[Show abstract][Hide abstract] ABSTRACT: Organizational characteristics in English NHS hospitals and the experiences of patients with three common cancers - breast, colorectal and lung - were examined using secondary data analyses. Two specific measures of satisfaction, Respect and Dignity, reflecting inpatient care, and Communication reflecting hospital outpatient care, were drawn from a national survey of cancer patients after first hospital treatment. They were compared at hospital level with hospital cancer service standards, and measures of hospital provision, each drawn from national surveys. Respect and Dignity was greater in hospitals with fewer complaints, slower admission procedures and a greater proportion of medicine consultants, for breast and colorectal cancers only. For breast cancer alone, Respect and Dignity was greater in hospitals achieving more participation in meetings by lead team members at the cancer unit level. For lung cancer alone, there were tumour-specific team organizational measures (relating to outpatient assessment) associated with Communication. However, the majority of recorded standards did not show associations, and there were occasional negative associations (dissatisfaction). The impact of organizational factors on patients may be examined through observational studies when experimental designs are not possible. Understanding how organizational factors affect quality of care for cancer patients can contribute to planning and management of cancer services.
European Journal of Cancer Care 12/2008; 18(3):287-94. DOI:10.1111/j.1365-2354.2008.00966.x · 1.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Cancer Plan for England, introduced in 2000, has promoted cancer service specialization. We have investigated how far specialization and general hospital factors each contributed to service performance for four common cancers-breast, colorectal, lung and prostate-at the time of the Cancer Plan. Performance measures of service standards, waiting time to treatment, satisfaction with care, in-hospital mortality and population-level survival were identified from secondary data sets for 167 acute hospitals and 34 cancer networks in England. We correlated rankings of networks and hospitals between the data sets using non-parametric statistics. At cancer network level, peer-review service standards were associated (P < 0.05) with 1-year survival for colorectal and lung cancers, and waiting times for lung cancer. At hospital level, standards were associated (P < 0.01) with waiting time to treatment for breast and colorectal cancers. However, there were stronger associations between specializations within hospitals: rankings of breast, colorectal and prostate cancers were highly associated (P < 0.001) for 5-year survival, patient satisfaction, standards and in-hospital mortality. Hospital-level differences appear to contribute more to variations in cancer performance than specialization differences within hospitals. The findings may be used for planning and commissioning better cancer services.
Journal of Public Health 03/2008; 30(1):69-74. DOI:10.1093/pubmed/fdm081 · 2.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In 2000, the national cancer plan for England created 34 cancer networks, new organisational structures to coordinate services across populations varying between a half and three million people. We investigated the availability of data sets reflecting measures of structure, process and outcome that could be used to support network management.
We investigated the properties of national data sets relating to four common cancers - breast, colorectal, lung and prostate. We reviewed the availability and completeness of these data sets, identified leading items within each set and put them into tables of the 34 cancer networks. We also investigated methods of presentation.
The Acute Hospitals Portfolio and the Cancer Standards Peer Review recorded structural characteristics at hospital and cancer service level. Process measures included Hospital Episode Statistics, recording admissions, and Hospital Waiting-List data. Patient outcome measures included the National Survey of Patient Satisfaction for cancer, and cancer survival, drawn from cancer registration. Data were drawn together to provide an exemplar indicator set a single network, and methods of graphical presentation were considered.
While not as yet used together in practice, comparative indicators are available within the National Health Service in England for use in performance assessment by cancer networks.
BMC Health Services Research 02/2008; 8(1):45. DOI:10.1186/1472-6963-8-45 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to demonstrate the use of a graphical method for real-time monitoring of the occurrence of surgical wound infection following cardiac surgery. This included developing and incorporating a risk scoring system so that variations in case-mix could be duly accounted for in the monitoring process. We analysed routinely collected data from a London teaching hospital. These data consisted of records for 2146 patients who had undergone cardiac surgery between April 2000 and March 2004 and whose surgical wounds were followed up as part of the local surveillance programme. The risk model was developed using logistic regression analysis with surgical wound infection diagnosed before hospital discharge as the outcome measure. Factors included in the model were the number of surgical wounds, patient age, operations that combined bypass surgery and valve replacement, renal disease and the number of days between hospital admission and surgery. The model was a good predictor of outcomes recorded within an independent data set (Chi-squared=3.81, P=0.58) and we incorporated it into a graphical tool for monitoring outcomes. The risk model and the associated graphical monitoring method could be valuable tools to assist with infection management. If used in real-time, problems with the care process can be quickly identified allowing timely remedial action to be taken.
[Show abstract][Hide abstract] ABSTRACT: To predict the public health impact on cervical disease by introducing human papillomavirus (HPV) vaccination in the United Kingdom, we developed a mathematical model that can be used to reflect the impact of vaccination in different countries with existing screening programmes. Its use is discussed in the context of the United Kingdom. The model was calibrated with published data. The impact of vaccination on cervical cancer and deaths, precancerous lesions and screening outcomes were estimated for a vaccinated cohort of 12-year-old girls, among which it is estimated that there would be a reduction of 66% in the prevalence of high-grade precancerous lesions and a 76% reduction in cervical cancer deaths. Estimates for various other measures of the population effects of vaccination are also presented. We concluded that it is feasible to forecast the potential effects of HPV vaccination in the context of an existing national screening programme. Results suggest a sizable reduction in the incidence of cervical cancer and related deaths. Areas for future research include investigation of the beneficial effects of HPV vaccination on infection transmission and epidemic dynamics, as well as HPV-related neoplasms in other sites.
British Journal of Cancer 02/2007; 96(1):143-50. DOI:10.1038/sj.bjc.6603501 · 4.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to develop a graphical method of risk-stratified outcome analysis in paediatric cardiac surgery to provide a means of continuous, prospective performance monitoring and allow real-time detection of change in outcomes.
Risk-adjusted survival following open-heart surgery was prospectively measured over a 15-month period (n=460). Outcomes were charted using variable life-adjusted display (VLAD) charts, which indicate the cumulative difference in observed minus expected survival against the cumulative number of cases performed. Risk stratification was based on RACHS-1 (risk adjustment in congenital heart surgery) risk category and age at surgery, using our previously published risk model. The probability of deviation in performance from the expected baseline level was determined using a mathematical model.
By the end of the series, observed survival (443/460=96.3%) exceeded that predicted by the risk model (434.5/460=94.5%), equivalent to a one-third reduction in expected mortality. Mathematical modelling indicated a 1-5% likelihood that this difference would have occurred by random variation alone, suggesting the outcomes represented genuine improvement.
VLAD charts provide an effective, easily visualised display of surgical performance and can be applied to paediatric cardiac surgery. Early detection of change, whether improvement or deterioration, is important for ongoing quality assurance within a cardiac surgery programme.
European Journal of Cardio-Thoracic Surgery 06/2006; 29(5):693-7; discussion 697-8. DOI:10.1016/j.ejcts.2006.01.034 · 3.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Infections acquired during patients' hospital stays are a major health care concern in the UK. They can be fatal, lead to excess morbidity and lengthen hospital stay. There is therefore considerable interest in using analytical tools for monitoring the occurrence of infections so that any problems with the quality of patient care can be quickly identified and rectified. The development and implementation of such tools are complicated as some infections can be difficult to diagnose and it can take several weeks before an infection manifests itself. Another important issue is that some patients are more likely to contract an infection than others, regardless of the standard of care they receive. This paper describes work that has been undertaken in collaboration with University College London Hospitals (UCLH) to develop appropriate outcome monitoring tools for surgical wound infections that are easy for hospital staff to use and interpret. The underlying risk model has been developed and validated locally at UCLH, and for more widespread implementation it would require revalidation for new centres.
Journal of the Operational Research Society 05/2006; 58(2). DOI:10.1057/palgrave.jors.2602223 · 0.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Surgical wound surveillance with postdischarge follow-up is rarely done in the UK as it is seen as expensive. The aim of this study was to determine whether employing a dedicated team was effective and reduced costs.
Infection data were collected prospectively with postdischarge follow-up at 2-3 months, and fed back to surgeons. Wound infection was defined using both ASEPSIS wound scoring and criteria of the US Centers for Disease Control (CDC) definitions.
Over 4 years, 15 548 patient episodes were included. Postdischarge surveillance data were available for 79.9 per cent of the 15 154 records of patients who survived. There was a significant reduction in the rate of wound infection between the first and fourth years by ASEPSIS and CDC definitions: odds ratio 0.77 (95 per cent confidence interval (c.i.) 0.64 to 0.92) and 0.69 (95 per cent c.i. 0.57 to 0.83), respectively. The proportion of infections fell significantly in orthopaedic, cardiac and thoracic surgery. The annual budget for wound surveillance was pound 91,600. Changes in infection rates contributed pound 347,491 to the reduction in cost among the patients surveyed.
Wound surveillance was associated with a reduction in rates of wound infection within 4 years. The cost reduction as a result of fewer infections exceeded the cost of surveillance after 2 years.
British Journal of Surgery 05/2006; 93(5):630-8. DOI:10.1002/bjs.5303 · 5.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Quality control in clinical care is becoming increasingly more prevalent, resulting in a need for tools that can be readily used by clinical teams for monitoring their own performance. The aim of this study was to devise a practical and effective scheme for monitoring coronary care mortality in real-time.
We obtained data for 2153 consecutive patients admitted after acute myocardial infarction between 1st September and 30th November 1995 to one of 20 acute hospitals in West Yorkshire participating in the NHS R and D funded EMMACE-1 study. We developed control charts for each centre to monitor 30-day mortality. These control charts used two complementary tools: the Risk-Adjusted Cumulative Sum chart (CUSUM) and a new 'Rocket Tail' chart based upon the Variable Life-Adjusted Display (VLAD). We also combined information from each of these to devise a further chart.
Control charts are shown for two centres in order to illustrate the important features of the different but complimentary monitoring tools. The Risk-Adjusted CUSUM is shown to be useful for detecting isolated runs of unsatisfactory outcome results but is not 'intuitive', and does not give any indication of the preceding history of outcomes. The Rocket Tail chart is shown to give a good summary of outcome history and also how overall performance compares with what would be expected for the case-mix. A chart that combines both approaches appeals to the advantages of each.
We propose a visual approach to health-care monitoring that beneficially combines and extends the different information of the previously used CUSUM and VLAD charts.
International Journal of Cardiology 05/2005; 100(2):301-7. DOI:10.1016/j.ijcard.2004.12.009 · 4.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In recent years there has been a growing need for effective monitoring of clinical outcomes. Two techniques for continuous monitoring that have emerged almost simultaneously are the Variable Life-Adjusted Display (VLAD) and risk-adjusted cumulative sum charts (CUSUM). The VLAD provides clinicians and management with an easily understandable overview of outcome history and is now in routine use in several hospitals. Although it can indicate runs of good and bad outcomes, unlike the CUSUM, it does not provide a quantitative means for assessing whether they merit investigation. This paper introduces a scheme for applying control limits from CUSUM charts onto the VLAD, thus enhancing its role as an effective monitoring tool.
Health Care Management Science 03/2005; 8(1):61-5. DOI:10.1007/s10729-005-5217-2 · 1.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In recent years, there has been increasing use of analytical and graphical methods to assist the monitoring of outcomes in adult cardiac surgery. In this paper, we present extensions to the basic VLAD methodology that add flexibility and assist in its interpretation.
Using techniques from probability theory, we have devised graphical tools whereby deviations from expected outcomes can be monitored to see how likely they are to have occurred by chance. The methods are based upon pre-operative assessments of risk and use exact analytical techniques.
These tools allow deviations from expected outcomes to be readily assessed and compared with the distribution of chance outcomes. Appropriate colour coding allows interpretation in terms of a temperature gradient.
Exact analysis methods based on the use of pre-operative risk assessment provide a useful means for assisting the interpretation of VLAD charts. Such analysis has the advantage that it is applicable even for relatively short series of operations. Also, it takes specific account of the heterogeneity of case mix when quantifying the variability that is expected. By displaying the overall history of outcomes in a visually intuitive manner, it complements the more formal tools for detecting isolated good and bad runs that are available.
European Journal of Cardio-Thoracic Surgery 12/2004; 26(5):1032-6. DOI:10.1016/j.ejcts.2004.07.026 · 3.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to evaluate different options for introducing liquid-based cytology (LBC) and human papillomavirus (HPV) testing into the UK cervical cancer screening programme. These include options that incorporate HPV testing either as a triage for mild and borderline smear abnormalities or as a primary screening test. Outcomes include the predicted impact on resource use, total cost, life years and cost-effectiveness. Extensive sensitivity analysis has been carried out to explore the importance of the uncertainty associated with disease natural history and the impact of screening. Under baseline assumptions, the cost-effectiveness of different options for introducing LBC appears favourable, and these results are consistent under a range of assumptions for its impact on the diagnostic effectiveness of cytology. However, if we assume a higher marginal cost of LBC in comparison to conventional methods, primary smear testing options are predicted to be more cost-effective without LBC. Combined LBC primary smear and HPV testing with a 5-year interval is similar in both cost and effectiveness to the other 3-yearly options of primary smear testing or primary HPV testing alone. However, both primary HPV testing and combined options would give rise to a far greater risk of inappropriate colposcopy throughout a woman's lifetime. British Journal of Cancer (2004) 91, 84-91. doi:10.1038/sj.bjc.6601884 www.bjcancer.com Published online 25 May 2004
British Journal of Cancer 08/2004; 91(1):84-91. DOI:10.1038/sj.bjc.6601884 · 4.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The need for effective surgical performance measurement has gained an increasingly high profile in recent years, particularly since events at Bristol Royal Infirmary, where apparent poor performance has prompted the UK Department of Health to instigate a major Public Inquiry. This paper describes issues that concern the measuring and monitoring of surgical performance, and methods that have been devised for judging a good surgeon from the less competent. The authors are a collaborative team composed of specialists in Cardiothoracic surgery and Operational Research analysts with experience of monitoring performance in cardiac surgery. This paper describes concrete examples from that knowledge base.
Health Care Management Science 12/2002; 5(4):243-8. DOI:10.1023/A:1020373921395 · 1.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cervical cancer screening with human papillomavirus (HPV) DNA testing has potential advantages over conventional, smear testing in that it can predict cases in which invasive cancers are more likely to develop, may be cheaper to implement and improve compliance. In areas of the world where little formalized cervical cancer screening takes place, or where health resources are limited, HPV testing has been suggested as a possible alternative for primary screening. In this paper we demonstrate the use of mathematical modelling to evaluate the effects of setting up screening programmes in Eastern Europe with HPV DNA testing as the primary screening tool and compare it with conventional smear testing. The impact of screening is measured in terms of the life years gained and the resulting resource usage and cost. We investigate several screening options with different screening intervals and age ranges for the target population.
Health Care Management Science 10/2000; 3(4):323-9. DOI:10.1023/A:1019074214801 · 1.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several methods exist for estimating the risk of perioperative mortality based on preoperative risk factors; graphical methods such as the variable life adjusted display (VLAD) can be used to examine how an individual surgeon's performance for a series of operations fares against what would be expected, given the case mix. This study aimed to devise a method for assessing the natural variation in outcome in order to assist with making judgements about individual performance, in particular whether seemingly poor performance could have occurred by chance.
The risk scoring system has been derived and validated locally for cardiac surgery. A method is described for calculating the probability that an observed number of deaths occurs within a sequence of operations if perioperative mortality is regarded as a chance event with an expected value derived from the risk score. To illustrate this method, nested prediction intervals are superimposed onto VLAD plots for a series of 393 isolated coronary artery bypass and isolated valve operations performed by a single surgeon.
Using the locally derived risk score, the VLAD plot for the individual surgeon shows a net life gain of about 6 over the predicted number of survivors, which is observed to be within the 90% prediction interval. If the Parsonnet scoring system is used instead of the locally derived risk score, the net life gain is considerably overestimated.
The nested prediction intervals are straightforward to generate and can be integrated into a visually informative display. As an indication of the inherent variability in outcome, they have a valuable role in the monitoring of surgical performance.