Quality of care in surgery and methods to assess the volume-outcome relationship
Author(s)
Mayer, Erik K.
Type
Thesis
Abstract
This thesis outlines the proposed attributes of healthcare which can define its
quality and reviews existing research in this area. Specifically, the limitations of
existing research into the volume-outcome relationship within surgery are
highlighted, thereby addressing the ‘health outcome’ dimension of quality of care.
The principles and existing application of funnel plots within surgery are reviewed
alongside their ability to overcome the limitations, risks and implications of
contemporary ranking of surgical performance. Methods by which future research
should be conducted are proposed as a conceptual model. This model, along with
the proposed ‘quality’ attributes, identifies the research themes of the empirical
studies.
The application of a validated methodological scoring system formally explores
the limitations of existing volume-outcome research within the uro-oncological
field. A cross-sectional analysis of administrative data assesses the volume-outcome
relationship for radical cystectomy in England, using an improved
methodology that incorporates a multilevel model to account for the relationship
and influence of both the surgeon and institution and adjustment for institutional
structural and process of care confounders. Subsequently, risk-adjusted funnel plot
methodology is applied to the dataset to further explore provider performance. A
longitudinal analysis assesses compliance with healthcare policy for radical pelvic
surgery in England by exploring the patterns of service provision, in response to
the existing understanding of the volume-outcome relationship for uro-oncology.
This thesis demonstrates the limitations with existing volume-outcome
methodology and the need for improved methodology for both the interpretation
and presentation of volume-outcome research. Appropriate handling of the data in
volume-outcome analysis, which recognises the hierarchical nature, is important
to adequately inform future service reconfiguration. Volume-outcome research is
just one component of a quality framework that will help align healthcare with
quality improvement programmes and must incorporate a multidimensional
approach to measuring and presenting both the clinical and patient-orientated
measures of quality of care.
quality and reviews existing research in this area. Specifically, the limitations of
existing research into the volume-outcome relationship within surgery are
highlighted, thereby addressing the ‘health outcome’ dimension of quality of care.
The principles and existing application of funnel plots within surgery are reviewed
alongside their ability to overcome the limitations, risks and implications of
contemporary ranking of surgical performance. Methods by which future research
should be conducted are proposed as a conceptual model. This model, along with
the proposed ‘quality’ attributes, identifies the research themes of the empirical
studies.
The application of a validated methodological scoring system formally explores
the limitations of existing volume-outcome research within the uro-oncological
field. A cross-sectional analysis of administrative data assesses the volume-outcome
relationship for radical cystectomy in England, using an improved
methodology that incorporates a multilevel model to account for the relationship
and influence of both the surgeon and institution and adjustment for institutional
structural and process of care confounders. Subsequently, risk-adjusted funnel plot
methodology is applied to the dataset to further explore provider performance. A
longitudinal analysis assesses compliance with healthcare policy for radical pelvic
surgery in England by exploring the patterns of service provision, in response to
the existing understanding of the volume-outcome relationship for uro-oncology.
This thesis demonstrates the limitations with existing volume-outcome
methodology and the need for improved methodology for both the interpretation
and presentation of volume-outcome research. Appropriate handling of the data in
volume-outcome analysis, which recognises the hierarchical nature, is important
to adequately inform future service reconfiguration. Volume-outcome research is
just one component of a quality framework that will help align healthcare with
quality improvement programmes and must incorporate a multidimensional
approach to measuring and presenting both the clinical and patient-orientated
measures of quality of care.
Date Issued
2010
Date Awarded
2011-01
Copyright Statement
Attribution NoDerivatives 4.0 International Licence (CC BY-ND)
Advisor
Darzi, Ara
Athanasiou, Thanos
Vale, Justin
Creator
Mayer, Erik K.
Publisher Department
Medicine: Division of Surgery
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)