Quality indicators for surgery. Development and application of a set of indicators

In the media and in scientific publications there is a growing interest in the quality of health care and possible differences in quality among hospitals and doctors. Quality of care is important for patients who receive care and for doctors who deliver care. Central in this discussion is the question how we should measure quality of care. Indicators may be helpful in measuring quality of care. In this study we developed and tested a set of quality-indicators for surgical care. The Dutch Health Care Inspectorate requested the National Institute for Public Health and the Environment (RIVM)to develop this set of indicators to support their inspection activities. This study was carried out in close collaboration with the Dutch Society for Surgeons (NVvH). To define a limited set of indicators for surgical care, three steps were taken. In the first step a working group, with members of the NVvH and researchers of RIVM, identified risks of suboptimal care. In the second step, indicators were identified to measure suboptimal care, based on the literature and expert opinion. In the third step, after a consensus procedure, a set of 9 indicators was selected: percentage reoperations within 30 days (planned or unplanned), percentage in-hospital mortality, percentage postoperative wound infections, percentage biliary duct injury, length of stay appendectomy, postoperative length of stay after colon resections, time between admission and hip fracture surgery, percentage exploratory thoracotomy and percentage pneumectomy versus pulmonary lobectomy. To evaluate the feasibility of the registration of these indicators, we tested the registration in several hospitals. Further development of a system for data registration and processing is necessary for successful implementation of the indicators. As a result of this study, the NVvH selected some indicators in agreement with the Inspectorate of Health Care to be included in the set 'performance indicators for hospitals'.In de media en in de wetenschap wordt in toenemende mate aandacht besteed aan de kwaliteit van medische zorg. Kwaliteit in de gezondheidszorg is belangrijk voor zowel patienten die een goede behandeling wensen, als voor artsen die goede kwaliteit willen leveren. Maar hoe kun je de kwaliteit van de gezondheidszorg inzichtelijk maken? Indicatoren kunnen mogelijk uitkomst bieden. In dit onderzoek is een set indicatoren ontwikkeld om de kwaliteit van de heelkunde in het ziekenhuis te meten. De Inspectie voor de Gezondheidszorg (IGZ) heeft opdracht gegeven aan het Rijksinstituut voor Volksgezondheid en Milieu (RIVM) om deze set indicatoren te ontwikkelen om daarmee haar taak als toezichthouder te ondersteunen. Hierbij is intensief samengewerkt met de Nederlandse Vereniging voor Heelkunde (NVvH). De ontwikkeling van de indicatoren is in een aantal stappen uitgevoerd. De eerste stap betrof het identificeren van terreinen binnen de heelkunde waar de zorg potentieel verbeterd kon worden. In de tweede stap heeft literatuuronderzoek en de inbreng van experts een aantal potentiele indicatoren opgeleverd. In de derde stap is na een consensusprocedure een set van negen indicatoren gedefinieerd: het percentage reoperaties binnen dertig dagen, het percentage ziekenhuismortaliteit, het percentage postoperatieve wondinfecties, het percentage choledochusletsels, de gemiddelde opnameduur na appendectomie, de postoperatieve opnameduur na colonresecties, de wachttijd bij heupfracturen, het percentage proefthoracotomie en het percentage pneumonectomie versus lobectomie. In een haalbaarheidsonderzoek is onderzocht in hoeverre de gegevens beschikbaar waren en op welke manier de gegevens ontsloten kunnen worden. Door de gebrekkige aansluiting bij bestaande systemen kostte de registratie veel tijd. De ontwikkeling van een goede structuur voor dataverzameling en verwerking is essentieel voor een goede implementatie van de indicatoren. Gedurende dit project heeft de NVvH in overeenstemming met de IGZ een aantal indicatoren opgenomen in de basisset 'Prestatie-indicatoren voor ziekenhuizen'. Hiermee is een belangrijke eerste stap gezet om de indicatoren in de toekomst te implementeren

A multicenter randomized controlled trial evaluating the effect of small stitches on the incidence of incisional hernia in midline incisions

Background: The median laparotomy is frequently used by abdominal surgeons to gain rapid and wide access to the abdominal cavity with minimal damage to nerves, vascular structures and muscles of the abdominal wall. However, incisional hernia remains the most common complication after median laparotomy, with reported incidences varying between 2-20%. Recent clinical and experimental data showed a continuous suture technique with many small tissue bites in the aponeurosis only, is possibly more effective in the prevention of incisional hernia when compared to the common used large bite technique or mass closure. Methods/Design: The STITCH trial is a double-blinded multicenter randomized controlled trial designed to compare a standardized large bite technique with a standardized small bites technique. The main objective is to compare both suture techniques for incidence of incisional hernia after one year. Secondary outcomes will include postoperative complications, direct costs, indirect costs and quality of life. A total of 576 patients will be randomized between a standardized small bites or large bites technique. At least 10 departments of general surgery and two departments of oncological gynaecology will participate in this trial. Both techniques have a standardized amount of stitches per cm wound length and suture length wound length ratio's are calculated in each patient. Follow up will be at 1 month for wound infection and 1 year for incisional hernia. Ultrasound examinations will be performed at both time points to measure the distance between the rectus muscles (at 3 points) and to objectify presence or absence of incisional hernia. Patients, investigators and radiologists will be blinded during follow up, although the surgeon can not be blinded during the surgical procedure. Conclusion: The STITCH trial will provide level 1b evidence to support the preference for either a continuous suture technique with many small tissue bites in the aponeurosis only or for the commonly used large bites technique