Quality and Outcomes
123 patients with symptomatic jaundice who underwent endoscopic (ERCP) or percutaneous interventional radiology (IR) stenting were evaluated. Probability of procedure success, durability of palliation, additional procedures, development of new symptoms, durability of symptom control, and survival were incorporated into the decision tree. Utilities incorporating patient preferences in the form of quality-adjusted life years (QALYs) were assigned to each outcome. Sensitivity analyses were done by changing probabilities of outcomes to determine if the model was responsive to various clinical scenarios. RESULTS: Using expected QALYs (range 0-10), ERCP and IR stenting were associated with 5.88 QALYs and 5.42 QALYs, respectively. Sensitivity analysis demonstrated that as the probability of ERCP success decreased, the expected QALY for IR was greater than for ERCP.
J Am Coll Surg
Table. Factors extracted in the principal components analysis Physical limitations Functional impairment Pain Visceral function Sleep Psychological function CONCLUSIONS: We developed a reliable and valid 18-item, 6-subscale measure of health-related quality of life after abdominal surgery, for use as an outcome measure in studies comparing laparoscopic and conventional abdominal surgery.
Creatinine clearance but not serum creatinine alone predicts long-term postoperative survival
CONCLUSIONS: Decision analysis is an effective instrument to outline issues associated with surgical palliative therapy as demonstrated with symptomatic malignant obstructive jaundice. This model provides a framework from which patients and physicians can make increasingly informed decisions about palliation treatments.
Shishir K. Maithel MD, Frank Pomposelli MD, FACS, Mark Williams MD, Malachi Sheahan MD, Sherry Scovell MD, David Campbell MD, FACS, Frank W LoGerfo MD, FACS, Allen D Hamdan MD, FACS Beth Israel Deaconess Medical Center Boston, MA
A measure of quality of life after abdominal surgery
INTRODUCTION: End-stage renal disease is a risk factor for perioperative morbidity and shortened survival after major surgery. Given the multiple confounding factors related to serum creatinine, we aimed to determine if estimated creatinine clearance more accurately predicts long-term survival.
David R Urbach MD, FACS, Julie Harnish MA, Jodi Herold McIlroy BHSc(PT), MA, David Streiner PhD University of Toronto Toronto, ON Canada INTRODUCTION: A major limitation of clinical trials evaluating laparoscopic surgical procedures has been the lack of a valid and reliable measure of short-term quality of life after abdominal surgery. METHODS: We used existing health status measures, focus groups, and semi-structured patient interviews to generate a prototype questionnaire of 51 items, which was administered to patients within 2 weeks after an abdominal surgical procedure. We used principal components factor analysis with varimax rotation to identify the health status domains underlying the concept of post-operative quality of life, and to reduce the number of items. We then used structural equation modeling to perform a confirmatory factor analysis to assess the reliability and construct validity of the instrument. RESULTS: We administered the prototype questionnaire to 500 patients (mean age [SD] 53.4 [16.0], 51.4% male, 73.0% inpatient) at a mean 4.1 days after an abdominal surgical procedure. We retained the 3 items with the highest factor loadings on each of the 6 factors that accounted for variation in quality of life after abdominal surgery (Table). This produced an 18-item measure with 6 sub-scales. The overall scale reliability was excellent (Cronbach’s alpha 0.91). The confirmatory factor analysis on the final instrument demonstrated good reliability and validity in relation to our hypothesized factors (root mean square error of approximation 0.085, goodnessof-fit index 0.89).
METHODS: We retrospectively reviewed the vascular registry at our institution. Logistic regression analysis was conducted to determine independent predictors of one-, two-, and three-year mortality. Creatinine clearance was calculated as [[140-age(yr)]*weight(kg)]/ [72*serum Cr(mg/dL)] (multiplied by 0.85 for women). RESULTS: 252 patients underwent infrainguinal bypass procedures between August 1999 and May 2000. Demographics included average age 68 years, 65% male, 74% diabetic, 12% dialysisdependent, 23% history of CHF, 12% history of stroke, and 20% serum creatinine ⬎2mg/dL. One-, two-, and three-year mortalities were 16%, 25%, and 35%, respectively. Creatinine did not differ between survivors and non-survivors at one year (1.8 vs 1.9, p ⫽ 0.802), two years (1.8 vs 2.0, p ⫽ 0.618), or three years (1.8 vs 2.0, p ⫽ 0.241), and creatinine ⬎2mg/dL did not predict long-term adverse outcomes. In contrast, reduced creatinine clearance (60 ml/min) was an independent predictor of mortality regardless of dialysis statis (1-yr: OR ⫽ 2.53, p ⫽ 0.014; 2-yrs: OR ⫽ 2.46, p ⫽ 0.004; 3-yrs: OR ⫽ 2.45, p ⫽ 0.001), and creatinine clearance was higher for survivors at all three time points (1-yr: 70.2 vs 49.5, p ⫽ 0.003; 2-yrs: 72.3 vs 51.2, p ⬍ 0.0001; 3-yrs: 74.7 vs 52.6, p ⬍ 0.0001). Other independent predictors of mortality included a prior history of stroke (1-yr: OR ⫽ 3.24, p ⫽ 0.009; 2-yrs: OR ⫽ 2.49, p ⫽ 0.03; 3-yrs: OR ⫽ 2.29, p ⫽ 0.04) and CHF (1-yr: OR ⫽ 2.65, p ⫽ 0.01; 2-yrs: OR ⫽ 2.31, p ⫽ 0.012; 3-yrs: OR ⫽ 1.91, p ⬍ 0.05). CONCLUSIONS: Regardless of dialysis status, a decreased creatinine clearance, but not elevated creatinine alone, is an independent predictor of postoperative mortality. This measure should be included in preoperative risk evaluations of patients undergoing major surgical procedures.