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Title: Quantifying outcomes after hospital care in England
Author: Sinha , Sidhartha
ISNI:       0000 0004 5368 4290
Awarding Body: St George's, University of London
Current Institution: St George's, University of London
Date of Award: 2015
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There is increasing interest in outcomes assessment in modern surgical research and the applicability of outcomes research to everyday clinical practice. Improving healthcare quality is a current political priority and since outcomes are the most visible and quantifiable end points of clinical care pathways, they are most frequently publicised. Standardised mortality metrics such as the Hospital Standardised Mortality Ratio are of particular interest given their current media spotlight following recent infamous failings in the quality of NHS care. Specialised mortality metrics such as the "failure-to-rescue" rate are of particular interest to clinicians given their theoretical superiority in identifying failings in standards of care but derivation of such metrics from administrative data requires identification of complications of care. However, a number of unanswered questions remain including the utility of Hospital Episode Statistics (the national administrative dataset) for providing outcomes data such as mortality and complication rates. Additionally the validity of hospital wide summary mortality measures remains incompletely defined given the lack of data on the inter-dependencies of outcomes between disparate patient groups within English hospitals. Methods Hospital Episode Statistics were used to provide national patient level data on various defined cohorts including patients undergoing emergency medical, emergency surgical, elective general surgical and elective vascular surgical care in England from 2000 - 2010. Outcomes included in hospital and longer term mortality as well as non-mortality metrics such as emergency readmission, length of stay, complication rates and "failure-to-rescue" rates. Complications data validation was performed through case note review for matched patients undergoing cholecystectomy. Novel methods were developed to manipulate the HES data, to analyse inter-provider variability in outcomes and to evaluate evidence of intra-provider inter-dependencies in outcomes amongst different clinical groups. A number of statistical methods were employed including systematic review for evidence base synthesis and multi-level regression modeling for risk-adjustment. Results 60.8% of published studies using HES data were on surgical specialties and the most common analytic theme was of inequalities and variations in treatment or outcome (27%). The volume of published studies has increased with time (r = 0.82, P < 0.0001) as has the length of study epoch (r = 0.76, P <0.001) and the number of outcomes assessed per study (r = 0.72, P = 0.0023). Generic methodologic data were better reported than those specific to HES data extraction. For the majority of parameters, there were no improvements with time. 2,406,709 admissions across 20 emergency groups, 116,596 emergency and elective vascular surgical admissions across 5 groups and 418,214 cholecystectomy procedures were considered in three separate analyses. Clinically and statistically significant variations in outcome were observed between providers (pO.s) between specific pairs of groups. The relative dearth of significant negative correlations suggested that outcomes were hospital-specific. For cholecystectomy provision, evidence was found that hospital characteristics (case volume and presence of specialized surgical units) were associated with improved processes of care (p
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available