Evidence, implementation and monitoring

2005

SURGICAL INTERVENTIONS AND OUTCOMES

Wednesday 15 June 2005 at Bojesen Conference Centre at Axelborg, Copenhagen

A conference organised by the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA), National Board of Health

Contents

Programme

page 2

The Surgery Project

page 4

Abstracts from presentations

page 7

Abstracts from poster presentations

page 17

Programme 8.30–9.30

Registration

9.30–9.40

Welcome Jens Kristian Gøtrik, Chief Medical Officer, Director-General of the National Board of Health

9.40–10.00 Why this meeting? Henrik Kehlet, Rigshospitalet 10.00–10.45 International experience of surgery volume, organisation and outcome Hospital volume and outcome – what to do next? John Birkmeyer, University of Michigan, Ann Arbor, USA 10.45–11.00 Discussion 11.00–11.35 Examples of Danish projects on surgery volume, organisation and outcome Morbidity and mortality after surgery for oesophageal, gastric and pancreatic cancer in Denmark Lone Susanne Jensen, Aarhus University Hospital 11.35–11.45 Discussion 11.45–12.45 Lunch 12.45–13.00 Examples of surgery organisation and monitoring in Denmark Monitoring clinical quality. Performance measures online: Experience from Copenhagen Hospital Corporation Johan Kjærgaard, Bispebjerg Hospital, Copenhagen Hospital Corporation (H:S) 13.00–13.15 Nationwide assessment of quality in surgery: Ovarian cancer Bent Ottesen, Rigshospitalet 13.15–13.30 Nation-wide surgical databases – do they confer improved outcome? Morten Bay Nielsen, Danish Hernia Database, Hvidovre Hospital (H:S) 13.30–14.00 Discussion 14.00–14.45 Implementation of evidence From science to clinic – how can we make progress? Guy Maddern, University of Adelaide, Australia 14.45–15.00 Discussion 15.00–15.30 Coffee break

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15.30–16.15 Future strategies (Panel discussion): John Birkmeyer, Guy Maddern, Bent Ottesen, Morten Bay Nielsen, Johan Kjærgaard, Lone Susanne Jensen and Henrik Kehlet Moderator: Finn Børlum Kristensen, DACEHTA 16.15–16.30 Concluding remarks, Finn Børlum Kristensen, DACEHTA

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The Surgery Project The aim of the project is to assess the quality of surgical treatment and generate new knowledge to serve as the foundation for improving the various surgical treatments. This is achieved by analysing, interpreting and disseminating data from the danish National Patient Register and using this to propose how quality can be improved in the surgical area. For example, there may be a need to enhance centralisation, select specific procedures or the suchlike. The results are used as feedback to departments, hospitals, regional authorities and scientific societies in order to foster quality improvement. A surgical intervention is affected by various factors that can to some extent be revealed through data from the National Patient Register. The factors in question include the level of specialisation at the departments performing the surgery, the number of operations per year, the type of operation selected, the age composition of the patient population, regional differences, etc. The Surgery Project was initiated in 1999 in response to a desire to develop field of surgery in Denmark. The idea for the project originated among surgical consultant physicians and professors from various surgical specialities. The project was initially the responsibility of the former Danish Hospital Evaluation Centre, which became part of the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) in 2001. Articles from completed studies are published in “Ugeskrift for Læger”, the journal of the Danish Medical Association. Below is a list of completed and ongoing projects and projects which are being updated. Articles and descriptions of ongoing projects are available at www.cemtv.dk. All articles and descriptions are in Danish. Completed projects •

Hysterektomi i Danmark (operation for nedsynkning af underlivet)

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Operation for gastroøsofageal refluks i Danmark 1997-1999 (operation, som hindrer mavesyren i at komme op i spiserøret).

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Esophagusresektioner i Danmark 1997-2000 (fjernelse af spiserøret).

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Vaginalkirurgi i Danmark 1999-2001 (operation for nedsunken livmoder).

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Pankreatikoduodenektomi i Danmark 1996-2001 (operation ved kræft i bugspytkirtlen).

Artikler om kvalitetsudvikling og anvendte metoder i kirugiprojektet • Vurdering af kirurgiske ydelser i Danmark •

Ranglister over sygehuses kvalitet – er de vejledende eller er de vildledende?

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Fører offentliggørelse af kvalitetsmålinger i sundhedsvæsenet til bedre kvalitet?

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Den kirurgiske service i Danmark – er det tid til reorganisering?

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Ongoing projects •

Fjernelse af udposning på hovedpulsåren (thorakale aortaaneurismer og aortadisektioner)

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Fjernelse af blæren (cystektomi)

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Fjernelse af livmoderhals, livmoder og ovarie (gynækologiske cancere)

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Hoftenære femurfrakturer

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Fjernelse af mavesækken (ventrikelcancer)

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Større ekstremitetsamputationer

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Fjernelse af galdeblæren (kolecystektomi og rekonstruktion af dybe galdeveje)

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Inkontinens

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Fjernelse af nyren (nefrektomi).

Projects being updated •

Operation, der hindrer mavesyren i at komme op i spiserøret (gastroøsofageal refluks)

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Fjernelse af spiserøret (esohagusresektioner)

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Operation af kræft i bugspytkirtlen (pankreatikoduodenektomi).

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Abstracts from presentations

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Why this meeting? Henrik Kehlet Section for Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet. 2100 Copenhagen, Denmark Postoperative outcome is determined by a multiplicicity of factors including surgical stress responses, pain, organ dysfunctions, anaesthetic, surgical and nurse expertise, hospital expertise and patient volume and support from diagnostic and intensive care units. In recent years major progress has been made within areas of surgical pathophysiology, the concept of postoperative multi-modal rehabilitation (fast-track surgery), minimal invasive surgery and pain relief. In addition, an increasing amount of data has demonstrated increased surgeon and hospital volume (expertise) to improve outcome. However, “volume” per se may not automatically improve outcome but serves as a prerequisite for valid statistical assessment of outcome and as a basis to perform scientific studies on potential for improvement. A sufficient monitoring system with procedure and/or disease-specific databases to assess current quality of surgical intervention is a prerequisite to provide optimal nationwide strategies to improve outcome. Such monitoring systems are also required to assess nationwide use of new technologies and to evaluate whether current practice needs reorganization of surgical care into more specialized units. Furthermore, monitoring of surgical outcome is important to assess appropriate level of implementation of scientific evidence within surgical interventions, in order to provide cost effective health care. Since Denmark is geographically small and with a well-defined population with unique personal identification numbers it allows a possibility for a unique survey and monitoring of surgical outcome. However, at this time only selective databases and other monitoring systems on surgical outcomes are available. The aim of this meeting has therefore been to discuss surgical outcomes on a national level in relation to existing monitoring systems and international experiences on monitoring and organization of surgical interventions. References: Kehlet H, Dahl JB. Anaesthesia, surgery and challenges for postoperative recovery. Lancet 2003; 362: 1921-28. Kizer KW. The volume-outcome conundrum. N Engl J Med 2003; 349: 2159-2161 Ihse I. The volume-outcome relationship in cancer surgery. A hard sell. Ann Surg 2003; 238: 777-781. Dimick JB, Welch HG, Birkmeyer JD. Surgical mortality as an indicator of hospital quality. The problem with small sample size. JAMA 2004; 292: 847-851 Birkmeyer JD, Dimick JB, Birkmeyer NJO. Measuring the quality of surgical care: structure, process or outcomes? J Am Coll Surg 2004; 198:626-632 Birkmeyer JD, Dimick JB. Potential benefits of the new Leapfrog standards: effect of process and outcomes measures. Surgery 2004; 135: 569-575. Birkmeyer JD, Stukel TA, Siewers AE et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349: 2117-2127.

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Improving the quality of surgical care: Volume and beyond Regionalization, surgery, mortality John D. Birkmeyer, MD, University of Michigan, Ann Arbor, Michigan, USA Purpose This lecture reviews the current evidence around volume-outcome relationships in surgery. I also consider the potential benefits and indirect harms associated with alternative regionalization strategies. Method/Planning NA Results For a growing list of surgical procedures, both hospital and surgeon volume are associated with surgical outcomes, including operative mortality rates, non-fatal complications, and late survival after cancer surgery. Efforts to translate this evidence into regionalization policy in the United States have been minimally successful, largely due to its non-regulatory traditions and fractured financing system. Although regionalization of selected surgical services may be more readily implemented in single-payer systems, these efforts should be targeted in a way that maximizes benefits and minimizes indirect harms. Conclusion/discussion Given the strong volume-outcome relationships observed with some procedures, procedure volume, assessed at the hospital or surgeon level, could be used to leverage quality improvement in surgery.

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Examples of Danish projects on surgery volume, organisation and outcome. Lone Susanne Jensen, Aarhus Universitets Hospital, Denmark

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Monitoring Clinical quality. Performance measures online. Experience from Copenhagen Hospital Corporation Kjaergaard J. MDSci, Head of Unit for Clinical Quality, Copenhagen Hospital Corporation. Key words. Monitoring clinical performance, statistical process control, clinical management information. Objective. To solve a fundamental problem: The quality of clinical care is unknown Methods Copenhagen Hospital Corporation with 6 municipal and university hospitals and 4.000 beds covers a population of 600.000 citizens. The hospitals were accredited by Joint Commission International in 2002 and 2005. A clinical indicator programme was launched in 2001 to measure, evaluate and improve the quality of clinical care focusing on direct measures of clinical performances. The goal of the programme is to develop indicators and implement the use of statistical process control covering 34 condition specific areas (including 18 surgical areas), each with 7 (312) indicators. Indicators have been developed by the appropriate Specialty Advisory Board. The data source for 1/3 of the indicators is patient administrative systems. For the 2/3 of the indicators the necessary data are registered as an integrated part of the clinical workflow. These clinical data are reported directly from the departments through a web-based interface to a central database. A generic IT system has been developed: Clinical Performance Measurement System (CPMS). CPMS is used to construct suitable electronic health care record-like data entry forms adapted to data specifications and validations for each condition. The database is conformant with Danish national safety requirements allowing it to contain and manage patient identifiable data. A web based IT system (CPMS: AnalysePortal) for analysing and reporting of clinical data has been developed (in cooperation with SAS Institute®). The CPMS: AnalysePortal system automated construct control- and comparison charts (Standard Reports). These statistical process control tools, enables each clinic to monitor their own quality over time, and to compare their observed indicator value with the average of the other clinics in the Corporation. The CPMS: AnalysePortal includes safety systems allowing authorized end-users in the clinical departments to access all patient level data including patient identifier (national security number) online and on time at their office computers. The system includes a “point-and-click” tool enabling the enduser to make specified patient lists, frequency tables, graphs and selected statistical tests (Dynamic Reports). Results The implementation has been delayed about 1½ year because of regulatory barriers, problems with IT functionalities and systems and resource constraints in the clinics where data registration involve extra workload and double registration. The consequence of the delay is that Standard Reports at present only covers 50% and Dynamic Reports 90% of the indicators. Accordingly, clinical audits are delayed. A promising result is that some Standard Reports with 1½-2 years of data demonstrate statistical significant improvements in performance of the condition in question.

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Conclusions Lessons learned: A medium size urban hospital system with a suitable organisation, a dedicated leadership, limited direct costs, restrained general resources and without having an electronic record, can - within a time frame of 4-5 years - implement a comprehensive clinical performance measurement system to deliver valid clinical management information as the fundamental prerequisite for continuous quality improvement of clinical performance and for accreditation of the hospitals.

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Nation-wide assessment of quality in surgery: Ovarian cancer. Bent Ottesen Department of Obstetrics and Gynaecology, Juliane Marie Centre, Rigshospitalet and The Surgery Project, Danish Centre for Evaluation and Health Technology Assessment, The National Board of health In Denmark 600 new cases of ovarian cancer are diagnosed every year. The incidence rate per 100,000 woman-years is one of the highest in the world and unfortunately this is also applies to the mortality rate. Thus, the survival in Denmark is 10% lower compared to the other Nordic countries. It is also noteworthy that USA during a ten years period from 1985-1995 has obtained an increase in survival of women with ovarian cancer from 40 % to 52 %, while the survival rate in Denmark has been unchanged around 32 % during the same period of time. A number of factors may contribute to these differences: Genetic, life-style, environmental, diagnostic and treatment. In this study we put focus on the quality of the surgical part of the treatment. The National Board of Health has recommended that the surgical treatment of ovarian cancer should take place on the five gynaecological oncology centres in order to obtain the best quality. From the National Patient Register (LPR) we obtained information from all women who had had surgery due to ovarian cancer from July 2002 to December 2003. Information included name of department, number of operations, length of postoperative hospital stay, number of readmissions and in hospital as well as 30 days mortality rates. A copy of the discharge résumé and the surgeons description of the surgical procedure were obtained for analysis. The latter was evaluated by a panel of five gynaecological oncology experts using a structured analysis based on the international guidelines published by Federation International Gynecologie et Obstetric (FIGO). Information from 766 patients was collected. The surgery was performed in 52 different departments each performing 1 – 86 operations. The reported overall length of postoperative hospital stay was 14 days (4 – 51 days, median and total range) and the 30 days mortality rate was 4.0 %. In the five gynaecological oncology centres the overall median hospital stay was 11 days 9-12 days. Evaluating 268 ovarian cancer stage III operations, the expert panel observed that as much as 52 % of the descriptions were not in accordance with international guidelines. Also, optimal cytoreduction was obtained in only 28 % of the cases and important information on the quality of the surgical assessment/procedure was missing in 18% of the records. These results demonstrate that the recommendations put forward by The National Board of Health concerning the treatment of ovarian cancer are not followed. The mean postoperative stay in some departments seems long and calls for further analyses. The percentage of operations with optimal cytoreduction in stage III cancers is in this sample low compared to international standards, where it is reported as high as 76 %. Furthermore, the descriptions of the surgical procedures need to be improved. The present data support centralisation of the treatment of ovarian cancer. The quality should be monitored by the nationwide database and regular audits of the surgical intervention. Our analysis suggests a potential for improvement in the surgical treatment of ovarian cancer hopefully to reduce the high Danish mortality rate of this disease.

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References: Chi DS, Franklin CC, Levine DA, et al. Improved optimal cytoreduction rates for stages IIIC and IV epithelial ovarian, fallopian tube, and primary peritoneal cancer: a change in surgical approach. Gynecologic Oncology 2004;94:650-4.

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Nationwide surgical databases – do they confer improved outcome ? Experiences from The Danish Hernia Database Morten Bay-Nielsen, Specialist registrar, Dept. of surgery, Copenhagen University Hospital Glostrup and Danish Hernia Database, Dept. of gastroenterology, H:S University Hospital Hvidovre. The Danish Hernia database was established in 1998, based on a number of recognized or assumed problems in inguinal hernia surgery: a high recurrence rate, a high proportion of operations performed under regional anaesthesia, underuse of ambulatory set up, variable and undocumented recommendations of convalescense, problems with long term postoperative pain and special issues (female inguinal hernias; femoral hernias) only sporadically or not addressed in current litterature. The Hernia Database has now been in function for > 7 years, with > 70.000 hernia repairs registered and can document improvements in the care of inguinal hernia patients, in terms of a lower rate of reoperations, a declining use of regional anaesthesia, increased use of ambulatory setup, well defined, evidence based convalescense recommendations and a number of specific studies delineating problems in inguinal hernia surgery. The following factors seems to have been central to the succes of the data base: − an existing gap between evidence and clinical practice − function based on clinical problems and hypotheses for improvement − a simple set up − national coverage − collaborative meetings with participants every 6 months − ongoing discussions and prospective projects within the database collaboration − feed-back to participants on individual and overall results every 6 months (1)

Bay-Nielsen M, Kehlet H, Strand L, Malmstrom J, Andersen FH, Wara P et al. Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001; 358:1124-1128.

(2) Jensen P, Bay-Nielsen M, Kehlet H. Planned inguinal herniorrhaphy but no hernia sac? Hernia 2004; 8:193-195. (3) Bay-Nielsen M, Nilsson E, Nordin P, Kehlet H. Chronic pain after open mesh vs. sutured repair of indirect inguinal hernia in young males. Br J Surg 2004; 91: 1372-1376. (4) Bay-Nielsen M, Thomsen H, Heidemann Andersen F, Bendix J, Sørensen O, Skovgaard N et al. Short convalescence in inguinal hernia repair - limiting factors and recurrence. Br J Surg 2004; 91:362-367. (5) Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg 2001; 233:1-7. (6) Wara P, Bay-Nielsen M, Juul P, Bendix J, Kehlet H. Laparoscopic compared to Lichtenstein repair of inguinal hernia. A prospective nationwide analysis. Br J Surg 2005. In press. 15

From science to clinic – how can we make progress? Guy J Maddern Surgical Director, ASERNIP-S, Royal Australasian College of Surgeons 2005 sees the conclusion of the first seven years of the ASERNIP-S initiative. To date the project has been remarkably successful with over 30 peer-reviewed publications, in excess of $5 million of funding and an increasing profile that has made the ASERNIP-S programme the most prominent organisation assessing new surgical technologies worldwide. Having now established credentials as an excellent research organisation, it has become important not only to continue to conduct systematic reviews of new surgical technologies, but also to look at newer and more cost effective inputs into the process of evaluating surgical technologies. Systematic reviews involve a review of a clearly formulated question using systematic and explicit methods to identify, critically appraise and summarise relevant studies (published and unpublished) according to predetermined criteria. Reported outcomes can be synthesised either quantitatively or narratively or can include meta-analysis to statistically analyse and summarise the results of the included studies. Systematic reviews are fundamental tools for decision making by health professionals, consumers and policy makers as they provide conclusions based on research evidence. In more recent times ASERNIP-S has developed the accelerated systematic review in order to provide a more timely and efficient assessment of new technologies to hospitals, surgeons and consumers. Accelerated systematic reviews (ASRs) are produced in response to a pressing need for a systematic summary and appraisal of the available literature for a new or emerging surgical procedure. ASRs use the same methodology as full systematic reviews, but may restrict the types of studies considered (for example, by only including comparative studies and not case series) in order to produce the review in a shorter time period than a full systematic review. Horizon scanning has become an important activity and we now have over 70 horizon scanning reports and summaries and many more procedures recorded on our database. Horizon scanning identifies and assesses advances in surgery that are likely to impact on the Australian or New Zealand health systems in the near future, that is, they are on the horizon of introduction into Australasian health care systems. Consumers have also been well served with excellent consumer summaries prepared on technologies reviewed and, with these, it is hoped that the results of ASERNIP-S research will not only reach surgeons and hospitals but also patients who are contemplating these new interventions. 2005 will be a challenging period for the ASERNIP-S project. We have an NHMRC Enabling Grant currently short-listed and we will need core funding from the Commonwealth Government to be renewed before July 2005. If these two initiatives are successful, the next five years promises to be an even more exciting and dynamic period for the project.

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Abstracts from poster presentations

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From dogma to evidence-based practice: Experience from the use of a hysterectomy database Finn Lauszus, Villy Hansen, Ditte Trolle, Britt Ljungstrøm, Kjeld Rasmussen Herning Hospital, Gl. Landevej 61, 7700 Herning, Denmark Subject headings: Hysterectomy, evaluation. Purpose: Establishing a database on the presumption that practice will change due to registered outcomes ignores that aggregation of data has been performed since medical profession started its existence. Published guidelines on hysterectomy were not common in the mid-nineties where the ground work for the database was done. We present the results of implementing a prospective routine of registration of women who underwent hysterectomy and the application of its use to alter practice. Methods: From 1998 to 2004 hysterectomies from four hospital in Jutland (Holstebro, Herning, Viborg and Silkeborg) were collected in a regional database containing preoperative information (i.e. indication for the hysterectomy, previous gynaecological surgery, body weight and height), operative procedure (mode of hysterectomy, additional surgery, duration of surgery, blood loss, uterine weight), postoperative data (length of postoperative stay, complications, haemoglobin at day 3), and results of a three months postoperative questionnaire on pain, work, sexological and urological symptoms. Results: In all nearly 4000 hysterectomies have been registered. The indications for the vaginal route of hysterectomy were explored. As the hospitals involved have the highest rate of vaginal hysterectomy in Denmark the accumulated experience gave inspiration to safeguard a trend towards increasing use of the operation (1,2).The discrepancy between the need to rest and the doctor’s advice was confirmed (3). The incongruence between the subjective postoperative symptoms of the women and the advice of sick leave based on former time’s empirism from the departments had gone unnoticed. New guidelines were drawn up and implemented. A second questionnaire on voiding symptoms found a substantial number of women with urological symptoms postoperatively, which could be related to operative procedure (4,5). New information from randomized studies confirms the trend to more differentiated advice on modes of hysterectomy and urological symptoms. Body mass index, though intuitively biasing the surgeons to do right for the patient’s well-being, does so rather for him/herself (6). The importance of prospective registration is stressed by the finding that 2-3 times more complications are found than by retrospective designs (4-7). Conclusions: What matters is the forum in which data and new evidence is acknowledged and the importance for adjusting practice with those professionals involved. The idea of prospective registration had to be transcended to all gynaecologists, as we in design of the database challenged the different aspects of indication for hysterectomy itself, choice of operative procedure, postoperative procedure, and subjective assumptions on sick leave.

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A new model for patient referral from the GP to the hospital in order to improve surgical outcome Hanne Tønnesen*, Helge Ralov1, Pernille Faurschou*, Bente Nelbom2, Finn Zierau2 1 *Clinical Unit of Health General Practitioner Promotion, WHO Coll. Centre Community of Copenhagen Bispebjerg University Hospital

Smoking Cessation Clinic and Alcohol Unit Bispebjerg University Hospital 2

Background Smoking and excessive drinking are important risk factors for complications after surgical procedures. The clinical outcome improves by abstinence from alcohol and smoking cessation 4 and 6-8 weeks, respectively, prior to surgery. Elective surgery is often performed shortly after admittance and the benefits of lifestyle intervention are therefore limited. If early life style intervention is initiated by the GP at referral, it will be possible to get the full benefit of preoperative intervention. Purpose ♦ To develop a new model for preoperative life style intervention initiated the GP and performed by the hospital ♦ To include GPs for testing, evaluating and adjusting the model. Model for Quality improvement The GP in the Community of Copenhagen ♦ Identifies patients who smoke daily or drink excessive ♦ Informs the patient about advantages of quitting smoking and of stopping drinking before surgery ♦ Refers the patients to the Smoking Cessation Clinic at the hospital (telephone call) ♦ Refers the patients to the surgical ward as usual (electronic procedure). The Smoking Cessation Clinic and Alcohol Unit at Bispebjerg Hospital ♦ Offer support to stop smoking or drinking ♦ Initiate the life style intervention in due time preoperatively. Results Flow of information: ♦Traditional information ♦Repeated information ♦Intensive information/communication (telephone calls, articles, individual feedback)

The number of included GPs: 13 GPs 13 GPs 40 GPs

The number of included GPs is still increasing and the attitude is progressively positive. Conclusion ♦ The number of GPs involved in preoperative lifestyle change among surgical patients has increased with intensive communicative activity from May 2004 to April 2005. 19

The Danish Gynaecological Cancer Database (DGCD) A way to register the quality of gynaecological cancer surgery. Petri AL and Høgdall CK. Gynaecological Clinic, The Juliane Marie Centre, Rigshospitalet, DK-Copenhagen. From 1st of January 2005 Denmark got a nationwide database to register gynaecological cancer diseases. Actually cancer of the Ovary, Fallopian Tube, Uterus and Cervix Uteri are registered. Cancer of the Vulva and Vagina are planned to be registered from 2006. The purpose of DGCD is to evaluate the efforts and results of Danish gynaecological health service to promote high quality treatment of the Danish gynaecological cancer patients. Moreover DGCD renders a lot of scientific possibilities including a large sample of patients that can be generated rapidly. From a surgical point of view further news about the reasons to surgical complications and the importance of different types of radical surgery on survival are of interest. With sufficient data on known confounding factors, risk-adjusted comparisons can be made. Material and Method: All Danish patients with one of the above mentioned gynaecological diseases will be registered with the chain of events in relation to their hospitalisation. Specific schemes with information of the disease and potential confounding factors have to be on-line registered from the treating gynaecologists, pathologists and oncologists. Every patient has a scheme with information of anamnesis, surgery, pathology and surgical complications of her disease and succeeding control examinations. To estimate the surgical interventions the data will be accessible on-line for all participating departments of gynaecology in Denmark. Results: At this moment, shortly after the introduction of DGCD, we only have very preliminary results unsuitable for conclusions. In the actual poster we present the DGCD history, the ITstructure, the schematic construction and the flow of DGCD to be followed by examples including the first preliminary results illustrated by baseline characteristics, complications and information of the radical level of the ovarian cancer surgery in Denmark. Discussion: In the future, however, DGCD can provide up-to-date accurate estimates of the probabilities of different outcomes in typical settings. More information on www.dgc-dk.dk

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PRACTICAL INFORMATION

Registration Desk During the conference the Conference Secretariat will be located in the entrance hall of Bojesen Conference Centre at Axelborg and can be contacted on telephone number +45 2511 1109. Registration starts at 8:30 am.

Conference Secretariat The Conference Secretariat before and after the conference is: SURGICAL2005 Conventum Congress Service Att.: Congress Manager Jette Husted Carit Etlars Vej 3 1814 Frederiksberg C Denmark Phone: +45 3331 0847, fax: +45 3325 2283 e-mail: [email protected] Registration fee A registration fee of DKK 800 will be charged. This includes coffee/tea and lunch. Registration is not valid until the registration fee has been received. Participants may register electronically via www.cemtv.dk. Alternatively you may submit the attached registration form together with payment details to Conventum Congress Service. Payment may be made by cheque payable to Conventum Congress Service and posted to Conventum Congress Service, Carit Etlars Vej 3, 1814 Frederiksberg C, Denmark or by bank transfer to BG Bank account no. 9543 7600 064031. Please identify all payments with your name and “SURGICAL2005”. The number of participants is limited. Cancellation Cancellations received in writing before 20 May 2005 will be entitled to a 50% refund. After this date, no refunds will be made.

Language The conference will be held in English. Poster presentations Poster presentations are welcome for viewing during the breaks. DACEHTA invites project leaders/researches to submit abstracts concerning projects relevant to the subject of the conference, both ongoing and completed. The poster abstracts will be evaluated by DACEHTA. Abstracts should be submitted to [email protected] no later than 1 May 2005. For further instructions, see www.cemtv.dk. Transportation Bojesen at Axelborg is a 5-minute walk from Copenhagen central station (opposite the main entrance of Tivoli). • From Århus: Express train at 05.48 or 06.30 arriving in Copenhagen at 08.48 and 09.22, respectively. • From Odense: Express train at 07.34 or 08.06 arriving in Copenhagen at 8.48 and 09.22, respectively. • Returning from Copenhagen: Express train at 16.53 arriving in Odense at 18.11 and in Århus at 19.44. Liability Neither DACEHTA nor Conventum Congress Service assume any liability for personal injury and/or material damage suffered during the conference.

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Rumfang 04368-102 · Photo: SPL/Foci

Conference venue Bojesen Conference Centre at Axelborg Vesterbrogade 4A 1620 Copenhagen V