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.