Assessment of whether in-hospital mortality for lobectomy is a useful standard for the quality of lung cancer surgery: retrospective study

Objectives To calculate in-hospital mortality after lobectomy for primary lung cancer in the United Kingdom; to explore the validity of using such data to assess the quality of UK thoracic surgeons; and to investigate the relation between in-hospital mortality and the number of procedures performed by surgeons.Design Retrospective study.Setting 36 departments dealing with thoracic surgery in UK hospitals.Participants 4028 patients who had undergone lobectomy for primary lung cancer by one of 102 surgeons.Main outcome measures In-hospital mortality in relation to individual surgeons, among all patients, and among each of five groups of patients defined by the number of operations performed by the surgeon.Results 103 patients (2.6%, 95% confidence interval 2.1% to 3.1%) died after surgery during the same hospital admission. No significant difference was found for in-hospital mortality between the five groups.Conclusions The number of procedures performed by a thoracic surgeon is not related to in-hospital mortality. Reporting data on in-hospital mortality after lobectomy for primary lung cancer is a poor tool for measuring a surgeon''s performance.     

Effect of polynomial,radial basis,and Pearson VII function kernels in support vector machine algorithm for classification of crayfish

Freshwater crayfish are one of the most important aquatic organisms that play a pivotal role in the aquatic food chain as well as serving as bioindicators for the aquatic ecosystem health assessment. Hemocytes, the blood cells of crustaceans, can be considered stress and health indicators in crayfish, and are used to evaluate the health response. Therefore, total hemocyte cell numbers (THCs) are useful parameters to show the health of crustaceans and serve as stress indicators to decide the quality of the habitat. Since, catching the fish and the other aquatic organisms, and collecting the data for further assessments are time-consuming and frustrating, today, scientists tend to use swift, more sophisticated, and more reliable methods for modeling the ecosystem stressors based on bioindicators. One tool which has attracted the attention of science communities in the last decades is machine learning algorithms that are reliable and accurate methods to solve classification and regression problems. In this study, a support vector machine is carried out as a machine learning algorithm to classify healthy and unhealthy crayfish based on physiological characteristics. To solve the non-linearity problem of the data by transporting data to high-dimensional space, different kernel functions including polynomial (PK), Pearson VII function-based universal (PUK), and radial basis function (RBF) kernels are used and their effect on the performance of the SVM model was evaluated. Both PK and PUK functions performed well in classifying the crayfish. RBF, however, had an adverse impact on the performance of the model. PUK kernel exhibited an outstanding performance (Accuracy = 100%) for the classification of the healthy and unhealthy crayfish.     

Visiting through the night.

OBJECTIVE--To describe the time distribution of visits at night and to evaluate trends in night visits from 1982 to 1992. DESIGN--Analysis of a sample of one in 12 claim forms for night visits submitted over one year beginning 1 July 1991, and estimation of the number of night visits in previous years from data on payment. Further information was obtained from performance indicators from the Department of Health. SETTING--General practices responsible to Berkshire family health services authority. MAIN OUTCOME MEASURES--Times of night visits, proportion performed by deputies, and trend in number of night visits after adjusting for the increased hours during which visits are claimed. RESULTS--The change in the hours for which payment may be claimed accounted for 33.8% (536/1584) of all night visits in the sample. After visits during these extra two hours were excluded, claims increased by 38.7% from 1989 to 1992 and more than doubled in the past 10 years. Use of deputies both in Berkshire and in England and Wales dropped by more than half since 1989. General practitioners in Berkshire claimed 31.5 night visits per 1000 population in 1992. CONCLUSIONS--The increase in the number of night visits is only partly due to the change in hours during which visits may be claimed. It is also due to a long term and possibly accelerating rise in demand. This is despite a major reduction in the proportion of calls performed by deputising services, the use of which had been said to be the main factor increasing the numbers of night visits.     

School Performance: A Matter of Health or Socio-Economic Background? Findings from the PIAMA Birth Cohort Study

Background

Performance in primary school is a determinant of children’s educational attainment and their socio-economic position and health inequalities in adulthood. We examined the relationship between five common childhood health conditions (asthma symptoms, eczema, general health, frequent respiratory infections, and overweight), health related school absence and family socio-economic status on children’s school performance.

Methods

We used data from 1,865 children in the Dutch PIAMA birth cohort study. School performance was measured as the teacher’s assessment of a suitable secondary school level for the child, and the child’s score on a standardized achievement test (Cito Test). Both school performance indicators were standardised using Z-scores. Childhood health was indicated by eczema, asthma symptoms, general health, frequent respiratory infections, overweight, and health related school absence. Children’s health conditions were reported repeatedly between the age of one to eleven. School absenteeism was reported at age eleven. Highest attained educational level of the mother and father indicated family socio-economic status. We used linear regression models with heteroskedasticity-robust standard errors for our analyses with adjustment for sex of the child.

Results

The health indicators used in our study were not associated with children’s school performance, independently from parental educational level, with the exception of asthma symptoms (-0.03 z-score / -0.04 z-score with Cito Test score after adjusting for respectively maternal and paternal education) and missing more than 5 schooldays due to illness (-0.18 z-score with Cito Test score and -0.17 z-score with school level assessment after adjustment for paternal education). The effect estimates for these health indicators were much smaller though than the effect estimates for parental education, which was strongly associated with children’s school performance.

Conclusion

Children’s school performance was affected only slightly by a number of common childhood health problems, but was strongly associated with parental education.     

Regional Differences in Intervention Coverage and Health System Strength in Tanzania

Background

Assessments of subnational progress and performance coverage within countries should be an integral part of health sector reviews, using recent data from multiple sources on health system strength and coverage.

Method

As part of the midterm review of the national health sector strategic plan of Tanzania mainland, summary measures of health system strength and coverage of interventions were developed for all 21 regions, focusing on the priority indicators of the national plan. Household surveys, health facility data and administrative databases were used to compute the regional scores.

Findings

Regional Millennium Development Goal (MDG) intervention coverage, based on 19 indicators, ranged from 47% in Shinyanga in the northwest to 71% in Dar es Salaam region. Regions in the eastern half of the country have higher coverage than in the western half of mainland. The MDG coverage score is strongly positively correlated with health systems strength (r = 0.84). Controlling for socioeconomic status in a multivariate analysis has no impact on the association between the MDG coverage score and health system strength. During 1991–2010 intervention coverage improved considerably in all regions, but the absolute gap between the regions did not change during the past two decades, with a gap of 22% between the top and bottom three regions.

Interpretation

The assessment of regional progress and performance in 21 regions of mainland Tanzania showed considerable inequalities in coverage and health system strength and allowed the identification of high and low-performing regions. Using summary measures derived from administrative, health facility and survey data, a subnational picture of progress and performance can be obtained for use in regular health sector reviews.     

Evidence based purchasing: understanding results of clinical trials and systematic reviews.

OBJECTIVE--To assess whether the way in which the results of a randomised controlled trial and a systematic review are presented influences health policy decisions. DESIGN--A postal questionnaire to all members of a health authority within one regional health authority. SETTING--Anglia and Oxford regional health authorities. SUBJECTS--182 executive and non-executive members of 13 health authorities, family health services authorities, or health commissions. MAIN OUTCOME MEASURES--The average score from all health authority members in terms of their willingness to fund a mammography programme or cardiac rehabilitation programme according to four different ways of presenting the same results of research evidence--namely, as a relative risk reduction, absolute risk reduction, proportion of event free patients, or as the number of patients needed to be treated to prevent an adverse event. RESULTS--The willingness to fund either programme was significantly influenced by the way in which data were presented. Results of both programmes when expressed as relative risk reductions produced significantly higher scores when compared with other methods (P < 0.05). The difference was more extreme for mammography, for which the outcome condition is rarer. CONCLUSIONS--The method of reporting trial results has a considerable influence on the health policy decisions made by health authority members.     

Status of Bone Allografting in Japan – Nation-Wide Survey of Bone Grafting Performed from 1995 through 1999

We report the status of bone allografting in Japan on the basis of the information obtained through questionnaires performed by the Japanese Orthopaedic Association (JOA). JOA performed a nation-wide survey in 2000, in order to clarify the current status of musculoskeletal tissue grafting in the orthopaedic practices in Japan. Conducted period was for 5 years from 1995 to 1999. As the results of this survey, it had been clarified that 92,984 bone graftings, which included autografts, allografts and synthetic bone substitutes, were performed during conducted 5 years. While the allografts were used only in 3,212 cases (3%), autograftings were performed in 64,193 cases (69%), synthetic bone substitutes were used in 25,576 cases (28%) in this series. The proportion of the number of operations for use bone substitutes increased every year, whereas that autografting decreased. The proportion of the number of allografting remained almost unaltered. Of the 706 institutions which answered to have experiences of tissue grafting, only 193 (27%) performed allograft.Since Kitasato University Hospital Bone Bank was developed in 1971, we have applied to clinical while doing basic research for preserved bone allograft. When extensive bone graft is required, allograft is very useful. In Japan, however, allograft is not performed widely. The foundation of regional bone banks is expected to resolve this problem. Since excision of bone preparations from cadaver donors is not common, bone allografts are not supplied sufficiently at present. It is needed to develop a network connecting bone banks in Japan. The enlightenment activities to the ordinary people and medical institutions will also be required.     

Housing,health, and illness.

Cases referred to a community physician in his role as medical adviser to a housing authority were reviewed. A new system of classifying health problems was devised because conventional diagnostic classification was found to be inappropriate. The effectiveness of medical intervention was apparently low, since only 29 out of 612 (4.7%) applications for rehousing on medical grounds were successful. The effectiveness of the community physician''s role was limited by the available resources and the number of cases he could take before the housing committee. It is proposed that the use of medical resources for intervention in such cases is acceptably efficient, though this proposal is based on value judgement rather than on economic grounds. Doctors should be concerned in improving housing conditions, which are still unacceptably poor in many parts of Britain, in the interests of improving general standards of public health.     

Audit of prenatal diagnosis for haemoglobin disorders in the United Kingdom: the first 20 years.

OBJECTIVES: To audit services for prenatal diagnosis for haemoglobin disorders in the United Kingdom. DESIGN: Comparison of the annual number of cases recorded in a United Kingdom register of prenatal diagnoses for haemoglobin disorders, with the annual number of pregnancies at risk of these disorders, by ethnic group and regional health authority. The number of pregnancies at risk was estimated using data on ethnic group from the 1991 census and data from the United Kingdom thalassaemia register, which records the number of babies born with thalassaemia. SETTING: The three national prenatal diagnosis centres for haemoglobin disorders. SUBJECTS: 2068 cases of prenatal diagnosis for haemoglobin disorders in the United Kingdom from 1974 to 1994. MAIN OUTCOME MEASURES: Utilisation of prenatal diagnosis by risk, ethnic group, and regional health authority. Proportion of referrals in the first trimester and before the birth of any affected child. RESULTS: National utilisation of prenatal diagnosis for haemoglobin disorders was around 20%. During the past 10 years it has remained steady at about 50% for thalassaemias and risen from 7% to 13% for sickle cell disorders. Utilisation for sickle cell disorders varies regionally from 2% to 20%. Utilisation for thalassaemias varies by ethnic group. It is almost 90% for Cypriots and ranges regionally for British Pakistanis from 0% to over 60%. About 60% of first prenatal diagnoses are done for couples without an affected child. Less than 50% of first referrals are in the first trimester. CONCLUSIONS: National utilisation of prenatal diagnosis for haemoglobin disorders is far lower than expected, and there are wide regional variations. A high proportion of referrals are still in the second trimester and after the birth of an affected child. The findings point to serious shortcomings in present antenatal screening practice and in local screening policies and to inadequate counselling resources, especially for British Pakistanis.     

Quantifying the Validity of Routine Neonatal Healthcare Data in the Greater Accra Region,Ghana

Objectives

The District Health Information Management System–2 (DHIMS–2) is the database for storing health service data in Ghana, and similar to other low and middle income countries, paper-based data collection is being used by the Ghana Health Service. As the DHIMS-2 database has not been validated before this study aimed to evaluate its validity.

Methods

Seven out of ten districts in the Greater Accra Region were randomly sampled; the district hospital and a polyclinic in each district were recruited for validation. Seven pre-specified neonatal health indicators were considered for validation: antenatal registrants, deliveries, total births, live birth, stillbirth, low birthweight, and neonatal death. Data were extracted on these health indicators from the primary data (hospital paper-registers) recorded from January to March 2012. We examined all the data captured during this period as these data have been uploaded to the DHIMS-2 database. The differences between the values of the health indicators obtained from the primary data and that of the facility and DHIMS–2 database were used to assess the accuracy of the database while its completeness was estimated by the percentage of missing data in the primary data.

Results

About 41,000 data were assessed and in almost all the districts, the error rates of the DHIMS-2 data were less than 2.1% while the percentages of missing data were below 2%. At the regional level, almost all the health indicators had an error rate below 1% while the overall error rate of the DHIMS-2 database was 0.68% (95% C I = 0.61–0.75) and the percentage of missing data was 3.1% (95% C I = 2.96–3.24).

Conclusion

This study demonstrated that the percentage of missing data in the DHIMS-2 database was negligible while its accuracy was close to the acceptable range for high quality data.     

The UK cardiac surgical register, 1977-82.

Data for 1977-82 obtained from the Cardiac Surgical Register, established by the Society of Thoracic and Cardiovascular Surgeons of Great Britain and Northern Ireland in 1977, were analysed for trends in incidence and mortality of cardiac surgery and regional workload in the United Kingdom. Operative mortality for most types of cardiac operation showed a general decline. The numbers of operations performed for valvular and congenital heart disease had remained unchanged, but a striking increase had occurred in the number of coronary bypass graft operations: 2297 in 1977 to 6008 in 1982. The figure for 1982, representing an annual rate of 107 operations per million population, was still well below that for other countries such as Australia (410 per million in 1982) and the United States (750 per million in 1981). A wide variation was seen in the regional provision of cardiac surgical services within the United Kingdom. This was particularly appreciable for coronary bypass graft surgery, in which there was a 10-fold difference in numbers of operations performed between the various regions. The UK Cardiac Surgical Register provides an important source of information on trends within the specialty that could well be followed by other surgical specialties.     

30-Day Survival Probabilities as a Quality Indicator for Norwegian Hospitals: Data Management and Analysis

Background

The Norwegian Knowledge Centre for the Health Services (NOKC) reports 30-day survival as a quality indicator for Norwegian hospitals. The indicators have been published annually since 2011 on the website of the Norwegian Directorate of Health (www.helsenorge.no), as part of the Norwegian Quality Indicator System authorized by the Ministry of Health. Openness regarding calculation of quality indicators is important, as it provides the opportunity to critically review and discuss the method. The purpose of this article is to describe the data collection, data pre-processing, and data analyses, as carried out by NOKC, for the calculation of 30-day risk-adjusted survival probability as a quality indicator.

Methods and Findings

Three diagnosis-specific 30-day survival indicators (first time acute myocardial infarction (AMI), stroke and hip fracture) are estimated based on all-cause deaths, occurring in-hospital or out-of-hospital, within 30 days counting from the first day of hospitalization. Furthermore, a hospital-wide (i.e. overall) 30-day survival indicator is calculated. Patient administrative data from all Norwegian hospitals and information from the Norwegian Population Register are retrieved annually, and linked to datasets for previous years. The outcome (alive/death within 30 days) is attributed to every hospital by the fraction of time spent in each hospital. A logistic regression followed by a hierarchical Bayesian analysis is used for the estimation of risk-adjusted survival probabilities. A multiple testing procedure with a false discovery rate of 5% is used to identify hospitals, hospital trusts and regional health authorities with significantly higher/lower survival than the reference. In addition, estimated risk-adjusted survival probabilities are published per hospital, hospital trust and regional health authority. The variation in risk-adjusted survival probabilities across hospitals for AMI shows a decreasing trend over time: estimated survival probabilities for AMI in 2011 varied from 80.6% (in the hospital with lowest estimated survival) to 91.7% (in the hospital with highest estimated survival), whereas it ranged from 83.8% to 91.2% in 2013.

Conclusions

Since 2011, several hospitals and hospital trusts have initiated quality improvement projects, and some of the hospitals have improved the survival over these years. Public reporting of survival/mortality indicators are increasingly being used as quality measures of health care systems. Openness regarding the methods used to calculate the indicators are important, as it provides the opportunity of critically reviewing and discussing the methods in the literature. In this way, the methods employed for establishing the indicators may be improved.     

The extent of the two tier service for fundholders.

OBJECTIVE--To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners. DESIGN--Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995. SETTING--District health authority in south-west England. SUBJECTS--10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients. MAIN OUTCOME MEASURES--Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times. RESULTS--In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5. CONCLUSIONS--Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients.     

Neural network-based segmentation and classification system for automated grading of histologic sections of bladder carcinoma

OBJECTIVE: To develop an image analysis system for automated nuclear segmentation and classification of histologic bladder sections employing quantitative nuclear features. STUDY DESIGN: Ninety-two cases were classified into three classes by experienced pathologists according to the WHO grading system: 18 cases as grade 1, 45 as grade 2, and 29 as grade 3. Nuclear segmentation was performed by means of an artificial neural network (ANN)-based pixel classification algorithm, and each case was represented by 36 nuclei features. Automated grading of bladder tumor histologic sections was performed by an ANN classifier implemented in a two-stage hierarchic tree. RESULTS: On average, 95% of the nuclei were correctly detected. At the first stage of the hierarchic tree, classifier performance in discriminating between cases of grade 1 and 2 and cases of grade 3 was 89%. At the second stage, 79% of grade 1 cases were correctly distinguished from grade 2 cases. CONCLUSION: The proposed image analysis system provides the means to reduce subjectivity in grading bladder tumors and may contribute to more accurate diagnosis and prognosis since it relies on nuclear features, the value of which has been confirmed.     

Minor operations in general practice.

An analysis of minor operations performed in one general practice showed that one doctor doing an average of only four minor operations a week can save the area health authority over 15 000 pounds a year.     

Cost analysis of early discharge after hip fracture.

OBJECTIVE--To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN--Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING--District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS--1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES--Cost per patient episode and number of bed days spent in hospital. RESULTS--Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS--About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.     

Surgical training: an objective assessment of recent changes for a single health board.

The reduction in doctors'' hours and the introduction of specialist training have reduced general surgical training by 60%. This study assessed the implications for a single health board. A questionnaire listing 13 representative operations was sent to 44 trainees and 52 trainers to determine the number of operations a trainee should perform. The total number of operations required for training was compared against the total actually performed across the health board. Operating times for five representative operations were audited prospectively. Trainers and trainees recommended a similar and conservative number of operations. The total number of operations available for training (4913) was 38% less than the number recommended (7946). Trainees required 50-75% more operating time than consultants. To increase the proportion of operations undertaken by trainees from the current 30% to 70% would require an extra 270 theatre days (of pounds 1.3m) yearly. The minimum number of operations required for training must be defined and the proportion of supervised operations undertaken by trainees substantially increased. Service and financial implications will have to be addressed. Action is needed urgently, as the first trainees will become consultants in less than five years.     

Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload.

OBJECTIVE--To present a more realistic assessment of surgical workload than that provided by a case count. DESIGN--Prospective study of all the operative procedures performed in one year, classified according to the British United Provident Association''s schedule of procedures and scored by the "intermediate equivalent" value (taking the recommended fee value of an intermediate operation as 1.0) compared with the number of operations performed. SETTING--General surgical unit of Taunton and Somerset Hospital, comparing four consultant surgeons and their teams. PATIENTS--Inpatients and day patients admitted under the care of general surgeons during 1989. MAIN OUTCOME MEASURE--Difference between the apparent workload represented by simple case counting (caseload) and the actual workload represented by calculation of the total "intermediate equivalent" value. RESULTS--The workload assessed in terms of intermediate equivalent values was greater than that suggested by case counting for complex operations (12% v 4%), operations at the district hospital (82% v 74%), and operations performed by consultants (53% v 35%) and was lower for minor operations (20% v 42%), operations at the community hospitals (18% v 26%), and operations performed by surgeons in training grades and clinical assistants (47% v 66%). CONCLUSIONS--The use of the intermediate equivalent values as an indicator of complexity allows a more realistic assessment of the operative workload than a simple case count of the number of different operations and is recommended for comparing workload in different hospitals and departments.     

Joint analysis of time-to-event and multiple binary indicators of latent classes

Multiple categorical variables are commonly used in medical and epidemiological research to measure specific aspects of human health and functioning. To analyze such data, models have been developed considering these categorical variables as imperfect indicators of an individual's "true" status of health or functioning. In this article, the latent class regression model is used to model the relationship between covariates, a latent class variable (the unobserved status of health or functioning), and the observed indicators (e.g., variables from a questionnaire). The Cox model is extended to encompass a latent class variable as predictor of time-to-event, while using information about latent class membership available from multiple categorical indicators. The expectation-maximization (EM) algorithm is employed to obtain maximum likelihood estimates, and standard errors are calculated based on the profile likelihood, treating the nonparametric baseline hazard as a nuisance parameter. A sampling-based method for model checking is proposed. It allows for graphical investigation of the assumption of proportional hazards across latent classes. It may also be used for checking other model assumptions, such as no additional effect of the observed indicators given latent class. The usefulness of the model framework and the proposed techniques are illustrated in an analysis of data from the Women's Health and Aging Study concerning the effect of severe mobility disability on time-to-death for elderly women.