The relative importance of quality of care information when choosing a hospital for surgical treatment: a hospital choice experiment.

OBJECTIVE: To assess the impact of quality of care and other hospital information on patients' choices between hospitals. METHODS: 665 former surgical patients were invited to respond to an Internet-based questionnaire including a choice-based conjoint analysis. Each patient was presented with 12 different comparisons of 2 hospitals, with each hospital characterized by 6 attributes containing 2 levels. Hospital attributes were included if frequently reported by patients as most important for future hospital choices. These included both general hospital information (e.g., atmosphere), information on quality of care (e.g., percentage of patients with "textbook outcome"), and surgery-specific information (e.g., possibility for minimally invasive procedure). Hierarchial Bayes estimation was used to estimate the utilities for each attribute level for each patient. Based on the ranges of these utilities, the relative importance of each hospital attribute was determined for each participant as a measure of the impact on patients' choices. RESULTS: 308 (46.3%) questionnaires were available for analysis. Of the hospital attributes that patients considered, surgery-specific information on average had the highest relative importance (25.7 [23.9-27.5]), regardless of gender, age, and education. Waiting time and hospital atmosphere were considered least important. The attribute concerning the percentage of patients with "textbook outcomes" had the second greatest impact (18.3 [16.9-19.6]), which was similar for patients with different adverse outcome experience. CONCLUSIONS: Surgery-specific and quality of care information are more important than general information when patients choose between hospitals.

The importance of experienced adverse outcomes on patients' future choice of a hospital for surgery.

OBJECTIVE: To assess whether patients who experience adverse outcomes during hospitalisation or after discharge differ in the information they would use for future choices of a hospital for surgery compared with patients without any adverse outcomes. DESIGN: Cross-sectional questionnaire study, including questions on (1) adverse outcome occurrence during hospitalisation and after discharge, (2) information patients would use for future hospital choice and (3) priority of information. SETTING: Three hospitals in the western part of The Netherlands. STUDY SAMPLE: All 2122 patients who underwent elective aorta reconstruction (for treatment of aneurysm), cholecystectomy, colon resection, inguinal hernia repair, oesophageal resection or thyroid surgery in the period 2005-2006, of whom 1329 (62.6%) responded. RESULTS: Patients who experienced postdischarge adverse outcomes intend to use more information items to choose a future hospital (on average 1.6 items more). They more often would use the item on information provision during hospitalisation (OR 2.35 (1.37 to 4.03)) and information on various quality-of-care measures, compared with patients without adverse outcomes. Patients who experienced in-hospital adverse outcomes would not use more information items but more often would use the item on mortality after surgery (OR 1.93 (1.27 to 2.94)) and extended hospital stay (OR 1.61 (1.10 to 2.36)). However, when asked for priority of information, previous treatment in that hospital is mentioned as the most important item by most patients (32%), regardless of adverse outcome occurrence, followed by hospital reputation and waiting time. CONCLUSIONS: Adverse outcome experience may change the information patients use (on quality of care) to choose a future hospital.

[Diagnostic image (288). A woman with lower right abdominal pain]. / Diagnose in beeld (288). Een vrouw met pijn rechts onder in de buik.

A woman with lower right abdominal pain was diagnosed with a nail perforating the appendix. She must have swallowed this nail in infancy.

Laparoscopic surgery in Crohn's disease.

In a prospective study the feasibility and safety of laparoscopic-assisted ileocaecal resection for Crohn's disease was studied and compared with 16 patients who had open ileocaecal resection, and the value of laparoscopic stoma surgery was assessed. From January to November 1995 laparoscopic-assisted ileocaecal resection for Crohn's disease was undertaken in 7 patients, laparoscopic-assisted stoma formation in 10 patients. In 1 patient laparoscopic ileocaecal resection was converted to open surgery due to an unrecognised ileocolic fistula. Operating time in laparoscopic-assisted ileocaecal resections was longer than in open ileocaecal resection (150 vs. 127 min, P = 0.7). Blood loss (386 vs. 445 ml, P = 0.7), first bowel movement (3.5 vs. 4.9 postoperative days, P = 0.07) and postoperative time to discharge (5.2 vs. 9.9 days, P < 0.01) in patients who had a laparoscopic-assisted ileocaecal resection were less than in patients who had open surgery. In all 10 patients laparoscopic formation of a stoma was possible. Operating time was 62 min. Oral solids were restored on the 1.5 postoperative day. Mean postoperative stay was 8.8 days, prolonged due to time needed for stoma-care training. These preliminary results indicate that laparoscopic-assisted ileocaecal resection and stoma surgery for Crohn's disease are feasible and safe. Both procedures are characterised by rapid recovery and superior cosmetic results.

Intramedullary femoral osteosynthesis: an additional cause of ARDS in multiply injured patients?

This study analysed the effects of reaming and intramedullary nailing and thoracic injury related to development of ARDS and multi-organ failure in multiply injured patients. Sixty patients were entered into a retrospective follow-up study. Twenty-one patients with thoracic injury and femoral shaft fracture, treated by intramedullary nailing, were compared with 17 patients with a femoral shaft fracture without thoracic injury, and with 22 patients without femoral shaft fracture but with major thoracic injury. The incidence of ARDS, multiple organ failure (MOF) and the mortality rate in the groups was analysed, using chi 2 and Fisher exact tests. No significant differences in age, sex and ISS existed between the groups. There were no statistically significant differences with regard to the incidence of developing ARDS (P > 0.5), MOF (P > 0.5) and mortality rate (P > 0.2) after injury. The results of this study suggest that reaming of the femoral shaft as part of an intramedullary nailing procedure is not a major cause in developing ARDS and MOF in patients with femoral shaft fractures and thoracic injury. Conventional intramedullary nailing can be considered as a safe procedure in femoral shaft fractures in multiply injured patients, as well as in the presence of major thoracic injury.