Variation In Surgical Practice Research Articles

Population-based study on surgical care for primary spontaneous pneumothorax.

The optimal surgical strategy for primary spontaneous pneumothorax remains a matter of debate and variation in surgical practice is expected. This variation may influence clinical outcomes, such as postoperative complications and length of stay. This national population-based registry study provides an overview and extent of variability of current surgical practice and outcomes in the Netherlands. To identify national patterns of care and between-hospital variability in the treatment of primary spontaneous pneumothorax, patients who underwent surgical pleurodesis and/or bullectomy between 2014 and 2021, were identified from the Dutch Lung Cancer Audit-Surgery database. The type of surgical intervention, postoperative complications, length of stay and ipsilateral recurrences were recorded. Out of 4338 patients, 1851 patients were identified to have primary spontaneous pneumothorax. The median age was 25 years (interquartile range 20-31) and 82% was male. The most performed surgical procedure was bullectomy with pleurodesis (83%). The overall complication rate was 12% (Clavien-Dindo grade ≥III 6%), with the highest recorded incidence for persistent air leak >5 days (5%). Median postoperative length of stay was 4 days (interquartile range 3-6) and 0.7% underwent a repeat pleurodesis for ipsilateral recurrence. Complication rate and length of stay differed considerably between hospitals. There were no differences between the surgical procedures. In the Netherlands, surgical patients with primary spontaneous pneumothorax are preferably treated with bullectomy plus pleurodesis. Postoperative complications and length of stay vary widely and are considerable in this young patient group. This may be reduced by optimization of surgical care.

Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter?

For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.

The DEFINITE Audit: a prospective audit of diabetic foot debridement in theatre – a protocol

Background: People with diabetes are commonly affected by foot ulceration (DFU) and subsequent or concurrent infection (DFI). Surgical debridement is often needed to contain infection. Despite international guidelines, there remains significant variation in surgical practice of diabetic foot wound debridement in the operating theatre. Methods: Diabetic Foot Ulcer Debridement in Theatre Audit (DEFINITE) is a global multicentre, prospective audit of consecutive patients undergoing a debridement or minor amputation in theatre for a diabetic foot complication. DEFINITE is led by the Vascular and Endovascular Research Network (VERN). The primary outcome is adherence to recommended practice as outlined in the International Working Group on the Diabetic Foot and Global Vascular Guidelines. Secondary outcomes are incidence of healing, re-admission, further amputation (minor and major) and mortality at 90 days. Anonymised data will be collected via REDCap. Eligibility and study registration at all hospital institutions performing in-theatre management of diabetic foot complications are eligible to participate after obtaining appropriate institutional level audit approvals. A lead clinician will be responsible for approvals and data management. Pathway to impact: This audit addresses shared patient-clinician priorities and is supported by the UK Vascular Society multidisciplinary Special Interest Group on the Diabetic Foot. The results will be presented at international scientific meetings and submitted for publication in peer-reviewed publications. The results will also be used to initiate improvement in patient care.

Regional variation and rising costs of groin hernia repairs in Australia: is there an urgent need for clinical consensus guidelines?

Regional variation and rising costs of groin hernia repairs in Australia: is there an urgent need for clinical consensus guidelines?

Surgeon preference for treatment allocation in older people facing major gastrointestinal surgery: an application of the discrete choice experiment methodology.

Variation in major gastrointestinal surgery rates in the older population suggests heterogeneity in surgical management. A higher prevalence of comorbidities, frailty and cognitive impairments in the older population may account for some variation. The aim of this study was to determine surgeon preference for major surgery versus conservative management in hypothetical patient scenarios based on key attributes. A survey was designed according to the discrete choice methodology guided by a separate qualitative study. Questions were designed to test for associations between key attributes (age, comorbidity, urgency of presentation, pathology, functional and cognitive status) and treatment preference for major gastrointestinal surgery versus conservative management. The survey consisting of 18 hypothetical scenarios was disseminated electronically to UK gastrointestinal surgeons. Binomial logistic regression was used to identify associations between the attributes and treatment preference. In total, 103 responses were received after 256 visits to the questionnaire site (response rate 40.2%). Participants answered 1847 out of the 1854 scenarios (99.6%). There was a preference for major surgery in 1112/1847 (60.2%) of all scenarios. Severe comorbidities (OR 0.001, 95% CI 0.000-0.030; P= 0.000), severe cognitive impairment (OR 0.001, 95% CI 0.000-0.033; P= 0.000) and age 85 years and above (OR 0.028, 95% CI 0.005-0.168; P= 0.000) were all significant in the decision not to offer major gastrointestinal surgery. This study has demonstrated variation in surgical treatment preference according to key attributes in hypothetical scenarios. The development of fitness-stratified guidelines may help to reduce variation in surgical practice in the older population.

BJS Prize 2 Exploring variation in surgical practice: the colorectal surgeon's personality influences anastomotic decision-making in rectal cancer

Abstract Background The influence of internal surgeon-specific factors, such as personality, on cognitive bias and decision-making in surgery is not well understood. These factors may be particularly influential in clinical cases where there is a high degree of equipoise. This study aimed to explore personality traits that may influence anastomotic decision-making in rectal cancer. Methods Colorectal surgeons were invited via social media to participate in a 2-part online survey (Snap11). The survey included: 1) 44-item Big Five Inventory (personality), 2) 30-item DOSPERT (risk-taking), 3) 3-item Cognitive Reflection Test (thinking style), and twenty hypothetical patient scenarios involving rectal anastomotic decisions. Results 186 certified colorectal surgeons participated with 127 completing both parts (68.3%). 143 participants in this cohort were aged 30–49 years (79.6%) and 131 participants were male (70.4%). Surgeons scored higher than average population levels for emotional stability (degree of even-temperedness; 3.25 vs 2.97), with lower levels of agreeableness (ability to cooperate with others; 3.03 vs 3.74) and openness (creativity; 3.19 vs 3.67). Personality influenced anastomotic decision-making in specific circumstances e.g., high levels of openness predicted stoma formation when providing a second opinion, whereas high levels of extraversion predicted stoma formation when the patient was a staff member. Early career surgeons were highly influenced by colleague criticism following recent anastomotic leakage. Conclusions Surgeon personality influences anastomotic decision-making in difficult circumstances. Colleague support is vital following anastomotic leakage and is influential upon early career surgeons’ subsequent decision-making. Personality is modifiable through experiences, therefore targeted educational interventions (e.g. reflexivity) may enable surgeons to recognize their own cognitive biases.

Exploring variation in surgical practice: does surgeon personality influence anastomotic decision-making?

Decision-making under uncertainty may be influenced by an individual's personality. The primary aim was to explore associations between surgeon personality traits and colorectal anastomotic decision-making. Colorectal surgeons worldwide participated in a two-part online survey. Part 1 evaluated surgeon characteristics using the Big Five Inventory to measure personality (five domains: agreeableness; conscientiousness; extraversion; emotional stability; openness) in response to scenarios presented in Part 2 involving anastomotic decisions (i.e. rejoining the bowel with/without temporary stomas, or permanent diversion with end colostomy). Anastomotic decisions were compared using repeated-measure ANOVA. Mean scores of traits domains were compared with normative data using two-tailed t tests. In total, 186 surgeons participated, with 127 surgeons completing both parts of the survey (68.3 per cent). One hundred and thirty-one surgeons were male (70.4 per cent) and 144 were based in Europe (77.4 per cent). Forty-one per cent (77 surgeons) had begun independent practice within the last 5 years. Surgeon personality differed from the general population, with statistically significantly higher levels of emotional stability (3.25 versus 2.97 respectively), lower levels of agreeableness (3.03 versus 3.74), extraversion (2.81 versus 3.38) and openness (3.19 versus 3.67), and similar levels of conscientiousness (3.42 versus 3.40 (all P <0.001)). Female surgeons had significantly lower levels of openness (P <0.001) than males (3.06 versus 3.25). Personality was associated with anastomotic decision-making in specific scenarios. Colorectal surgeons have different personality traits from the general population. Certain traits seem to be associated with anastomotic decision-making but only in specific scenarios. Further exploration of the association of personality, risk-taking, and decision-making in surgery is necessary.

P95. Geographic variation in the philosophy of adult spinal deformity management and patient outcomes: A propensity score matching analysis from the Prospective Evaluation Deformity Surgery (PEEDS) Study

<h3>BACKGROUND CONTEXT</h3> Severity of deformity, preoperative disability, and surgical strategies are variable between, and within, centers performing reconstructive surgery for spinal deformity. However, geographic variation in how surgeons manage ASD patients worldwide is unknown. <h3>PURPOSE</h3> The purpose of this study was to compare the surgical approach and clinical outcomes of elderly patients treated with fusion for spinal deformity in North America and Asia. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of the prospectively collected data. <h3>PATIENT SAMPLE</h3> All patients enrolled in the database were eligible and were propensity score matched according to their region (North America and Asia) <h3>OUTCOME MEASURES</h3> Surgical details, postoperative radiological parameter and health-related quality of life (HRQoL) scores at preoperative and 2 years, and occurrence of adverse events within the study period were compared in the matched pairs with dependent statistical tests. <h3>METHODS</h3> The two largest regions (North America and Asia) from the Prospective Evaluation Deformity Surgery (PEEDS) database, consisting of ASD patients over aged 60 with primary spinal fusion of at least 5 segments with a minimum of 2 year follow-up, were compared. Patients were 1:1 propensity score-matched using age, gender, Charlson Comorbidity Index, lumbar lordosis (LL), pelvic incidence (PI)-LL mismatch, sagittal vertical axis (SVA), absolute lumbar cobb angle, and sacral slope for calculation of propensity score and applying greedy algorithm to identify the best matches between the 2 regions with maximal absolute distance of 0.25 in propensity score to each other. <h3>RESULTS</h3> Out of the 219 patients enrolled in the database, 82 propensity score-matched patients were identified (n=41 in each region), with a median age of 68.0 (range 64-72) years (NA) and 68.0 (range 63-73) years (A). Both cohorts had comparable distributions of all preoperative radiological parameters and HRQoL scores. Out of the 219 patients enrolled in the database, 82 propensity score-matched patients were identified (n=41 in each region), with a median age of 68.0 (range 64-72) years (NA) and 68.0 (range 63-73) years (A). Both cohorts had comparable distributions of all preoperative radiological parameters and HRQoL scores. Patients treated in NA had higher proportion of single stage surgery (88% vs 44%, p<0.001), more levels fused throughout all stages (11.5±3.7 vs 9.1±2.3, p<0.001), and higher cumulative median blood loss (1500ml vs 1200ml, p=0.010) compared with those treated in A. Surgical procedures differed between the two groups: posterior instrumentation with TLIF were predominant in NA (83%), whereas a combined lateral and posterior approach (49% vs 5%) was more common in A. The occurrence of having any adverse events was higher in the NA group (82% vs 35%, p=0.002), due to a difference in the incidence of deep vein thrombosis (21% vs 0%, p=0.016) and other AEs (44% vs 15%, p=0.013). At 2-year follow-up, there was no difference in the correction of radiological parameters between the two groups. In terms of HRQoL, at 2 year follow-up patients in NA had a more favourable SRS-22r total score, EQ-5D VAS and leg pain NRS compared with the matched pairs in A, but similar EQ-5D index, ODI and back pain scores. <h3>CONCLUSIONS</h3> In this propensity score matched analysis, we demonstrated marked geographic variation in surgical practice toward surgeries for adult spinal deformity despite similar baseline patient characteristics and radiological parameters between North America and Asia. However, the 2 year radiological and clinical outcomes were similar. Further study is necessary to understand the drivers of this variation. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection

PurposeSurgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice.MethodsA mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached.ResultsThere was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured.ConclusionsThrough an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed “core” steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The “optional” steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world.

P113: National variation in surgical practice to minimise post-operative complications during implant based breast surgery - A questionnaire study

Introduction: Post-operative infection in patients undergoing breast implant surgery may lead to explantation. ABS standards are set at <5% at 3 months however the National Mastectomy and Breast Reconstruction audit showed that 15-18% of women undergoing immediate reconstruction experience serious complications. In 2018 a survey based on Allergan's 14-point plan to minimise complications related to implant based surgery was disseminated amongst the Kent, Surrey and Sussex (KSS) deanery. This showed that there was regional variation in surgical practice highlighting the importance of rolling this out nationally.

Management of stage II endometrial cancer and subsequent oncologic outcomes: a National Cancer Database study.

ObjectiveThe management of stage II endometrial cancer (EC) is challenging due to the wide variation in surgical practice and adjuvant treatment recommendations. We sought to describe the treatment patterns for patients with stage II EC and to evaluate the association between surgical management and adjuvant therapy on survival outcomes in a large cohort of patients with stage II EC.MethodsUsing data from the National Cancer Database, we identified 9,690 women with stage II EC. We used logistic regression to identify association of sociodemographic and tumor characteristics with surgery type and receipt of adjuvant therapy. We used Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between adjuvant therapy, hysterectomy type, and overall survival.ResultsAlmost 11% of the cohort underwent radical hysterectomy; however, there was no difference in survival between surgical types even when adjusted for adjuvant therapy (HR=0.94; 95% CI=0.82–1.07). Compared to no adjuvant treatment, radiation only (HR=0.66; 95% CI=0.61–0.73) and combination radiation and chemotherapy (HR=0.53; 95% CI=0.45–0.62) were associated with lower risk of death. There was no survival benefit of chemotherapy alone even when separated by histologic subtype (HR range, 0.55–1.46).ConclusionsWomen with stage II EC do not appear to benefit from routine radical hysterectomy though all patients appear to benefit from receipt of radiation therapy (RT), regardless of modality. Additionally, there may be an added survival benefit with the combination of computed tomography and RT in patients with non-endometrioid, high-risk histologies.

Explaining the Variation in Surgical Practice for Differentiated Thyroid Cancer in Ontario, Canada

In the management of differentiated thyroid cancer (DTC), the extent of surgical treatment required for most patients remains controversial and varies widely. This variation may be associated with the Enthusiasm Hypothesis, the notion that geographic differences in use of health care services are driven by the prevalence of physicians with a preference for particular services. To evaluate the Enthusiasm Hypothesis and its applicability to the variation in the surgical treatment of thyroid cancer in Ontario, Canada. This population-based study obtained electronic data on all health care-associated events for the complete population of insured residents of Ontario, Canada. Patients (n = 28 754) who were 18 years of age or older and underwent an initial therapeutic thyroid surgical procedure for a papillary or follicular carcinoma diagnosis between January 1, 2000, and December 31, 2015, were included. The final data analysis was performed January 31, 2019. Therapeutic thyroid cancer surgical procedure. Numbers of surgeons, extent of surgical treatment, and case volumes in 14 geographic regions in Ontario. In total, 28 754 patients with DTC were included, of whom 22 600 (78.6%) were female, with a mean (SD) age of 49 (14) years. The use of total thyroidectomy for DTC varied widely across geographic regions of Ontario, from 45.8% to 77.1% of all cancer cases. More than 90% of the overall variation in practice (total thyroidectomy vs less-than-total thyroidectomy) could be explained by the practices of the high-volume surgeons (enthusiasts) in regions with the highest rates of thyroid cancer diagnosis. The Enthusiasm Hypothesis appears to be consistent with the findings of this study. The practices of the high-volume surgeons who were enthusiastic for total thyroidectomy in the geographic regions with the highest rates of thyroid cancer diagnosis may account for the variation in practice across Ontario between 2000 and 2015.

Outcome of intensive rehabilitation following single-event multilevel surgery for crouch gait in children with cerebral palsy

BackgroundCrouch gait is one of the most common gait patterns in ambulatory children with cerebral palsy (CP) and is contributed by several factors. The literature reports wide variations in surgical practice and rehabilitation programs following single-event multilevel surgeries.ObjectiveTo evaluate the outcome of rehabilitation after single-event multilevel orthopedic surgery for crouch gait in children with CP.Patients and methodsA total of 20 children with bilateral spastic CP and walked with a crouch gait, with gross motor function classification system levels II, III, and IV, were subjected to single-event multilevel surgery. Ten (20 limbs) patients were men and eight (14 limbs) were women. Their age ranged from 5.5 to 19 years. To assess the outcome of our rehabilitation program, we used clinical couch examination parameters, functional mobility scale, and instrumented three-dimensional gait analysis. Rehabilitation program included preoperative and postoperative rehabilitation at 1-year postoperatively.ResultsHighly statistically significant improvements in clinical parameters, which include hip abduction, femoral anteversion, fixed flexion deformity, popliteal angle, and extension lag, were demonstrated (P<0.01), whereas tibial torsion showed a statistically significant improvement (P<0.05). Functional mobility scale at 5, 50, and 500m improved in 10 (55.6%) cases, 13 (72.2%) cases, and 11 (61.1%) cases, respectively. Instrumented gait laboratory parameters, namely, stride length, crouch angle at initial stance, and peak knee flexion in mid-swing, showed improvement but did not reach statistical significance.ConclusionThe rehabilitation program we offered improves clinical and functional mobility of children with CP with crouch gait. Thus, it is viewed as an important contributor to the overall outcome together with multilevel orthopedic surgery.

The colorectal surgeon's personality may influence the rectal anastomotic decision.

Colorectal surgeons regularly make the decision to anastomose, defunction or form an end colostomy when performing rectal surgery. This study aimed to define personality traits of colorectal surgeons and explore any influence of such traits on the decision to perform a rectal anastomosis. Fifty attendees of The Association of Coloproctology of Great Britain and Ireland 2016 Conference participated. After written consent, all underwent personality testing: alexithymia (inability to understand emotions), type of thinking process (intuitive versus rational) and personality traits (extraversion, agreeableness, openness, emotional stability, conscientiousness). Questions were answered regarding anastomotic decisions in various clinical scenarios and results analysed to reveal any influence of the surgeon's personality on anastomotic decision. Participants were: male (86%), consultants (84%) and based in England (68%). Alexithymia was low (4%) with 81% displaying intuitive thinking (reflex, fast). Participants scored higher in emotional stability (ability to remain calm) and conscientiousness (organized, methodical) compared with population norms. Personality traits influenced the next anastomotic decision if: surgeons had recently received criticism at a departmental audit meeting; were operating with an anaesthetist that was not their regular one; or there had been no anastomotic leaks in their patients for over 1 year. Colorectal surgeons have speciality relevant personalities that potentially influence the important decision to anastomose and could explain the variation in surgical practice across the UK. Future work should explore these findings in other countries and any link of personality traits to patient-related outcomes.

Variation in surgical practice to minimise post-operative complications during implant based breast surgery

Variation in surgical practice to minimise post-operative complications during implant based breast surgery

Moving the goalposts: A comparison of different definitions for primary external ventricular drain infection and its risk factors: A multi-center study of 2575 patients

External ventricular drainage is the most common procedure performed in daily neurosurgical practice. One devastating complication is ventriculostomy-associated infection, but the establishment of evidence-based management guidelines has been hindered by the lack of an universal definition. There is also limited data with regard to the utility of comorbidity health indices and surgery-related factors in predicting infection. This study aims to compare the incidence of infection according to five commonly used definitions and to identify risk factors for this complication. 2575 patients from seven neurosurgical centers in Hong Kong underwent primary external ventricular drainage. The frequency of infection according to Gozal was 2.2% (n=57), 4.7% (Chi), 0.6% (Lozier), 0.8% (Lyke) and 2.8% (Scheithauer). The commonest pathogen was coagulase negative staphylococcus (39%) and 49% of all microbial isolates were multiple-drug resistant. The mean Charlson comorbidity index was 0.5±1.1. Using Gozal’s definition as the primary endpoint, the index was not predictive of infection and no surgical risk factors were identified. The only significant risk factor was the performance of two or more additional neurosurgical procedures within 30days of catheterization (OR: 2.1, 95% CI 1.1–4.5). The rate of infection is relatively low, but considerable disparity exists depending on the definition used. Our data implies that patient factors, in particular the Charlson comorbidity index, and variations in surgical practice are less influential than the strict observance of infection control measures. The high incidence of antibiotic-resistant bacteria is concerning and the routine of exchange of catheters within 30days should be discouraged.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Audit and Outcome Reporting.

Defining quality in colorectal cancer surgery is complex. Single metrics that describe safety or performance fail to adequately describe the complexity of colorectal care (Almoudaris et al., 2013). Meaningful performance measurement is dependent upon a) case-mix adjustment, b) an understanding of volume-outcome effects and c) reliable data sources. Old age and patient co-morbidity significantly increase the likelihood of peri-operative events and mortality. To enable comparison of surgical performance, adjustment must be made for case-mix differences between providers. Scoring systems, such as Charlson (Charlson et al., 1987) and Elixhauser (Elixhauser et al., 1998) are used widely to case-mix adjust models derived from large clinical datasets. Currently risk stratification models used for comparison of outcomes have limitations as they do not adjust for case mix, including BMI (body mass index) and socio-economic deprivation (Harris et al., 2009; Haydon et al., 2006). The main data sources in the United Kingdom are; The National Bowel Cancer Audit (NBOCA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) delivered by the Health and Social Care Information Centre working in collaboration with the ACPGBI. The data are submitted from various NHS Trusts in the UK and the Republic of Ireland via the Open Exeter system. These data are used to examine variation in surgical practice, to describe outcome following colorectal resections for cancer and to derive predictive models of mortality (Tan et al., 2007; Tekkis et al., 2003; Tilney et al., 2009). Findings are disseminated in an annual report. These datasets are primarily collected for administrative purposes but are increasingly used for clinical performance benchmarking. The Hospital Episode Statistics (HES) represents the dataset for NHS England [www.hesonline.nhs.uk] and Information Services Division Scotland (ISD) for Scotland [www.isdscotland.org]. Such databases comprise of clinical codes that relate to diagnoses, procedures and demographic information. These data can be used to examine procedure volumes and basic clinical outcomes, including inpatient mortality rates, readmission rates and length of hospital stay. HES data have been linked to other national datasets such as the Office of National Statistics and the Cancer Registry for additional clinical and outcome information, such as out-of-hospital survival and tumour staging. The latter National Cancer Data Repository (NCDR) has recently been used in research studies to compare institutional mortality rates following colorectal surgery in England (Morris et al., 2011). The NCDR can also been linked to the national Radiotherapy Dataset (RTDS) to investigate patterns of management of rectal cancer across the English NHS (Morris et al., 2016). Surgeon level reporting of colorectal cancer surgery outcomes to the UK public was introduced in 2013. Capture of information on patients undergoing planned colorectal resection for cancer (excluding appendiceal neoplasms) are included in analyses. Surgeon level reporting has been spearheaded by Cardiac Surgeons but there are concerns amongst many surgeons that unit level reporting may be more appropriate. The ACPGBI agreed to participate in the process as the Department of Health stated that it would proceed with, or without the involvement of the ACPGBI. There are concerns regarding the quality of data and limitations of their interpretation. There are discrepancies in both information technology infrastructure and the availability of data capture personnel. As of 2013, NHS England (through the Healthcare Quality Improvement Partnership) has published 90-day risk-adjusted mortality figures for colorectal cancer patients undergoing planned surgery on a hospital and surgeon basis. This is based on data submitted to NBOCA. Monitoring of outcomes is required to define acceptable quality of care in elective colorectal cancer surgery. For the reasons already cited comparison can only be made when funnel plots are used to adjust for operative volumes, when data are reliable and when case-mix has been adjusted for. Outcomes for emergency surgery are generally less favourable. The following figures represent some published outcomes following elective colorectal cancer surgery: Surgeons and trusts must make provisions for the prospective collection of accurate clinical data for submission to the National Bowel Cancer Audit (NBOCA). Recommendation grade B Omar Faiz has no conflicts of interest to declare.

Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative

ObjectivePrior studies on the cause and effect of surgical variation have been limited by utilization of administrative data. The Vascular Quality Initiative (VQI), a robust national clinical registry, provides anatomic and perioperative details allowing a more robust analysis of variation in surgical practice. MethodsThe VQI was used to identify all patients undergoing infrainguinal open bypass or endovascular intervention from 2009 to 2014. Asymptomatic patients were excluded. The 16 regional groups of the VQI were used to compare variation in patient selection, operative indication, technical approach, and process measures. χ2 analysis was used to assess for differences across regions where appropriate. ResultsA total of 52,373 interventions were included (31%). Of the 16,145 bypasses, 5% were performed for asymptomatic disease, 26% for claudication, 56% for chronic limb-threatening ischemia (CLI) (61% of these for tissue loss), and 13% for acute limb-threatening ischemia. Of the 35,338 endovascular procedures, 4% were for asymptomatic disease, 40% for claudication, 46% for CLI (73% tissue loss), and 12% for acute limb-threatening ischemia. Potentially unwarranted variation included proportion of prosthetic conduit for infrapopliteal bypass in claudication (13%-41%, median, 29%; P < .001), isolated tibial endovascular intervention for claudication (0.0%-5.0%, median, 3.0%; P < .001), discharge on antiplatelet and statin (bypass: 62%-84%; P < .001; endovascular: 63%-89%; P < .001), and ultrasound guidance for percutaneous access (claudication: range, 7%-60%; P < .001; CLI: 5%-65%; P < .001). Notable areas needing further research with significant variation include proportion of CLI vs claudication treated by bypass (38%-71%; P < .001) and endovascular intervention (28%-63%; P < .001), and use of closure devices in percutaneous access (claudication; 26%-76%; P < .001; CLI: 30%-78%; P < .001). ConclusionsSignificant variation exists both in areas where evidence exists for best practice and, therefore, potentially unwarranted variation, and in areas of clinical ambiguity. Quality improvement efforts should be focused on reducing unwarranted variation. Further research should be directed at identifying best practice where no established guidelines and high variation exists.

Effects of a regional guideline for completion axillary lymph node dissection in women with breast cancer to reduce variation in surgical practice: A qualitative study of physicians' views

BackgroundRecently the impact of completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy on significant outcomes has been questioned, leading to variation in surgical practice. To address this variation, a multidisciplinary working group created a regional guideline for cALND. We explored the views and experiences of surgeons, medical oncologists (MOs), radiation oncologists (ROs) in a qualitative study that examined guideline implementation in practice. MethodsThe Pathman framework (awareness, agreement, adoption and adherence) informed the interview guide design and analysis. Semi-structured interviews were conducted with MOs, ROs and surgeons and transcribed. Transcripts were coded independently by 2 members of the study team and analyzed. Disagreements were resolved through consensus. ResultsTwenty-eight physicians (5 MO; 6RO; 17S) of 41 (68% of those approached) were interviewed. Ten of 11 (91%) hospital sites (54% community; 46% academic) and all 4 cancer clinics within the region were represented. Twenty-seven physicians (96%) were aware of the guideline, with all physicians reporting agreement and general adherence to the guideline. Most physicians indicated nodal factors, age and patient preference were key components of cALND decision-making. Physicians from all disciplines perceived that the guideline helped reduce variation in practice across the region. There were concerns that the guideline could be applied rigidly and not permit individual decision-making. ConclusionsPhysicians identified breast cancer as an increasingly complex and multidisciplinary issue. Facilitators to guideline implementation included perceived flexibility and buy-in from all disciplines, while individual patient factors and controversial supporting evidence may hinder its implementation.

Preoperative removal of lower third molars and bilateral sagittal split osteotomy in the UK

To find out what consultants in Oral and Maxillofacial Surgery (OMFS) in the UK think about complications of bilateral sagittal split osteotomy (BSSO) in relation to lower third molars we organised a national postal questionnaire during 2012-13. Of 378 consultants, 192 practised orthognathic surgery of whom 132 replied (a 69% response rate). Eighty-one respondents routinely removed lower third molars before BSSO; 51 did not. Eighty-nine respondents thought that there was an increased risk of complications if third molars were present at the time of BSSO, mainly an increased risk of unfavourable fractures. Forty-three respondents did not think there was an increased risk of complications of BSSO when third molars were present. Of the 81 who routinely removed the lower third molars, 13 removed them within the six-month period before BSSO, 56 removed them 6-12 months before, and 11 removed them more than 12 months before. There seemed to be no difference in self-reported unfavourable fracture rates between those surgeons who routinely removed lower third molars and those who did not. The results of the questionnaire showed that there was considerable variation in surgical practice across the UK in the management of lower third molars before BSSO, both in terms of whether or not to remove these teeth at all, and if so, when to remove them.