Continuous monitoring tools for pediatric surgical outcomes: an example using biliary atresia
Nokuthaba Sibanda1, James D Lewsey, Jan H P van der Meulen
1Clinical Effectiveness Unit, The Royal College of Surgeons of England, London WC2A 3PE, UK.
Insights
Cumulative Sum (CUSUM) charts effectively monitor surgical outcomes. This study shows CUSUM charts provide earlier detection of lower-than-expected Kasai portoenterostomy failure rates in infants with biliary atresia.
Area of Science:
- Pediatric Surgery
- Surgical Outcomes Monitoring
- Biliary Atresia Treatment
Background:
- Continuous monitoring of surgical outcomes is crucial for maintaining high standards of care.
- Kasai portoenterostomy is a key procedure for treating biliary atresia in infants.
- Traditional aggregate data analysis may not provide timely feedback on procedural success rates.
Purpose of the Study:
- To illustrate the application of Cumulative Sum (CUSUM) charts for monitoring outcomes of Kasai portoenterostomy.
- To compare the efficacy of different CUSUM chart variations and standard data analysis in detecting changes in surgical success rates.
- To highlight the value of continuous monitoring in pediatric surgical units.
Main Methods:
- Analysis of data from 57 consecutive infants undergoing Kasai portoenterostomy by a single surgeon.
- Definition of surgical success as jaundice clearance (<20 micromol/l bilirubin) within 6 months.
- Application of CUSUM charts, including zero-resetting SPRT, and comparison with aggregate data analysis using an expected failure rate of 43.0%.
Main Results:
- The observed failure rate for Kasai portoenterostomy was 29.8%, lower than the national average.
- The zero-resetting SPRT CUSUM chart identified a lower-than-expected failure rate earlier than aggregate data analysis.
- Continuous monitoring techniques, particularly the zero-resetting SPRT CUSUM chart, offered more sensitive and timely outcome assessment.
Conclusions:
- CUSUM charts offer valuable, ongoing feedback for continuous monitoring of surgical procedure outcomes.
- Routine implementation of CUSUM charts in pediatric surgery can help maintain and improve standards of care.
- The CUSUM methodology warrants broader adoption and recognition in surgical quality improvement initiatives.
Purpose:
Continuous monitoring tools can be used to monitor surgical outcomes over time. We illustrate the use of CUmulative SUM (CUSUM) charts in monitoring outcomes of Kasai portoenterostomy for treatment of biliary atresia at a supraregional unit.
Methods:
Data on 57 consecutive infants who underwent a Kasai portoenterostomy performed by a single surgeon between June 1994 and June 2006 were collected. A procedure was defined as successful if clearance of jaundice (plasma bilirubin level <20 micromol/l) was achieved within 6 months of surgery. We applied cumulative observed-minus-expected, sequential probability ratio test (SPRT), and zero-resetting SPRT CUSUM charts and compared the results with those of standard aggregate data analyses. An expected failure rate of 43.0%, based on the national average failure rate, was used.
Results:
The failure rate observed after 57 operations was 29.8%. The zero-resetting SPRT chart indicated a lower-than-expected failure rate earlier than did the aggregate data analyses and any of the other continuous monitoring techniques.
Conclusions:
The CUSUM chart method provides ongoing feedback that can be used for continuous monitoring of the outcome of a procedure to ensure that standards of care are maintained. Its use as a routine monitoring tool in pediatric surgery deserves wider recognition.