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MCC 2011 - Slide 23
 

MCC 2011 - Slide 23

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    MCC 2011 - Slide 23 MCC 2011 - Slide 23 Presentation Transcript

    • Colorectal Cancer Audit Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden
    • Quality control in surgery
    • Quality control in surgery
      • There is only one way
      • Registration and audit !
    • Quality control in surgery
      • The Swedish model
      • National registries
      • Population - based data
      • All hospitals involved !
      • Mandatory to participate
      • Transparent reports
    • Quality control in surgery
      • Requirements for a ‘good’ registry
      • Population - based
      •  100 % of patients registered
      • All hospitals involved
      • Few ‘missing’ data in all parameters
      • ‘ Good’ follow-up
    • Quality control in surgery
      • If not 100 % ?
      • At least those hospitals involved should include 100 % !
    • Why 100 % ?
    • Quality control in surgery
      • The ‘Lap-chole’ Registry
      • One end - point was injury to the common bile - duct
      • 95 % of all patients registered
      • No increased risk compared to open surgery !
    • Quality control in surgery
      • The ‘Lap-chole’ Registry
      • The common bile - duct injuries was found among the 5 % not registered !
      • They were referred to a tertiary hospital for treatment and were missed !
    • Quality control in surgery
      • How to use registries ?
      • Interpret unexpected findings
      • Evaluate outcomes ?
      • Define end - points !
      • Compare units ?
    • Unexpecting findings
    • Swedish Rectal Cancer Registry
      • Anastomotic leaks (%) after ant. resection
    • Anastomotic leakage study
      • Leakage rate
      • Stapler A 84/1,150 7 %
      • Stapler B 126/1,173 11 %
      • Unknown 83/993 8 %
      • p = 0.0039
      Folkesson et al. Colorectal Disease 2004
    • Anastomotic leakage study
      • Conclusion
      • How come these results ?
      • Confounding factors ?
      • Do we just measure individual surgeons ?
      • Place for a randomised trial ?
      Folkesson et al. Colorectal Disease 2004
    • Stapler trial
      • The randomised trial
      • Tyco has a new stapler we must stop the trial
      • > 500 patients included
      • Interim analysis showed less leakage than calculated >1,600 must than be included
      • Several centres were using the new Tyco stapler
    • Stapler trial
      • Results
      • Leakage overall 8,3 %
      • Tyco 18/259 6,9 %
      • Ethicon 25/254 9,8 %
      • p = 0.33
      Folkesson et al. Manuscript
    • Conclusion
      • A fool with a tool
      • is still just a fool
    • Evaluate outcomes
    • Swedish Hip Replacement Registry
      • > 200.000 Hip Replacements
      • Some are good
      • Some (4 different providers) have such bad results that they have been ‘thrown out’ from Sweden !
      • Why invest in the bad one ?
      • How to avoid providers with bad devices if they have no data !
    • Conclusion
      • Why do not surgical devices undergo the same critical evaluations as drugs ?
    • Define end-points
    • Quality Assurance in Surgery
      • Rectal Cancer ideal
      • End - points well defined
      • A common disease
      • Surgery an important treatment option
    • Quality Control in Surgery
      • Rectal Cancer; end - points
      • Postop. morbidity and mortality
      • Sphincter preservation
      • Local recurrence
      • Survival
      • Quality of life
    • Transparent reports
    • Swedish Rectal Cancer Registry
      • Data report
      • Feed - back to surgeons
      • National report every year
      • Data divided for each region
      • Data divided for each unit
      • Data based on volume
    • Swedish Rectal Cancer Registry
      • 30 days mortality according to volume (AR, APR and Hartmann) 1995 - 2004
    • Postoperative mortality
    • Swedish Rectal Cancer Registry
      • Postop. mortality; ASA IV
    • Swedish Rectal Cancer Registry
      • Postop. MDT-conference
    • Swedish Rectal Cancer Registry
      • Postop. MDT-conference
    • Swedish Rectal Cancer Registry
      • Included in trials
    • Swedish Rectal Cancer Registry
      • Included in trials
    • Swedish Rectal Cancer Registry
      • Protecting stoma
    • Swedish Rectal Cancer Registry
      • Peroperative bleeding
    • Swedish Rectal Cancer Registry
      • More than 12 lymph nodes
    • Local recurrence High volume hospital
    • Local recurrence rate
    • 5-year survival
    • Hospital volume
    • Volume - fact or fancy
      • What is a low volume ?
      • One procedure / week
      • One procedure / month
      • One procedure / year
    • Swedish Rectal Cancer Registry
      • Proportion procedures AR, APR or Hartmann according to hospital volume
    • Swedish Rectal Cancer Registry
      • Local recurrence rates according to
      • hospital volume 1995 - 2002
      • irradiated not irradiated
    • Quality Control in Surgery
      • Differences among hospitals
      • The differences between low - and high - volume hospitals is less than;
      • the differences between some high volume hospitals
    • Aim - related scores
    • Swedish Rectal Cancer Registry
      • Important data from 2001
      • Total number 1,510
      • 48 % LAR 24 % APR
      • 46 % preop. irradiation
      • 35 % overall postop. complications
      • 9 % re-operations within 30 days
      • 2.5 % postop. mortality
      • 7 % local recurrence rate
      • 47 % OS 60 % RS
    • Rectal Cancer in Sweden
      • A tremendous change !
      • From > 30 % local failure rate at
      • the end of the 80’s in most centres
      • to  7 % in the new century.
      • Survival improved !
    •  
    • Smoking is dangerous
    • Swedish Rectal Cancer Registry
      • Local recurrence rates 1995 - 2002
      • All patients R 0 surgery
    • Swedish Rectal Cancer Registry
      • Local recurrence rates 1995 - 2002
      • Stage I -II Stage III
    • Swedish Rectal Cancer Registry
      • Relative survival according to geographic region 1995 - 2007
    • Swedish Rectal Cancer Registry
      • Relative survival according to stage 1995 – 2007
      • Stage I Stage II
    • Swedish Rectal Cancer Registry
      • Relative survival according to stage 1995 – 2007
      • Stage III Stage IV
    • Quality Assurance in Surgery
      • How to improve further ?
      • Close the hospital ?
      • Propose training
      • Supervise surgery
      • Aim – related scores
    • Swedish Rectal Cancer Registry
      • Adjuvant chemotherapy
    • Swedish Rectal Cancer Registry
      • Hospital stay
    • Swedish Rectal Cancer Registry
      • Irrigation of rectal stump
      • 1999 - 2002 2003 - 2007
      13 42 39 103 52 52 41 56 48 40 51 85 69 85 88 89 62 91 79 185 74 97 66 40 36 73 32 28 21 28 22 17 20 28 21 17 17 14 9 11 7 5 2 0 0% 20% 40% 60% 80% 100% Huddinge Eskilstuna Skövde Östra sjukhuset Karlstad Örebro Gävle Lund Karolinska, Solna Linköping Kristianstad Södersjukhuset Danderyd St Görans Malmö Uppsala Borås Uddevalla Umeå Ersta Falun Västerås Sköljda Ej sköljda