Surgery (RMH) - Theses
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ItemAn international comparison of outcomes in acute diverticulitis( 2016)Acute diverticulitis is an increasingly common disease but the rate of emergency operative intervention for this condition is decreasing. Despite this decrease, there has been no obvious detriment in outcomes, which suggests that emergency operative intervention may not always improve outcomes. Operative intervention represents higher resource use compared with non-operative intervention. Excessive utilisation of healthcare resources without improvement of outcomes threatens the sustainability of healthcare. Value in healthcare has become a global priority in the developed world. The term ‘value’ represents the optimum use of healthcare resources for quality in outcomes. International variation in surgical practice and outcomes can highlight differences in the value of healthcare systems around the world. The drivers of resource utilisation in healthcare are complex and include financial incentives for surgical activity. The surgical community can improve the value of surgical care by reducing variation through use of the most efficient surgical practices. Administrative data are routinely collected for every inpatient admission in most countries. They are stored as alphanumeric codes for diagnoses and procedures that occur during each inpatient episode. Advances in computing have unlocked the ‘big data’ era and administrative data are currently the only feasible method for international comparisons. Their optimum use as a measurement tool remains undefined. This thesis aimed to explore the limits of administrative data in the context of acute diverticulitis. Specifically, it explored the use of administrative data in performing an international comparison of the emergency operative intervention rate between USA, England and Australia. It also examined their ability to provide meaningful outcomes data about acute diverticulitis admissions in each country. This sets a foundation for their use in surgical audit. Differences in international coding systems require the use of logic algorithms to more clearly define cohorts of uncomplicated and complicated diverticulitis in each country. These algorithms represent combinations of codes that could account for international differences in coding systems as well as predict variations in coding. These logic algorithms were developed after a chart review of Australian coding for diverticular disease. This focussed on how cases that were missed by only searching for diverticular codes, were actually coded. This novel method can be applied to outcomes research in other diseases. Outcomes for unplanned admissions for acute diverticulitis were explored in several hospitals in each of the three countries. The Dr Foster Global Comparators international dataset containing administrative data from hospitals in these countries was used. In addition to providing meaningful outcomes data for a patient with acute diverticulitis in each of these countries, we showed that Hartmann’s procedure remains the most common emergency operation for acute complicated diverticulitis in these countries. Multivariable logistic regression analysis found that Australia had the lowest propensity for emergency operation and that England had the highest inpatient mortality risk for acute diverticulitis. This demonstration of international variation suggests differences in international resource utilisation, their outcomes and therefore healthcare value. This thesis shows how administrative data can be used to measure international variation in the management and outcomes of surgical disease, which is a critical process in addressing healthcare resource utilisation and value.
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ItemImpact of consultant-led care on patient outcomes within an acute care surgical unit( 2016)Background and aims: Healthcare services globally are faced with having to respond to increasing demands of emergency surgery presentations. It is widely recognised that the care and management of emergency patients needs to be prioritised and improved. Consultant-led acute surgical units are being increasingly introduced as a means of addressing this need. To date, improvements in patient outcomes within the acute surgical unit model of care have been reported in the context of prevalent conditions such as acute cholecystitis and acute appendicitis. Studies involving all emergency general surgical conditions have been lacking. The aim of this study was to determine the impact of consultant-led model of care on patient outcomes within an acute care surgical unit at a tertiary centre. In addition to being inclusive of all emergency general surgical conditions, it aimed to report on multiple outcomes including: morbidity and mortality, timeliness of care, elective surgery workload and cancellation rate, as well as impact on surgical training and education. The workforce involved in provision of emergency general surgery at both trainee and consultant level was surveyed to determine current perceptions and future challenges facing consultant-led acute surgical units in Australia. Methods: A retrospective observational study of all consecutive emergency general surgical admissions in 2009-2012 was performed. A 2-year time frame before and after the establishment of the emergency general surgery (EGS) service was used to determine the number of admissions and operations, emergency department and hospital length of stay, as well as complication rates for all emergency general surgery patients. For patients presenting with acute benign biliary disease additional outcomes of time to theatre, rate of definitive surgical management during index admission, conversion from laparoscopic to open cholecystectomy rate, and use of diagnostic radiology in management of biliary disease was determined. On-line questionnaires were used to qualitatively assess the impact on the surgeons and trainees involved in provision of emergency general surgery. Results: The study included 7233 acute admissions. The EGS service managed 4468 patients (61·6 per cent increase) and performed 1804 operations (41·0 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 11·9 per cent), biliary disease (361, 8·1 per cent) and abdominal pain (561, 12·6 per cent). Appendicectomy (536, 29·7 per cent), cholecystectomy (239, 13·2 per cent) and laparotomy (226, 12·5 per cent) were the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 8·0 to 6·0 h; P < 0·001), as was length of hospital stay (from 3·0 to 2·0 days; P < 0·001). The number of complications was reduced by 46·8 per cent, from 172 (6·2 per cent) to 147 (3·3 per cent) (P < 0·001), with a 53 per cent reduction in the number of deaths in the EGS period, from 29 (16·9 per cent) to seven (8 per cent) (P = 0·039). A total of 566 patients with benign biliary disease were further analysed (pre-EGS 254 vs. EGS 312). In the EGS period, the number of patients having surgery on index admission increased from 43.7 to 58.7 per cent (p < 0.001) as did use of intra-operative cholangiography from 75.7 to 89.6 per cent (p = 0.003). The conversion to open cholecystectomy rate was reduced from 14.4 to 3.3 per cent (p < 0.001). Overall, a 14 per cent reduction in use of multiple (>1) imaging modalities for diagnosis was noted (p = 0.003). There was a positive trend in reduction of bile leaks but no significant difference in the overall morbidity and mortality. Time to theatre was reduced by 1 day [pre-EGS 2.7 (IQR 1.5-5.0) vs. EGS 1.7 (IQR 1.2-2.6) p < 0.001]. The overall hospital LOS was reduced by 1.5 days [pre-EGS 5.0 (IQR 3-7) vs. EGS 3.5 (IQR 2-5) p < 0.001]. In the EGS period of the study, elective surgery workload increased by 23.7 per cent with a corresponding 16.9 per cent reduction in cancellation rates. Consultant presence in theatre, and surgical trainees’ primary operating role also increased by 12 and 21.5 per cent respectively. The surveys demonstrated overall support for the consultant-led model of acute surgical units. Impact on private practice, remuneration and need for appropriate resource allocation were highlighted as issues needing further consideration. Conclusions: The establishment of a consultant-led emergency surgical service has been associated with improved provision of care, resulting in timely management and improved clinical outcomes.