Investigating and managing chronic dysphagia: Dysphagia should prompt urgent gastroenterological referral (original) (raw)
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Adverse events reporting in English hospital statistics: Patients should be involved as partners
BMJ, 2004
Improving mortality of coronary surgery Study conclusions are paradoxical Editor-The findings of the study by Bridgewater et al of improving mortality of coronary surgery over the first four years of independent practice in 15 surgeons are relevant and clinically important. 1 But aren't the conclusions paradoxical? The authors report that mortality in patients operated on by newly appointed consultant surgeons is similar to mortality in patients operated on by established consultants. Yet new consultants experience a halving in mortality after four years when they become established consultants. The reason is that Bridgewater et al used their peers as the benchmark to qualify the first statement, and their own results for the second. This modest group of surgeons have underplayed their own good results that become excellent after four years; the final ratio of observed mortality to expected mortality of 0.36 compared with the additive EuroSCORE is impressive. Unfortunately, this affects the conclusions. The advantage that the authors used themselves as a benchmark for established consultants offers a more valid comparison. Case selection, operative performance, and management of postoperative complications will inevitably be more similar. If so, the conclusions would say that mortality in patients operated on by newly appointed consultants is twice that of established surgeons (the authors using themselves as internal controls). The real yardstick would be the next 15 newly appointed surgeons to the Northwest region comparing their results with established surgeons, as these new consultants would compare their initial results with a lower Northwest average (because of the contribution of this excellent newly appointed cohort). In this way a more accurate comparison would be obtained to determine if the results of newly appointed surgeons are on a par with their established peers.
Adverse events reporting in English hospital statistics: Authors' reply
BMJ, 2004
Improving mortality of coronary surgery Study conclusions are paradoxical Editor-The findings of the study by Bridgewater et al of improving mortality of coronary surgery over the first four years of independent practice in 15 surgeons are relevant and clinically important. 1 But aren't the conclusions paradoxical? The authors report that mortality in patients operated on by newly appointed consultant surgeons is similar to mortality in patients operated on by established consultants. Yet new consultants experience a halving in mortality after four years when they become established consultants. The reason is that Bridgewater et al used their peers as the benchmark to qualify the first statement, and their own results for the second. This modest group of surgeons have underplayed their own good results that become excellent after four years; the final ratio of observed mortality to expected mortality of 0.36 compared with the additive EuroSCORE is impressive. Unfortunately, this affects the conclusions. The advantage that the authors used themselves as a benchmark for established consultants offers a more valid comparison. Case selection, operative performance, and management of postoperative complications will inevitably be more similar. If so, the conclusions would say that mortality in patients operated on by newly appointed consultants is twice that of established surgeons (the authors using themselves as internal controls). The real yardstick would be the next 15 newly appointed surgeons to the Northwest region comparing their results with established surgeons, as these new consultants would compare their initial results with a lower Northwest average (because of the contribution of this excellent newly appointed cohort). In this way a more accurate comparison would be obtained to determine if the results of newly appointed surgeons are on a par with their established peers.
Hospital episode statistics: time for clinicians to get involved?
Clinical Medicine, 2002
The validity of hospital episode statistics was questioned by Körner in 1982. Recent publications have shown that problems persist in England and Wales, and that the quality of the data is inadequate for the task. The lack of involvement of clinicians in the process of data collection and validation is no longer acceptable. To rectify the situation there should be a change of process and culture, supported by education and investment. NHS data definitions of terms such as 'spells' , 'episodes' and 'diagnoses' need to be reviewed. The development of separate data processes to monitor national service frameworks is regrettable.
The Lancet
Evidence before this study Emergency abdominal surgery is associated with poor post-operative outcomes. Around 30,000 patients undergo this type of surgery each year in the UK National Health Service (NHS), with 30-day mortality rates in excess of 10% and wide variation in standards of care between hospitals. We searched for peer reviewed publications describing the effects of quality improvement programmes on survival for adult patients using the terms 'emergency abdominal surgery' and 'emergency laparotomy'. Several groups have studied the effect of quality improvement initiatives to implement individual interventions or 'care bundles' of several treatments, and so improve care for these patients. Overall, the findings of these small studies suggest survival benefit, but most utilised weak study designs associated with a high risk of bias. The feasibility and benefit of a national quality improvement programme to implement a more extensive acute care pathway for this patient group remain uncertain. Added value of this study We conducted a large national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. In a stepped-wedge cluster randomised trial of 15,873 patients aged ≥40 years, in 93 NHS hospitals organised into fifteen geographical clusters, we did not identify any survival benefit at either 90 or 180 days after surgery. There was good engagement with the quality improvement programme but staff had limited time and resources to implement change. Consequently, there were only modest overall changes in the processes of patient care from before to after quality improvement implementation. There were wide variations in intervention fidelity between hospitals, with differences in the processes teams tried to change, the rate of change and eventual success. Implications of all the available evidence Despite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.