Abstract Background Quality assurance is acknowledged as a crucial factor in the assessment of oncological surgical care. The aim of this study was to develop a composite measure of multiple outcome parameters defined as ‘textbook outcome’, to assess quality of care for patients undergoing oesophagogastric cancer surgery. Methods Patients with oesophagogastric cancer, operated on with the intent of curative resection between 2011 and 2014, were identified from a national database (Dutch Upper Gastrointestinal Cancer Audit). Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. Hospital variation in textbook outcome was analysed after adjustment for case-mix factors. Results In total, 2748 patients with oesophageal cancer and 1772 with gastric cancer were included in this study. A textbook outcome was achieved in 29·7 per cent of patients with oesophageal cancer and 32·1 per cent of those with gastric cancer. Adjusted textbook outcome rates varied from 8·5 to 52·4 per cent between hospitals. The outcome parameter ‘at least 15 lymph nodes examined’ had the greatest negative impact on a textbook outcome both for patients with oesophageal cancer and for those with gastric cancer. Conclusion Most patients did not achieve a textbook outcome and there was wide variation between hospitals.
Abstract Background Blood cultures are commonly used at emergency departments (EDs), while only 5-10% yields a relevant pathogen. We aimed to develop an automatable prediction model in ED patients with suspected bacteremia. This may reduce the use of blood cultures and prevent potential harm from false-positive blood cultures, while minimizing the risk of missing positive cultures. Methods In this observational study, we included consecutive adult patients who had a blood culture taken at the ED of the Haga Teaching Hospital, the Netherlands, for a one-year period. Demographics, laboratory, and outcome data were collected from electronic patient records. We defined 23 candidate predictors for our “full model”, of which nine were used for the "basic" model because they are readily automatable (Table 1). Regression analysis with the Least Absolute Shrinkage and Selection Operator was used to define the model. Bootstrapping was performed for internal validation, including imputation of missing values. We assessed discriminative performance using the C-statistic and calibration using the calibration intercept and slope. Clinical utility was assessed by sensitivity, specificity, negative and positive predictive values and decision curves. Results We included 2111 unique patients; mean age 63 years and 46% male. 272 patients had true positive blood cultures (13%); 79 patients (3.7%) had contaminated blood cultures. Our basic model included 8 predictors: age, systolic blood pressure, heart rate, breathing frequency, temperature, Glasgow coma score, C-reactive protein, procalcitonin. The corrected C-statistic was 0.81 (95% CI 0.79-0.83). The full model additionally included recent antibiotic use, indwelling vascular catheter, chills, and suspected infection site. The corrected C-statistic was 0.87 (95% CI 0.85-0.88). Calibration was good for both models. Sensitivity for bacteremia was 97.4% in the basic model, saving 18% of blood cultures (Table 2). The full model could save 26% of blood cultures while maintaining a sensitivity of 98.5% (Table 3).Figure 1.Decision curve analysis Conclusion The proposed bacteremia prediction models are designed for easy implementation in electronic patient records and can reduce unnecessary blood cultures. Further external validation is needed before implementation in clinical practice. Disclosures All Authors: No reported disclosures
• In Nederland zijn bevriezingsletsels in de gezonde populatie zeldzaam. Door een groeiend aantal winter- en buitensporters en reizigers naar hooggelegen gebieden, neemt het risico op bevriezingsletsel wel toe. • Bevriezing is een koudegeinduceerd letsel veroorzaakt door 2 processen: bevriezing en microvasculaire occlusie. • Een goede eerste opvang, bestaande uit voorkoming van opnieuw bevriezen en van mechanisch letsel in combinatie met snel opwarmen en ibuprofen, is de belangrijkste factor die de uiteindelijke weefselschade kan beperken. • Als een patient zich presenteert binnen 24 uur nadat het bevroren lichaamsdeel is ontdooid en de ernst van het letsel van dien aard is dat ernstige morbiditeit verwacht kan worden, is behandeling met iloprost en eventueel recombinant weefselplasminogeenactivator geindiceerd. • Als een patient zich later presenteert, is hyperbare-zuurstofbehandeling te overwegen; het bewijs hiervoor is echter beperkt.
To compare actual 90-day hospital costs between elective open and laparoscopic colon and rectal cancer resection in a daily practice multicenter setting stratified for operative risk.Laparoscopic resection has developed as a commonly accepted surgical procedure for colorectal cancer. There are conflicting data on the influence of laparoscopy on hospital costs, without separate analyses based on operative risk.Retrospective analyses using a population-based database (Dutch Surgical Colorectal Audit). All elective resections for a T1-3N0-2M0 stage colorectal cancer were included between 2010 and 2012 in 29 Dutch hospitals. Operative risk was stratified for age (<75 years or ≥75 years) and ASA status (I-II/III-IV). Ninety-day hospital costs were measured uniformly in all hospitals based on time-driven activity-based costing.Total 90-day hospital costs ranged from &OV0556;10474 to &OV0556;20865 in the predefined subgroups. For colon cancer surgery (N = 4202), laparoscopic resection was significant less expensive than open resection in all subgroups, savings because of laparoscopy ranged from &OV0556;409 (<75 years ASA I-II) to &OV0556;1932 (≥75 years ASA I-II). In patients ≥75 years and ASA I-II, laparoscopic resection was associated with 46% less mortality (P = 0.05), 41% less severe complications (P < 0.001), 25% less hospital stay (P = 0.013), and 65% less ICU stay (P < 0.001). For rectal cancer surgery (N=2328), all laparoscopic subgroups had significantly higher total hospital costs, ranging from &OV0556;501 (<75 years ASA I-II) to &OV0556;2515 (≥75 years ASA III-IV).Laparoscopic resection resulted in the largest cost reduction in patients over 75 years with ASA I-II undergoing colonic resection, and the largest cost increase in patients over 75 years with ASA III-IV undergoing rectal resection as compared with an open approach.
Older adults with an acute moderate-to-severe lower respiratory tract infection (LRTI) or pneumonia are generally treated in hospitals causing risk of iatrogenic harm such as functional decline and delirium. These hospitalisations are often a consequence of poor collaboration between regional care partners, the lack of (acute) diagnostic and treatment possibilities in primary care, and the presence of financial barriers. We will evaluate the implementation of an integrated regional care pathway ('The Hague RTI Care Bridge') developed with the aim to treat and coordinate care for these patients outside the hospital.This is a prospective mixed methods study. Participants will be older adults (age≥65 years) with an acute moderate-to-severe LRTI or pneumonia treated outside the hospital (care pathway group) versus those treated in the hospital (control group). In addition, patients, their informal caregivers and treating physicians will be asked about their experiences with the care pathway. The primary outcome of this study will be the feasibility of the care pathway, which is defined as the percentage of patients treated outside the hospital, according to the care pathway, whom fully complete their treatment without the need for hospitalisation within 30 days of follow-up. Secondary outcomes include the safety of the care pathway (30-day mortality and occurrence of complications (readmissions, delirium, falls) within 30 days); the satisfaction, usability and acceptance of the care pathway; the total number of days of bedridden status or hospitalisation; sleep quantity and quality; functional outcomes and quality of life.The Medical Research Ethics Committee Leiden The Hague Delft (reference number N22.078) has confirmed that the Medical Research Involving Human Subjects Act does not apply to this study. The results will be published in international peer-reviewed journals.ISRCTN68786381.
