Background: Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care. Methods: We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged between 2007 and 2012. We correlated standardized and risk-adjusted hospital outcomes on mortality, readmission and long LOS. We constructed a composite measure with 5 levels, based on literature review and expert advice, from survival without readmission and normal LOS (best) to mortality (worst outcome). This composite measure was analyzed using ordinal regression, to obtain a standardized outcome measure to compare hospitals. Results: Overall, we observed a 3.1% mortality rate, 7.8% readmission rate (in survivors) and 20.8% long LOS rate among 4,327,105 admissions. Mortality and LOS were correlated at the patient and the hospital level. A patient in the upper quartile LOS had higher odds of mortality (odds ratio = 1.45, 95% confidence interval 1.43-1.47) than those in the lowest quartile. Hospitals with a high standardized mortality had higher proportions of long LOS (r = 0.79, p < 0.01). Readmission rates did not correlate with either mortality or long LOS rates. The interquartile range of the standardized ordinal composite outcome was 74-117. The composite outcome had similar or better reliability in ranking hospitals than individual outcomes. Conclusions: Correlations between different outcome measures are complex and differ between hospital- and patient-level. The proposed composite measure combines three outcomes in an ordinal fashion for a more comprehensive and reliable view of hospital performance than its component indicators.

Objective: To identify, on the basis of past performance, those hospitals that demonstrate good outcomes in sufficient numbers to make it likely that they will provide adequate quality of care in the future, using a combined measure of volume and outcome (CM-V&O). To compare this CM-V&O with measures using outcome-only (O-O) or volume-only (V-O), and verify 2010-quality of care assessment on 2011 data. Design: Secondary analysis of clinical audit data. Setting: The Dutch Surgical Colorectal Audit database of 2010 and 2011, the Netherlands. Participants: 8911 patients (test population, treated in 2010) and 9212 patients (verification population, treated in 2011) who underwent a resection of primary colorectal cancer in 89 Dutch hospitals. Main Outcome Measures: Outcome was measured by Observed/Expected (O/E) postoperative mortality and morbidity. CM-V&O states 2 criteria; 1) outcome is not significantly worse than average, and 2) outcome is significantly better than substandard, with 'substandard care' being defined as an unacceptably high O/E threshold for mortality and/or morbidity (which we set at 2 and 1.5 respectively). Results: Average mortality and morbidity in 2010 were 4.1 and 24.3% respectively. 84 (94%) hospitals performed 'not worse than average' for mortality, but only 21 (24%) of those were able to prove they were also 'better than substandard' (O/E<2). For morbidity, 42 hospitals (47%) met the CM-V&O. Morbidity in 2011 was significantly lower in these hospitals (19.8 vs. 22.8% p<0.01). No relationship was found between hospitals' 2010 performance on O-O en V-O, and the quality of their care in 2011. Conclusion: CM-V&O for morbidity can be used to identify hospitals that provide adequate quality and is associated with better outcomes in the subsequent year.

OBJECTIVE: To investigate the safety of laparoscopic colorectal cancer resections in a nationwide population-based study. BACKGROUND: Although laparoscopic techniques are increasingly used in colorectal cancer surgery, little is known on results outside trials. With the fast introduction of laparoscopic resection (LR), questions were raised about safety. METHODS: Of all patients who underwent an elective colorectal cancer resection in 2010 in the Netherlands, 93% were included in the Dutch Surgical Colorectal Audit. Short-term outcome after LR, open resection (OR), and converted LR were compared in a generalized linear mixed model. We further explored hospital differences in LR and conversion rates. RESULTS: A total of 7350 patients, treated in 90 hospitals, were included. LR rate was 41% with a conversion rate of 15%. After adjustment for differences in case-mix, LR was associated with a lower risk of mortality (odds ratio 0.63, P < 0.01), major morbidity (odds ratio 0.72, P < 0.01), any complications (odds ratio 0.74, P < 0.01), hospital stay more than 14 days (odds ratio 0.71, P < 0.01), and irradical resections (odds ratio 0.68, P < 0.01), compared to OR. Outcome after conversion was similar to OR (P > 0.05). A large variation in LR and conversion rates among hospitals was found; however, the difference in outcome associated with operative techniques was not influenced by hospital of treatment. CONCLUSIONS: Use of laparoscopic techniques in colorectal cancer surgery in the Netherlands is safe and results are better in short-term outcome than open surgery, irrespective of the hospital of treatment. Outcome after conversion was similar to OR.

Objective: The aim of the study was to identify risk factors for postoperative mortality in patients undergoing surgery for colon cancer. We looked specifically at patients ≥ 80 years of age in whom a nonelective colon cancer resection was performed. Study Design: Observational study. Methods: We included data from 6,161 patients who underwent colon cancer surgery in 2010 in a Dutch hospital; a nonelective colon cancer resection was performed in 1,172 of these patients. Risk factors for postoperative mortality were identified using a multivariate logistic regression analysis. We studied elective and nonelective intestinal resections separately in different age groups. Results: Mortality in the total study population was 4.9%. Mortality increased with age in patients who underwent either elective or nonelective intestinal resection. For patients ≥ 80 years of age who underwent nonelective intestinal resection, each additional risk factor doubled the mortality risk. In patients aged ≥ 80 years with an American Society of Anesthesiologists classification of class ≥ 3 who underwent a left hemicolectomy or 'other' intestinal resection, the postoperative mortality rate was 41%; in patients of the same age without additional risk factors this was 7%. CONCLUSIONS In patients ≥ 80 years of age with 2 or more additional risk factors, nonelective intestinal resection should be considered a high-risk procedure with a mortality risk of up to 41%. This result can be used in clinical decision making concerning treatment and in providing information for patients and their families.

To assess whether patients use information on quality of care when choosing a hospital for surgery compared with more general hospital information. In this cross-sectional study in 3 Dutch hospitals, questionnaires were sent to 2122 patients who underwent 1 of 6 elective surgical procedures in 2005-2006 (aorta reconstruction [for treatment of aneurysm], cholecystectomy, colon resection, inguinal hernia repair, esophageal resection, thyroid surgery). Patients were asked which information they had used to choose this hospital and which information they intended to use if they would need similar surgical treatment in the future. In total, 1329 questionnaires were available for analysis (response rate 62.6%). Most patients indicated having used the hospital's good reputation (69.1%) and friendly hospital atmosphere (63.3%) to choose a hospital. For future choices, most patients intended to use the fact that they were already treated in that hospital (79.3%) and the hospital's good reputation (74.1%). Regarding quality-of-care information, patients preferred a summary measure (% patients with ''textbook outcome'') over separate more detailed measures (52.1% v. 38.0%, χ2 = 291, P < 0.01). For future choices, patients intend to use more information items than in 2005-2006, both in absolute terms (9 v. 4 items, t = 38.3, P < 0.01) as relative to the total number of available items (41.3% [40.1%-42.5%] v. 29.2% [28.1%-30.2%]). Patients intended to use more information for future choices than they used for past choices. For future choices, most patients prefer a summary measure on quality of care over more detailed measures but seem to value that they were already treated in that hospital or a hospital's good reputation even more.

Background: Surgeons may improve their decision making by assessing the extent to which their initial clinical diagnosis of a surgical site infection (SSI) was supported by culture results. Aim of the present study was to evaluate routinely reported SSI by surgeons against microbiological culture results, to identify patient groups with lower agreement where decision making may be improved. Methods: 701 admissions with SSI were reported by surgeons in a university medical centre in the period 1997-2005, which were retrospectively checked for microbiological culture results. Reporting a SSI was conditional on treatment being given (e.g. antibiotics) and was classified by severity. To identify specific patient groups, patients were classified according to the surgery group of the first operation during admission (e.g. trauma). Results: Of all reported SSI, 523 (74.6%) had a positive culture result, 102 (14.6%) a negative culture result and 76 (10.8%) were classified as unknown culture result (due to no culture taken). Given a known culture result, reported SSI with positive culture results less often concerned trauma patients (16% versus 26%, X2 = 4.99 p = 0.03) and less severe SSI (49% versus 85%, X2 = 10.11 p < 0.01) suggesting that a more conservative approach may be warranted in these patients. The trauma surgeons themselves perceived to have become too liberal in administering antibiotics (and reporting SSI). Conclusion: Routine reporting of SSI was mostly supported by culture results. However, this support was less often found in trauma patients and less severe SSI, thereby giving surgeons feedback that diagnosis and treatment may be improved in these cases.

Purpose: To assess the impact of variables related to setting, study design and definition on adverse outcome occurrence and mortality in hospitalized patients. Data sources: Pubmed and Embase. Study selection: Articles in English from 1980 onwards, in non-selected patients or surgical patients only. Data extraction: Data were extracted independently by two authors using a predefined form. Included study methodology variables were general variables such as setting, patient variables like age, study variables like number of reviewers and definition and the resulting adverse outcome occurrence and mortality. Results: Eleven studies reporting on 76 617 non-selected patients and 18 studies representing 136 292 surgical patients were included. Adverse outcomes were estimated to occur in 16% (12-19%) of non-selected patients and in 18% (14-22%) of surgical patients, taking into account the heterogeneity between studies. The study methodology variables were not statistically significant in explaining variation in adverse outcome occurrence, but the individual studies, when used as a random effect variable, were significant. Conversely, the study variable was not significant to explain variation in mortality rates, whereas the study methodology variables were: having more than one reviewer increased mortality by 30-80%, older study populations resulted in higher mortality and including a cause in the definition halved the mortality rate. Conclusion: Study methodology variables do not explain differences in adverse outcome occurrence between studies. Other inter-study differences are more important. However, study methodology is an important predictor for mortality differences and should be taken into account when interpreting differences between studies.

Background: Previous research has shown that sicker patients are less satisfied with their healthcare, but specific effects of adverse health outcomes have not been investigated. The present study aimed to assess whether patients who experience adverse outcomes, in hospital or after discharge, differ in their evaluation of quality of care compared with patients without adverse outcomes. Method: Inhospital adverse outcomes were prospectively recorded by surgeons and surgical residents as part of routine care. Four weeks after discharge, patients were interviewed by telephone about the occurrence of post-discharge adverse outcomes, and their overall evaluation of quality of hospital care and specific suggestions for improvements in the healthcare provided. Results: Of 2145 surgical patients admitted to the Leiden University Medical Center in 2003, 1876 (88%) agreed to be interviewed. Overall evaluation was less favourable by patients who experienced post-discharge adverse outcomes only (average 19% lower). These patients were also more often dissatisfied (OR 2.02, 95% CI 1.24 to 3.31) than patients without adverse outcomes, and they more often suggested that improvements were needed in medical care (OR 2.07, 1.45 to 2.95) and that patients were discharged too early (OR 3.26, 1.72 to 6.20). The effect of inhospital adverse outcomes alone was not statistically significant. Patients with both inhospital and post-discharge adverse outcomes also found the quality of care to be lower (on average 33% lower) than patients without adverse outcomes. Conclusions: Post-discharge adverse outcomes negatively influence patients' overall evaluation of quality of care and are perceived as being discharged too early, suggesting that patients need better information at discharge.

Objective: Follow-up after curative resection of colorectal carcinoma (CRC) has been subjected to debate concerning its effectiveness to reduce cancer mortality. Current national and international guidelines advise CEA measurements every 3 months during 3 years after surgery. The common clinical practice and opinion about follow-up for colorectal carcinoma, was evaluated by means of a survey among Dutch general surgeons. Method: A web-based survey of follow-up after treatment of CRC was sent to all registered Dutch general surgeons. A reply from 246 surgeons treating patients for colorectal carcinoma in 105 out of 118 hospitals was received (response rate 91%). Questions related to actual follow-up protocol, opinion about serum CEA monitoring, liver and/or lung metastasectomy, and motivation to participate in a new trial concerning follow-up. Results: For the majority of surgeons the length of follow-up was influenced by age of the patient (62%) and physical condition (76%) prohibiting hepatic metastasectomy. The generally accepted follow-up protocol consisted of CEA measurements every 3 months in the first year and six-monthly thereafter, and ultrasound examination of the liver every 6 months. Nearly all surgeons (92%) were willing to participate in a new study of follow-up protocol. Conclusion: The adherence to national guidelines for the follow-up of colorectal carcinoma is low. The indistinctness about follow-up after curative treatment of colorectal carcinoma also affects clinical practice. Recent advancements in imaging techniques, liver and lung surgery have changed circumstances, which are not yet anticipated upon in current guidelines. Renewal of follow-up based upon scientific evidence is required.