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Objectives To examine whether rate of reoperation after breast conserving surgery is associated with patients' characteristics and investigate whether reoperation rates vary among English NHS trusts. DesignCohort study using patient level data from hospital episode statistics.Setting English NHS trusts. Participants Adult women who had breast conserving surgery between 1 April 2005 and 31 March 2008.Main outcome measure Reoperation rates after primary breast conserving surgery within 3 months, adjusted using logistic regression for tumour type, age, comorbidity, and socioeconomic deprivation. Tumours were grouped by whether a carcinoma in situ component was coded at the time of the primary breast conserving surgery.Results 55 297 women had primary breast conserving surgery in 156 NHS trusts during the three year period. 11 032 (20.0%, 95% confidence interval 19.6% to 20.3%) women had at least one reoperation. 10 212 (18.5%, 18.2% to 18.8%) had one reoperation only; of these, 5943 (10.7%, 10.5% to 11.0%) had another breast conserving procedure and 4269 (7.7%, 7.5% to 7.9%) had a mastectomy. Of the 45 793 women with isolated invasive disease, 8229 (18.0%) had at least one reoperation. In comparison, 2803 (29.5%) of the 9504 women with carcinoma in situ had at least one reoperation (adjusted odds ratio 1.9, 95% confidence interval 1.8 to 2.0). Substantial differences were found in the adjusted reoperation rates among the NHS trusts (10th and 90th centiles 12.2% and 30.2%). Conclusion:One in five women who had breast conserving surgery in England had a reoperation. Reoperation was nearly twice as likely when the tumour had a carcinoma in situ component coded. Women should be informed of this reoperation risk when deciding on the type of surgical treatment of their breast cancer.

The results confirm that "hot" tonsillectomy techniques carry a substantially elevated risk of postoperative hemorrhage when diathermy is used as a dissection tool in tonsillectomy.

A Mahmood, vice president,4 Allan Templeton, professor of obstetrics and gynaecology, 4 Jan H van der Meulen, professor of clinical epidemiology 1,4 ABSTRACT Objective To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors. Design A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model. Setting 146 English NHS trusts. Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008. Main outcome measure Rate of caesarean sections per 100 births (live or stillborn). Results Among 620 604 singleton births, 147 726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section. Conclusion Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section. INTRODUCTIONSince the 1970s, many developed countries have experienced substantial growth in the rates of caesarean section.1-3 In England, for example, the rate of caesarean sections has increased from 9% in 1980 to 24.6%