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1.  Evaluation of indications for and outcomes of elective surgery 
Wide small-area variations in the rates of elective surgical procedures and lack of systematic outcome measurement have raised questions about the appropriateness of such surgery. Our objective was to determine the feasibility of routine evaluation of indications for and outcomes of elective surgery.
Participants consisted of 138 surgeons and 5313 patients who underwent 1 or more of 6 specific surgical procedures (for a total of 6274 operations). Surgical indications were evaluated according to published guidelines. Patients' self-reported health-related quality of life (HRQOL) before and at appropriate intervals after surgery was measured with standard, validated generic and disease-specific instruments. Patient-specific results were routinely sent to the surgeons, from whom feedback was requested.
Surgeons provided information on the indications for surgery for 44% to 95% of the 6 procedures, and the indications matched the guidelines in 73% to 99% of cases. Completed HRQOL questionnaires were returned by 58% of the patients. Postoperative HRQOL scores were markedly improved in most patients, but in 2% to 26% of the various procedures, there was either no change or a deterioration in HRQOL. In most of the procedure groups a small proportion of patients had relatively minor symptoms and disability preoperatively, but in the cataract surgery group this proportion was large. Opinion among the participating surgeons was divided as to the potential value of this method of evaluation. The cost of the outcome evaluation program was about $12/patient.
Evaluation of indications for and outcomes of elective surgery could be implemented systematically at reasonable cost and could be included in an accountability framework for health services. Most surgeons were not enthusiastic about this kind of evaluation.
PMCID: PMC121962  PMID: 12240811
2.  Ratings of global outcome at the first post-operative assessment after spinal surgery: how often do the surgeon and patient agree? 
European Spine Journal  2009;18(Suppl 3):386-394.
Patient-orientated questionnaires are becoming increasingly popular in the assessment of outcome and are considered to provide a less biased assessment of the surgical result than traditional surgeon-based ratings. The present study sought to quantify the level of agreement between patients’ and doctors’ global outcome ratings after spine surgery. 1,113 German-speaking patients (59.0 ± 16.6 years; 643 F, 470 M) who had undergone spine surgery rated the global outcome of the operation 3 months later, using a 5-point scale: operation helped a lot, helped, helped only little, didn’t help, made things worse. They also rated pain, function, quality-of-life and disability, using the Core Outcome Measures Index (COMI), and their satisfaction with treatment (5-point scale). The surgeon completed a SSE Spine Tango Follow-up form, blind to the patient’s evaluation, rating the outcome with the McNab criteria as excellent, good, fair, and poor. The data were compared, in terms of (1) the correlation between surgeons’ and patients’ ratings and (2) the proportions of identical ratings, where the doctor’s “excellent” was considered equivalent to the patient’s “operation helped a lot”, “good” to “operation helped”, “fair” to “operation helped only little” and “poor” to “operation didn’t help/made things worse”. There was a significant correlation (Spearman Rho = 0.57, p < 0.0001) between the surgeons’ and patients’ ratings. Their ratings were identical in 51.2% of the cases; the surgeon gave better ratings than the patient (“overrated”) in 25.6% cases and worse ratings (“underrated”) in 23.2% cases. There were significant differences between the six surgeons in the degree to which their ratings matched those of the patients, with senior surgeons “overrating” significantly more often than junior surgeons (p < 0.001). “Overrating” was significantly more prevalent for patients with a poor self-rated outcome (measured as global outcome, COMI score, or satisfaction with treatment; each p < 0.001). In a multivariate model controlling for age and gender, “low satisfaction with treatment” and “being a senior surgeon” were the most significant unique predictors of surgeon “overrating” (p < 0.0001; adjusted R2 = 0.21). Factors with no unique significant influence included comorbidity (ASA score), first time versus repeat surgery, one-level versus multilevel surgery. In conclusion, approximately half of the patient’s perceptions of outcome after spine surgery were identical to those of the surgeon. Generally, where discrepancies arose, there was a tendency for the surgeon to be slightly more optimistic than the patient, and more so in relation to patients who themselves declared a poor outcome. This highlights the potential bias in outcome studies that rely solely on surgeon ratings of outcome and indicates the importance of collecting data from both the patient and the surgeon, in order to provide a balanced view of the outcome of spine surgery.
PMCID: PMC2899319  PMID: 19462185
Spine surgery; Satisfaction; Global outcome; Self-assessment; Registry
3.  Development and Evaluation of the Universal ACS NSQIP Surgical Risk Calculator: A Decision Aide and Informed Consent Tool for Patients and Surgeons 
Accurately estimating surgical risks is critical for shared decision making and informed consent. The Centers for Medicare and Medicaid Services may soon put forth a measure requiring surgeons to provide patients with patient-specific, empirically-derived estimates of postoperative complications. Our objectives were (1) to develop a universal surgical risk estimation tool, (2) to compare performance of the universal vs. prior procedure-specific Surgical Risk Calculators, and (3) to allow surgeons to empirically adjust the estimates of risk.
Using standardized clinical data from 393 ACS NSQIP hospitals, a web-based tool was developed to allow surgeons to easily enter 21 preoperative factors (demographics, comorbidities, procedure). Regression models were developed to predict 8 outcomes based on the preoperative risk factors. The universal model was compared to procedure-specific models. To incorporate surgeon input, a subjective Surgeon Adjustment Score, allowing risk estimates to vary within the estimate's confidence interval, was introduced and tested with 80 surgeons using 10 case scenarios.
Based on 1,414,006 patients encompassing 1,557 unique CPT codes, a universal Surgical Risk Calculator model was developed which had excellent performance for mortality (c-statistic=0.944; Brier=0.011[ where scores approaching zero are better]), morbidity (c-statistic=0.816, Brier=0.069), and 6 additional complications (c-statistics>0.8). Predictions were similarly robust for the universal calculator vs. procedure-specific calculators (e.g., colorectal). Surgeons demonstrated considerable agreement on the case scenario scoring (80-100% agreement), suggesting reliable score assignment between surgeons.
The ACS NSQIP Surgical Risk Calculator is a decision-support tool based on reliable multi-institutional clinical data which can be used to estimate the risks of most operations. The ACS NSQIP Surgical Risk Calculator will allow clinicians and patients to make decisions using empirically derived, patient-specific postoperative risks.
PMCID: PMC3805776  PMID: 24055383
Surgery; Hospital; Quality; Morbidity; Mortality; Complications; Deaths; National Surgery Quality Improvement Program; Risk; Prognostication; Calculator; Decision aide; Shared decision making; informed consent
4.  The Western Ontario Shoulder Instability Index (WOSI): validity, reliability, and responsiveness retested with a Swedish translation 
Acta Orthopaedica  2009;80(2):233-238.
Background and purpose The WOSI score questionnaire is a tool designed for self-assessment of shoulder function for patients with instability problems. We made a translation into Swedish and retested the score by analyzing the psychometric properties validity, reliability, and responsiveness.
Patients and methods 3 patient materials were used for the assessment: (A) a follow-up on a group of 32 patients more than 8 years after having primary posttraumatic shoulder dislocation. Evaluation of Pearson’s correlation coefficient between WOSI and Rowe score and for test-retest reliability was made; (B) 22 patients, treated with a surgical stabilization of the shoulder at our department, were evaluated with Pearson’s correlation coefficient between WOSI and EQ-5D, and between WOSI and a VAS-scale of general shoulder function. Also, Cronbach’s alpha, effect size, and floor, and ceiling effects were analyzed; (C) 45 students with healthy shoulders (reference group) had their WOSI score determined.
Results The construct validity (Pearson’s correlation coefficient) was adequate (0.59) between the WOSI score and the Rowe score. The agreement with an ICC value (test-retest) for the WOSI score was excellent (0.94). Cronbach’s alpha (internal consistency) was satisfactory, with 0.89 preoperatively and 0.95 postoperatively. All 22 patients in group B reported improvement in the WOSI score (mean 29%). Responsiveness was excellent, with an effect size of 1.67 for the WOSI score. There were no floor or ceiling effects for the Swedish WOSI score. The mean WOSI score from group C with 45 normal healthy shoulders was 96%, with no floor but high ceiling effects.
Interpretation WOSI score does not require an examination of the patient and can be administered by mail. The high ICC and sensitivity makes it able to monitor an individual patient’s progress. At this retest, the WOSI score has good validity, a high degree of reliability, and a high degree of responsiveness, all at the same level as in the original publication. We recommend the WOSI when evaluating patients with instability problems.
PMCID: PMC2823179  PMID: 19404809
5.  Adhesion Awareness: A National Survey of Surgeons 
World Journal of Surgery  2010;34(12):2805-2812.
Postoperative adhesions are the most frequent complication of abdominal surgery, leading to high morbidity, mortality, and costs. However, the problem seems to be neglected by surgeons for largely unknown reasons.
A survey assessing knowledge and personal opinion about the extent and impact of adhesions was sent to all Dutch surgeons and surgical trainees. The informed-consent process and application of antiadhesive agents were questioned in addition.
The response rate was 34.4%. Two thirds of all respondents (67.7%) agreed that adhesions exert a clinically relevant, negative effect. A negative perception of adhesions correlated with a positive attitude regarding adhesion prevention (ρ = 0.182, p < 0.001). However, underestimation of the extent and impact of adhesions resulted in low knowledge scores (mean test score 37.6%). Lower scores correlated with more uncertainty about indications for antiadhesive agents which, in turn, correlated with never having used any of these agents (ρ = 0.140, p = 0.002; ρ = 0.095, p = 0.035; respectively). Four in 10 respondents (40.9%) indicated that they never inform patients on adhesions and only 9.8% informed patients routinely. A majority of surgeons (55.9%) used antiadhesive agents in the past, but only a minority (13.4%) did in the previous year. Of trainees, 82.1% foresaw an increase in the use of antiadhesive agents compared to 64.5% of surgeons (p < 0.001).
The magnitude of the problem of postoperative adhesions is underestimated and informed consent is provided inadequately by Dutch surgeons. Exerting adhesion prevention is related to the perception of and knowledge about adhesions.
PMCID: PMC2982960  PMID: 20814678
6.  Endoscopic transforaminal decompression, interbody fusion, and percutaneous pedicle screw implantation of the lumbar spine: A case series report 
On the basis of the experiences gained from conventional open spinal procedures, a long list of desirable objectives have emerged with the evolution of the lesser invasive spinal procedures. At the top of that list is the desire to minimize the trauma of surgery. The rest of the objectives, which include reductions of operating time, surgical blood loss, hospital stay, postoperative narcotic medication, convalescence, complication rates, and escalating health care costs, as well as the desire of elderly patients to continue rigorous physical activities, largely depend on the ability to minimize the trauma of surgery. The purpose of this study was to investigate the feasibility of the least invasive lumbar decompression, interbody fusion and percutaneous pedicle screw implantation, to minimize surgical trauma without compromising the quality of the treatment outcome, as well as to minimize risk of complications.
In this case series, 60 patients with diagnoses of degenerative disc disease, degenerative motion segments with stenosis, and spondylolisthesis, in whom nonoperative treatments failed, were treated with endoscopic transforaminal decompression and interbody fusion by 1 surgeon in 2 centers. The outcome measures were as follows: operating time, intraoperative blood loss, hospital stay, Visual Analogue Scale (VAS) scores for back and leg pain, scores on the Roland-Morris Disability Questionnaire, and postoperative imaging studies. A consecutive series of patients who met the treatment criteria completed VAS forms and Roland-Morris questionnaires preoperatively. Surgical procedures included arthroscopic decompression of the foramina and the discs; endplate preparation and implantation of allograft bone chips and bone morphogenetic protein 2 on absorbable collagen sponge into the disc space; and percutaneous implantation of pedicle screws. Postoperatively, the patients again completed the VAS forms and Roland-Morris questionnaires. Their charts were reviewed for office notes, operative notes, hospital stay, medications, and imaging studies. The latest X-ray and computed tomography scan films were reviewed and analyzed. Patients were followed up for a minimum of 6 months. The literature was reviewed for comparison of outcomes.
Sixty patients met the inclusion criteria. The mean age was 52.8 years. The duration of illness averaged 5 years. Follow-up ranged from 6 to 25 months, with a mean of 12 months. Preoperative diagnoses included degenerative disc disease, degenerative motion segments with stenosis, and spondylolisthesis. The mean time in the operating room was 2 hours 54 minutes. Estimated blood loss averaged 57.6 mL. The duration of the hospital stay averaged 2.6 days. Preoperative back pain and leg pain were significantly reduced (P < .005). Forty-seven imaging studies obtained at the last visit, including X-ray and computed tomography scans, showed solid fusion in 28 patients (59.6%), stable fixation in 17 (36.2%), and osteolysis around the pedicle screws in 2 (4.2%). All patients had improvement of motor function, whereas 2 patients complained of residual numbness. In addition, 8 patients (13%) complained of residual discomfort on extension of the lumbar spine. Two patients had pedicle screw–related complications requiring surgery. A review of the literature showed that endoscopic transforaminal decompression and interbody fusion performed better than open transforaminal lumbar interbody fusion/posterior lumbar interbody fusion, minimally invasive transforaminal lumbar interbody fusion, and extreme lateral lumbar interbody fusion, with regard to most parameters studied.
The endoscopic transforaminal lumbar decompression, interbody fusion, and percutaneous pedicle screw instrumentation consistently produced satisfactory results in all demographics. It performed better than the alternative procedures for most parameters studied.
PMCID: PMC4300894
ETDIF; Arthroscopic; Posterolateral; Interbody; Percutaneous; BMP-2
7.  Transition to a novel advanced integrated vitrectomy platform: comparison of the surgical impact of moving from the Accurus vitrectomy platform to the Constellation Vision System for microincisional vitrectomy surgery 
Microincisional vitrectomy surgery (MIVS) is the current standard surgical approach for pars plana vitrectomy. Historically, the most common surgical platform for vitrectomy surgery, since its introduction in 1997, has been the Accurus vitrectomy system. Recent introduction of the next generation of vitrectomy platforms has generated concerns associated with transitioning to new technology in the operating room environment. This study compared, in a matched fashion, surgical use of the Accurus vitrectomy system and the next generation Constellation Vision System to evaluate surgical efficiencies, complications, and user perceptions of this transition.
Electronic health records were abstracted as a hospital quality assurance activity and included all vitreoretinal surgical procedures at the Bascom Palmer Eye Institute, Anne Bates Leach Eye Hospital, during two discrete 12-month time periods. These two periods reflected dedicated usage of the Accurus (June 2008–May 2009) and Constellation Vision (July 2009–June 2010) systems. Data were limited to a single surgeon and evaluated for operating room (OR) total time usage/day, OR case time/case, and OR surgical time/case. Further analysis evaluated all patients undergoing combined MIVS and clear cornea phacoemulsification/intraocular lens (IOL) implantation during each individual time period to determine the impact of the instrumentation on these parameters. All records were evaluated for intraoperative complications.
Five hundred and fourteen eligible patients underwent MIVS during the 2-year study windows, with 281 patients undergoing surgery with the Accurus system and 233 patients undergoing surgery with the Constellation system. Combined MIVS and phacoemulsification with IOL implantation was performed 141 times during this period with the Accurus and 158 times during the second study period with the Constellation. Total number of patients operated per day increased from 7.55 with Accurus to 8.53 with Constellation. Surgical room time decreased from 56 minutes with Accurus to 52 minutes with Constellation, and procedure time decreased from 35 minutes with Accurus to 31 minutes with Constellation (P < 0.004). Combined MIVS/phacoemulsification surgery saw similar declines in surgical room time and procedure time (P < 0.001). Subset analysis of procedures limited by case number per day (eg, four cases/day, five cases/day, six cases/day, and seven or more cases/day) showed similar outcomes with a decrease in surgical room time and procedure time. No increases in surgery-related complications were noted by quality assurance review during these time periods.
Transitioning to advanced surgical technology is a complex issue for the surgeon, the hospital team, and the hospital administration. This study documents improvement in three significant measures of surgical efficiency: operative number of patients per day, operative room time, and surgical procedure time that reflect the positive impact of the novel, combined, integrated, posterior and anterior, ophthalmologic surgical platform of the Constellation Vision System. These data are imperative to evaluate the impact of transition from one surgical platform to another. During this transition, hospital quality assurance review and surgeon evaluation of operative complications showed no increased concerns for the shift from the Accurus to the Constellation Vision System surgical platform. Further, both operative staff and surgeons felt that the transition to the Constellation was not associated with increases in difficulty with setup, turnover, or use and that the Constellation decreased safety concerns for surgical usage. Ultimately, in this case, new technology benefited the surgeon, the patient, and the hospital.
PMCID: PMC3581355  PMID: 23450081
MIVS; vitrectomy; new technology
8.  Are recommended spine operations either unnecessary or too complex? Evidence from second opinions 
Surgical Neurology International  2013;4(Suppl 5):S353-S358.
In 2011, Epstein and Hood documented that 17.2% of 274 patients with cervical/lumbar complaints seen in first or second opinion over one year were told they needed “unnecessary” spine surgery (e.g., defined as for pain alone, without neurological deficits, or significant radiographic abnormalities). Subsequently, in 2012 Gamache found that 69 (44.5%) of the 155 second opinion patients seen over a 14-month period were told by outside spine surgeons that they needed surgery; the second opinion surgeon (Gamache) found those operations to be unnecessary. Increasingly, patients, spine surgeons, hospitals, and insurance carriers should not only be questioning whether spinal operations are “unnecessary”, but also whether they are “wrong” (e.g., overly extensive, anterior vs. posterior operations), or “right” (appropriate).
Prospectively, 437 patients with cervical or lumbar complaints were seen in spinal consultation over a 20-month period. Of the 254 (58.1%) patients coming in for first opinions those with surgical vs. non-surgical lesions were identified. Of the 183 (41.9%) patients coming in for second opinions, who were previously told by outside surgeons that they needed spine operations, the second opinion surgeon documented the number of “unnecessary”, “wrong”, or “right” operations previously recommended.
Surgical pathology was identified in 138 (54.3%) patients presenting for first opinions. For patients seen in second opinion, 111 (60.7%) were told by outside surgeons that they required “unnecessary”, 61 (33.3%) the “wrong”, or 11 (6%) the “right” operations.
Of 183 second opinions seen over 20 months, the second opinion surgeon documented that previous spine surgeons recommended “unnecessary” (60.7%), the “wrong” (33.3%), or the “right” (6%) operations.
PMCID: PMC3841934  PMID: 24340231
First opinions; right; spine surgery; second opinions; unnecessary; wrong
9.  The Incidence and Reporting Rates of Needle-Stick Injury Amongst UK Surgeons 
Needle-stick injuries are common. Such accidents are associated with a small, but significant, risk to our career, health, families and not least our patients. National guidelines steer institution-specific strategies to provide a consistent and safe method of dealing with such incidents. Surgeon-specific guidelines are not currently available. We have observed that hospital sharps policy is often considered cumbersome to the surgeon, resulting in on-the-spot decision making with potential long-term implications. By their essence, these decisions are inconsistent, not reproducible and, thus, we believe them to be unsafe. The under-reporting to occupational health departments is well documented. Current surgical practice has the potential to expose the surgeon to unnecessary risk. The aims of this study were to establish the true incidence of contaminations caused by needle-stick injury in our hospital and to assess how well current protocols are really implemented.
We identified all surgeons of consultant, non-career staff grade (NCSG) and registrar grade working in a large 687-bed district general hospital serving a population of 550,000, in the UK. We designed a retrospective, anonymous 30-second survey. Surgeons' awareness and opinion of local policy was sought in a free-text section.
Of the 98 surgeons in the hospital, 77% responded to the questionnaire and 44% anonymously admitted to having a needle-stick injury. Only 3 of the 33 (9%) who sustained an needle-stick injury said that they followed the agreed local policy. Twenty-three surgeons (70%) performed first aid type procedures such as informing scrub nurse, changing needle and gloves. Seven surgeons (21%) simply ignored the incident and continued. Forty-three surgeons commented on the policy's nature with only 9 who regarded it as ‘user friendly’.
Needle-stick injury is still a common problem, particularly in the surgical cohort and remains significantly under-reported. The disparity between hospital sharps policy and actual surgical practice is considered and an explanation for the difference sought. Without this awareness of ‘real-life’ surgical practice, the occupational health figures for sharps injury will always tell a rosy story under-estimating a real problem. We strongly advocate universal precautions in the operating theatre. However, we acknowledge that sharps injuries will occur. We should remain vigilant and act upon contaminations without surgical bravado but with mater-of-fact professionalism. This includes regular review of policy and, particularly, promotion of surgical awareness.
PMCID: PMC2752234  PMID: 18990263
Needle-stick injury; Sharps injury; Surgical contamination; Blood-borne viruses; Reporting rates
10.  An outcome measure of functionality in patients with lumber spinal stenosis: a validation study of the Iranian version of Neurogenic Claudication Outcome Score (NCOS) 
BMC Neurology  2012;12:101.
Neurogenic claudication (NC) is a common symptom in patients with lumbar spinal stenosis (LSS). The Neurogenic Claudication Outcome Score (NCOS) is a very short instrument for measuring functional status in these patients. This study aimed to translate and validate the NCOS in Iran.
This was a prospective clinical validation study. The 'forward-backward' procedure was applied to translate the NCOS from English into Persian (Iranian language). A total of 84 patients with NC were asked to respond to the questionnaire at two points in time: at preoperative and at postoperative (6 months follow-up) assessments. The Oswestry Disabiltiy Index (ODI) also was completed for patients. To test reliability, the internal consistency was assessed by Cronbach's alpha coefficient. Validity was evaluated using known groups comparison and criterion validity (convergent validity). Internal responsiveness of the NCOS to the clinical intervention (surgery) also was assessed comparing patients’ pre- and postoperative scores.
The Cronbach’s alpha coefficients for the NCOS at preoperative and postoperative assessments were 0.77 and 0.91, respectively. Known groups analysis showed satisfactory results. The instrument discriminated well between sub-groups of patients who differed in claudication distance as measured by the Self-Paced Walking Test (SPWT). The change in the ODI after surgery was strongly correlated with change in the NCOS, lending support to its good convergent validity (r = 0.81; P < 0.001). Further analysis also indicated that the questionnaire was responsive to the clinical intervention (surgery) as expected (P < 0.0001).
In general, the Iranian version of the NCOS performed well and the findings suggest that it is a reliable and valid measure of functionality in patients with lumbar spinal stenosis who are suffering from neurogenic claudication.
PMCID: PMC3502137  PMID: 23006983
11.  Surgeons’ opinions and practice of informed consent in Nigeria 
Journal of Medical Ethics  2010;36(12):741-745.
Informed consent is perhaps more relevant to surgical specialties than to other clinical disciplines. Fundamental to this concept is the provision of relevant information for the patient to make an informed choice about a surgical intervention. The opinions of surgeons in Nigeria about informed consent in their practice were surveyed.
A cross-sectional survey of surgeons in Nigeria was undertaken in 2004/5 using self-administered semistructured questionnaires.
There were 102 respondents, 85.3% of whom were men and 58.8% were aged 31–40 years. 43.1% were consultants and 54.0% were surgical trainees. 27.4% were in surgical subspecialties, 26.5% in general surgery and 21.6% were obstetricians and gynaecologists. 54.9% agreed that sufficient information is not provided to patients while obtaining their consent for surgical procedures. They listed medicolegal reasons (70.6%), informing patients about benefits, risks and alternatives (64.7%) and hospital policy (50.0%) as some reasons for obtaining consent for surgical procedures. When patients decline to give consent for surgery, 84.3% of them thought that poor communication between surgeons and patients may be contributory. They identified taking a course in bioethics during surgical training and compulsory communication skills course as some ways to improve communication between surgeons and patients.
Most Nigerian surgeons seemed to have a good knowledge of the informed consent requirements and process but fall short in practice. There is a need to improve the surgeon–patient relationship in line with modern exigencies to provide interactive environments for fruitful patient communication and involvement.
PMCID: PMC3332031  PMID: 20940174
12.  Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons 
BMJ Open  2011;1(2):e000391.
To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain.
Design and setting
Nationwide survey among spine surgeons in the Netherlands.
Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain.
Primary and secondary outcome measures
The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined.
The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy.
The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision making in patients with chronic low back pain.
Article summary
Article focus
What is the level of professional consensus among spine surgeons regarding spinal fusion surgery for chronic low back pain?
How are tests for patient selection appreciated and to what extent are they used in clinical practice?
Are prognostic patient factors incorporated in the process of surgical decision making for chronic low back pain?
Key messages
In clinical practice, there is no professional consensus on surgical treatment strategy for chronic low back pain.
Prognostic patient factors as well as tests for patient selection are not consistently used in clinical decision making for spinal fusion.
Because of a lack of consensus on spinal fusion strategy for chronic low back pain in clinical practice, no guidelines for proper patient counselling can be installed at present.
Strengths and limitations of this study
A survey among physicians provides valuable insight in the actual decision-making process in clinical practice. Understanding contributory factors in treatment strategy may help in the creation of consensus guidelines.
The introduction of an interviewer bias could be avoided by the use of a neutral intermediary instead of direct questions from peers in spine surgery.
This study focused on surgeon members of the Dutch Spine Society whose practice may not reflect that of all surgeons performing spinal fusion for chronic low back pain. Moreover, no information on conservative treatment options was acquired.
To define consensus, we chose for uniformity of opinion of at least 70%, which we considered to be sufficient for implementation in guidelines. Such a cut-off level remains arbitrary.
PMCID: PMC3278483  PMID: 22189352
13.  Cognitive Investigation Study of Patients Admitted for Cosmetic Surgery: Information, Expectations, and Consent for Treatment 
Archives of Plastic Surgery  2015;42(1):46-51.
In all branches of medicine, it is the surgeon's responsibility to provide the patient with accurate information before surgery. This is especially important in cosmetic surgery because the surgeon must focus on the aesthetic results desired by the patient.
An experimental protocol was developed based on an original questionnaire given to 72 patients. The nature of the responses, the patients' motivation and expectations, the degree of patient awareness regarding the planned operation, and the patients' perceptions of the purpose of the required consent for cosmetic surgery were all analyzed using Fisher's exact test.
Candidates for abdominal wall surgery had significantly more preoperative psychological problems than their counterparts did (P=0.035). A significantly different percentage of patients under 40 years of age compared to those over 40 years of age searched for additional sources of information prior to the operation (P=0.046). Only 30% of patients with a lower educational background stated that the preoperative information had been adequate, whereas 92% of subjects with secondary schooling or a postsecondary degree felt that the information was sufficient (P=0.001). A statistically significant difference was also present between patients according to their educational background regarding expected improvements in their quality of life postoperatively (P=0.008).
This study suggests that patients require more attention in presurgical consultations and that clear communication should be prioritized to ensure that the surgeon understands the patient's expectations.
PMCID: PMC4297806  PMID: 25606489
Informed consent; Cosmetic surgery; Quality of life; Aesthetic
14.  Preoperative education for lumbar radiculopathy: A survey of US spine surgeons 
We sought to determine current utilization, importance, content, and delivery methods of preoperative education by spine surgeons in the United States for patients with lumbar radiculopathy.
An online cross-sectional survey was used to study a random sample of spine surgeons in the United States. The Spinal Surgery Education Questionnaire (SSEQ) was developed based on previous related surveys and assessed for face and content validity by an expert panel. The SSEQ captured information on demographics, content, delivery methods, utilization, and importance of preoperative education as rated by surgeons. Descriptive statistics were used to describe the current utilization, importance, content, and delivery methods of preoperative education by spine surgeons in the United States for patients with lumbar radiculopathy.
Of 200 surgeons, 89 (45% response rate) responded to the online survey. The majority (64.2%) provide preoperative education informally during the course of clinical consultation versus a formal preoperative education session. The mean time from the decision to undergo surgery to the date of surgery was 33.65 days. The highest rated educational topics are surgical procedure (96.3%), complications (96.3%), outcomes/expectations (93.8%), anatomy (92.6%), amount of postoperative pain expected (90.1%), and hospital stay (90.1%). Surgeons estimated spending approximately 20% of the preoperative education time specifically addressing pain. Seventy-five percent of the surgeons personally provide the education, and nearly all surgeons (96.3%) use verbal communication with the use of a spine model.
Spine surgeons believe that preoperative education is important and use a predominantly biomedical approach in preparing patients for surgery. Larger studies are needed to validate these findings.
PMCID: PMC4300892
Spine; Surgery; Education; Survey; Preoperative
15.  Determinants of satisfaction 1 year after total hip arthroplasty: the role of expectations fulfilment 
Between 7% and 15% of patients are dissatisfied after total hip arthroplasty (THA). To assess predictors and postoperative determinants of satisfaction and expectation fulfilment one year after (THA).
Before THA surgery, 132 patients from three tertiary care centres and their surgeons were interviewed to assess their expectations using the Hospital for Special Surgery Total Hip Replacement Expectations Survey (THR survey). One year after surgery, patients (n = 123) were contacted by phone to complete a questionnaire on expectation fulfilment (THR survey), satisfaction, functional outcome (Womac), and health-related quality of life (SF 12). Univariate and multivariate analyses were performed.
Preoperative predictors of satisfaction were a good mental wellbeing (adjusted OR 1.09 [1.02; 1.16], p = 0.01) and optimistic surgeons expectations (1.07 [1.01; 1.14], p = 0.02). The main postoperative determinant of satisfaction was the fulfilment of patient’s expectations (1.08 [1.04; 1.12], p < 0.001). Expectation fulfilment could be predicted before surgery by young age (regression coefficient −0.55 [−0.88; -0.21], p = 0.002), good physical function (−0.96 [−1.82; -0.10], p = 0.03) and good mental wellbeing (0.56 [0.14; 0.99], p = 0.01). Postoperative determinants of expectation fulfilment were functional outcome (−2.10 [−2.79; -1.42], p <0.001) and pain relief (−14.83 [−22.38; -7.29], p < 0.001).
To improve patient satisfaction after THA, patients’ expectations and their fulfilment need to be carefully addressed. Patients with low mental wellbeing or physical function should be identified and specifically informed on expected surgical outcome. Surgeons’ expectations are predictive of satisfaction and information should aim to lower discrepancy between surgeons’ and patients’ expectations.
PMCID: PMC3936828  PMID: 24564856
Total hip arthroplasty; Expectations; Expectations’ fulfilment; Satisfaction; Outcome
16.  Cumulative risk adjusted mortality chart for detecting changes in death rate: observational study of heart surgery 
BMJ : British Medical Journal  1998;316(7146):1697-1700.
Objective: To detect changes in mortality after surgery, with allowance being made for variations in case mix.
Design: Observational study of postoperative mortality from January 1992 to August 1995.
Setting: Regional cardiothoracic unit.
Subjects: 3983 patients aged 16 and over who had open heart operations.
Main outcome measures: Preoperative risk factors and postoperative mortality in hospital within 30 days were recorded for all surgical heart operations. Mortality was adjusted for case mix using a preoperative estimate of risk based on additive Parsonnet factors. The number of operations required for statistical power to detect a doubling of mortality was examined, and control limits at a nominal significance level of P=0.01 for detection of an adverse trend were determined.
Results: Total mortality of 7.0% was 26% below the Parsonnet predictor (P<0.0001). There was a highly significant variation in annual case mix (Parsonnet scores 8.7-10.6, P<0.0001). There was no significant variation in mortality after adjustment for case mix (odds ratio 1-1.5, P=0.18) with monitoring by calendar year. With continuous monitoring, however, nominal 99% control limits based on 16 expected deaths were crossed on two occasions.
Conclusions: Hospital league tables for mortality from heart surgery will be of limited value because year to year differences in death rate can be large (odds ratio 1.5) even when the underlying risk or case mix does not change. Statistical quality control of a single series with adjustment for case mix is the only way to take into account recent performance when informing a patient of the risk of surgery at a particular hospital. If there is an increase in the number of deaths the chances of the next patient surviving surgery can be calculated from the last 16 deaths.
Key messages Changes in the patient population affect a hospital’s annual death rate Year to year differences in death rate can be large even when there is no change in the underlying risk or case mix It takes surprisingly many operations before an increase in death rate can be distinguished from random fluctuation A formal inquiry should take place in a hospital if the death rate rises above control limits The chances of the next patient surviving surgery should be calculated using the surgeon’s most recent results
PMCID: PMC28566  PMID: 9614015
17.  Development and psychometric testing of a scale assessing the sharing of medical information and interprofessional communication: the CSI scale 
Interprofessional collaboration is essential in creating a safer patient environment. It includes the need to develop communication and coordination between professionals, implying a better sharing of medical information. Several questionnaires exist in the literature, but none of them have been developed in the French context. The objective was to develop and test the psychometric properties of the communication and sharing information (CSI) scale which assesses specifically interprofessional communication, especially the sharing of medical information and the effectiveness of communication between members of the team.
The questionnaire construction process used a literature review and involved a panel of voluntary professionals. A list of 32 items explored the quality of shared information delivered to patients and the effectiveness of interprofessional communication. The study was conducted in 16 voluntary units in a University Hospital (France), which included medical, surgical, obstetrics, intensive care, pediatrics, oncology and rehabilitation care. The scale-development process comprised an exploratory principal component analysis, Cronbach’s α-coefficients and structural equation modeling (SEM).
From these 16 units, a total of 503 health professionals took part in the study. Among them, 23.9% were physicians (n = 120), 43.9% nurses (n = 221) and 32.2% nurse assistants (n = 162).
The validated questionnaire comprised 13 items and 3 dimensions relative to “the sharing of medical information” (5 items), “communication between physicians” (4 items) and “communication between nurses and nurse assistants” (4 items). The 3 dimensions accounted for 63.7% of the variance of the final questionnaire. Their respective Cronbach’s alpha coefficients were 0.80, 0.87 and 0.81. SEM confirmed the existence of the 3 latent dimensions but the best characteristics were obtained with a hierarchical model including the three latent factors and a global “communication between healthcare professionals” latent factor, bringing the 8 items linked to communication together. All the structural coefficients were highly significant (P < 0.001).
This self-perception CSI scale assessing several facets of interprofessional communication is the first one developed in the French context. The development study exhibited excellent psychometric properties. Further psychometric analysis is needed to establish test-retest reliability, sensibility to change and concurrent validity.
PMCID: PMC4008265  PMID: 24625318
Interprofessional communication; Patient information; Patient safety; Questionnaire; Psychometric properties; Scale validation
The Journal of urology  2005;173(6):2099-2103.
A strong association between surgeon, hospital volume and postoperative morbidity of radical prostatectomy has been demonstrated. While better outcomes are associated with high volume surgeons, the degree of variation in outcomes among surgeons has not been fully examined.
Materials and Methods
Using a linked database from Surveillance, Epidemiology and End Results registries and federal Medicare claims data, we analyzed outcomes of consecutive patients treated with radical prostatectomy between 1992 and 1996. We focused on variations in several measures of morbidity (perioperative complications, late urinary complications and long-term incontinence) among patients of high volume surgeons, defined as those with 20 or more patients in the study period. After adjusting for hospital, surgeon volume and case mix, we examined the extent to which variations in the rates of adverse outcomes differed among surgeons for all 3 end points.
Of the 999 surgeons 16% (159) performed 48.7% (5,238) of the 10,737 radical prostatectomies during the study. The 30-day mortality rate was 0.5%, the major postoperative complication rate was 28.6%, late urinary complications 25.2% (major events 16%) and long-term incontinence 6.7%. For all 3 morbidity outcomes the variation among surgeons in the rate of complications was significantly greater than that expected by chance (p =0.001 for each) after adjustment of covariates. Furthermore, surgeons with better (or worse) than average results with regard to 1 outcome were likely to have better (or worse, respectively) results with regard to the other2 outcome measures.
Morbidity end points that directly affect quality of life showed significant variability among high volume providers. Surgeons who performed well in 1 area (eg postoperative complications) performed well in others. These results further suggest that variations in surgical technique and postoperative care lead to variations in outcomes after radical prostatectomy, indicating that outcomes of this operation are sensitive to small differences in performance.
PMCID: PMC1855289  PMID: 15879851
outcome and process assessment; prostatectomy; complications; urinary incontinence; workload
19.  Patient safety risk factors in minimally invasive surgery: a validation study 
Gynecological Surgery  2011;9(3):265-270.
This study was conducted to adapt and validate a patient safety (PS) framework for minimally invasive surgery (MIS) as a first step in understanding the clinical relevance of various PS risk factors in MIS. Eight patient safety risk factor domains were identified using frameworks from a systems approach to patient safety. A questionnaire was drafted containing 34 questions. Three experts in the field of patient safety critically reviewed the questionnaire on clinical relevance and completeness. The questionnaire was distributed among known patient safety experts in person and also sent electronically. A total of 41 questionnaires were distributed and the response rate was 71%. The intraclass correlation coefficient was 0.42 representing moderate agreement. For seven of nine risk domains, Cronbach’s alpha was sufficient (α > 0.7). Mean scores of the risk domains showed the following order of influence on patient safety from high to low: surgeon’s experience [6.6, standard deviation (SD) 0.5], technical skills surgeon (6.6, SD 0.7), technology (5.9, SD 1.1), complications (5.9, SD 1.2), social interaction (5.0, SD 1.0), leadership surgeon (5.4, SD 1.2), blood loss (5.0, SD 1.2), length of surgery (5.0, SD 1.3), surgical team (4.9, SD 1.3), fallibility (4.9, SD 1.3), patient (4.5, SD 1.5), safety measures (4.4, SD 1.5), and finally environment(3.9, SD 1.5). This study is an initiative to give insight into clinical relevance of the maze of PS risk factors in MIS. All investigated risk domains were considered to be of noticeable influence on PS. Nevertheless, it is possible to prioritize various risk domains. In fact, experience and technical skills of the surgeon, technology, and complications are rated as the most important risk factors, closely followed by social interaction and leadership of the surgeon. Patient, safety measures, and environment are rated as the least important risk factors.
PMCID: PMC3401291  PMID: 22837734
Patient safety; Risk factors; Risk domains; MIS; Laparoscopy; Systems approach
20.  Is Circumferential Minimally Invasive Surgery Effective in the Treatment of Moderate Adult Idiopathic Scoliosis? 
Outcomes for minimally invasive scoliosis correction surgery have been reported for mild adult scoliosis. Larger curves historically have been treated with open surgical procedures including facet resections or posterior column osteotomies, which have been associated with high-volume blood loss. Further, minimally invasive techniques have been largely reported in the setting of degenerative scoliosis.
We describe the effects of circumferential minimally invasive surgery (cMIS) for moderate to severe scoliosis in terms of (1) operative time and blood loss, (2) overall health and disease-specific patient-reported outcomes, (3) deformity correction and fusion rate, and (4) frequency and types of complications.
Between January 2007 and January 2012, we performed 50 cMIS adult idiopathic scoliosis corrections in patients with a Cobb angle of greater than 30° but less than 75° who did not have prior thoracolumbar fusion surgery; this series represented all patients we treated surgically during that time meeting those indications. Our general indications for this approach during that period were increasing back pain unresponsive to nonoperative therapy with cosmetic and radiographic worsening of curves. Surgical times and estimated blood loss were recorded. Functional clinical outcomes including VAS pain score, Oswestry Disability Index (ODI), and SF-36 were recorded preoperatively and postoperatively. Patients’ deformity correction was assessed on pre- and postoperative 36-inch (91-cm) standing films and fusion was assessed on CT scan. Minimum followup was 24 months (mean, 48 months; range, 24–77 months).
Mean blood loss was 613 mL for one-stage surgery and 763 mL for two-stage surgery. Mean operative time was 351 minutes for one-stage surgery and 482 minutes for two-stage surgery. At last followup, mean VAS and ODI scores decreased from 5.7 and 44 preoperatively to 2.9 and 22 (p < 0.001 and 0.03, respectively) and mean SF-36 score increased from 48 preoperatively to 74 (p = 0.026). Mean Cobb angle and sagittal vertical axis decreased from 42° and 51 mm preoperatively to 16° and 27 mm postoperatively (both p < 0.001). An 88% fusion rate was confirmed on CT scan. Perioperative complications occurred in 11 of the 50 patients (22%), with delayed complications needing further surgery in 10 more patients at last followup.
cMIS provides for good clinical and radiographic outcomes for moderate (30°–75°) adult idiopathic scoliosis. Patients undergoing cMIS should be carefully selected to avoid fixed, rigid deformities and a preoperative sagittal vertical axis of greater than 10 cm; surgeons should consider alternative techniques in those patients.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC4016423  PMID: 24658900
21.  Discrepant perceptions of communication, teamwork and situation awareness among surgical team members 
To assess surgical team members’ differences in perception of non-technical skills.
Questionnaire design.
Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands.
Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists.
All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT.
Ratings for ‘communication’ were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for ‘teamwork’ differed significantly between all team members (P ≤ 0.005). Within ‘situation awareness’ significant differences were mainly observed for ‘gathering information’ between surgeons and other team members (P < 0.001). Finally, 72–90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate.
This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.
PMCID: PMC3055275  PMID: 21242160
patient safety; quality of care; teamwork; communication; surgery
22.  The efficacy of a computer-assisted preoperative tutorial for clinical clerks 
Canadian Journal of Surgery  1996;39(3):221-224.
To assess the effectiveness of computer-assisted preoperative tutorials on human anatomy in improving the operating-room learning experience for clinical clerks.
Crossover trials with immediate assessment and approximately 1-week delay between trials.
General surgery operating room of a university teaching hospital.
Eight 4th-year clinical clerks on a single 8-week surgical rotation.
Main Outcome Measures
The senior surgeon’s assessment of the clerk’s knowledge and understanding of the operation, according to a six-item questionnaire, and the clerk’s own assessment of the experience in the operating room, according to an eight-item questionnaire.
Surgeons rated the clerks’ performances in the operating room as better when they had received the preoperative tutorial (mean [and standard deviation], 3.7 [0.4]) than when they had not received the preoperative tutorial (3.0 [0.3]). The difference (0.7 [0.6]) was statistically significant (t7 = 3.3, p < 0.01). Similarly, clerks rated their own experience more positively when they had received the tutorial (4.0 [0.2]) than when they had not (3.1 [0.3]), with the difference (0.9 [0.5]) being statistically significant (t7 = 4.9, p < 0.001).
Short, preoperative, computer-assisted tutorials on human anatomy can have a positive impact on the clerk’s level of knowledge and confidence in the operating room. Further research is warranted into the extent to which students spontaneously make use of these tutorials.
PMCID: PMC3950010  PMID: 8640621
23.  Opinions on the Treatment of People With Tetraplegia: Contrasting Perceptions of Physiatrists and Hand Surgeons 
Upper-extremity reconstruction for people with tetraplegia is underused, and we felt that physicians' beliefs could be contributing to this phenomenon. This research sought to determine whether (a) physicians underestimate the importance of upper-extremity function for people with tetraplegia, (b) physiatrists and hand surgeons disagree on the quality of life of those with tetraplegia, (c) surgeons believe that social issues make people with tetraplegia poor surgical candidates, and (d) the 2 specialties disagree on the benefits of upper-extremity reconstruction.
A self-administered questionnaire was mailed to a national sample of 384 physiatrists and 379 hand surgeons. The data were analyzed with bivariate statistics.
The response rate was 62%. 65% of surgeons and 49% of physiatrists (P < 0.001) ranked upper-extremity function as the most important rehabilitative goal for people with tetraplegia. Both specialties believed the quality of life with tetraplegia was low (less than 60 on a scale of 0 to 100, with 100 representing perfect health). The 2 specialties have significantly different opinions regarding patient compliance, social support, and the effectiveness of surgery.
The majority of physicians believe that upper-extremity function is a rehabilitative priority for people with tetraplegia. However, physiatrists and hand surgeons have significantly different views about people with tetraplegia and the benefits of reconstructive surgery. Physician preconceptions and interdisciplinary divergence may be contributing to the underuse of these procedures, and these issues should be considered when designing programs to improve access to these procedures.
PMCID: PMC2031964  PMID: 17684892
Outcome assessment (healthcare); Health care surveys; Tetraplegia; Upper extremity reconstruction; Physiatry; Hand surgery; Attitude of health personnel
24.  Challenges in multidisciplinary cancer care among general surgeons in Canada 
While many factors can influence the way that cancer care is delivered, including the way that evidence is packaged and disseminated, little research has evaluated how health care professionals who manage cancer patients seek and use this information to identify whether and how this could be supported. Through interviews we identified that general surgeons experience challenges in coordinating care for complex cancer patients whose management is not easily addressed by guidelines, and conducted a population-based survey of general surgeon information needs and information seeking practices to extend these findings.
General surgeons with privileges at acute care hospitals in Ontario, Canada were mailed a questionnaire to solicit information needs (task, importance), information seeking (source, frequency of and reasons for use), key challenges and suggested solutions. Non-responders received up to three reminder packages. Significant differences among sub-groups (age, setting) were examined statistically (Kruskal Wallis, Mann Whitney, Chi Square). Standard qualitative methods were used to thematically analyze open-ended responses.
The response rate was 44.2% (170/385) representing all 14 health regions. System resource constraints (60.4%), comorbidities (56.4%) and physiologic factors (51.8%) were top-ranked issues creating information needs. Local surgical colleagues (84.6%), other local colleagues (82.2%) and the Internet (81.1%) were top-ranked sources of information, primarily due to familiarity and speed of access. No resources were considered to be highly applicable to patient care. Challenges were related to limitations in diagnostics and staging, operative resources, and systems to support multidisciplinary care, together accounting for 76.0% of all reported issues. Findings did not differ significantly by surgeon age or setting of care.
General surgeons appear to use a wide range of information resources but they may not address the complex needs of many cancer patients. Decision-making is challenged by informational and logistical issues related to the coordination of multidisciplinary care. This suggests that limitations in system capacity may, in part, contribute to variable guideline compliance. Further research is required to evaluate the appropriateness of information seeking, and both concurrent and consecutive mechanisms by which to achieve multidisciplinary care.
PMCID: PMC2631026  PMID: 19102761
25.  Comparison of NHS and private patients undergoing elective transurethral resection of the prostate for benign prostatic hypertrophy. 
Quality in Health Care  1993;2(1):11-16.
OBJECTIVES--To compare the operative thresholds and clinical management of men undergoing elective transurethral resection of the prostate for benign prostatic hypertrophy in the NHS and privately. DESIGN--Cohort study of patients recruited by 25 surgeons during 1988. SETTING--Hospitals in Oxford and North West Thames regions. PATIENTS--Of 400 consecutive patients, 129 were excluded because of open surgery (nine), lack of surgeons' information (three), and emergency admission (117) and three failed to give information, leaving 268 patients, 214 NHS patients and 54 private patients. MAIN MEASURES--Sociodemographic factors, prevalence and severity of symptoms, comorbidity, general health (Nottingham health profile) obtained from patient questionnaire preoperatively and reasons for operating, and operative management obtained from surgeons perioperatively. RESULTS--NHS and private patients were similar in severity of symptoms and prevalence of urinary tract abnormalities. They differed in four respects: NHS patients' general health was poorer as a consequence of more comorbid conditions (49, 23% v 7, 13% in severe category); the condition had a greater detrimental effect on their lives (36, 17% v 2, 4% severely affected; p < 0.01); private patients received more personalised care more quickly and were investigated more before surgery, (29, 54% v 60, 20% receiving ultrasonography of the urinary tract); and NHS patients stayed in hospital longer (57, 27% v 3, 6% more than seven days; p < 0.001). CONCLUSIONS--Private patients' need for surgery, judged by symptom severity, was as great as that of NHS patients, and there was no evidence of different operative thresholds in the two sectors, but, judged by impact on lifestyle, NHS patients' need was greater.
PMCID: PMC1055055  PMID: 10171799

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