Benchmarking in Thoracic Surgery. Third Edition | Archivos de Bronconeumología

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Tercera edición" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1615 "Ancho" => 3209 "Tamanyo" => 245494 ] ] "descripcion" => array:1 [ "en" => "Activity of participating thoracic surgery units." ] ] ] "textoCompleto" => "IntroductionBenchmarking (BM) is the process of comparing services. The aim of BM is to evaluate efficacy and efficiency, in the pursuit of excellence in standard practice.<a class="elsevierStyleCrossRef" href="#bib0105">1</a> Its application in healthcare services has been limited to date, and only a few experiences in public health services and some hospital specialties have been published.<a class="elsevierStyleCrossRefs" href="#bib0110">2,3</a>In Spain, the first BM study in thoracic surgery departments was conducted in 2004, examining data from 2002 and 2003, with the participation of 9 units.<a class="elsevierStyleCrossRef" href="#bib0120">4</a> In this first edition, proposals were made for improving the data recorded in discharge reports, avoiding unnecessary hospital admissions, and standardizing measures aimed at improving the quality of lung resections. The second BM study was conducted in 2008, with the participation of 13 units.<a class="elsevierStyleCrossRef" href="#bib0125">5</a> A third procedure was undertaken in 2013, in which 17 units participated, the results of which are presented in this article.MethodsParticipating CentersA total of 17 thoracic surgery units (TSU), all in university hospitals, participated in this study (<a class="elsevierStyleCrossRef" href="#sec0090">Annex 1</a>). In this edition, the thirteen units previously involved in the second BM study were joined by a further 4 TSUs.Data SourceInformation was obtained from the minimum basic data set (MBDS) for hospitalization in 2012, retrieved from discharge reports issued during that period. The data was processed, anonymously and independently, by IASIST S.A., a company specializing in the conduct of studies of this type. The databases of 33 teaching hospitals from the Spanish National Health Service were used as an external reference pattern, known as the external norm (EN).Case SelectionFor the purpose of comparison, 13 of the participating centers were used to determine an internal norm for the BM (4 centers were excluded, as their MBDS were incomplete). Cases of major pulmonary resection for lung cancer were selected (lobectomies, pneumonectomies, atypical segmental resections, and video-assisted lobectomies). These cases were identified using the codes of the 9th edition of the 2008 International Classification of Diseases, Clinical Modification (ICD-9-CM) retrieved from the records of the surgical procedures. The following cases were selected: lobectomy (codes ICD-9-CM: 32.3 and 32.4), pneumonectomy (codes ICD-9-CM: 32.5 and 32.6), video-assisted lung resections (codes ICD-9-CM: 32.20, 32.25 and 32.28), atypical segmental resections (code ICD-9-CM 32.29), pneumothorax (code ICD-9-CM 512.0 and 512.8). To ensure that all thoracic surgery activity was recorded, surgical cases coded CM 04 (respiratory system) were also included.Performance IndicatorsComplexity of the Case-MixThe following indicators were used:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Mean weight. Calculated from the diagnosis-related groups (DRG), version AP 21: all patients seen in all hospitals were classified.</li><li class="elsevierStyleListItem" id="lsti0010">•Relative weight. This is the ratio between the mean weight of the BM study cases and the mean weight of the external norm. This is a measure of the complexity of the case-mix compared to the external norm.</li><li class="elsevierStyleListItem" id="lsti0015">•Indicators of performance outcomes, such as average length of stay (ALOS) and readmissions, were adjusted by case-mix, using refined DRG, with a subclassification of DRG in categories of severity based on secondary diagnoses recorded for each patient.</li></ul>Performance Outcome IndicatorsThe following indicators were included in the evaluation of outcomes:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">•Average length of stay (ALOS). Preoperative, postoperative and overall ALOS were analyzed with respect to lobectomies, pneumonectomies, video-assisted resections, atypical lung resections, and pneumothorax. ALOS adjusted for severity of the case-mix in each TSU [risk-adjusted ALOS, or RAALOS] was also analyzed. Severity was adjusted using the IASIST procedure, which is not specific to thoracic surgery. The length of stay (LOS) index was calculated, i.e., the ratio of the observed length of stay and the expected length of stay (that which would be applicable if the patient's stay had been according to the norm).</li><li class="elsevierStyleListItem" id="lsti0025">•Mortality. In-hospital mortality was evaluated and adjusted for risk. The risk-adjusted mortality index (RAMI) was the ratio of observed and expected mortality in the study case series. Expected mortality was calculated using a logistic regression model, which calculates the probability of mortality for each patient from a database of more than 3 million hospital discharges.</li><li class="elsevierStyleListItem" id="lsti0030">•Complications. A group of 25 general complications and 7 sentinel complications were evaluated. The following complications were analyzed: pulmonary (atelectasis, pneumonia, respiratory failure), pleural (pneumothorax, empyema, hemothorax), cardiovascular, post-operative bleeding, and wound infections. Specific complications included bronchopleural fistula, and wound dehiscence. The indicator used was the risk-adjusted complication index (RACI), the ratio between the number of observed and expected complications. The expected complications were calculated in the same way as mortality, using a logistic regression model to calculate the probability of complications from a database of more than 3 million hospital discharges.</li><li class="elsevierStyleListItem" id="lsti0035">•Readmissions. Urgent readmissions related to the original admission were analyzed. Readmissions were also adjusted for the complexity of each TSU (risk-adjusted readmission index [RARI]). The RARI index was used to show the ratio between observed and expected readmission, according to the readmissions indicator of the norm.</li></ul>ActivityAll Major Disease Category 04 (MDC4) surgical activity, successive and first outpatient visits, and hospitalization were taken into account. The following aspects were studied:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040">•Surgical activity by department.</li><li class="elsevierStyleListItem" id="lsti0045">•Number of hospital beds and bed/surgeon ratio.</li><li class="elsevierStyleListItem" id="lsti0050">•Number of surgeons/department.</li><li class="elsevierStyleListItem" id="lsti0055">•Hospital activity by department (units of hospital output per surgeon).</li><li class="elsevierStyleListItem" id="lsti0060">•Resolution capacity of outpatient visits (ratio of successive/first visits).</li><li class="elsevierStyleListItem" id="lsti0065">•Occupation rates.</li></ul>ResultsBM results from the 17 Spanish TSUs were analyzed. Of a total of 1125011 hospital episodes, 8250 treated in the participating TSU were selected. After exclusion of episodes of MDC14 and MDC15 and patients <18 years of age, 7807 episodes remained.Overall ResultsThe TSUs were responsible for between 0.6% and 1.6% of all discharges from their respective hospitals. The numbers ranged widely, from 168 to 794 (BM norm 432; EN 366). The mean weight lay between 2.39 and 5.02 (BM norm 3.2; EN 2.9) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The relative weight with respect to the BM ranged between 0.7 and 1.6. The case-mix in each TSU followed the same trend. The distribution of DRGs 075. 077. 095 and 538 is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, which includes the calculation of the N ratio (DRG 538/(DRG 075+DRG 538).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>ALOS varied widely among the TSUs, ranging from 4.1 to 10.7 (BM 7.5; EN 7.1). The RAALOS ranged between 0.5 and 1. The preoperative ALOS was between 0.2 and 1.7 (BM 0.9; EN 1). LOS index was between 0.2 and 4.5, also confirming high variability.Mortality ranged between 0.2 and 2.5% (BM 1.1%; EN 1%). RAMI ranged from 0.1 to 1.2. The complication rate was 0.6–11.1% (BM 6.3%; EN 6.5%). RACI was between 0.2 and 1.6. Postoperative empyemas occurred at a rate of 0–1.5% (BM; EN 0.7%); bronchopleural fistula, 0–1.1% (BM 0.4%; EN 0.3%); nosocomial pneumonia, 0–3.2% (BM 1.3%; EN 1.1%), and operative wound dehiscence, 0–0.9% (BM 0.3%; EN 0.2%). Readmissions within 30 days of discharge ranged between 0% and 6.4% (BM 4.5%; EN 4.4%). RARI was 0–1.9.Activity assessment is shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>. The number of beds per TSU ranges from 5 to 13 (BM 9), and the number of surgeons from 2 to 7 (median 4, BM 4). The number of beds per surgeon ranges from 1 to 6; most TSUs have between 1.5 and 3 (BM norm 3). The BM norm for units of hospital output per surgeon was 363, but most TSUs are below this figure. Occupation rates ranged between 33% and 151% (EN 86%). The ratio of first outpatient visits ranged between 0.6 and 5.4 (BM 2.6).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Analysis of Surgical ProceduresThe percentage of surgical activity among the total number of admissions ranged from 71% to 91% (BM 84%). The surgical ALOS ranged from 4.3 to 14 (BM 8.7; EN 9.1), and RAALOS from 0.5 to 1. The rate of surgical mortality ranged from 1.3% to 6.1% (BM 3.02; EN 2.7%) and RAMI from 0.5 to 1.8. The complication rate varied between 1% and 14% (BM and EN, 9.5%), and the RACI ranged from 0.3 to 1.6. The number of interventions varied widely (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Activity per surgeon also showed wide variability (34–158; BM 42).Pulmonary LobectomiesHalf of the units (50%) performed between 50 and 70 lobectomies (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) (BM 107; EN 79), with an ALOS of between 5.9 and 10.8 (BM 8.6; EN 8.8), and a RAALOS of between 0.6 and 1.2 (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Preoperative ALOS was 0 to 1.3 (BM 0.9; EN 1). The LOS index ranged from 0 to 2.8; most units scored more than 2. Mortality rates ranged from 0% to 5.2% (BM 2.2%; EN 1.9%), while RAMI was between 0 and 1.6. The rate of complications ranged from 0% to 20% (BM 9.3%; EN 12.1%), with a RACI of 0–2. Most TSUs scored between 1.3 and 1.5. The readmissions rate was between 0% and 8.6% (BM; EN 4.3%), with a RARI of 0–3.5.<elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>Other InterventionsBetween 3 and 20 pneumonectomies/year were performed (BM 9; EN 8). Most TSUs performed 8–9/year, with an ALOS of between 6.6 and 32.5 (BM 11.3 and EN 12.8), RAALOS 0.7–2.1. Complications and mortality ranged from 0%–35% to 0%–25%, respectively.A large number of video-assisted lobectomies were performed in some TSUs (with up to 68 in 1 unit, and more than 30 in another 4). Other TSUs performed fewer video-assisted resections (between 1 and 25/year). ALOS ranged between 3.7 and 12.6 (BM and EN 7.4); ALOS was 1.2 days shorter than for conventional lobectomies.Atypical resections varied widely. In 4 TSUs, 10 or fewer atypical resections were performed, and another 7 TSUs performed between 20 and 33 of these procedures. Other TSUs performed interventions of this type on more than 40 occasions. ALOS ranged between 4.3 and 11.2 (BM 7.5; EN 7.9).Pneumothorax also occurred at varying rates in the different TSUs, ranging from 7 to 79 (BM 38; EN 33), with an ALOS of 2.6–8 (BM 5.8; EN 6.2).DiscussionBM has increased in recent years.<a class="elsevierStyleCrossRefs" href="#bib0130">6–8</a> Despite the reported advantages of analyses of this type, no well-designed studies have demonstrated the clinical benefits of undertaking benchmarking.<a class="elsevierStyleCrossRef" href="#bib0125">5</a> Indeed, the results of this edition of our BM study reveal that problems detected in previous analyses persist, as does the wide variability among TSUs. Specific corrective measures obviously need to be implemented and quality standards need to be created. This issue should probably be addressed by ad hoc committees already operating within scientific societies. Other authors have also suggested that the medical societies could initiate BM procedures, as was the case in this study, and could even create prospective databases.<a class="elsevierStyleCrossRefs" href="#bib0145">9,10</a>The most significant limitation of a BM study is that it is carried out without a full analysis of the processes. This flies in the face of some observations on the validity of using administrative databases in the evaluation of healthcare quality,<a class="elsevierStyleCrossRef" href="#bib0155">11</a> although some groups defend this approach.<a class="elsevierStyleCrossRefs" href="#bib0160">12–14</a> Another problem is the origin of the data. The basic minimum data set has some limitations that were pointed out in our earlier publications.<a class="elsevierStyleCrossRefs" href="#bib0120">4,5</a> The creation of prospective databases with internal quality control, supported by the European Society of Thoracic Surgeons,<a class="elsevierStyleCrossRef" href="#bib0175">15</a> may be of great importance for benchmarking in the future.One important finding, also a feature of previous benchmarking studies, was the wide variability in the results obtained from the different TSUs. The number of discharges, the population profile, the distribution of discharges by DRG, and the rate of surgical activity all vary widely, and this affects the mean weight and complexity index of the participating TSUs. This has also been reflected in the percentage of DRG 075 in each of the TSUs, which ranged between 25% and 50%, and in the number of lobectomies performed (25–200). Complexity calculations and risk adjustments are therefore essential when comparing data from different units.<a class="elsevierStyleCrossRef" href="#bib0180">16</a> Measuring severity, however, depends heavily on the quality of departmental discharge reports, which must detail all patient comorbidities and complications. The importance of this has been discussed at length in previous BM evaluations.<a class="elsevierStyleCrossRefs" href="#bib0120">4,5</a> The analysis of complications also revealed wide differences among the participating sites, possibly because these data were missing from discharge reports. Improvement and standardization of discharge reports is one of the main areas of improvement in some TSUs.Some specific complications associated with thoracic surgery occurred at rates similar to internationally accepted standards, and mortality was in the same range.<a class="elsevierStyleCrossRef" href="#bib0185">17</a> These aspects have varied little since previous BM studies, although some sites should perform a detailed analysis of their data and their impact on patient safety.Emergency admissions generally impact negatively on clinical management and services. A significant number of admissions of this type occurred in the BM participants, ranging from 17% to 46%. This is another area for improvement in the future, and the introduction of patient admission protocols would probably be useful.ALOS is a widely used hospital indicator,<a class="elsevierStyleCrossRef" href="#bib0190">18</a> and varied greatly among our TSU participants, as can be seen in the RAALOS, a more objective data point. It ranged from 5.9 to 10.8 in lung resections, with a mean BM value of 8.6 and a LOS index of 0.6–1.2. Preoperative ALOS also varied significantly, from 0.3 to 1.6.Lobectomy outcomes were good, in general, and RAALOS values were low. Preoperative ALOS, however, could be improved in the future. Mortality after lobectomy was low (2%), but morbidity varied widely, possibly due to differences in the quality of the discharge reports. Some departments reported a high rate of related emergency readmissions, also reflected in the widely ranging RARI, suggesting that the discharge procedures for this type of surgery need to be reviewed.The use of video-assisted lobectomies varied widely among the participating groups. A few units carried out more than 30 procedures of this type every year, but others performed hardly any. Another point of interest is the moderate impact of the procedure on ALOS: 1.2 days less than for conventional lobectomy.Clinical pathways and fast track procedures need to be implemented in pulmonary resection surgery.<a class="elsevierStyleCrossRef" href="#bib0195">19</a> Benchmarking, along with other more conventional methods of auditing healthcare performance<a class="elsevierStyleCrossRef" href="#bib0150">10</a> and patients’ perception of quality,<a class="elsevierStyleCrossRef" href="#bib0200">20</a> is useful for the overall analysis of clinical activity. The analysis of activity, not included in our previous BM studies, provided widely variable data, as can been seen from the range of units of hospital output – 200–800. Activity needs to be analyzed in greater depth in future BM studies, and some areas, such as outpatient visits, merit particular attention.ConclusionsWe found considerable variability in quality, activity, and efficiency parameters among our participating TSUs.We identified obvious areas for improvement: admission processes must be standardized to avoid urgent admissions and to shorten preoperative ALOS, hospital discharges must be streamlined, and discharge reports improved by including all procedures and complications.Some thoracic surgery units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area which could be improved in some units.Conflict of InterestsThe authors state that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres624892" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec638209" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres624893" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec638208" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Participating Centers" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Data Source" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Case Selection" ] 3 => array:3 [ "identificador" => "sec0030" "titulo" => "Performance Indicators" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Complexity of the Case-Mix" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Performance Outcome Indicators" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Activity" ] ] ] ] ] 6 => array:3 [ "identificador" => "sec0050" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Overall Results" ] 1 => array:3 [ "identificador" => "sec0060" "titulo" => "Analysis of Surgical Procedures" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Pulmonary Lobectomies" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Other Interventions" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0075" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of Interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-08-06" "fechaAceptado" => "2015-09-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec638209" "palabras" => array:4 [ 0 => "Thoracic surgery" 1 => "Lobectomy" 2 => "Lung resections" 3 => "Benchmarking" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec638208" "palabras" => array:4 [ 0 => "Cirugía torácica" 1 => "Lobectomía" 2 => "Resecciones pulmonares" 3 => "Benchmarking" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionBenchmarking entails continuous comparison of efficacy and quality among products and activities, with the primary objective of achieving excellence. ObjectiveTo analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units. MethodsStudy data were obtained from the basic minimum data set for hospitalization, registered in 2012. Data from hospital discharge reports were submitted by the participating groups, but staff from the corresponding departments did not intervene in data collection. Study cases all involved hospital discharges recorded in the participating sites. Episodes included were respiratory surgery (Major Diagnostic Category 04, Surgery), and those of the thoracic surgery unit. Cases were labeled using codes from the International Classification of Diseases, 9th revision, Clinical Modification. The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases. ResultsGeneral parameters (number of cases, mean stay, complications, readmissions, mortality, and activity) varied widely among the participating groups. Specific interventions (lobectomy, pneumonectomy, atypical resections, and treatment of pneumothorax) also varied widely. ConclusionsAs in previous editions, practices among participating groups varied considerably. Some areas for improvement emerge: admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications. Some units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area where improvement is needed." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónBenchmarking hace referencia a la comparación continuada de la eficiencia y la calidad entre productos y actividades con el objetivo fundamental de alcanzar la excelencia. ObjetivoAnalizar los resultados del benchmarking realizado en 2013 con la actividad asistencial de Cirugía Torácica en el año 2012 en 17 servicios de Cirugía Torácica españoles participantes. MétodosLa fuente de información para el estudio ha sido el conjunto mínimo básico de datos de hospitalización correspondiente al año 2012. Los datos han sido proporcionados por los centros participantes, a partir de los informes de alta hospitalaria, sin intervención de los responsables de los correspondientes servicios asistenciales. Los casos objeto del estudio han sido todas las altas de hospitalización registradas en los centros participantes. Los episodios incluidos han sido los de enfermedad quirúrgica respiratoria (CDM4-Q) y los del servicio de Cirugía Torácica. La identificación de estos casos se realizó usando los códigos de la novena edición de la Clasificación Internacional de Enfermedades, Modificación Clínica. Para valorar las diferencias en gravedad y complejidad de los casos se ha utilizado la clasificación de los grupos relacionados por el diagnóstico refinados. ResultadosLos diversos parámetros generales estudiados (casuística, estancia media, complicaciones, readmisiones, mortalidad y actividad) han tenido una gran variabilidad entre los participantes. El análisis concreto de intervenciones (lobectomía, neumonectomía, resecciones atípicas y neumotórax), también han oscilado considerablemente. ConclusionesSe observa, al igual que en ediciones previas, una considerable variabilidad entre los grupos participantes. Existen áreas de mejora evidentes: estandarización de los procesos de admisión, evitando ingresos urgentes y mejorando la estancia preoperatoria; agilización de las altas hospitalarias y mejora de los informes de alta, reflejando toda la actividad y las complicaciones habidas. Algunas unidades de Cirugía Torácica deben hacer una revisión profunda de sus procesos porque pueden tener algunos parámetros con una desviación excesiva de la norma. También deben mejorarse los procesos de codificación de diagnósticos y comorbilidades." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Freixinet Gilart J, Varela Simó G, Rodríguez Suárez P, Embún Flor R, de Andrés JJR, de la Torre Bravos M, et al. Benchmarking en cirugía torácica. Tercera edición. Arch Bronconeumol. 2016;52:204–210." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Mercedes de la Torre. Hospital Universitario Juan Canalejo de la Coruña. Laureano Molins López-Rodó. Hospital Universitari Clinic de Barcelona. Juan José Fibla Alfara. Hospital Universitari Sagrat Cor de Barcelona. Florentino Hernando Trancho. Hospital Clínico San Carlos de Madrid. Joaquín Pac Ferrer. Hospital Universitario de Cruces. Baracaldo. José Miguel Izquierdo Elena. Hospital Universitario de Donosti. Jorge Freixinet Gilart. Hospital Universitario de Gran Canaria Dr. Negrín. Las Palmas de Gran Canaria. Benno Baschwitz. Hospital Universitario de Alicante. Pedro López de Castro. Hospital Universitari Germans Trías i Pujol de Badalona. Juan José Rivas de Andrés. Hospital Universitario Miguel Servet de Zaragoza. Ángel Carvajal. Hospital Universitari Son Espases de Palma de Mallorca. Mercedes Canela. Hospital Universitario Vall d¿Hebrón de Barcelona. Emilio Canalís Arrayás. Hospital Universitari Juan XXIII de Tarragona. Ángel Salvatierra Velázquez. Hospital Universitario Reina Sofía de Córdoba. Juan Torres Lanzas. Hospital Universitario Virgen de la Arraixaca de Murcia. Gonzalo Varela Simó. Complejo Asistencial Universitario de Salamanca. Nicolás Moreno Mata. 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Original Article

Benchmarking in Thoracic Surgery. Third Edition

Benchmarking en cirugía torácica. Tercera edición

Jorge Freixinet Gilarta,

Corresponding author

jfregil@gobiernodecanarias.org
jfreixinet@dcmq.ulpgc.es

Corresponding author.

, Gonzalo Varela Simób, Pedro Rodríguez Suáreza, Raúl Embún Florc, Juan José Rivas de Andrésc, Mercedes de la Torre Bravosd, Laureano Molins López-Rodóe, Joaquín Pac Ferrerf, José Miguel Izquierdo Elenag, Benno Baschwitzh, Pedro E. López de Castroi, Juan José Fibla Alfaraj, Florentino Hernando Tranchok, Ángel Carvajal Carrascol, Emili Canalís Arrayásm, Ángel Salvatierra Velázquezn, Mercedes Canela Cardonao, Juan Torres Lanzasp, Nicolás Moreno Mataq

a Unidad de Cirugía Torácica, Hospital Universitario Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain

b Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain

c Servicio de Cirugía Torácica, Hospital Universitario Miguel Servet, Zaragoza, Spain

d Servicio de Cirugía Torácica, Hospital Universitario Juan Canalejo, La Coruña, Spain

e Servicio de Cirugía Torácica, Hospital Universitari Clínic i Provincial de Barcelona, Barcelona, Spain

f Servicio de Cirugía Torácica, Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain

g Servicio de Cirugía Torácica, Hospital Universitario de Donostia, San Sebastián, Guipúzcoa, Spain

h Servicio de Cirugía Torácica, Hospital Universitario de Alicante, Alicante, Spain

i Servicio de Cirugía Torácica, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain

j Servicio de Cirugía Torácica, Hospital Universitari Sagrat Cor, Barcelona, Spain

k Servicio de Cirugía Torácica, Hospital Universitario Clínico San Carlos, Madrid, Spain

l Servicio de Cirugía Torácica, Hospital Universitario Son Espases, Palma de Mallorca, Spain

m Unidad de Cirugía Torácica, Hospital Universitario Joan XXII de Tarragona, Tarragona, Spain

n Servicio de Cirugía Torácica, Hospital Universitario Reina Sofía, Córdoba, Spain

o Servicio de Cirugía Torácica, Hospital Universitario Vall d’Hebron, Barcelona, Spain

p Servicio de Cirugía Torácica, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain

q Servicio de Cirugía Torácica, Hospital Universitario Virgen del Rocío de Sevilla, Sevilla, Spain

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            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario de Alicante&#44; Alicante&#44; Spain"
            "etiqueta" => "h"
            "identificador" => "aff0040"
          ]
          8 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario Germans Trias i Pujol&#44; Badalona&#44; Barcelona&#44; Spain"
            "etiqueta" => "i"
            "identificador" => "aff0045"
          ]
          9 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitari Sagrat Cor&#44; Barcelona&#44; Spain"
            "etiqueta" => "j"
            "identificador" => "aff0050"
          ]
          10 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario Cl&#237;nico San Carlos&#44; Madrid&#44; Spain"
            "etiqueta" => "k"
            "identificador" => "aff0055"
          ]
          11 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario Son Espases&#44; Palma de Mallorca&#44; Spain"
            "etiqueta" => "l"
            "identificador" => "aff0060"
          ]
          12 => array:3 [
            "entidad" => "Unidad de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario Joan XXII de Tarragona&#44; Tarragona&#44; Spain"
            "etiqueta" => "m"
            "identificador" => "aff0065"
          ]
          13 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario Reina Sof&#237;a&#44; C&#243;rdoba&#44; Spain"
            "etiqueta" => "n"
            "identificador" => "aff0070"
          ]
          14 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario Vall d&#8217;Hebron&#44; Barcelona&#44; Spain"
            "etiqueta" => "o"
            "identificador" => "aff0075"
          ]
          15 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario Virgen de la Arrixaca&#44; Murcia&#44; Spain"
            "etiqueta" => "p"
            "identificador" => "aff0080"
          ]
          16 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Tor&#225;cica&#44; Hospital Universitario Virgen del Roc&#237;o de Sevilla&#44; Sevilla&#44; Spain"
            "etiqueta" => "q"
            "identificador" => "aff0085"
          ]
        ]
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        "titulo" => "<span class="elsevierStyleItalic">Benchmarking</span> en cirug&#237;a tor&#225;cica&#46; Tercera edici&#243;n"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Benchmarking &#40;BM&#41; is the process of comparing services&#46; The aim of BM is to evaluate efficacy and efficiency&#44; in the pursuit of excellence in standard practice&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Its application in healthcare services has been limited to date&#44; and only a few experiences in public health services and some hospital specialties have been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In Spain&#44; the first BM study in thoracic surgery departments was conducted in 2004&#44; examining data from 2002 and 2003&#44; with the participation of 9 units&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> In this first edition&#44; proposals were made for improving the data recorded in discharge reports&#44; avoiding unnecessary hospital admissions&#44; and standardizing measures aimed at improving the quality of lung resections&#46; The second BM study was conducted in 2008&#44; with the participation of 13 units&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> A third procedure was undertaken in 2013&#44; in which 17 units participated&#44; the results of which are presented in this article&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participating Centers</span><p id="par0015" class="elsevierStylePara elsevierViewall">A total of 17 thoracic surgery units &#40;TSU&#41;&#44; all in university hospitals&#44; participated in this study &#40;<a class="elsevierStyleCrossRef" href="#sec0090">Annex 1</a>&#41;&#46; In this edition&#44; the thirteen units previously involved in the second BM study were joined by a further 4 TSUs&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data Source</span><p id="par0020" class="elsevierStylePara elsevierViewall">Information was obtained from the minimum basic data set &#40;MBDS&#41; for hospitalization in 2012&#44; retrieved from discharge reports issued during that period&#46; The data was processed&#44; anonymously and independently&#44; by IASIST S&#46;A&#46;&#44; a company specializing in the conduct of studies of this type&#46; The databases of 33 teaching hospitals from the Spanish National Health Service were used as an external reference pattern&#44; known as the external norm &#40;EN&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Case Selection</span><p id="par0025" class="elsevierStylePara elsevierViewall">For the purpose of comparison&#44; 13 of the participating centers were used to determine an internal norm for the BM &#40;4 centers were excluded&#44; as their MBDS were incomplete&#41;&#46; Cases of major pulmonary resection for lung cancer were selected &#40;lobectomies&#44; pneumonectomies&#44; atypical segmental resections&#44; and video-assisted lobectomies&#41;&#46; These cases were identified using the codes of the 9th edition of the 2008 International Classification of Diseases&#44; Clinical Modification &#40;ICD-9-CM&#41; retrieved from the records of the surgical procedures&#46; The following cases were selected&#58; lobectomy &#40;codes ICD-9-CM&#58; 32&#46;3 and 32&#46;4&#41;&#44; pneumonectomy &#40;codes ICD-9-CM&#58; 32&#46;5 and 32&#46;6&#41;&#44; video-assisted lung resections &#40;codes ICD-9-CM&#58; 32&#46;20&#44; 32&#46;25 and 32&#46;28&#41;&#44; atypical segmental resections &#40;code ICD-9-CM 32&#46;29&#41;&#44; pneumothorax &#40;code ICD-9-CM 512&#46;0 and 512&#46;8&#41;&#46; To ensure that all thoracic surgery activity was recorded&#44; surgical cases coded CM 04 &#40;respiratory system&#41; were also included&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Performance Indicators</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Complexity of the Case-Mix</span><p id="par0030" class="elsevierStylePara elsevierViewall">The following indicators were used&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Mean weight&#46; Calculated from the diagnosis-related groups &#40;DRG&#41;&#44; version AP 21&#58; all patients seen in all hospitals were classified&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Relative weight&#46; This is the ratio between the mean weight of the BM study cases and the mean weight of the external norm&#46; This is a measure of the complexity of the case-mix compared to the external norm&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Indicators of performance outcomes&#44; such as average length of stay &#40;ALOS&#41; and readmissions&#44; were adjusted by case-mix&#44; using refined DRG&#44; with a subclassification of DRG in categories of severity based on secondary diagnoses recorded for each patient&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Performance Outcome Indicators</span><p id="par0050" class="elsevierStylePara elsevierViewall">The following indicators were included in the evaluation of outcomes&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Average length of stay &#40;ALOS&#41;&#46; Preoperative&#44; postoperative and overall ALOS were analyzed with respect to lobectomies&#44; pneumonectomies&#44; video-assisted resections&#44; atypical lung resections&#44; and pneumothorax&#46; ALOS adjusted for severity of the case-mix in each TSU &#91;risk-adjusted ALOS&#44; or RAALOS&#93; was also analyzed&#46; Severity was adjusted using the IASIST procedure&#44; which is not specific to thoracic surgery&#46; The length of stay &#40;LOS&#41; index was calculated&#44; <span class="elsevierStyleItalic">i&#46;e&#46;</span>&#44; the ratio of the observed length of stay and the expected length of stay &#40;that which would be applicable if the patient&#39;s stay had been according to the norm&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Mortality&#46; In-hospital mortality was evaluated and adjusted for risk&#46; The risk-adjusted mortality index &#40;RAMI&#41; was the ratio of observed and expected mortality in the study case series&#46; Expected mortality was calculated using a logistic regression model&#44; which calculates the probability of mortality for each patient from a database of more than 3 million hospital discharges&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Complications&#46; A group of 25 general complications and 7 sentinel complications were evaluated&#46; The following complications were analyzed&#58; pulmonary &#40;atelectasis&#44; pneumonia&#44; respiratory failure&#41;&#44; pleural &#40;pneumothorax&#44; empyema&#44; hemothorax&#41;&#44; cardiovascular&#44; post-operative bleeding&#44; and wound infections&#46; Specific complications included bronchopleural fistula&#44; and wound dehiscence&#46; The indicator used was the risk-adjusted complication index &#40;RACI&#41;&#44; the ratio between the number of observed and expected complications&#46; The expected complications were calculated in the same way as mortality&#44; using a logistic regression model to calculate the probability of complications from a database of more than 3 million hospital discharges&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Readmissions&#46; Urgent readmissions related to the original admission were analyzed&#46; Readmissions were also adjusted for the complexity of each TSU &#40;risk-adjusted readmission index &#91;RARI&#93;&#41;&#46; The RARI index was used to show the ratio between observed and expected readmission&#44; according to the readmissions indicator of the norm&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Activity</span><p id="par0075" class="elsevierStylePara elsevierViewall">All Major Disease Category 04 &#40;MDC4&#41; surgical activity&#44; successive and first outpatient visits&#44; and hospitalization were taken into account&#46; The following aspects were studied&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Surgical activity by department&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Number of hospital beds and bed&#47;surgeon ratio&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Number of surgeons&#47;department&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Hospital activity by department &#40;units of hospital output per surgeon&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Resolution capacity of outpatient visits &#40;ratio of successive&#47;first visits&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Occupation rates&#46;</p></li></ul></p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0110" class="elsevierStylePara elsevierViewall">BM results from the 17 Spanish TSUs were analyzed&#46; Of a total of 1<span class="elsevierStyleHsp" style=""></span>125<span class="elsevierStyleHsp" style=""></span>011 hospital episodes&#44; 8250 treated in the participating TSU were selected&#46; After exclusion of episodes of MDC14 and MDC15 and patients &#60;18 years of age&#44; 7807 episodes remained&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Overall Results</span><p id="par0115" class="elsevierStylePara elsevierViewall">The TSUs were responsible for between 0&#46;6&#37; and 1&#46;6&#37; of all discharges from their respective hospitals&#46; The numbers ranged widely&#44; from 168 to 794 &#40;BM norm 432&#59; EN 366&#41;&#46; The mean weight lay between 2&#46;39 and 5&#46;02 &#40;BM norm 3&#46;2&#59; EN 2&#46;9&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The relative weight with respect to the BM ranged between 0&#46;7 and 1&#46;6&#46; The case-mix in each TSU followed the same trend&#46; The distribution of DRGs 075&#46; 077&#46; 095 and 538 is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; which includes the calculation of the N ratio &#40;DRG 538&#47;&#40;DRG 075&#43;DRG 538&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">ALOS varied widely among the TSUs&#44; ranging from 4&#46;1 to 10&#46;7 &#40;BM 7&#46;5&#59; EN 7&#46;1&#41;&#46; The RAALOS ranged between 0&#46;5 and 1&#46; The preoperative ALOS was between 0&#46;2 and 1&#46;7 &#40;BM 0&#46;9&#59; EN 1&#41;&#46; LOS index was between 0&#46;2 and 4&#46;5&#44; also confirming high variability&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Mortality ranged between 0&#46;2 and 2&#46;5&#37; &#40;BM 1&#46;1&#37;&#59; EN 1&#37;&#41;&#46; RAMI ranged from 0&#46;1 to 1&#46;2&#46; The complication rate was 0&#46;6&#8211;11&#46;1&#37; &#40;BM 6&#46;3&#37;&#59; EN 6&#46;5&#37;&#41;&#46; RACI was between 0&#46;2 and 1&#46;6&#46; Postoperative empyemas occurred at a rate of 0&#8211;1&#46;5&#37; &#40;BM&#59; EN 0&#46;7&#37;&#41;&#59; bronchopleural fistula&#44; 0&#8211;1&#46;1&#37; &#40;BM 0&#46;4&#37;&#59; EN 0&#46;3&#37;&#41;&#59; nosocomial pneumonia&#44; 0&#8211;3&#46;2&#37; &#40;BM 1&#46;3&#37;&#59; EN 1&#46;1&#37;&#41;&#44; and operative wound dehiscence&#44; 0&#8211;0&#46;9&#37; &#40;BM 0&#46;3&#37;&#59; EN 0&#46;2&#37;&#41;&#46; Readmissions within 30 days of discharge ranged between 0&#37; and 6&#46;4&#37; &#40;BM 4&#46;5&#37;&#59; EN 4&#46;4&#37;&#41;&#46; RARI was 0&#8211;1&#46;9&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Activity assessment is shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; The number of beds per TSU ranges from 5 to 13 &#40;BM 9&#41;&#44; and the number of surgeons from 2 to 7 &#40;median 4&#44; BM 4&#41;&#46; The number of beds per surgeon ranges from 1 to 6&#59; most TSUs have between 1&#46;5 and 3 &#40;BM norm 3&#41;&#46; The BM norm for units of hospital output per surgeon was 363&#44; but most TSUs are below this figure&#46; Occupation rates ranged between 33&#37; and 151&#37; &#40;EN 86&#37;&#41;&#46; The ratio of first outpatient visits ranged between 0&#46;6 and 5&#46;4 &#40;BM 2&#46;6&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Analysis of Surgical Procedures</span><p id="par0135" class="elsevierStylePara elsevierViewall">The percentage of surgical activity among the total number of admissions ranged from 71&#37; to 91&#37; &#40;BM 84&#37;&#41;&#46; The surgical ALOS ranged from 4&#46;3 to 14 &#40;BM 8&#46;7&#59; EN 9&#46;1&#41;&#44; and RAALOS from 0&#46;5 to 1&#46; The rate of surgical mortality ranged from 1&#46;3&#37; to 6&#46;1&#37; &#40;BM 3&#46;02&#59; EN 2&#46;7&#37;&#41; and RAMI from 0&#46;5 to 1&#46;8&#46; The complication rate varied between 1&#37; and 14&#37; &#40;BM and EN&#44; 9&#46;5&#37;&#41;&#44; and the RACI ranged from 0&#46;3 to 1&#46;6&#46; The number of interventions varied widely &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Activity per surgeon also showed wide variability &#40;34&#8211;158&#59; BM 42&#41;&#46;</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Pulmonary Lobectomies</span><p id="par0140" class="elsevierStylePara elsevierViewall">Half of the units &#40;50&#37;&#41; performed between 50 and 70 lobectomies &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; &#40;BM 107&#59; EN 79&#41;&#44; with an ALOS of between 5&#46;9 and 10&#46;8 &#40;BM 8&#46;6&#59; EN 8&#46;8&#41;&#44; and a RAALOS of between 0&#46;6 and 1&#46;2 &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Preoperative ALOS was 0 to 1&#46;3 &#40;BM 0&#46;9&#59; EN 1&#41;&#46; The LOS index ranged from 0 to 2&#46;8&#59; most units scored more than 2&#46; Mortality rates ranged from 0&#37; to 5&#46;2&#37; &#40;BM 2&#46;2&#37;&#59; EN 1&#46;9&#37;&#41;&#44; while RAMI was between 0 and 1&#46;6&#46; The rate of complications ranged from 0&#37; to 20&#37; &#40;BM 9&#46;3&#37;&#59; EN 12&#46;1&#37;&#41;&#44; with a RACI of 0&#8211;2&#46; Most TSUs scored between 1&#46;3 and 1&#46;5&#46; The readmissions rate was between 0&#37; and 8&#46;6&#37; &#40;BM&#59; EN 4&#46;3&#37;&#41;&#44; with a RARI of 0&#8211;3&#46;5&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Other Interventions</span><p id="par0145" class="elsevierStylePara elsevierViewall">Between 3 and 20 pneumonectomies&#47;year were performed &#40;BM 9&#59; EN 8&#41;&#46; Most TSUs performed 8&#8211;9&#47;year&#44; with an ALOS of between 6&#46;6 and 32&#46;5 &#40;BM 11&#46;3 and EN 12&#46;8&#41;&#44; RAALOS 0&#46;7&#8211;2&#46;1&#46; Complications and mortality ranged from 0&#37;&#8211;35&#37; to 0&#37;&#8211;25&#37;&#44; respectively&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A large number of video-assisted lobectomies were performed in some TSUs &#40;with up to 68 in 1 unit&#44; and more than 30 in another 4&#41;&#46; Other TSUs performed fewer video-assisted resections &#40;between 1 and 25&#47;year&#41;&#46; ALOS ranged between 3&#46;7 and 12&#46;6 &#40;BM and EN 7&#46;4&#41;&#59; ALOS was 1&#46;2 days shorter than for conventional lobectomies&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Atypical resections varied widely&#46; In 4 TSUs&#44; 10 or fewer atypical resections were performed&#44; and another 7 TSUs performed between 20 and 33 of these procedures&#46; Other TSUs performed interventions of this type on more than 40 occasions&#46; ALOS ranged between 4&#46;3 and 11&#46;2 &#40;BM 7&#46;5&#59; EN 7&#46;9&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Pneumothorax also occurred at varying rates in the different TSUs&#44; ranging from 7 to 79 &#40;BM 38&#59; EN 33&#41;&#44; with an ALOS of 2&#46;6&#8211;8 &#40;BM 5&#46;8&#59; EN 6&#46;2&#41;&#46;</p></span></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">BM has increased in recent years&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;8</span></a> Despite the reported advantages of analyses of this type&#44; no well-designed studies have demonstrated the clinical benefits of undertaking benchmarking&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> Indeed&#44; the results of this edition of our BM study reveal that problems detected in previous analyses persist&#44; as does the wide variability among TSUs&#46; Specific corrective measures obviously need to be implemented and quality standards need to be created&#46; This issue should probably be addressed by <span class="elsevierStyleItalic">ad hoc</span> committees already operating within scientific societies&#46; Other authors have also suggested that the medical societies could initiate BM procedures&#44; as was the case in this study&#44; and could even create prospective databases&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The most significant limitation of a BM study is that it is carried out without a full analysis of the processes&#46; This flies in the face of some observations on the validity of using administrative databases in the evaluation of healthcare quality&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> although some groups defend this approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">12&#8211;14</span></a> Another problem is the origin of the data&#46; The basic minimum data set has some limitations that were pointed out in our earlier publications&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4&#44;5</span></a> The creation of prospective databases with internal quality control&#44; supported by the European Society of Thoracic Surgeons&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> may be of great importance for benchmarking in the future&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">One important finding&#44; also a feature of previous benchmarking studies&#44; was the wide variability in the results obtained from the different TSUs&#46; The number of discharges&#44; the population profile&#44; the distribution of discharges by DRG&#44; and the rate of surgical activity all vary widely&#44; and this affects the mean weight and complexity index of the participating TSUs&#46; This has also been reflected in the percentage of DRG 075 in each of the TSUs&#44; which ranged between 25&#37; and 50&#37;&#44; and in the number of lobectomies performed &#40;25&#8211;200&#41;&#46; Complexity calculations and risk adjustments are therefore essential when comparing data from different units&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> Measuring severity&#44; however&#44; depends heavily on the quality of departmental discharge reports&#44; which must detail all patient comorbidities and complications&#46; The importance of this has been discussed at length in previous BM evaluations&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4&#44;5</span></a> The analysis of complications also revealed wide differences among the participating sites&#44; possibly because these data were missing from discharge reports&#46; Improvement and standardization of discharge reports is one of the main areas of improvement in some TSUs&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Some specific complications associated with thoracic surgery occurred at rates similar to internationally accepted standards&#44; and mortality was in the same range&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> These aspects have varied little since previous BM studies&#44; although some sites should perform a detailed analysis of their data and their impact on patient safety&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Emergency admissions generally impact negatively on clinical management and services&#46; A significant number of admissions of this type occurred in the BM participants&#44; ranging from 17&#37; to 46&#37;&#46; This is another area for improvement in the future&#44; and the introduction of patient admission protocols would probably be useful&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">ALOS is a widely used hospital indicator&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> and varied greatly among our TSU participants&#44; as can be seen in the RAALOS&#44; a more objective data point&#46; It ranged from 5&#46;9 to 10&#46;8 in lung resections&#44; with a mean BM value of 8&#46;6 and a LOS index of 0&#46;6&#8211;1&#46;2&#46; Preoperative ALOS also varied significantly&#44; from 0&#46;3 to 1&#46;6&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Lobectomy outcomes were good&#44; in general&#44; and RAALOS values were low&#46; Preoperative ALOS&#44; however&#44; could be improved in the future&#46; Mortality after lobectomy was low &#40;2&#37;&#41;&#44; but morbidity varied widely&#44; possibly due to differences in the quality of the discharge reports&#46; Some departments reported a high rate of related emergency readmissions&#44; also reflected in the widely ranging RARI&#44; suggesting that the discharge procedures for this type of surgery need to be reviewed&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The use of video-assisted lobectomies varied widely among the participating groups&#46; A few units carried out more than 30 procedures of this type every year&#44; but others performed hardly any&#46; Another point of interest is the moderate impact of the procedure on ALOS&#58; 1&#46;2 days less than for conventional lobectomy&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Clinical pathways and fast track procedures need to be implemented in pulmonary resection surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> Benchmarking&#44; along with other more conventional methods of auditing healthcare performance<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> and patients&#8217; perception of quality&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> is useful for the overall analysis of clinical activity&#46; The analysis of activity&#44; not included in our previous BM studies&#44; provided widely variable data&#44; as can been seen from the range of units of hospital output &#8211; 200&#8211;800&#46; Activity needs to be analyzed in greater depth in future BM studies&#44; and some areas&#44; such as outpatient visits&#44; merit particular attention&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0210" class="elsevierStylePara elsevierViewall">We found considerable variability in quality&#44; activity&#44; and efficiency parameters among our participating TSUs&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">We identified obvious areas for improvement&#58; admission processes must be standardized to avoid urgent admissions and to shorten preoperative ALOS&#44; hospital discharges must be streamlined&#44; and discharge reports improved by including all procedures and complications&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Some thoracic surgery units have parameters which deviate excessively from the norm&#44; and these sites need to review their processes in depth&#46; Coding of diagnoses and comorbidities is another area which could be improved in some units&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflict of Interests</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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              "titulo" => "Analysis of Surgical Procedures"
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    "fechaRecibido" => "2015-08-06"
    "fechaAceptado" => "2015-09-21"
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            2 => "Lung resections"
            3 => "Benchmarking"
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            0 => "Cirug&#237;a tor&#225;cica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Benchmarking entails continuous comparison of efficacy and quality among products and activities&#44; with the primary objective of achieving excellence&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Study data were obtained from the basic minimum data set for hospitalization&#44; registered in 2012&#46; Data from hospital discharge reports were submitted by the participating groups&#44; but staff from the corresponding departments did not intervene in data collection&#46; Study cases all involved hospital discharges recorded in the participating sites&#46; Episodes included were respiratory surgery &#40;Major Diagnostic Category 04&#44; Surgery&#41;&#44; and those of the thoracic surgery unit&#46; Cases were labeled using codes from the International Classification of Diseases&#44; 9th revision&#44; Clinical Modification&#46; The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">General parameters &#40;number of cases&#44; mean stay&#44; complications&#44; readmissions&#44; mortality&#44; and activity&#41; varied widely among the participating groups&#46; Specific interventions &#40;lobectomy&#44; pneumonectomy&#44; atypical resections&#44; and treatment of pneumothorax&#41; also varied widely&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">As in previous editions&#44; practices among participating groups varied considerably&#46; Some areas for improvement emerge&#58; admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care&#59; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications&#46; Some units have parameters which deviate excessively from the norm&#44; and these sites need to review their processes in depth&#46; Coding of diagnoses and comorbidities is another area where improvement is needed&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Benchmarking</span> hace referencia a la comparaci&#243;n continuada de la eficiencia y la calidad entre productos y actividades con el objetivo fundamental de alcanzar la excelencia&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analizar los resultados del <span class="elsevierStyleItalic">benchmarking</span> realizado en 2013 con la actividad asistencial de Cirug&#237;a Tor&#225;cica en el a&#241;o 2012 en 17 servicios de Cirug&#237;a Tor&#225;cica espa&#241;oles participantes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La fuente de informaci&#243;n para el estudio ha sido el conjunto m&#237;nimo b&#225;sico de datos de hospitalizaci&#243;n correspondiente al a&#241;o 2012&#46; Los datos han sido proporcionados por los centros participantes&#44; a partir de los informes de alta hospitalaria&#44; sin intervenci&#243;n de los responsables de los correspondientes servicios asistenciales&#46; Los casos objeto del estudio han sido todas las altas de hospitalizaci&#243;n registradas en los centros participantes&#46; Los episodios incluidos han sido los de enfermedad quir&#250;rgica respiratoria &#40;CDM4-Q&#41; y los del servicio de Cirug&#237;a Tor&#225;cica&#46; La identificaci&#243;n de estos casos se realiz&#243; usando los c&#243;digos de la novena edici&#243;n de la Clasificaci&#243;n Internacional de Enfermedades&#44; Modificaci&#243;n Cl&#237;nica&#46; Para valorar las diferencias en gravedad y complejidad de los casos se ha utilizado la clasificaci&#243;n de los grupos relacionados por el diagn&#243;stico refinados&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los diversos par&#225;metros generales estudiados &#40;casu&#237;stica&#44; estancia media&#44; complicaciones&#44; readmisiones&#44; mortalidad y actividad&#41; han tenido una gran variabilidad entre los participantes&#46; El an&#225;lisis concreto de intervenciones &#40;lobectom&#237;a&#44; neumonectom&#237;a&#44; resecciones at&#237;picas y neumot&#243;rax&#41;&#44; tambi&#233;n han oscilado considerablemente&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se observa&#44; al igual que en ediciones previas&#44; una considerable variabilidad entre los grupos participantes&#46; Existen &#225;reas de mejora evidentes&#58; estandarizaci&#243;n de los procesos de admisi&#243;n&#44; evitando ingresos urgentes y mejorando la estancia preoperatoria&#59; agilizaci&#243;n de las altas hospitalarias y mejora de los informes de alta&#44; reflejando toda la actividad y las complicaciones habidas&#46; Algunas unidades de Cirug&#237;a Tor&#225;cica deben hacer una revisi&#243;n profunda de sus procesos porque pueden tener algunos par&#225;metros con una desviaci&#243;n excesiva de la norma&#46; Tambi&#233;n deben mejorarse los procesos de codificaci&#243;n de diagn&#243;sticos y comorbilidades&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Freixinet Gilart J&#44; Varela Sim&#243; G&#44; Rodr&#237;guez Su&#225;rez P&#44; Emb&#250;n Flor R&#44; de Andr&#233;s JJR&#44; de la Torre Bravos M&#44; et al&#46; <span class="elsevierStyleItalic">Benchmarking</span> en cirug&#237;a tor&#225;cica&#46; Tercera edici&#243;n&#46; Arch Bronconeumol&#46; 2016&#59;52&#58;204&#8211;210&#46;</p>"
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            "apendice" => "<p id="par0235" class="elsevierStylePara elsevierViewall">Mercedes de la Torre&#46; Hospital Universitario Juan Canalejo de la Coru&#241;a&#46;</p> <p id="par0240" class="elsevierStylePara elsevierViewall">Laureano Molins L&#243;pez-Rod&#243;&#46; Hospital Universitari Clinic de Barcelona&#46;</p> <p id="par0245" class="elsevierStylePara elsevierViewall">Juan Jos&#233; Fibla Alfara&#46; Hospital Universitari Sagrat Cor de Barcelona&#46;</p> <p id="par0250" class="elsevierStylePara elsevierViewall">Florentino Hernando Trancho&#46; Hospital Cl&#237;nico San Carlos de Madrid&#46;</p> <p id="par0255" class="elsevierStylePara elsevierViewall">Joaqu&#237;n Pac Ferrer&#46; Hospital Universitario de Cruces&#46; Baracaldo&#46;</p> <p id="par0260" class="elsevierStylePara elsevierViewall">Jos&#233; Miguel Izquierdo Elena&#46; Hospital Universitario de Donosti&#46;</p> <p id="par0265" class="elsevierStylePara elsevierViewall">Jorge Freixinet Gilart&#46; Hospital Universitario de Gran Canaria Dr&#46; Negr&#237;n&#46; Las Palmas de Gran Canaria&#46;</p> <p id="par0270" class="elsevierStylePara elsevierViewall">Benno Baschwitz&#46; Hospital Universitario de Alicante&#46;</p> <p id="par0275" class="elsevierStylePara elsevierViewall">Pedro L&#243;pez de Castro&#46; Hospital Universitari Germans Tr&#237;as i Pujol de Badalona&#46;</p> <p id="par0280" class="elsevierStylePara elsevierViewall">Juan Jos&#233; Rivas de Andr&#233;s&#46; Hospital Universitario Miguel Servet de Zaragoza&#46;</p> <p id="par0285" class="elsevierStylePara elsevierViewall">&#193;ngel Carvajal&#46; Hospital Universitari Son Espases de Palma de Mallorca&#46;</p> <p id="par0290" class="elsevierStylePara elsevierViewall">Mercedes Canela&#46; Hospital Universitario Vall d¿Hebr&#243;n de Barcelona&#46;</p> <p id="par0295" class="elsevierStylePara elsevierViewall">Emilio Canal&#237;s Array&#225;s&#46; Hospital Universitari Juan XXIII de Tarragona&#46;</p> <p id="par0300" class="elsevierStylePara elsevierViewall">&#193;ngel Salvatierra Vel&#225;zquez&#46; Hospital Universitario Reina Sof&#237;a de C&#243;rdoba&#46;</p> <p id="par0305" class="elsevierStylePara elsevierViewall">Juan Torres Lanzas&#46; Hospital Universitario Virgen de la Arraixaca de Murcia&#46;</p> <p id="par0310" class="elsevierStylePara elsevierViewall">Gonzalo Varela Sim&#243;&#46; Complejo Asistencial Universitario de Salamanca&#46;</p> <p id="par0315" class="elsevierStylePara elsevierViewall">Nicol&#225;s Moreno Mata&#46; Hospital Universitario Virgen del Roc&#237;o de Sevilla&#46;</p>"
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            "titulo" => "Participating investigators and sites"
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    "bibliografia" => array:2 [
      "titulo" => "References"
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                    0 => array:2 [
                      "titulo" => "Benchmarking&#58; a tool for continuous improvement"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;J&#46; McNair"
                            1 => "K&#46;H&#46; Leibfriend"
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2016.02.010

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2022 June	32	37	69
2022 May	46	45	91
2022 April	48	21	69
2022 March	50	35	85
2022 February	50	29	79
2022 January	56	43	99
2021 December	34	37	71
2021 November	37	49	86
2021 October	47	50	97
2021 September	48	50	98
2021 August	35	40	75
2021 July	46	30	76
2021 June	46	34	80
2021 May	46	42	88
2021 April	129	73	202
2021 March	81	29	110
2021 February	57	30	87
2021 January	41	17	58
2020 December	60	32	92
2020 November	37	16	53
2020 October	41	20	61
2020 September	23	12	35
2020 August	31	8	39
2020 July	45	24	69
2020 June	36	14	50
2020 May	50	17	67
2020 April	52	22	74
2020 March	39	20	59
2020 February	40	17	57
2020 January	47	18	65
2019 December	43	19	62
2019 November	30	20	50
2019 October	22	13	35
2019 September	32	8	40
2019 August	44	25	69
2019 July	26	12	38
2019 June	25	12	37
2019 May	53	18	71
2019 April	45	14	59
2019 March	47	17	64
2019 February	44	13	57
2019 January	51	21	72
2018 December	57	13	70
2018 November	79	30	109
2018 October	59	35	94
2018 September	37	15	52
2018 June	1	0	1
2018 May	12	0	12
2018 April	41	1	42
2018 March	22	6	28
2018 February	18	7	25
2018 January	17	5	22
2017 December	46	4	50
2017 November	20	8	28
2017 October	20	5	25
2017 September	21	5	26
2017 August	14	8	22
2017 July	14	3	17
2017 June	17	6	23
2017 May	29	9	38
2017 April	39	9	48
2017 March	18	14	32
2017 February	19	4	23
2017 January	12	7	19
2016 December	24	19	43
2016 November	53	24	77
2016 October	44	24	68
2016 September	41	3	44
2016 August	61	7	68
2016 July	38	7	45

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