Author Interviews, Hand Washing, Hospital Acquired / 12.04.2016

MedicalResearch.com Interview with: Professor Jacqui Reilly PhD Institute for Applied Health Research Glasgow Caledonian University Glasgow MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Reilly: Hand hygiene is the single most important intervention to reduce avoidable illness and prevent infections. Two techniques have been reported for hand hygiene use with alcohol-based hand rub (ABHR) in international guidance:  6 step by the WHO and 3 step by the Center for Disease Control. Neither of these techniques have an evidence base to support their effectiveness. The study provides the first evidence in a RCT that the 6 step technique is superior in reducing residual bacterial load on the hands. The reduction was not related to coverage, type of organism or staff group. The 6 step technique was microbiologically more effective at reducing the median log10 bacterial count (3.28  to 2.58)than the 3 step (3.08  to 2.88), (p=0.02), but did not increase the total hand coverage area (98.8% versus 99.0%, p=0.15) and required 25% (95% CI: 6%-24%) more time (42.50 seconds  vs 35.0 seconds, p=0.002). Total hand coverage was not related to the reduction in bacterial count. (more…)
Author Interviews, Hospital Acquired, JAMA, Outcomes & Safety, Surgical Research / 12.04.2016

MedicalResearch.com Interview with: Christina A. Minami, MD Surgical Outcomes and Quality Improvement Center Department of Surgery, Feinberg School of Medicine, Center for Healthcare Studies, Feinberg School of Medicine Northwestern University, Chicago, Illinois MedicalResearch.com: What is the background for this study? Dr. Minami: An earlier study by our group demonstrated a seemingly paradoxical relationship between hospital quality and hospital penalization in the Hospital-Acquired Condition, or HAC, Reduction Program. Basically, of those hospitals that were penalized more frequently were those that were major teaching hospitals, had more quality accreditations, and had better performance on process and outcome measures. When CMS released that surgical-site infections were going to be added to the HAC scoring, we decided to see if these additional measures might exhibit the same paradoxical association between quality and penalization. MedicalResearch.com: What are the main findings? Dr. Minami: The SSI measures follow the same trend as was previously illustrated. Basically, the hospitals who were in the bottom 25% (that is, those who were the worst performers) were more often those that were major teaching hospitals, with more quality accreditations, and offered more advanced services. It’s possible that this is due in part to surveillance bias, or “the more you look, the more you find” phenomenon. Also, what do we really call an infection? The National Healthcare Safety Network has specific definitions and guidelines, but there are still different data collections used by different hospitals. (more…)
Author Interviews, Cost of Health Care, Hospital Readmissions, Outcomes & Safety, UT Southwestern / 04.04.2016

MedicalResearch.com Interview with: Oanh Kieu Nguyen, MD, MAS | Assistant Professor UT Southwestern Medical Center Divisions of General Internal Medicine and Outcomes and Health Services Research Dallas, TXOanh Kieu Nguyen, MD, MAS | Assistant Professor UT Southwestern Medical Center Divisions of General Internal Medicine and Outcomes and Health Services Research Dallas, TX MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Nguyen: The impetus for this study was Steven Brill’s 2013 Time magazine award-winning article, “Bitter Pill: Why Medical Bills Are Killing Us.” This report investigated inflated charges for hospital bills, and and suggested that a major driver of irrationally high charges was the disproportionate negotiating power of hospitals, as evidenced through their high profit margins. As hospital physicians, our reaction was “But what if hospitals that make more money are delivering more value and better outcomes to patients? If that’s the case, wouldn’t most people say that their profits justifiably earned?” Surprisingly, we found that no one had really looked at this issue in a systematic way. We set out to answer this question using hospital financial data from California’s Office of Statewide Health Planning and Development (OSHPD) and outcomes data on 30-day readmissions and mortality for congestive heart failure, acute myocardial infarction (‘heart attacks’), and pneumonia from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website. California has more hospitals than any other state other than Texas, and also has a wide diversity of hospital types. The OSHPD financial data are also audited, so we thought these would be more reliable than using data from other sources. Because the outcomes reported on Hospital Compare are viewable by the general public, we thought hospitals would be most motivated to target improvements in these outcomes. We found that there was almost no association between how much money a hospital made and its subsequent performance on outcomes. The exception to this was we found that hospitals that had better finances reported higher rates of 30-day mortality for congestive heart failure, which was counterintuitive. We’re not sure why this was the case but speculate that it is possible that hospitals with better finances take care of sicker heart failure patients because they have more advanced (and more expensive) treatments available. Additionally, we looked to see if hospitals with lower readmissions rates subsequently made less money. This is a specific area of policy concern given federal penalties in the U.S. for excessive hospital readmissions. Many critics of these penalties have argued that reducing readmissions makes no financial sense for hospitals, since readmissions still generate hospital revenue despite the penalties. Thus, reducing readmissions would reduce a key source of hospital revenue and lead to poorer hospital finances. However, our analysis showed that lower readmissions rates were not associated with poorer hospital finances, as has been feared.  (more…)
Author Interviews, Hospital Acquired, Outcomes & Safety / 28.03.2016

MedicalResearch.com Interview with: Peggy Luebbert, MS, MT, CIC, CHSP, CBSPD; Infection Preventionist at Nebraska Orthopaedic Hospital; Owner and Consultant at Healthcare Interventions, Inc.; and Brian Heimbuch, MS, Associate Division Manager/Sr. Bioaerosol Scientist, Applied Research Associates MedicalResearch: What is the background for this study? Mr. Heimbuch: The purpose of the study was to examine the ability of sterilization packaging systems to maintain sterility of surgical instruments and devices from the time of sterilization until use. Ms. Luebbert: Maintaining a sterile environment in the operating room is essential for preventing the estimated 300,000 surgical site infections (SSIs) that occur annually in U.S. hospitals and result in approximately 9,000 deaths.[i]-iii Sterilization packaging systems are designed to maintain the sterility of surgical instruments and devices from the time of sterilization until use in the operating room. The two primary types of sterilization packaging systems include trays covered in sterilization wrap and rigid containers. Sterilization wrap is composed of polypropylene or cloth and is disposed of after use. Rigid containers are reusable and come in a variety of materials (including metals, aluminum and polymers) and sizes. (more…)
Author Interviews, Hand Washing, Hospital Acquired, JAMA, University of Michigan / 15.03.2016

MedicalResearch.com Interview with: Lona Mody, MD, MS Veterans Affairs Healthcare System, Geriatric Research, Education, and Clinical Center Division of Geriatric and Palliative Medicine, University of Michigan Medical School, School of Public Health University of Michigan, Ann Arbor MedicalResearch.com: What is the background for this study? Dr. Mody: Hand hygiene is considered to be the most important strategy to prevent infections and spread of drug resistant organisms. Surprisingly, all strategies and efforts have predominantly involved healthcare workers and that too mainly in acute care hospitals.  We are now facing a tsunami of an aging population in our hospitals, post-acute care facilities and long-term care facilities.  Hand hygiene falls off when patients are hospitalized compared to when they are at home.  So, we were very interested, first, in hand colonization in older patients who have recently been transferred from the acute care hospital to a post-acute care (PAC) facility for rehabilitation or other medical care before fully returning home. We were also interested in evaluating whether these organisms persisted. MedicalResearch.com: What are the main findings? Dr. Mody: We recruited and followed 357 patients (54.9 percent female with an average age of 76 years). The dominant hands of patients were swabbed at baseline when they were first enrolled in a post-acute care facility, at day 14 and then monthly for up to 180 days or until discharge. The study found:
  • To our surprise, nearly one-quarter (86 of 357) of patients had at least one multi-drug resistant organism on their hands when they were transferred from the hospital to the post-acute care facility
  • During follow-up, 34.2 percent of patients’ hands (122 of 357) were colonized with a resistant organism and 10.1 percent of patients (36 of 357) newly acquired one or more resistant organisms.
  • Overall, 67.2 percent of colonized patients (82 of 122) remained colonized at discharge from PAC.
(more…)
Author Interviews, Hospital Readmissions, JAMA, Orthopedics, Surgical Research / 11.03.2016

MedicalResearch.com Interview with: Ronald S. Chamberlain, MD, MPA, FACS Chairman and Surgeon-in-Chief Department of Surgery Saint Barnabas Medical Center Professor of Surgery New Jersey Medical School Rutgers University MedicalResearch.com: What is the background for this study? Dr. Chamberlain:  With the rapidly growing arthritic, aging, and obese population, total hip replacement (THR) has become the most commonly performed orthopedic procedure in the United States (US).  The Affordable Care Act signed by President Barack Obama imposed financial penalties for excess readmissions following certain procedures and diagnoses. While the initial program aimed to reduce readmissions for heart failure, pneumonia, and acute myocardial infarction (AMI), the program expanded to include THR in 2015. With current research estimating a 10%, 30-day readmission rate following a total or partial hip replacement, this study sought to identify factors associated with readmission and to create a scale which could reliably stratify preoperative readmission risk. (more…)
Author Interviews, CMAJ, Outcomes & Safety, Pulmonary Disease, Respiratory / 08.03.2016

MedicalResearch.com Interview with: Dr. Gary Garber MD Chief of infection prevention and control Public Health Ontario Professor of medicine University of Ottawa  MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Garber: There are conflicting recommendations regarding the use of respirators vs face masks to protect healthcare workers against acute respiratory infections. Our systematic review and meta-analysis show that although N95 respirators have improved efficiency in reducing filter penetration under laboratory conditions, there is insufficient data to show a protective advantage compared to surgical mask in clinical settings. (more…)
Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, Hand Washing, Health Care Systems, JAMA, UCSF / 07.03.2016

MedicalResearch.com Interview with: Dr. Andrew Auerbach MD Professor of Medicine in Residence Director of Research Division of Hospital Medicine UCSF and Jeffrey L. Schnipper, MD, MPH Associate Physician, Brigham and Women's Hospital Associate Professor of Medicine, Harvard Medical School Department of Medicine Brigham and Women's Hospital     MedicalResearch.com: What is the background for this study? Response: The Affordable Care Act required the Department of Health and Human Services to establish a program to reduce what has been dubbed a “revolving door of re-hospitalizations.” Effective October 2012, 1 percent of every Medicare payment was deducted for a hospital that was determined to have excessive readmissions. This percentage has subsequently increased to up to 3 percent. Penalties apply to readmitted Medicare patients with some heart conditions, pneumonia, chronic lung disease, and hip and knee replacements. Unfortunately, few data exist to guide us in determining how many readmissions are preventable, and in those cases how they might have been prevented. MedicalResearch.com: What are the main findings? Response: Our main findings were that 27 percent of readmissions were preventable, and that the most common contributors to readmission were being discharged too soon, poor coordination between inpatient and outpatient care providers, particularly in the Emergency Departments and in arranging post acute care. (more…)
Author Interviews, Hand Washing, Hospital Acquired, Infections / 04.03.2016

MedicalResearch.com Interview with: Dr Laurence Senn, médecin associée Service de médecine préventive hospitalière Mont Paisible Lausanne MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Senn: Pseudomonas aeruginosa is a ubiquitous environmental bacterium that can cause infection in patients severely ill, and is thus a major cause of nosocomial infections in intensive care units. During an environmental investigation on potential reservoirs of P. aeruginosa, the liquid hand soap was found highly contaminated with this pathogen. The fact that unopened soap containers were found contaminated with P. aeruginosa proved that the contamination occurred during product manufacturing. Contaminated batches had been used in our hospital over the previous 5 months. In order to evaluate the burden of this contamination on patients, our infection control team conducted an epidemiological investigation combining two molecular methods. First, we analyzed with a classical molecular typing method all P. aeruginosa isolated from patients during the period of exposition to the contaminated soap. Secondly, we targeted the analysis on some isolates sharing the same genotype that the one found in the soap with a modern, recently developed tool which consists in sequencing the whole genome of the bacteria. This method allowed us to have the "fingerprint" of each isolate. Our investigation ruled out any impact of the contaminated soap on patients. (more…)
Author Interviews, Health Care Systems, JAMA, Outcomes & Safety / 29.02.2016

MedicalResearch.com Interview with: Dr. Alisa Khan, MD MPH Division of General Pediatrics Boston Children’s Hospital Department of Pediatrics, Harvard Medical School, Boston, Massachusetts Medical Research: What is the background for this study? What are the main findings? Dr. Khan: Medical errors, or mistakes in the process of caring for patients, occur frequently. While methods of detecting errors have improved, parents and families are not typically included in routine hospital safety monitoring systems. We found that nearly 1 in 11 parents reported their child had experienced a safety incident during hospitalization. Most of these reports were confirmed to be medical errors when reviewed by physicians, and many were not otherwise documented in the patient’s medical record. (more…)
Author Interviews, Cost of Health Care, Health Care Systems, Hospital Readmissions, Technology / 25.02.2016

MedicalResearch.com Interview with: Andrey Ostrovsky, MD CEO | Co-Founder Care at Hand  Medical Research: What is the background for this study? Dr. Ostrovsky: Hospital readmissions are a large source of wasteful healthcare spending, and current care transition models are too expensive to be sustainable. One way to circumvent cost-prohibitive care transition programs is complement nurse-staffed care transition programs with those staffed by less expensive nonmedical workers. A major barrier to utilizing nonmedical workers is determining the appropriate time to escalate care to a clinician with a wider scope of practice. The objective of this study is to show how mobile technology can use the observations of nonmedical workers to stratify patients on the basis of their hospital readmission risk. (more…)
Author Interviews, Breast Cancer, JAMA, Outcomes & Safety, Surgical Research / 17.02.2016

MedicalResearch.com Interview with: Dr. Art Sedrakyan MD PhD ScD Professor of Healthcare Policy and Research in Cardiothoracic Surgery Department of Public Health Weill Cornell Medical College  Medical Research: What is the background for this study? What are the main findings? Dr. Sedrakyan: In the most recent years available to us for research(2011-2013) one in four women underwent repeat surgery within 90 days after breast conserving approach to cancer removal. Patients operated by higher volume physicians had lower chance of undergoing repeat surgery.Uniform guidelines and increased surgical training are needed to standardize the breast conserving surgery to reduce the high rate of repeat surgery. (more…)
Author Interviews, Heart Disease, Hospital Readmissions / 16.02.2016

MedicalResearch.com Interview with: Rashmee U. Shah, MD MS Cardiovascular Medicine University of Utah School of Medicine Medical Research: What is the background for this study? What are the main findings? Dr. Shah: The purpose of this study was to evaluate long term outcomes of acute myocardial infarction (AMI) survivors who have cardiogenic shock. We used the ACTION Registry-GWTG (from the NCDR), which is the largest database of AMI, or heart attack, patients in the United States. Some heart attack patients develop cardiogenic shock which is a condition in which the heart muscle becomes so weak that it cannot effectively pump blood to the rest of the body. These patients are critically ill, but with advances in our treatment for heart attacks, many will survive to hospital discharge. We wanted to know, after all the intense treatment and sometimes long hospitalization, how do these patients fare when they leave the hospital? From a total of 112,668 heart attack patients who survived hospitalization, we identified 5,555 who had cardiogenic shock. Over half of all patients were either hospitalized or died within one year of discharge, and this poor outcome was more common among patients who had cardiogenic shock. In fact, the risk of death or hospitalization seems to be clustered in the early post-discharge time period, within 60 days, for patients with cardiogenic shock. After 60 days, shock and non-shock patients experience similar risk. In other words, we found that heart attack patients who had cardiogenic shock are particularly vulnerable during the first 60 days after hospital discharge. (more…)
Author Interviews, Hospital Readmissions, JAMA, Pediatrics / 16.02.2016

MedicalResearch.com Interview with: Marion R. Sills, MD, MPH Associate Professor, Departments of Pediatrics and Emergency Medicine University of Colorado School of Medicine Medical Research: What is the background for this study? Dr. Sills: My co-authors and I know that studies show that patients who are poorer or are minorities are readmitted at higher rates than other patients, and that readmissions penalties, which are far more commonly applied in relation to readmissions of adult patients, have been shown to punish hospitals for the type of patients that they serve, rather than purely for the quality of care they provide.  Currently, these penalties impact hospitals treating Medicare patients in all 50 states but only impact readmissions of children in 4 states, although other states are considering implementing these penalties.  This was our rationale for exploring the impact of patients’ social determinants of health (factors like race, ethnicity, health insurance and income) on how likely it was that a hospital would be penalized for readmissions under a typical state-level pay-for-performance measure based on hospital readmissions. Readmissions penalties are designed to penalize hospitals that provide lower quality care. However, without adjusting for social determinants of health factors, these pay-for-performance measures may unfairly penalize hospitals based on the type of patient they treat as well as the quality of care they provide. Medical Research: What are the main findings? Dr. Sills: We found that risk adjustment for social determinants of health factors changed hospitals’ penalty status on a readmissions-based pay-for-performance measure. Without adjusting the pay-for-performance measures for social determinants of health, hospitals may receive penalties partially related to patient factors beyond the quality of hospital care. (more…)
Author Interviews, Hospital Acquired, Outcomes & Safety / 12.02.2016

MedicalResearch.com Interview with: Christine Greene, Ph.D. and Chuanwu Xi, Ph.D. School of Public Health, Department of Environmental Health Sciences University of Michigan Medical Research: What is the background for this study? Response: Healthcare-associated infections (HAIs) are a serious problem globally.  Acinetobacter baumannii, a gram-negative opportunistic pathogen, was mostly unheard of 10-15 years ago, but is now a clinically significant pathogen in hospitals.  A. baumannii causes a variety of infections ranging from urinary tract infections to bacteremia and patients who are at high risk of A. baumannii infection are those who are critically ill, who have indwelling catheters or patients with long hospital says.  Once infected, the risk of mortality is high – up to 26% for in-hospital patients and as much as 43% for those in the ICU.  The mortality rate is high largely due to the rapid ability for this pathogen to develop antibiotic resistance.  Despite patient isolation, we still see hospital outbreaks because A. baumannii survives very well in the environment and it is resistant to most biocides, detergents, dehydration, and UV radiation.  A. baumannii is also a known biofilm former.  Biofilms serve to protect the microorganism.  In the open environment, biofilms protect from desiccation and other harsh environmental insults such as biocides, thereby promoting persistence in the open environment.  In the human body, biofilms protect against the immune system, provide an additional layer of protection from antibiotics and contribute to reoccurring infections in the patient. This research characterizes the fitness (desiccation tolerance) trade-offs imposed on A. baumannii isolated from clinical and environmental settings.  This investigation compares isolates of A. baumannii from both environments on the basis of multidrug resistance, biofilms and desiccation tolerance.  We looked to see if either MDR or biofilm formation increased fitness (ability to tolerate desiccation) or impose a fitness cost depending on environmental conditions. Medical Research: What are the main findings? Response: We provide evidence of variation in desiccation tolerance between clinical and environmental isolates of similar phenotypes and show a trend of increased desiccation tolerance for high biofilm forming clinical isolates with additional tolerance when the ability to form biofilms is coupled with the multidrug resistance.  By contrast, biofilm formation had a significant impact on desiccation tolerance for environmental isolates.

(more…)

AHRQ, Author Interviews, Electronic Records, Outcomes & Safety / 11.02.2016

MedicalResearch.com Interview with: Mr. Noel Eldridge Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality Medical Research: What is the background for this study? What are the main findings? Mr. Eldridge: We used existing data on adverse events from the Medicare Patient Safety Monitoring System, which AHRQ, CMS, and Qualidigm have been analyzing for years, and focused on the question as to whether rates of the adverse event measures were higher or lower in patients whose charts indicated that they had been treated with a full electronic health record (EHR) or a partial EHR during their inpatient stay. The main finding was that the adverse event rates were lower in the full EHR patients. We saw three different diagnosis groups of patients (cardiovascular, pneumonia, and major surgery), and looked at combined rates for all adverse event types, as well as for four combined subtypes separately: hospital-acquired infections, adverse drug events, post-procedural events, and falls and pressure ulcers combined. Not all of our findings were what people unfamiliar with our measures would have expected. (more…)
Annals Thoracic Surgery, Author Interviews, Heart Disease, Outcomes & Safety, Surgical Research / 27.01.2016

MedicalResearch.com Interview with: Dr. Christian McNeely, MD Resident Physician, Department of Medicine Barnes-Jewish Hospital/Washington University Medical Center St. Louis, Missosuri  MedicalResearch: What is the background for this study? What are the main findings? Dr. McNeely : Since year 2000, 30-day mortality of aortic valve replacement (AVR) in Medicare beneficiaries has improved. Additionally, mechanical valve use in the elderly, which are often avoided in older patients largely because the risk of bleeding complications outweighs the risk of valve deterioration over time, has fallen significantly. Prior research has demonstrated worse outcomes in cardiac surgery for lower volume centers. Therefore, we sought to investigate the longitudinal relationship between institutional volume and outcomes in AVR using the Medicare database, looking at patients only > 65 years over a 10-year period. We found that, in general, mechanical valve use in the elderly decreased with increasing hospital volume. Lower volume hospitals exhibited increased adjusted operative mortality. Importantly, the discrepancy in operative mortality between low and high-volume hospitals diverged during the course of the study such that higher volume centers demonstrated significantly greater improvement over time compared to lower volume centers. (more…)
Author Interviews, Hand Washing, Hospital Acquired, Nursing / 26.01.2016

MedicalResearch.com Interview with: Donna Powers, DNP, RN Kransoff Quality Management Institute North Shore Long Island Jewish Health System New York, NY  Medical Research: What is the background for this study? What are the main findings? Dr. Powers: Despite widely published, accessible guidelines on infection control and negative health consequences of noncompliance with the guidelines, significant issues remain around the use of Standard Precautions to protect nurses  from bloodborne infectious diseases. Only 17.4% of ambulatory nurses reported compliance with all nine standards. The nurses represented medicine, cardiology, dialysis, oncology, pre - surgical testing, radiation and urology practices. Compliance rates varied considerably and were highest for wearing gloves (92%) when exposure of hands to bodily fluids was anticipated, however only 63% reported washing hands after glove removal.  68% provided nursing care considering all patients as potentially contagious. Overall, the ambulatory care nurses chose to implement some behaviors and not others, and this behavior puts them at risk for acquiring a bloodborne infection.” The study also found knowledge of HCV was variable. Although HCV is not efficiently transmitted by sexual activity, more than one in four nurses (26 %) believed that sexual transmission is a common way that HCV is spread.  14 percent believed incorrectly that most people with HCV will die prematurely because of the infection, 12 percent did not know that HCV antibodies can be present without an infection, and 11 percent did not know there are multiple HCV genotypes. A statistically significant relationship was found between compliance and perception of susceptibility to HCV illness (P = .05) and between compliance and perception of barriers to use of Standard precautions (P=.005). (more…)
Author Interviews, JAMA, Nursing, Outcomes & Safety, Surgical Research, University of Pennsylvania / 20.01.2016

More on Nursing Research on MedicalResearch.com MedicalResearch.com Interview with: Jeffrey H. Silber, M.D., Ph.D. The Nancy Abramson Wolfson Professor of Health Services Research Professor of Pediatrics and Anesthesiology & Critical Care,  The University of Pennsylvania Perelman School of Medicine Professor of Health Care Management The Wharton School Director, Center for Outcomes Research The Children's Hospital of Philadelphia Philadelphia, PA 19104  Medical Research: What is the background for this study? Response: We wanted to test whether hospitals with better nursing work environments displayed better outcomes and value than those with worse nursing environments, and to determine whether these results depended on how sick patients were when first admitted to the hospital. Medical Research: What are the main findings? Response: Hospitals with better nursing work environments (defined by Magnet status), and staffing that was above average (a nurse-to-bed ratio greater than or equal to 1), had lower mortality than those hospitals with worse nursing environments and below average staffing levels. The mortality rate in Medicare patients undergoing general surgery was 4.8% in the hospitals with the better nursing environments versus 5.8% in those hospitals with worse nursing environments. Furthermore, cost per patient was similar. We found that better nursing environments were also associated with lower need to use the Intensive Care Unit. The greatest mortality benefit occurred in patients in the highest risk groups. (more…)
Author Interviews, Hospital Acquired, Infections, OBGYNE, Outcomes & Safety / 30.12.2015

MedicalResearch.com Interview with: Muhammad A. Halwani, MSc, PhD Faculty of Medicine, Al Baha University Al Baha, Saudi Arabia.  Medical Research: What is the background for this study? What are the main findings? Response: The study idea was based on examining the current rate of post cesarean section infections that were detected in the hospital at the time. It was hypothesized that the detected infections were actually less than the real number identified. Therefore, we challenged the traditional surveillance method that was applied in the hospital with a new enhanced methodology which is telephone follow-ups for patients who under go C-section operations. Our main finding proved that this new applied method was able to detect more cases than the traditional one. Using phone calls as a gold standard, the sensitivity of the standard methodology to capture SSI after cesarean increased to 73.3% with the new methodology identifying an extra five cases. These patients represented 26.3% (5 of 19) of all the patients who developed SSI. In other words, for every 100 C-section procedures there were 2.6% missed cases which the new method was able to detect. The duration of the calls ranged from 1 to 5 minutes and were well received by the patients. (more…)
Author Interviews, Heart Disease, Hospital Readmissions / 15.12.2015

MedicalResearch.com Interview with: Javed Butler MD MPH Chief, Division of Cardiology Stony Brook University Health Sciences Center SUNY at Stony Brook, NY Medical Research: What is the background for this study? What are the main findings? Dr. Butler: There is a lot of emphasis on reducing the risk of readmission after heart failure hospitalization. The main focus is on early readmissions as the risk for readmission is highest earlier post discharge. In this study, we described the fact that certainly there is some increased risk post discharge, the majority of the risk is actually dependent on the patient and disease characteristics at the time of discharge as opposed to true reduction in risk over time, which is partially related to differential attrition of high risk patients earlier post discharge. (more…)
Author Interviews, Colon Cancer, Cost of Health Care, Health Care Systems, Outcomes & Safety, Surgical Research / 06.12.2015

MedicalResearch.com Interview with: Johannes Govaert MD Department of Surgery Leiden University Medical Center Leiden, The Netherlands Medical Research: What is the background for this study? Dr. Govaert: The Value Based Health Care agenda ofPprof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined. Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing. Medical Research: What are the main findings? Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction. (more…)
Author Interviews, Cost of Health Care, Health Care Systems, JAMA, Outcomes & Safety / 25.11.2015

MedicalResearch.com Interview with: Anup Das Medical Scientist Training Program Department of Health Management and Policy University of Michigan, Ann Arbor Medical Research: What is the background for this study? What are the main findings? Response: The Centers for Medicare & Medicaid Services (CMS) recently added a new measure of episode spending to the Hospital Value Based Purchasing program. Participation in this program allows hospitals to receive a financial bonus if they perform well on the included measures. This is the first spending measure in the program, and this change now incentivizes hospitals to improve their quality as well as their spending. The measure evaluates spending from three days before a hospitalization through 30 days post-discharge. In this study, we find that while high-cost hospitals had higher spending levels in each of the three components of an episode of care (pre-admission, index admission, and post-discharge), differences in post-discharge spending were the main determinants of hospital performance on this measure. High-cost hospitals spent on average $4,691 more than low-cost hospitals in post-discharge care. The majority of post-discharge spending comes from skilled nursing facility or readmission costs. Similarly, hospitals that did worse on this new measure of spending over time did so because of increases in their post-discharge spending. (more…)
Author Interviews, OBGYNE, Outcomes & Safety / 25.11.2015

MedicalResearch.com Interview with: Dr William L Palmer Honorary research fellow Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London Medical Research: What is the background for this study? Dr. Palmer: For the majority of women and their newborns, their care will be safe and result in good outcomes. However, previous research has suggested that outcomes across a range of healthcare areas might be worse at weekends. We therefore undertook to investigate whether there was an association between day of delivery and complications, using a range of different outcomes: perinatal mortality and - for both women and neonate - injury, infection and emergency readmission rates. Our analysis was based on every delivery to public health services in the NHS in England across a two-year period so accounting for some 1.3 million births. To account for possible differences in case-mix and maternal characteristics we controlled for a range of factors including gestational age, delivery type, maternal age, birth-weight, and pre-existing diabetes or hypertension.  (more…)
Author Interviews, JAMA, Outcomes & Safety, Urinary Tract Infections, Urology / 19.11.2015

MedicalResearch.com Interview with: Jerome A. Leis, MD MSc FRCPC Staff physician, General Internal Medicine and Infectious Diseases Physician Lead, Antimicrobial Stewardship Team Staff member, Centre for Quality Improvement and Patient Safety Sunnybrook Health Sciences Centre Assistant Professor, Department of Medicine, University of Toronto Medical Research: What is the background for this study? What are the main findings? Dr. Leis: Overuse of urinary catheters leads to significant morbidity among hospitalized patients.  In most hospitals, discontinuation of urinary catheters relies on individual providers remembering to re-assess whether patients have an ongoing reason for a urinary catheter.  We engaged all of the attending physicians to agree on the appropriate reasons for leaving a urinary catheter in place and developed a medical directive for nurses to remove all urinary catheters lacking these indications.  This nurse-led intervention resulted in a significant reduction in urinary catheter use and catheter-associated urinary tract infections, compared with wards that continued to rely on usual practice. (more…)
AHA Journals, Author Interviews, Duke, Outcomes & Safety, Stroke, Surgical Research / 04.11.2015

MedicalResearch.com Interview with: Soko Setoguchi-Iwata, M.D MPH Adjunct Associate Professor Department of Medicine Duke Clinical Research Institute Medical Research: What is the background for this study? What are the main findings? Dr. Setoguchi: Medicare made a decision to cover Carotid Artery Stenting (CAS) in 2005 after publication of SAPPHIRE, which demonstrated the efficacy of Carotid Artery Stenting vs Carotid Endarterectomy in high risk patients for CEA. Despite the data showing increased carotid artery stenting dissemination following the 2005 National Coverage Determination, peri-procedural and long-term outcomes have not been described among Medicare beneficiaries, who are quite different from trial patients, older and with more comorbidities in general population. Understanding the outcomes in these population is particularly important in the light of more recent study, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which established CAS as a safe and efficacious alternative to CEA among non-high-surgical risk patients that also expanded the clinical indication of carotid artery stenting. Another motivation to study ‘real world outcomes in the general population is expected differences in the proficiency of physicians performing stenting in trial setting vs. real world practice setting. SAPPHIRE and CREST physicians were enrolled only after having demonstrated  Carotid Artery Stenting proficiency with low complication rates whereas hands-on experience and patient outcomes among real-world physicians and hospitals is likely to be more diverse. We found that unadjusted mortality risks over study period of 5 years with an mean of 2 years of follow-up in our population was 32%.  Much higher mortality risks observed among certain subgroups with older age, symptomatic patients and non-elective hospitalizations.   (more…)
AHA Journals, Author Interviews, Health Care Systems, Outcomes & Safety, Stroke / 29.10.2015

MedicalResearch.com Interview with: Mathew J. Reeves BVSc, PhD, FAHA Professor, Department of Epidemiology and Biostatistics, Michigan State University East Lansing, MI 48824  Medical Research: What is the background for this study? Dr. Reeves: The National Institutes of Health Stroke Scale (NIHSS) is the single most important prognostic factor in predicting outcomes of individual stroke patients. NIHSS data is obviously important at the patient level but also at a hospital level since the case mix of stroke patients are assumed to vary widely across different hospitals and referral centers. Measuring stroke outcomes at a hospital level is becoming increasingly important as work proceeds in the US to develop integrated stroke systems of care. But it is also very relevant to the new payment models being introduced by CMS which are based on hospital rankings that are developed from statistical risk adjustment models. One would expect that NIHSS would be a major contributor to these models but currently a major limitation is that NIHSS is incompletely documented in clinical registries such as GWTG-Stroke, and is completely absent from administrative data. The problem of missing NIHSS data plays havoc with the ability to risk adjust stroke outcomes across hospitals. Missing data results is a smaller number of stroke cases being included in the risk adjusted calculations for a given hospital which results in greater uncertainty over what the actual hospital outcomes are. Further there is concern that NIHSS data is not missing at random, and so the NIHSS data that is documented may represent a biased selection of all the cases that a hospital admits. This too could have important consequences for hospital rankings. To determine the degree of potential bias in the documentation of NIHSS data this study examined trends in and predictors of documentation of NIHSS across 10 years of data (2003-2012) in the GWTG-Stroke program. (more…)
Author Interviews, Infections, Lancet, Outcomes & Safety, Respiratory / 22.10.2015

MedicalResearch.com Interview with: Yuichiro Shindo, M.D., Ph.D. Assistant Professor Institute for Advanced Research, Nagoya University, Department of Respiratory Medicine, Nagoya University Graduate School of Medicine Showa-ku, Nagoya Japan Medical Research: What is the background for this study? What are the main findings? Dr. Shindo: Appropriate initial antibiotic treatment is essential for the treatment of pneumonia.  However, many patients may develop adverse outcomes, even if they receive appropriate initial antibiotics.  To our knowledge, there have been no studies that clearly demonstrated the risk factors in patients who receive appropriate antibiotic treatment.  If these factors are clarified, we can identify those patients with pneumonia for whom adjunctive therapy other than antibiotic treatment can prove beneficial in terms of improved outcomes.  This study aimed to clarify the risk factors for 30-day mortality in patients who received appropriate initial antibiotic treatment and elucidate potential candidates for adjunctive therapy. In this study, the 30-day mortality in 579 pneumonia patients who received appropriate initial antibiotics was 10.5%.  The independent risk factors included albumin < 3.0 mg/dL, nonambulatory status, pH < 7.35, respiration rate ≥ 30/min, and blood urea nitrogen ≥ 20 mg/dL.  The 30-day mortality for the number of risk factors was 0.8% (0), 1.2% (1), 16.8% (2), 22.5% (3), and 43.8% (4–5). (more…)
Author Interviews, Case Western, Hand Washing, Infections / 17.10.2015

MedicalResearch.com Interview with: Curtis J. Donskey, MD Professor of Medicine Case Western Reserve University Staff Physician, Infectious Diseases Section, Louis Stokes Cleveland VA Medical Center Medical Research: What is the background for this study? Dr. Donskey: Personal protective equipment (PPE) is intended to protect healthcare personnel by preventing them from acquiring an infection and to protect patients by preventing pathogen transmission. This study focused on gloves and gowns which are designed to reduce contamination of the skin and clothing of personnel. There are several concerns about the effectiveness of gloves and gowns.
  • First, several studies have demonstrated that personnel may acquire pathogens such as Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) on their hands and clothing during patient care activities despite wearing gloves and gowns.
  • Second, some studies involving simulations have suggested that contamination of the skin and clothing occurs frequently during removal of gloves and gowns.
  • Finally, lapses in technique for PPE removal may contribute to acquisition of potentially fatal pathogens such as Ebola virus. These concerns highlight the urgent need for improved strategies to prevent contamination of personnel during PPE removal.
We had 3 goals in the study.
  • First, we wanted to determine if contamination with a fluorescent lotion during glove and gown removal would correlate well with contamination with a benign virus. We did this because the fluorescent lotion method could potentially be very useful for training personnel because you can easily visualize contamination with a black light and provide immediate feedback.
  • Second, we used the fluorescent lotion method to evaluate contamination of the skin and clothing of personnel from 4 hospitals during removal of contaminated gloves or gowns.
  • Finally, we tested whether an intervention would reduce contamination in one of the 4 hospitals. The intervention included practice in removal of contaminated gloves and gowns with immediate visual feedback based on fluorescent lotion contamination of skin and clothing.
Medical Research: What are the main findings? Dr. Donskey: Our first key finding was that contamination with the fluorescent lotion correlated well with contamination with the benign virus. This was an important finding because it suggests that the fluorescent lotion method is a useful surrogate method to assess pathogen contamination during Personal protective equipment removal. Our second key finding was that contamination of the skin and clothing of personnel occurred frequently during removal of contaminated gloves or gowns. For 435 total simulations, contamination occurred 46% of the time, with similar results for each the 4 study hospitals (43%-50%). Incorrect donning or doffing technique was common and was associated with an increase in contamination (70% of the time with incorrect technique versus 30% with correct technique). Our final key finding was that the intervention was very effective in reducing contamination during PPE removal. Immediately after the training session, the frequency of contamination decreased from 60% to 20% and then was 12% at 1 and 3 months after the intervention. (more…)