Improving clinical outcomes through centralization of rectal cancer surgery and clinical audit: a mixed-methods assessment

Background: The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective. Methods: A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was 25 assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September- December 2014, with healthcare professionals, managers and experts. Results: From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision 30 (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level. Conclusion: The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to 35 strengthen the centralization strategy

A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study

Aim: the oncological risk/benefit trade-off for laparoscopy in rectal cancer is controversial. Our aim was to compare laparoscopic vs open surgery for resection of rectal cancer, using unselected data from the public healthcare system of Catalonia. Methods: this was a multicentre retrospective cohort study of all patients who had surgery with curative intent for primary rectal cancer at Catalonian public hospitals from 2011 to 2012. We obtained follow-up data for up to 5 years. To minimize the differences between the two groups, we performed propensity score matching on baseline patient characteristics. We used multivariate Cox proportional hazards regression analyses to assess locoregional relapse at 2 years and death at 2 and 5 years. Results: of 1513 patients with Stage I-III rectal cancer, 933 (61.7%) had laparoscopy (conversion rate 13.2%). After applying our propensity score matching strategy (2:1), 842 laparoscopy patients were matched to 517 open surgery patients. Multivariate Cox analysis of death at 2 years [hazard ratio (HR) 0.65, 95% CI 0.48, 0.87; P = 0.004] and 5 years (HR 0.61, 95% CI 0.5, 0.75; P < 0.001) and of local relapse at 2 years (HR 0.44, 95% CI 0.27, 0.72; P = 0.001) showed laparoscopy to be an independent protective factor compared with open surgery. Cconclusions: laparoscopy results in lower locoregional relapse and long-term mortality in rectal cancer in unselected patients with all-risk groups included. Studies using long-term follow-up of cohorts and unselected data can provide information on clinically relevant outcomes to supplement randomized controlled trials

Avaluació dels resultats de la concentració de la cirurgia oncològica digestiva d’alta especialització a Catalunya: actualització 2014-2015

Cirurgia oncològica; Avaluació; IndicadorsCirugía oncológica; Evaluación; IndicadoresOncological surgery; Evaluation; IndicatorsEl presente trabajo corresponde a la segunda evaluación de los resultados de la cirugía oncológica digestiva de alta especialización con intención curativa de cirugía de esófago, de páncreas y de hígado (que incluye metástasis hepáticas desde la primera evaluación, actualmente ampliado a vías biliares y tumor hepático primario) para los años 2014 y 2015. A diferencia de la primera evaluación basada en el uso de la auditoría clínica "externa", la metodología aplicada en esta segunda evaluación incorpora información directa de los propios profesionales. En ambos casos ha habido feedback, y validación de los resultados finales por su parte.El present treball correspon a la segona avaluació dels resultats de la cirurgia oncològica digestiva d’alta especialització amb intenció curativa de cirurgia d’esòfag, de pàncrees i de fetge (que inclou metàstasis hepàtiques des de la primera avaluació, actualment ampliat a vies biliars i tumor hepàtic primari) per als anys 2014 i 2015. A diferència de la primera avaluació basada en l’ús de l’auditoria clínica “externa”, la metodologia aplicada en aquesta segona avaluació incorpora informació directa dels propis professionals. En ambdós casos hi ha hagut feedback, i validació dels resultats finals per part seva.The present work corresponds to the second evaluation of the results of the digestive oncology surgery of high specialization with a curative intention of surgery of the esophagus, pancreas and liver (which includes hepatic metastases from the first evaluation, currently extended to bile ducts and primary hepatic tumor) for the years 2014 and 2015. Unlike the first evaluation based on the use of the "external" clinical audit, the methodology applied in this second evaluation incorporates direct information from the professionals themselves. In both cases there has been feedback, and validation of the final results on his part

Measuring the performance of urban healthcare services: results of an international experience

The objective of this paper is to apply a framework for country‐level performance assessment to the cities of Montreal, Canada, and Barcelona, Spain, and to use this framework to explore and understand the differences in their health systems. The UK National Health Service Performance Assessment Framework was chosen. Its indicators went through a process of selection, adaptation and prioritisation. Most of them were calculated for the period 2001–3, with data obtained from epidemiological, activity and economic registries. Montreal has a higher number of old people living alone and with limitations on performing one or more activities of daily life, as well as longer hospital stays for several conditions, especially in the case of elderly patients. This highlights a lack of mid‐term, long‐term and home care services. Diabetes‐avoidable hospitalisation rates are also significant in Montreal, and are likely to improve following reforms in primary care. Efficient health policies such as generic drug prescription and major ambulatory surgery are lower in Barcelona. Rates of caesarean deliveries are higher in Barcelona, owing to demographics and clinical practice. Waiting times for knee arthroplasty are longer in Barcelona, which has triggered a plan to reduce them. In both cities, avoidable mortality and the prevalence of smoking have been identified as areas for improvement through preventive services. In conclusion, performance assessment fits perfectly in an urban context, as it has been shown to be a useful tool in designing and monitoring the accomplishment of programmes in both cities, to assess the performance of the services delivered, and for use in policy development

Razones para acudir a los servicios de urgencias hospitalarios: La población opina Reasons for attending emergency departments: People speak out

Objetivo: Conocer por qué las personas acuden a los servicios de urgencia hospitalarios (SUH) por problemas de salud de baja complejidad. Método: Se realizó una investigación cualitativa de tipo fenomenológica interaccionista. La muestra teórica pertenecía a un área urbana y otra rural de Cataluña. Se escogieron personas (n = 36) que habían acudido a los SUH o a servicios de urgencia de la atención primaria de salud (SUAP) en el mes previo a su selección. Se recogieron datos en 8 grupos focales. Se realizó un análisis inductivo descriptivo-interpretativo, construyendo categorías emergentes a partir de la triangulación. Resultados: Emergieron 5 categorías: síntomas, elaboración de autodiagnóstico, percepción de necesidad, conocimiento de la oferta y contexto global de la persona. Los síntomas generan la consideración de pérdida de salud y desencadenan la acción. La elaboración del autodiagnóstico determina la necesidad-tipo de atención. Del contraste entre la percepción-tipo de necesidad y el conocimiento de la oferta de los servicios, así como de la situación vital de la persona, surge la decisión de acudir a un servicio u otro y se genera la acción. El conocimiento de la oferta de los SUH es mejor que el de los SUAP. El tiempo parece básico en la toma de decisiones. Conclusiones: La elaboración de un autodiagnóstico es crítica en la determinación de la acción, pero el conocimiento de la oferta de los servicios, las experiencias previas y la situación vital de la persona modulan el tipo de demanda.Objective: To ascertain why people attend hospital emergency departments (ED) for low complexity health problems. Method: A phenomenological, interactionist, qualitative study was performed. A theoretical sample that selected one urban and one rural area from Catalonia (Spain) was designed. In each setting, persons (n = 36) who had used the ED or a primary care emergency service 1 month before the beginning of the study were chosen. Data were obtained through 8 focus groups. An interpretative content analysis was performed, and emergent categories were constructed through research triangulation. Results: Five categories emerged: symptoms, whether or not self-diagnosis was involved, perception of needs, awareness of the health services available, and the overall context of the person. Symptoms generated feelings of failing health and thus initiated care seeking. Self-diagnosis determined perceived need and the type of care sought. People contrasted their self-perception of need with their own opinion about the health services available. The decision to go to one or other service was made as a result of this contrast, but the individual's family, work, and social situations also played a part. Informants were more familiar with the service provided by the ED than with that provided by primary care. Time consumption also figured heavily in decision making. Conclusions: The presence or absence of self-diagnosis is a determining factor in attendance at EDs. Other factors that influence demand are the level of awareness of the heatlh services available, previous experiences, and the life situation of the individua

A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study

Aim: the oncological risk/benefit trade-off for laparoscopy in rectal cancer is controversial. Our aim was to compare laparoscopic vs open surgery for resection of rectal cancer, using unselected data from the public healthcare system of Catalonia. Methods: this was a multicentre retrospective cohort study of all patients who had surgery with curative intent for primary rectal cancer at Catalonian public hospitals from 2011 to 2012. We obtained follow-up data for up to 5 years. To minimize the differences between the two groups, we performed propensity score matching on baseline patient characteristics. We used multivariate Cox proportional hazards regression analyses to assess locoregional relapse at 2 years and death at 2 and 5 years. Results: of 1513 patients with Stage I-III rectal cancer, 933 (61.7%) had laparoscopy (conversion rate 13.2%). After applying our propensity score matching strategy (2:1), 842 laparoscopy patients were matched to 517 open surgery patients. Multivariate Cox analysis of death at 2 years [hazard ratio (HR) 0.65, 95% CI 0.48, 0.87; P = 0.004] and 5 years (HR 0.61, 95% CI 0.5, 0.75; P < 0.001) and of local relapse at 2 years (HR 0.44, 95% CI 0.27, 0.72; P = 0.001) showed laparoscopy to be an independent protective factor compared with open surgery. Cconclusions: laparoscopy results in lower locoregional relapse and long-term mortality in rectal cancer in unselected patients with all-risk groups included. Studies using long-term follow-up of cohorts and unselected data can provide information on clinically relevant outcomes to supplement randomized controlled trials

A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study

Aim: the oncological risk/benefit trade-off for laparoscopy in rectal cancer is controversial. Our aim was to compare laparoscopic vs open surgery for resection of rectal cancer, using unselected data from the public healthcare system of Catalonia. Methods: this was a multicentre retrospective cohort study of all patients who had surgery with curative intent for primary rectal cancer at Catalonian public hospitals from 2011 to 2012. We obtained follow-up data for up to 5 years. To minimize the differences between the two groups, we performed propensity score matching on baseline patient characteristics. We used multivariate Cox proportional hazards regression analyses to assess locoregional relapse at 2 years and death at 2 and 5 years. Results: of 1513 patients with Stage I-III rectal cancer, 933 (61.7%) had laparoscopy (conversion rate 13.2%). After applying our propensity score matching strategy (2:1), 842 laparoscopy patients were matched to 517 open surgery patients. Multivariate Cox analysis of death at 2 years [hazard ratio (HR) 0.65, 95% CI 0.48, 0.87; P = 0.004] and 5 years (HR 0.61, 95% CI 0.5, 0.75; P < 0.001) and of local relapse at 2 years (HR 0.44, 95% CI 0.27, 0.72; P = 0.001) showed laparoscopy to be an independent protective factor compared with open surgery. Cconclusions: laparoscopy results in lower locoregional relapse and long-term mortality in rectal cancer in unselected patients with all-risk groups included. Studies using long-term follow-up of cohorts and unselected data can provide information on clinically relevant outcomes to supplement randomized controlled trials

A propensity-score-matched analysis of laparoscopic vs open surgery for rectal cancer in a population-based study

Aim: the oncological risk/benefit trade-off for laparoscopy in rectal cancer is controversial. Our aim was to compare laparoscopic vs open surgery for resection of rectal cancer, using unselected data from the public healthcare system of Catalonia. Methods: this was a multicentre retrospective cohort study of all patients who had surgery with curative intent for primary rectal cancer at Catalonian public hospitals from 2011 to 2012. We obtained follow-up data for up to 5 years. To minimize the differences between the two groups, we performed propensity score matching on baseline patient characteristics. We used multivariate Cox proportional hazards regression analyses to assess locoregional relapse at 2 years and death at 2 and 5 years. Results: of 1513 patients with Stage I-III rectal cancer, 933 (61.7%) had laparoscopy (conversion rate 13.2%). After applying our propensity score matching strategy (2:1), 842 laparoscopy patients were matched to 517 open surgery patients. Multivariate Cox analysis of death at 2 years [hazard ratio (HR) 0.65, 95% CI 0.48, 0.87; P = 0.004] and 5 years (HR 0.61, 95% CI 0.5, 0.75; P < 0.001) and of local relapse at 2 years (HR 0.44, 95% CI 0.27, 0.72; P = 0.001) showed laparoscopy to be an independent protective factor compared with open surgery. Cconclusions: laparoscopy results in lower locoregional relapse and long-term mortality in rectal cancer in unselected patients with all-risk groups included. Studies using long-term follow-up of cohorts and unselected data can provide information on clinically relevant outcomes to supplement randomized controlled trials

Transanal total mesorectal excision versus anterior total mesorectal excision for rectal cancer: a propensity-score matched, population-based study in Catalonia, Spain

Background: the clinical value of transanal total mesorectal excision is debated. Objective: to compare short- and medium-term effects of transanal versus anterior total mesorectal excision for rectal cancer. Design: this was a multicenter retrospective cohort study. Setting: the study included all Catalonian public hospitals. Patients: all non-metastatic patients receiving transanal or anterior total mesorectal excision (open or laparoscopic) for primary rectal cancer in 2015-16. Main outcome measures: data on vital status were collected to March 2019. Between-group differences were minimized by applying propensity score matching to baseline patient characteristics. Competing risk models were used to assess systemic and local recurrence along with death at two years, and multivariable Cox regression to assess two-year disease-free survival. Results are expressed with their 95% confidence intervals. Results: the final subsample was 537 patients receiving total mesorectal excision (transanal approach: n=145; anterior approach: n=392). Median follow-up was 39.2 months (interquartile range 33.0-45.8). Accounting for death as a competing event, there was no association between transanal total mesorectal excision and local recurrence (matched sub-hazard ratio 1.28, 0.55-2.96). There were no statistical differences in the comparative rate of local recurrence (transanal: 1.77 per 100 person-years, 0.76-3.34; anterior: 1.37 per 100 person-year, 0.8-2.15) or mortality (transanal: 3.98 per 100 person-year, 2.36-6.16; anterior: 2.99 per 100 person-years, 2.1-4.07). Groups presented similar two-year cumulative incidence of local recurrence (4.83% versus 3.57%, respectively) and disease-free survival (hazard ratio 1.33, 0.92-1.92). Limitations: we used data only from the public system, the study is retrospective, and data on individual surgeons are not reported. Conclusion: these population-based results support the use of either the transanal, open, or laparoscopic approach for rectal cancer in Catalonia. See Video Abstract at http://links.lww.com/DCR/B744