PubMed · 7892140
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Y W Wu. Hierarchical linear models: a multilevel data analysis technique.. https://doi.org/10.1097/00006199-199503000-00012
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BACKGROUND: Evidence suggests that there is considerable variation in the types of procedures used to treat cancer. This variation may result in suboptimal or cost-ineffective care. The present study examined the variation in surgical treatment of melanoma before the establishment of a Melanoma Network that could promote more uniform high-quality care in New South Wales (NSW). The variations in the use of surgical procedures for melanoma by NSW Area Health Service of patient residence were examined. METHODS: Data in the Health Information Exchange of NSW Health collected on procedures carried out on patients with a diagnosis of melanoma in NSW public and private hospitals from 1 July 2001 to 30 June 2002 were examined. Data were aggregated by Area Health Services of patient residence. These data were compared with the numbers of new cases of melanoma notified to the NSW Central Cancer Registry in the same areas in 2001-2002. Excision of skin lesions, skin grafting and numbers and types of lymph node procedures were examined. RESULTS: During the study period, the Central Cancer Registry reported that there were 3085 notifications of melanoma, whereas hospital inpatient data recorded that 6864 procedures were carried out for patients with a melanoma diagnosis in NSW public and private hospitals. Sixty-seven per cent of procedures were carried out in private hospitals. A total of 852 skin grafting procedures were recorded. Of these, 60% were carried out in private hospitals. The average proportion of skin grafts associated with excisions in NSW was 30% (range, 0-53%). Eight hundred and fifty-eight lymph node procedures were recorded for 747 NSW residents. These were biopsies, excisions or both. Forty per cent were carried out in private hospitals. The average proportion of new cases of melanoma associated with a lymph node procedure in NSW was 28% (range, 0-47%). CONCLUSION: Most of the inpatient procedures for patients with melanoma were carried out in private hospitals. The proportions of new cases that underwent skin grafting after excision, or underwent lymph node dissection, varied more than fivefold from one Area Health Service to another. This may indicate variations in casemix, variations in clinical practice or both.
OBJECTIVE: To compare two methods for identifying adverse events using routinely recorded hospital abstract data in all public and private hospitals in Victoria, Australia. METHODS: Secondary analysis of data on all admissions in the period 1 July 2000-30 June 2001 (n = 1,645,992) to estimate the rates of adverse events using International Classification of Diseases 10th Revision Australian Modification codes alone and in combination with an "incidence" data flag indicating complicating diagnoses which arise after hospitalization; rates of incidence and pre-existing adverse events, and rates for same-day and multi-day admissions. RESULTS: In total, 8% of all admissions were recorded with an adverse event. Use of ICD codes alone identified only 59% of the events identified using the combined method, giving a prevalence rate of only 5%. Incident cases, that is, those occurring in the index admission, represented 68% of identified adverse events. The adverse events incidence rate for multi-day admissions was significantly higher at 12%, compared with the same day rate of 0.4%. CONCLUSION: An "incidence flag" is essential to identify those adverse events for which a hospital has unambiguous responsibility. Using such a flag, secondary analysis of administrative data can provide hospital quality assurance programmes with a comprehensive view of all adverse events (not just "sentinel" events) at a reasonable cost and with more timely results than more intensive methods can achieve. Although the method is likely to underestimate the true rate of adverse events (in particular, by not capturing adverse events which only manifest after discharge), in this study of Australian hospitals, rates of adverse events were found to be similar to those derived from studies using manual review of patient records.
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