Quality in surgery: current issues for the future.
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Costs and Cost Analysis↗
Biomedical subjects
Melinda Maggard
Publications and source records attributed to Melinda Maggard.
Evaluating health utility in patients with melanoma, breast cancer, colon cancer, and lung cancer: a nationwide, population-based assessment.
BACKGROUND: Understanding the quality of life and health utility for cancer survivors is important; however, little data are available-particularly for long-term (>5 year) survivors. Using "health utility" scores as a proxy for quality of life may be advantageous because it is a single value. Utility scores range from 1.0 (perfect health) to 0 (death), and have been shown to be a good numerical summary of overall quality of life. Using a validated instrument for health utility (HALex), we calculated and report the scores of four different surgical cancers at multiple periods of follow-up, ranging from <1 year to >5 years after diagnosis. METHODS: Patients diagnosed with either breast, colon, melanoma, or lung cancer were studied using the 1998 National Health Information Survey. Responses to several validated questions were collected and health utility scores were calculated. Different time periods were measured; acute (<1 year), short term (1-5 years), and long term (>5 years). Once a single health utility score was calculated, multivariate analyses were performed to identify important predictors of better versus worse health utility scores. RESULTS: The total sample size was 692 (breast 377, colon 169, melanoma 92, lung 54). Mean ages at diagnosis for the cancer groups were 56, 61, 52, and 60 years, respectively. The mean health utility scores in the acute period after diagnosis were: breast 0.62, colon 0.67, melanoma 0.73, and lung 0.42. In this acute period, the mean utility score for lung cancer survivors was statistically lower versus the others in the acute period (P < 0.001). Although variable trends were noted in the short-term period, all cancers demonstrated an increase in mean scores in the long-term period; the percent increases were: breast 15% (P = 0.01), colon 12%, melanoma 7%, and lung 47%. Multivariate regression analyses identified important associations of health utility scores. Significant predictors of lower health utility included the presence of pain and the presence of co-existent diseases, most commonly joint problems, cardiovascular disease, and diabetes. CONCLUSIONS: For four surgical cancers in three time periods after diagnosis, health utility scores were lowest immediately after treatment and improved over time. Long-term (>5 year) survivors had the highest scores. Additionally, our analyses show that a part of health utility in this cohort is determined by the presence of pain and co-existent diseases, which are often items that can be improved by quality clinical care.
Aged↗
Laparoscopic Nissen fundoplication improves quality of life in patients with atypical symptoms of gastroesophageal reflux.
Laparoscopic Nissen fundoplication has been shown to improve overall quality of life (QOL) in patients with gastroesophageal reflux, but most studies have not addressed patients with atypical symptoms. We investigated the effect of laparoscopic Nissen fundoplication on QOL using the Gastrointestinal Quality of Life Index (GIQLI) survey modified to address both typical (heartburn, regurgitation, dysphagia) and atypical (hoarse voice, chronic cough, adult-onset asthma, vocal cord polyps) symptoms. One-hundred forty-eight patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) at UCLA Medical Center from January 1, 1995 to May 1, 2002. Surveys evaluating pre- and postoperative QOL were administered after surgery: 55 per cent of patients responded (82/148). Forty-eight per cent of all patients (72/148) had atypical symptoms. Perioperative morbidity and mortality were 8.8 per cent and 0.7 per cent, respectively. Mean length of postoperative stay was 2.96 +/- 1.5 days. Mean follow-up for the entire cohort was 18.5 months. Postoperative dysphagia not present before surgery occurred in 4.7 per cent of patients. Eighty per cent of patients were medication-free following surgery. QOL scores for all participants increased significantly from 52.5 +/- 15.3 preoperatively to 72.0 +/- 14.9 postoperatively (P < 0.0001). Patients with atypical symptoms or typical symptoms alone showed significant mean QOL score increases from 48.3 +/- 17.6 preoperatively to 71 +/- 15.7 postoperatively (P < 0.0001) and from 55.7 +/- 12.6 to 72.8 +/- 14.4 (P < 0.0001), respectively. Laparoscopic Nissen fundoplication can effectively improve overall QOL for patients with GERD. Patients with atypical GERD symptoms can experience increases in QOL similar to those with only typical gastrointestinal symptoms.
Adult↗
What predicts serious complications in colorectal cancer resection?
Virtually all volume-outcome studies use mortality as their outcome measure, yet most general surgical procedures have low in-patient death rates. We examined whether hospital surgical volume impacts other colorectal cancer resection outcomes and complications. Colorectal cancer (CRC) resections from 1996 to 2000 were identified using the California hospital discharge database. Comorbidity was graded using a modified Charlson index. Hospital CRC resection volume was calculated. Serious medical complications were defined as life-threatening cardiac or respiratory events, renal failure, or shock. Serious surgical complications were defined as vascular events, need for reoperation, or bleeding. Multivariate logistic regression analyses were performed to estimate the impact of predictors on complications. We identified 56,621 resections. Median age was 70 to 74 years. Eighty-one per cent of patients were white. Most had localized (57%) versus distant (22%) disease. Serious medical (17.5%) and surgical (9.8%) complications were not infrequent. In multivariate analyses, greater annual CRC surgical volume predicted lower odds of serious complication, but patient characteristics (age, comorbidity, and acuity of surgery) were more important. Although patients receiving CRC resection at lower-volume hospitals have greater odds of complication than patients treated at higher-volume institutions, patient factors remain the most important determinants of complication.
Adult↗