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25-10-2011 | Article

Surgery concerns in ISTCs put to rest by patient outcomes audit


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MedWire News: Concerns in terms of patient outcomes after elective surgery in independent sector treatment centers (ISTCs) are "lessened" by the latest research.

The ISTC program began in 2002 with the intention of improving efficiency by separating elective care from complex and emergency care, explain Jan van der Meulen and colleagues from the London School of Hygiene and Tropical Medicine. ISTCs are operated by private companies rather than the National Health Service (NHS), sparking criticism of the system, they add.

"It was feared that ISTCs might have significantly worse outcomes for patients and increased rates of complications," they say. "Another concern was the negative impact of ISTCs as a result of siphoning off the easier cases, which are essential for surgical training."

The Patient Outcomes in Surgery (POiS) audit was established on recommendation from a Commons Select Committee enquiry, and aimed to compare the patient outcomes for hip and knee replacements, inguinal hernia repair, and varicose vein surgery undertaken by ISTCs with those by NHS providers. The study design enabled adjustment for case mix and complication rates.

All ISTCs undertaking these procedures were invited to participate in the study, the results of which are published in the British Medical Journal, and at least two NHS providers were invited for each ISTC. In all, 25 ISTCs took part alongside 72 NHS providers. Participation was lower for centers providing hernia repair and varicose vein surgery compared with those undertaking orthopedic surgery.

Patients were asked to complete pre- and postsurgery questionnaires designed to measure severity of symptoms and disability associated with their condition and their general health-related quality of life. A total of 5640 ISTC patients and 14,293 NHS patients returned their post-operative questionnaires.

The ISTC patients tended to be healthier and have less severe presurgery conditions than the NHS patients, report the researchers. After adjusting for this difference they found that ISTC patients who underwent a hip or knee replacement had better outcomes than those in NHS centers. However, van der Meulen et al note that these differences were "small," their clinical relevance "slight," and they could be attributable to "differences in case mix that were not fully taken into account."

There was no significant difference in outcome after hernia repair and varicose vein surgery between ISTC- and NHS-treated patients.

The researchers explain that determining the clinical significance of these modest differences is "challenging."

They write that their results support separating elective surgical care from emergency services to improve the quality of care, but that "there are no generally accepted 'minimally important differences' (that is, the smallest differences that a patient perceives as beneficial and would mandate a change in the patient's management) for the outcome measures that we used."

The team concludes that the differences observed are minor compared with the ISTC program's potential for improving the provision of elective services.

By Chloe McIvor