Variation in outcomes and use of laparoscopy in elective inguinal hernia repair.

Background: The early outcomes of inguinal hernia repair in routine practice and the extent to which the laparoscopic approach is used are unknown. The aims of this study were to identify national benchmarks for early reoperation and readmission rates, to identify the degree to which the laparoscopic approach is used for elective hernia surgery in England, and to identify whether there is any variation nationally. Methods: All adults who underwent publically funded elective inguinal hernia repair in England during the six financial years from 2011-2012 to 2016-2017 were identified in the Surgeon's Workload Outcomes and Research Database (SWORD). Patients were grouped according to whether they had a primary, recurrent or bilateral hernia, and according to sex. Overall rates of readmission, reoperation and laparoscopic approach were calculated, and variation was assessed using funnel plots. Results: Some 390 777 patients were included. Overall, 11 448 patients (2·9 per cent) were readmitted to hospital as an emergency within 30 days of surgery and 2872 (0·7 per cent) had a further operation. Laparoscopic repair was performed for 65·5 per cent of bilateral inguinal hernias compared with 17·1 per cent of primary unilateral inguinal hernias, 31·3 per cent of recurrent hernia repairs and 14·0 per cent of primary unilateral hernias in women. The unadjusted readmission, reoperation and laparoscopy rates varied significantly between hospitals. Conclusion: The likelihood of a patient being readmitted to hospital, having an emergency reoperation or undergoing laparoscopic inguinal hernia repair varies significantly depending on the hospital to which they are referred. Hospitals and service commissioners should use this data to drive service improvement and reduce this variation.

Validation of the acute cholecystectomy rate as a quality indicator for emergency general surgery using the SWORD database.

INTRODUCTION: Despite an increasing emphasis on data-driven quality improvement, few validated quality indicators for emergency surgical services have been published. The aims of this study therefore were: 1) to investigate whether the acute cholecystectomy rate is a valid process indicator; and 2) to use this rate to examine variation in the provision of acute cholecystectomy in England. MATERIALS AND METHODS: The Surgical Workload and Outcomes Research Database (SWORD), derived from the Hospital Episode Statistics database, was interrogated for the 2012-2017 financial years. All adult patients admitted with acute biliary pancreatitis, cholecystitis or biliary colic to hospitals in England were included and the acute cholecystectomy rate in each one examined. RESULTS: A total of 328,789 patients were included, of whom 42,642 (12.9%) underwent an acute cholecystectomy. The acute cholecystectomy rate varied significantly between hospitals, with the overall rate ranging from 1.2% to 36.5%. This variation was consistent across all disease groupings and time periods, and was independent of the annual number of procedures performed by each NHS trust. In 41 (29.9%) trusts, fewer than one in ten patients with acute gallbladder disease underwent cholecystectomy within two weeks. CONCLUSIONS: The acute cholecystectomy rate is easily measurable using routine administrative datasets, modifiable by local services and has a strong evidence base linking it to patient outcomes. We therefore advocate that it is an ideal process indicator that should be used in quality monitoring and improvement. Using it, we identified significant variation in the quality of care for acute biliary disease in England.

Early definitive treatment rate as a quality indicator of care in acute gallstone pancreatitis.

BACKGROUND: Early definitive treatment (cholecystectomy or endoscopic sphincterotomy in the same admission or within 2 weeks after discharge) of gallstone disease after a biliary attack of acute pancreatitis is standard of care. This study investigated whether compliance with early definitive treatment for acute gallstone pancreatitis can be used as a care quality indicator for the condition. METHODS: A retrospective cohort study was conducted using the Hospital Episode Statistics database. All emergency admissions to National Health Service hospitals in England with a first time diagnosis of acute gallstone pancreatitis in the financial years 2008, 2009 and 2010 were examined. Trends in early definitive treatment between hospital trusts were examined and patient morbidity outcomes were determined. RESULTS: During the study interval there were 19 510 patients with an overall rate of early definitive treatment at 34·7 (range 9·4-84·7) per cent. In the 1-year follow-up period, 4661 patients (23·9 per cent) had one or more emergency readmissions for complications related to gallstone pancreatitis. Of these, 2692 (57·8 per cent) were readmissions for acute pancreatitis; 911 (33·8 per cent) were within the first 2 weeks of discharge, with the remaining 1781 (66·2 per cent) occurring after the point at which definitive treatment should have been received. Early definitive treatment resulted in a 39 per cent reduction in readmission risk (adjusted risk ratio (RR) 0·61, 95 per cent c.i. 0·58 to 0·65). The risk was further reduced for acute pancreatitis readmissions to 54 per cent in the early definitive treatment group (adjusted RR 0·46, 0·42 to 0·51). CONCLUSION: In acute gallstone pancreatitis, compliance with recommended early definitive treatment varied considerably, with associated variation in outcomes. Compliance should be used as a quality indicator to improve care.