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Type: Thesis
Title: An Analysis of the Trends and Variability of Hepatic and Pancreatic Surgery in Australia
Author: Stevens, Claire L.
Issue Date: 2020
School/Discipline: Adelaide Medical School
Abstract: For many general surgical procedures, quality of care does not differ greatly between providers or hospitals. However, the outcomes of complex surgical procedures such as those performed on the liver or pancreas have been shown to vary by hospital, surgeon and their respective volume or experience. This research sought to provide an assessment of the current state of hepatic and pancreas surgery in Australia with identification of potential areas for improvement. A systematic search for studies investigating the determinants of mortality and morbidity for hepatic resection and pancreaticoduodenectomy (PD) was performed. A particular focus on Australian studies revealed gaps in the current available evidence. The first objective was to evaluate the mortality due to hepatic resection in Australia. Publication 1 (Variability of perioperative mortality of hepatic resection in Australia) reflected this aim. Australian Institute of Health and Welfare (AIHW) data was interrogated for hepatic resection. The overall POMR for hepatic resection in Australia was 1.6% with significant interstate variability but without significant variability over time. Publications 2 (Peer review of mortality after pancreaticoduodenectomy in Australia) and 3 (Peer review of mortality after hepatectomy in Australia) used the data collected from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) to examine the factors leading to mortality post hepatic or pancreas resection. This was a unique approach not previously employed to examine the drivers of mortality for a specific procedure. For each patient death following PD or hepatic resection, the ANZASM Assessor’s determination of whether patient care could have been improved was reviewed and summarised using thematic analysis. ANZASM assessors determined that a poor decision to operate contributed to 17% of deaths post PD and 25% of deaths post hepatic resection. Delay in the recognition of serious complication was considered relevant in 21% and 18% of PD and hepatic resection deaths respectively. Multi-disciplinary decision making has been strongly recommended in deciding which patients to offer these complex procedures. Optimal care includes early recognition of complications and enactment of an adequate rescue plan. Finally, mortality data from the Victorian Admitted Episodes Database was interrogated for patients who underwent PD in public hospitals and reported in publication 4 (The short-term outcomes of pancreaticoduodenectomy in the state of Victoria – Hospital resources are more important than volume). Risk adjusted perioperative outcomes were reported and compared for hospital volume and hospital peer group. The overall inpatient mortality for PD in Victoria was 2.7% with a significant difference in mortality between hospital peer groups and not hospital volume. This finding highlights the importance of resource availability in the care of these complex patients. The results seen in this group of studies contribute new evidence into the current status and variability of hepatic and pancreatic surgery in Australia. Furthermore, the two studies investigating the determinants of perioperative mortality provide a new perspective to the current international literature on hepatobiliary surgery.
Advisor: Maddern, Guy
Trochlser, Marcus
Dissertation Note: Thesis (MPhil) -- University of Adelaide, Adelaide Medical School, 2020
Keywords: Hepatobiliary surgery
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