality evidence on indications for surgery. A quality of care cycle was executed on this topic in the Netherlands. The objective of this study was to estimate changes in healthcare utilisation for paediatric tonsil surgery in the Netherlands.MethodsPopulation‐based data on tonsillectomies and adenoidectomies in children up to age 10 were retrieved retrospectively from Dutch administrative databases between 2005 and 2018. A change point analysis was performed to detect the most pivotal change point in surgical rates. We performed univariate analyses to compare surgical patients’ characteristics before and after the pivotalpoint . Impact on healthcare budget and societal costs were estimated using current prices and data from cost‐effectiveness analyses.ResultsThe annual number of adenotonsillectomies reduced by 10 952 procedures (−39%; from 129 per 10 000 children to 87 per 10 000 children) between 2005 and 2018, and the number of adenoidectomies by 14 757 procedures (−49%; from 138 per 10 000 children to 78 per 10 000 children). The most pivotal change point was observed around 2012, accompanied by small changes in patient selection for surgery before and after 2012. An estimated €5.3 million per year was saved on the healthcare budget and €10.4 million per year on societal costs.ConclusionThe quality of care cycle resulted in fewer operations, with a concomitant reduction of costs. We suggest that part of these savings be invested in new research to maintain the quality of care cycle.

Patterns in Pediatric Dental Surgery under General Anesthesia across 7 State Medicaid Programs.

Children's access to dental general anesthesia (DGA) is limited, with highly variable wait times. Access factors occur at the levels of facility, dental provider, and anesthesia provider. It is unknown if these factors also influence utilization of dental surgery. We characterized patterns in DGA utilization by system, provider, population, and individual disease levels to explain variation. We conducted a cross-sectional analysis of Medicaid-enrolled children (≤9 y) who received DGA in Massachusetts, Maryland, Texas, Connecticut, Washington, Illinois, and Florida from 2011 to 2012. DGA events were characterized by the place of service, measures of disease burden, average reimbursements for dental provider and anesthesia provider, and average total expenditures. A total of 10,149,793 children met study eligibility criteria. States with similar patterns of caries-related visits, such as Illinois (16% of Medicaid enrollees had a caries-related claim) and Washington (22%), had different DGA rates (1% and 17%, respectively). Reimbursement rates for dental providers, DGA services, and nonhospital places of services did not consistently align in states with higher DGA rates. Surgical extraction rates, as a proxy for the most severe disease, exceeded 75% in Maryland, which had the lowest DGA rate (0.3%). Variation in DGA rates across states was not explained by reimbursements rates (provider, DGA services, place of service) or population or individual level of caries burden. Efforts to evaluate and alter utilization of DGA should consider factors such as dental and anesthesia provider capacity, health facility capacity (hospital vs. ambulatory surgery center vs. office), and population- and individual-level disease burden. Our negative findings suggest the presence of other social determinants of oral health that influence utilization of services (e.g., race/ethnicity, language preference, immigration status, policy and budget goals), which should be explored. Our findings also raise the specter that variation in surgical rates may represent instances of unmet needs or overtreatment. The results of this study can be used by clinicians and policy makers as they address policy and clinical interventions to influence children with severe caries. Interventions to change utilization of surgical services on a population level may need to include state-specific factors that extend beyond reimbursement, disease burden, anesthesia provider type, or facility type.

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study.

Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS. The RAND/UCLA appropriateness methodology was performed. An international, multi-disciplinary panel of 10 experts in CRS was formed and completed two rounds of a modified Delphi ranking process along with a face-to-face meeting. A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20. This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment option during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment option and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high quality, patient-centered care to patients with CRS.

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study.

Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS. The RAND/UCLA appropriateness methodology was performed. An international, multi-disciplinary panel of 10 experts in CRS was formed and completed two rounds of a modified Delphi ranking process along with a face-to-face meeting. A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20. This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment option during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment option and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high quality, patient-centered care to patients with CRS.

Regional variation exists in patient selection and treatment of abdominal aortic aneurysms

Significant regional variation in surgical rates has been identified following multiple surgical procedures. However, limited data have examined the regional variability in patient selection and treatment of abdominal aortic aneurysms (AAAs). This study aimed to evaluate regional variation in patient selection, perioperative management, and operative approach for the repair of AAAs. All patients undergoing open repair or endovascular aneurysm repair (EVAR) of an AAA in the Vascular Quality Initiative from 2009 to 2014 were identified. All regional groups were deidentified, and those with fewer than 100 open repairs were combined into a single region. We identified 17,269 elective repairs (EVAR, 13,759; open, 3510) and 1462 ruptured AAAs (EVAR, 749; open, 713). There was significant regional variation in the use of EVAR for elective repair (range, 66%-88%; P< .01) andruptured AAA repair (40%-80%; P< .01). The median diameter for elective repair was similar among regions (EVAR,5.4cm; open, 5.7cm). There was wide variation in the treatment of small aneurysms in male patients (<5.5cm) for EVAR (34%-49%; P< .01) and open repair (17%-38%; P< .01) and variation in the treatment of small aneurysms in female patients (<5cm) for EVAR (14%-32%; P< .01) but not significant for open repair (6%-24%). For elective cases, preoperative aspirin (EVAR, 50%-75% [P< .01]; open, 49%-78% [P< .01]) and statin use (EVAR, 61%-75% [P< .01]; open, 56%-80% [P< .01]) varied widely. Among elective cardiac patients, preoperative management varied significantly, including beta-blocker use (EVAR, 66%-78% [P< .01]; open, 69%-88% [P= .01]) and the frequency of stress tests (EVAR, 33%-64% [P< .01]; open, 31%-73% [P< .01]). Among open repairs for aneurysms extending at or beyond the juxtarenal segment, there was wide variation in the use of retroperitoneal exposures (7%-70%; P< .01) and adjunctive renal protective measures (cold renal perfusion, 2%-43% [P< .01]; mannitol, 47%-92% [P< .01]). Significant regional variation exists in patient selection, perioperative management, and operative approach for the repair of AAA. Definitive evidence is lacking in many aspects of operative care, including the use of the retroperitoneal approach and renal protective strategies. However, this variation emphasizes the importance of research to determine best practice in the areas of greatest variation. Furthermore, where current clinical process measures exist and data are clear, such as the use of statin and antiplatelet agents, the high degree of variation should serve as an impetus for regional quality improvement projects.

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study.

Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS. The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting. A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20. This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment "option" during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment "option" and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS.

Cataract Surgery among Medicare Beneficiaries

Purpose: To present descriptive epidemiology of cataract surgery among Medicare recipients in the United States.Setting: Cataract surgery performed on Medicare beneficiaries in 2003 and 2004.Methods: Medicare claims data were used to identify all cataract surgery claims for procedures performed in the United States in 2003–2004. Standard assumptions were used to limit the claims to actual cataract surgery procedures performed. Summary statistics were created to determine the number of procedures performed for each outcome of interest: cataract surgery rates by age, sex, race and state; surgical volume by facility type and surgeon characteristics; time interval between first- and second-eye cataract surgery.Results: The national cataract surgery rate for 2003–2004 was 61.8 per 1000 Medicare beneficiary person-years. The rate was significantly higher for females and for those aged 75–84 years. After adjustment for age and sex, blacks had approximately a 30% lower rate of surgery than whites. While only 5% of cataract surgeons performed more than 500 cataract surgeries annually, these surgeons performed 26% of the total cataract surgeries. Increasing surgical volume was found to be highly correlated with use of ambulatory surgical centers and reduced time interval between first- and second-eye surgery in the same patient.Conclusions: The epidemiology of cataract surgery in the United States Medicare population documents substantial variation in surgical rates by race, sex, age, and by certain provider characteristics.

Whoʼs in the Driverʼs Seat? The Influence of Patient and Physician Enthusiasm on Regional Variation in Degenerative Lumbar Spinal Surgery

Cross-sectional population-based study using administrative databases, census data, and surveys of orthopedic/neurosurgeons, family physicians (FPs) and patients in Ontario, Canada. To determine the influence of the enthusiasm of patients, FPs, and surgeons for surgery on the regional variation in surgical rates for degenerative diseases of the lumbar spine (DDLS), such as spinal stenosis and degenerative spondylolisthesis. Rates of surgery and healthcare costs for treating DDLS have been increasing. Regional variation in spinal surgical rates has been observed and it is thought that the enthusiasm of patients and physicians for surgery contributes to this variation. Using population-based administrative databases, we included all patients aged 50 years and older who underwent DDLS surgery (i.e., decompression/laminectomy, fusion) from 2002 to 2006 and calculated standardized utilization rates across counties. We measured regional "enthusiasm for surgery" for surgeons, FPs, and patients, using responses from a province-wide survey. Small-area variation analysis and multivariate Poisson regression models were performed calculating incidence rate ratios (IRRs) controlling for county demographics, socioeconomic measures, prevalence of disease, and community resources. We identified 10,318 DDLS surgeries (mean age 65 years, 50.6% female). Significant regional variation was observed (extremal quotient 5.0, coefficient of variation 28.0). Counties with higher rates of surgery had higher surgeon enthusiasm for surgery (IRR: 1.26, P < 0.013), older (IRR: 2.17, P < 0.0001) male patients (IRR: 1.19, P < 0.0001), lower income (IRR: 0.89, P < 0.0015), more knowledge of official languages (IRR: 1.12, P < 0.0003), and the presence of magnetic resonance imaging scanners (IRR: 1.30, P < 0.004). FP and patient enthusiasm for surgery, physician supply, and prevalence of disease were not statistically associated with higher surgical rates. Prior studies have not addressed the role of patient enthusiasm for surgery. Although patients and FPs had variable enthusiasm for surgery, surgeon enthusiasm was the dominant potentially modifiable factor influencing surgical rates. Prevalence of disease and community resources were not related to surgical rates. Strategies targeting surgeon practices may reduce regional variation in care and improve access disparities.

The case for restraint in spinal surgery: does quality management have a role to play?

Most quality improvement efforts in surgery have focused on the technical quality of care provided, rather than whether the care was indicated, or could have been provided with a safer procedure. Because risk is inherent in any procedure, reducing the number of unnecessary operations is an important issue in patient safety. In the case of lumbar spine surgery, several lines of evidence suggest that, in at least some locations, there may be excessively high surgery rates. This evidence comes from international comparisons of surgical rates; study of small area variations within countries; increasing surgical rates in the absence of new indications; comparisons of surgical outcomes between geographic areas with high or low surgical rates; expert opinion; the preferences of well-informed patients; and increasing rates of repeat surgery. From a population perspective, reducing unnecessary surgery may have a greater impact on complication rates than improving the technical quality of surgery that is performed. Evidence suggests this may be true for coronary bypass surgery in the US and hysterectomy rates in Canada. Though similar studies have not been done for spine surgery, wide geographic variations in surgical rates suggest that this could be the case for spine surgery as well. We suggest that monitoring geographic variations in surgery rates may become an important aspect of quality improvement, and that rates of repeat surgery may bear special attention. Patient registries can help in this regard, if they are very complete and rigorously maintained. They can provide data on surgical rates; offer post-marketing surveillance for new surgical devices and techniques; and help to identify patient subgroups that may benefit most from certain procedures.

Costs, Risks and Benefits of Surgery: a milestone in the development of health services research.

In 2006, the Journal of Health Services Research and Policy included Costs, Risks and Benefits of Surgery1 in a list of 26 books considered to have been most influential in changing health services and health care policy over the previous century and a half.2 How did Costs, Risks and Benefits of Surgery come to be written? The early 1970s was characterized by a growing acknowledgement in medicine, public health and the social sciences that contemporary health provision was neither evidence-based nor necessarily what people would prefer, given true choices. The great variation in health care utilization rates observed across countries and communities gave rise to legitimate questions about macro-economic effectiveness and efficiency. Archie Cochrane’s book Effectiveness and Efficiency: Random Reflections on Health Services3 asserted and justified the view that much of modern health care was not based on reasonable evidence about efficacy or safety. This came as a shock to many. Cochrane’s book was especially popular in the USA, exemplified by Cochrane’s recollection of meeting an American who said ‘So you are Archie Cochrane. I bought fifty copies of your book as Christmas cards this year.’ Fifty years previously, Codman had proposed and implemented systematic assessment of the end results of surgery at his hospital in Boston.4 Although questions about the use of discretionary surgery had been raised in the 1930s by Glover’s demonstration of widely varying rates of tonsillectomy,5 the late 1960s and early 1970s witnessed an explosion of studies documenting unexplained interand intra-national variations in surgical rates.6–11 Each of these studies raised fundamental questions about what health care was for, and ultimately for whose benefit. When such different amounts of it were being delivered to apparently similar patient populations with similar outcomes, it was not possible any longer to entertain the notion that all of it was unambiguously beneficial and appropriate. The variations in cost were also fairly clear (surgery is expensive), but the benefits and the consequent risks of these variations were much less obvious. It seemed irrational to remain so ignorant when it was so unclear that greater expenditure resulted in greater aggregate benefit. Given the general level of uncertainty evident throughout health provision, both about morbidity levels and the effects of most treatments, questions about how much health care is best for communities cannot generally be resolved by knowing whether treatment A is better (or not) than treatment B, among a specific group of patients. The justification offered for high rates of surgery was often that prophylactic procedures (cholecystectomy and hysterectomy, for example) prevented problems in the longer term. However, although prophylactic surgery with modern infection control and anaesthesia might well fulfil the needs of individuals, what were the costs for communities? Moreover, did the community want to use its resources in this way, given other options? Why was there no strong evidence that, within developed countries at least, more health care resulted in measurably better health? Was health care running away with itself in places, on essentially spurious implied clinical benefit grounds? The move to Harvard University of two of the researchers who had contributed to the surgical variations evidence—John Bunker and Jack Wennberg—provided a stimulus to address some of these quandaries. Fred Mosteller, Professor of Statistics at Harvard, and Howard Hyatt, Dean of the Harvard School of Public Health, had already planned to have multidisciplinary seminars, accompanied by a meal at the Faculty Club, and Bunker persuaded them that the questions raised by the surgical variations data should be addressed in these. The basis for this kind of question and indeed many of the methodologies to address them had already received impetus from the creation, in the School of Public Health, of the Centre for the Analysis of Health Practices (CAHP) in the early 1970s. People like Milt Weinstein and Don Shephard, under the direction of Hyatt, had progressed with the hard-nosed assessment of comparing treatments for chronic disease using models and other methods—clearly the nature of the question already had a resonance. Fortnightly seminars were held between 1973 and 1976, and, in all, about fifty people FR O M T H E JA M E S L IN D L IB R A R Y

Geographic Variations in the Use of Medical and Surgical Therapies for Benign Prostatic Hyperplasia

Patients with BPH have several treatment options. Little is known about geographic variations in surgical rates for BPH and the market relationships to medical therapy, health resources and sociodemographic factors. We conducted a cross-sectional study using administrative data from 5 states in 2000. Rates of surgical and medical therapy were calculated per 100,000 men 55 years old or older. Main outcome measures were county level weighted coefficient of variation and systematic component of variation in therapy rates, as well as surgery rates as a function of medication dispensing rates, health care resources and sociodemographic characteristics. North Carolina had the lowest surgery rates (26.3 minimally invasive procedures and 332.1 invasive surgeries per 100,000) and finasteride dispensing rates (503.5 per 100,000). Overall rates of medical therapy were 5 times higher than surgery rates. Geographic variations in surgical and medical therapy rates were significant for each state, and North Carolina had the greatest variation. An increase of 11.6 per 100,000 (95% CI, 6.5-55.8) in annual county level finasteride dispensing would be associated with a decrease in the surgery rate of 1 per 100,000, controlling for other variables. There is significant systematic variation in rates of surgical and medical therapy for BPH at county and state levels. The relationship between finasteride and surgery in randomized clinical trials is generalizable to the marketplace. Finasteride rates are inversely related to surgery rates, and tamsulosin rates are positively associated with surgery rates. Surgery rates are not significantly associated with urologists per capita.

Physician and population determinants of rates of middle-ear surgery in Ontario.

Small-area variations in surgical rates raise concerns about access to care, treatment appropriateness, and the quality and cost of care. To measure small-area variations in rates of myringotomy with insertion of tympanostomy tubes (TTs) and to identify determinants of rate variation. Retrospective analyses using hospital discharge data for patients who had undergone a myringotomy with insertion of TT by county in Ontario between April 1, 1996, and March 31, 1999. Information on possible determinants was taken from a survey of otolaryngologists and primary care physicians in 1996 and from the 1996 Canadian census and physician demographic databases for 1996-1999. A total of 75 358 hospitalizations for TT placement of children and adolescents (aged </=14 years). Small-area variation in rates of TT. An almost 10-fold difference between the areas with the highest and lowest rates was found (extremal quotient, 9.6; 95% confidence interval [CI], 8.2-11.1; P<.001). Higher rates occurred in counties with higher percentages of high school graduates (parameter estimate, 0.01; 95% CI, 0-0.02; P =.049); and where referring physicians were more likely to be male (parameter estimate, 0.01; 95% CI, 0-0.02; P =.01), North American-trained (parameter estimate, 0.01; 95% CI, 0.01-0.02; P<.001), and have higher propensities to refer for surgery (parameter estimate, 0.40; 95% CI, 0.09-0.72; P =.02). Otolaryngologist opinion was not a significant predictor. Substantial area variation in TT rates was observed. The opinion of primary care physicians was the dominant modifiable determinant, suggesting an area of research that may be important in reducing area variation in TT procedures.

Even detailed analysis of wide variations in surgical rates did not produce convincing explanations that could be easily used by purchasers

Even detailed analysis of wide variations in surgical rates did not produce convincing explanations that could be easily used by purchasers

Body height changes with hyperextension

Objective. To automatize the lumbar physical examination with an acceptable rate of error. Design. An external skin marker method for automatizing the physical examination was developed and its ability to discriminate between normal and abnormal subjects tested in a blind clinical trial. Background. The low reproducibility of clinical findings, even among experienced doctors, has been well documented. This is of particular concern and may explain why there is such a wide variation in surgical rates across the USA (tenfold for disc herniation). Inconsistencies among physicians in the evaluation of benign low back conditions make standardization desirable. Methods. A computerized physical examination was used to evaluate patients with low back pain and compare their results with a normative database obtained from a selection of healthy subjects. A high-resolution motion analysis system tracked the movement of skin markers placed on the midline and pelvis. Surface EMG electrodes placed above L 5 collected data from multifidus. From the kinematics of skin markers during flexion-extension with lifts up to 32 kg, and lateral bending with lifts up to 10 kg, the following parameters were estimated: lumbosacral angle and elongation, contribution of each lumbar segment to the lordosis reduction, relative pelvic/spine motion, and trunk velocity. First the average normal value for each estimated parameter was determined using 40 normal subjects. For each subject the difference between his parameter and the normal was processed by an expert system generating a normality index varying from zero (perfect abnormal) to one (perfect normal). To develop the expert system's rules, a preliminary group of 20 very abnormal subjects was used, such that the normality index separated them from the normals. For validation, a set of 29 back-sprain patients and another set of 42 discogram-positive patients were selected. Each subject was tested and his computerized normality index calculated without any clinician's input, then compared with the clinician's evaluation, which was taken to be the gold standard. The receiver operating characteristic technique was used to quantify the discrepancies. Results. The expert system could detect clinically abnormal subjects with accuracy (sensitivity 83–91% and specificity >90%) while providing quantitative information on workers' functional capacities. Conclusions. Once a reference normative database is agreed upon, each patient can be compared with that reference according to the same rules, with the resulting machine classification being independent of the clinician. This eliminates the inter- and intra-clinician variability in patient follow-up. Because of the severity of the selection criteria, this study is based upon a relatively restricted number of subjects, as well as a limited normative database of 40 subjects.

Methods of selection for adenoidectomy in childhood otitis media with effusion

We have examined the implications of selecting children with otitis media with effusion (OME) for adenoidectomy using different criteria. Data were collected pre-operatively on 125 consecutive cases of OME. Ages 1–13 years, mean = 4.9 years; 68 males and 57 females. The criteria used were: (1) obstructive nasal symptoms, (with three sub-categories); (2) age: and (3) nasopharyngeal airway size. The three sub-categories of obstructive nasal symptoms were based on the clinical practices of colleagues in the UK. Thus we analysed five criterion groups in all. These were: (1) snoring; (2) snoring + mouth breathing; (3) snoring + nasal obstruction; (4) age = 4–8 years and (5) nasopharyngeal airway < 4 mm. We found that applying each criterion separately to the group of children would result in widely differing numbers of children being selected for adenoidectomy. Of the 125 children, the percentage selected by each method varied considerably, ranging from 35–70%. In addition, there was only limited overlap, (43–71%) between the composition of the groups. This helps to explain the variations in surgical rates in different centres. In the absence of any universally acceptable guidelines, therefore, the importance of individual assessment of children can not be overemphasised.

Factors that affect surgical rates in Iowa.

This study analyzed insurance claims to estimate the probability of medical and surgical treatments in different Iowa communities. The likelihood of surgical treatment was associated with patient characteristics of age and gender as well as hospital characteristics of size (number of beds), occupancy rate, and number of staff. Our findings are being used by a study group of 25 physicians to understand the causes of variation in surgical rates for low back pain. Medical education and other interventions are being implemented. Hospitalization rates for lower back operations in the United States increased by more than 20% from 1978 to 1985. Consequently, several studies in Iowa and the US have been initiated to examine the medical effectiveness of these treatments. A logistic regression model was used to determine the factors associated with the likelihood of having a low back surgery in a population of Blue Cross/Blue Shield (BCBS) subscribers in Iowa. The outcome, or dependent variable, of interest was a hospitalization that resulted in a surgical procedure on a low back pain patient. Surgical rates for the treatment of low back pain are likely to be increased if a BCBS Iowa subscriber is female, older than 44 years of age, or if the surgery is performed in a hospital with either an occupancy rate less than 62%, with fewer than 774 staff members, fewer than 267 beds, or no residency programs.

Epidemiologic aspects of cataract surgery. II: Regional variation in frequencies.

A large data source was examined to determine age and sex specific cataract extraction rates in different counties and urbanization areas in Denmark. Significant regional variation in surgical rates could be demonstrated in spite of a comprehensive Public Health Service System. When comparing rates in different urbanization areas and in towns with and without ophthalmologists, we found the lowest surgical rates in areas or towns short of ophthalmic service. However, a direct correlation could not be found between standard operation ratio and ophthalmic surgeon/ophthalmic bed supply on county level. The reason might be that cataract extraction rates are influenced by a number of other factors, as cataract extraction has become an elective surgical procedure.

Surgical rate variations: do they reflect the health or socioeconomic characteristics of the population?

Major unexplained variations in surgical rates have been documented across geographic areas over at least the last four decades. This paper attempts to assess the contribution that population characteristics make to these variations. Variations in surgical rates among the elderly across 56 small rural areas are compared with variations in characteristics of the elderly population of these areas including self-reported health status, levels of disability, mental status, socioeconomic status, ethnic characteristics, etc. The data do not support a needs model for explaining variations in surgical rates. High rate areas were not characterized by an elderly population that was disabled and in ill health. High rate areas did contain a more educated elderly populations, as well as more elderly whose national origins were Canadian, British or American.