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PURPOSE - Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card.
METHODS - Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports.
RESULTS - Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705-$1025) to $388 (IQR $182-$776), p<0.001. No significant change was detected in median OR duration (47min [IQR 36-63] to 50min [IQR 38-64], p=0.520) or adverse events (1 [0.9%] to 6 [4.7%], p=0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%).
CONCLUSION - Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes.
LEVEL OF EVIDENCE - Level II.
Copyright © 2018 Elsevier Inc. All rights reserved.
Obstetric care refers to the care provided to patients during ante-, intra-, and postpartum periods. Predicting length of stay (LOS) for these patients during their hospitalizations can assist healthcare organizations in allocating hospital resources more effectively and efficiently, ultimately improving maternal care quality and reducing costs to patients. In this paper, we investigate the extent to which LOS can be forecast from a patient's medical history. We introduce a machine learning framework to incorporate a patient's prior conditions (e.g., diagnostic codes) as features in a predictive model for LOS. We evaluate the framework with three years of historical billing data from the electronic medical records of 9188 obstetric patients in a large academic medical center. The results indicate that our framework achieved an average accuracy of 49.3%, which is higher than the baseline accuracy 37.7% (that relies solely on a patient's age). The most predictive features were found to have statistically significant discriminative ability. These features included billing codes for normal delivery (indicative of shorter stay) and antepartum hypertension (indicative of longer stay).
BACKGROUND - Early preparation for renal replacement therapy (RRT) is recommended for patients with advanced chronic kidney disease (CKD), yet many patients initiate RRT urgently and/or are inadequately prepared.
METHODS - We conducted audio-recorded, qualitative, directed telephone interviews of nephrology health care providers (n = 10, nephrologists, physician assistants, and nurses) and primary care physicians (PCPs, n = 4) to identify modifiable challenges to optimal RRT preparation to inform future interventions. We recruited providers from public safety-net hospital-based and community-based nephrology and primary care practices. We asked providers open-ended questions to assess their perceived challenges and their views on the role of PCPs and nephrologist-PCP collaboration in patients' RRT preparation. Two independent and trained abstractors coded transcribed audio-recorded interviews and identified major themes.
RESULTS - Nephrology providers identified several factors contributing to patients' suboptimal RRT preparation, including health system resources (e.g., limited time for preparation, referral process delays, and poorly integrated nephrology and primary care), provider skills (e.g., their difficulty explaining CKD to patients), and patient attitudes and cultural differences (e.g., their poor understanding and acceptance of their CKD and its treatment options, their low perceived urgency for RRT preparation; their negative perceptions about RRT, lack of trust, or language differences). PCPs desired more involvement in preparation to ensure RRT transitions could be as "smooth as possible", including providing patients with emotional support, helping patients weigh RRT options, and affirming nephrologist recommendations. Both nephrology providers and PCPs desired improved collaboration, including better information exchange and delineation of roles during the RRT preparation process.
CONCLUSIONS - Nephrology and primary care providers identified health system resources, provider skills, and patient attitudes and cultural differences as challenges to patients' optimal RRT preparation. Interventions to improve these factors may improve patients' preparation and initiation of optimal RRTs.
Patient-centered care is upheld as one of the fundamental components of high quality health care. Although a deceptively easy concept, patient-centered care is an elusive goal in clinical practice. A core objective for patient-centered care is a collaboration between health care providers and patients that aligns therapy with patients' values and preferences through shared decision making. Advances in communication training that are tailored to the specific requirements of nephrology care are promising methods for enhancing the skill-set of our providers. However, patient-centered care extends beyond shared decision-making and also involves attention to patients' physical and emotional symptoms, care coordination, and the inclusion of family members. Research about patient-centered care processes, interventions and outcomes among patients with kidney disease is sparse. Recent discussions among nephrology experts name patient-centered care as a priority for research and quality improvement in care. Given recent advances in methods for quantifying patient-centered care as well as patient reported outcomes, now is the time to prioritize our resources to evolve our health system and meet the needs of all patients with kidney disease.
© 2014 Wiley Periodicals, Inc.
BACKGROUND - The period following hospital discharge is a vulnerable time for patients when errors and poorly coordinated care are common. Suboptimal care transitions for patients admitted with cardiovascular conditions can contribute to readmission and other adverse health outcomes. Little research has examined the role of health literacy and other social determinants of health in predicting post-discharge outcomes.
METHODS - The Vanderbilt Inpatient Cohort Study (VICS), funded by the National Institutes of Health, is a prospective longitudinal study of 3,000 patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Enrollment began in October 2011 and is planned through October 2015. During hospitalization, a set of validated demographic, cognitive, psychological, social, behavioral, and functional measures are administered, and health status and comorbidities are assessed. Patients are interviewed by phone during the first week after discharge to assess the quality of hospital discharge, communication, and initial medication management. At approximately 30 and 90 days post-discharge, interviewers collect additional data on medication adherence, social support, functional status, quality of life, and health care utilization. Mortality will be determined with up to 3.5 years follow-up. Statistical models will examine hypothesized relationships of health literacy and other social determinants on medication management, functional status, quality of life, utilization, and mortality. In this paper, we describe recruitment, eligibility, follow-up, data collection, and analysis plans for VICS, as well as characteristics of the accruing patient cohort.
DISCUSSION - This research will enhance understanding of how health literacy and other patient factors affect the quality of care transitions and outcomes after hospitalization. Findings will help inform the design of interventions to improve care transitions and post-discharge outcomes.
BACKGROUND - Differences in quality of care may contribute to racial variation in outcomes of bladder cancer (BCa). Quality indicators in patients undergoing surgery for BCa include the use of high-volume surgeons and high-volume hospitals, and, when clinically indicated, receipt of pelvic lymphadenectomy, receipt of continent urinary diversion, and undergoing radical cystectomy instead of partial cystectomy. The authors compared these quality indicators as well as adverse perioperative outcomes in black patients and white patients with BCa.
METHODS - The Healthcare Cost and Utilization Project State Inpatient Databases for New York, Florida, and Maryland (1996-2009) were used, because they consistently included race, surgeon, and hospital identifiers. Quality indicators were compared across racial groups using regression models adjusting for age, sex, Elixhauser comorbidity sum, insurance, state, and year of surgery, accounting for clustering within hospital.
RESULTS - Black patients were treated more often by lower volume surgeons and hospitals, they had significantly lower receipt of pelvic lymphadenectomy and continent diversion, and they experienced higher rates of adverse outcomes compared with white patients. These associations remained significant for black patients who received treatment from surgeons and at hospitals in the top volume decile.
CONCLUSIONS - Black patients with BCa had lower use of experienced providers and institutions for BCa surgery. In addition, the quality of care for black patients was lower than that for whites even if they received treatment in a high-volume setting. This gap in quality of care requires further investigation.
© 2013 American Cancer Society.
OBJECTIVES - Patient satisfaction is a key determinant of the quality of care and an important component of pay for performance metrics. The purpose of this study was to evaluate the impact of a simple intervention aimed to increase patients' understanding of their orthopaedic trauma surgeon and improve patient satisfaction with the overall quality of inpatient care delivered by the attending surgeon.
DESIGN - Prospective quality improvement initiative using a randomized intervention.
SETTING - Level 1 academic trauma center.
PATIENTS/PARTICIPANTS - Two hundred twelve patients were eligible; 100 patients were randomized to the intervention group, and 112 patients were randomized to the control group. Overall, 76 patients could be reached for follow-up satisfaction survey, including 34 patients in the intervention group and 42 patients in the control group.
INTERVENTION - Patients randomized to the intervention group received an attending biosketch card, which included a picture of the attending orthopaedic surgeon with a brief synopsis of his educational background, specialty, surgical interests, and research interests.
MAIN OUTCOME MEASURES - Our primary outcome measure was a patient satisfaction survey assessing patients' rating of the overall quality of inpatient care delivered by the attending surgeon.
RESULTS - Overall, 25 (74%) of 34 patients who received an attending biosketch card reported "excellent overall quality of doctor care," whereas only 22 (52%) of 42 patients in the control group reported "excellent overall quality of doctor care" (P = 0.05). Age, gender, race, education, insurance status, primary injury type, and the length of hospital stay were not significant with reference to "excellent" outcome.
CONCLUSIONS - Clinically significant improvements in satisfaction with the overall quality of inpatient care by the attending surgeon were identified in patients who received a biosketch card of his or her attending orthopaedic surgeon.
OBJECTIVE - The updated clinical practice guidelines for the management of pain, agitation, and delirium recommend either daily sedation interruption or maintaining light levels of sedation as methods to improve outcomes for patients who are sedated in the ICU. We review the evidence supporting both methods and discuss whether one method is preferable or if they should be used concurrently.
DATA SOURCE - Original research articles identified using the electronic PubMed database.
STUDY SELECTION AND DATA EXTRACTION - Randomized controlled trials and large prospective cohort studies of mechanically ventilated ICU patients requiring sedation were selected.
DATA SYNTHESIS - The methods of daily sedation interruption and targeting light sedation levels (including avoidance of deep sedation) are safe in critically ill patients with no increase, and a potential decrease, in long-term psychiatric disturbances. Randomized trials comparing these methods with standard care, which has traditionally involved moderate to heavy sedation, found that both methods reduced duration of mechanical ventilation and ICU length of stay. Additionally, one trial noted that daily sedation interruption paired with spontaneous breathing trials improved 1-year survival, whereas a large observational study found that deep sedation was associated with decreased 180-day survival. Two common characteristics of these interventions in trials showing benefits were avoidance of deep levels of sedation and significant reductions in sedative doses, especially benzodiazepines. Thus, combining targeted light sedation with daily sedation interruption may be more beneficial than either method alone if sedative doses are reduced and arousal and mobility are facilitated during the ICU stay.
CONCLUSION - Daily sedation interruption and targeting light sedation levels are safe and proven to improve outcomes for sedated ICU patients when these approaches result in reduced sedative exposure and facilitate arousal. It remains unclear as to whether one approach is superior, and further studies are needed to evaluate which patients benefit most from either or both techniques.