Robotic-Assisted Radical Nephrectomy: No Difference in Outcomes But Takes Longer and Costs More

MedicalResearch.com Interview with:
In Gab Jeong, MD

Associate Professor
Department of Urology, Asan Medical Center
University of Ulsan College of Medicine
Seoul, Korea

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Use of robotic surgery has increased in urological practice over the last decade especially for the surgery that was difficult to perform with laparoscopic techniques such as radical prostatectomy for prostate cancer or partial resection of kidney cancer. However, the use, outcomes, and costs of robotic nephrectomy are unknown.

We examined the trend in use of robotic-assisted operations for radical nephrectomy in the United States and compared the perioperative outcomes and costs with laparoscopic radical nephrectomy. The proportion of radical nephrectomies using robotic-assisted operations increased from 1.5% in 2003 to 27.0% in 2015. Although there was no significant difference between robotic-assisted vs laparoscopic radical nephrectomy in major postoperative complications, robotic-assisted procedures were associated with longer operating time and higher direct hospital costs. The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19530 vs $16851; difference, $2678; 95% CI, $838 to $4519).

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Hospital Onset Clostridium difficile Infections Increased With Electronic Sepsis Alerts

MedicalResearch.com Interview with:

Dr. Robert Hiensch MD Assistant Professor, Medicine, Pulmonary, Critical Care and Sleep Medicine Icahn School of Medicine at Mount Sinai

Dr. Hiensch

Dr. Robert Hiensch MD
Assistant Professor, Medicine, Pulmonary, Critical Care and Sleep Medicine
Icahn School of Medicine at Mount Sinai.

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: New sepsis guidelines that recommend screening and early treatment for sepsis cases appear to have significant positive impacts on patient outcomes. Less research has been published on what potential side effects may result from these guidelines.

Antibiotics are a cornerstone of sepsis treatment and early antibiotic administration is strongly recommended.  We examined whether the introduction of an electronic based sepsis initiative changed antibiotic prescribing patterns at our hospital. Antibiotics, even when appropriate, contribute to hospital onset Clostridium difficile infections (HO CDIs).  While the authors do not dispute the importance of antibiotic administration in sepsis, it is valuable to know whether the sepsis initiative coincided with both increased antibiotic administration and HO CDIs.

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NHS: Delayed Hospital Discharges May Be Linked To Increase in Mortality

MedicalResearch.com Interview with:
Dr Mark A Green 
BA (Hons), MSc, PhD, AFHEA
Lecturer in Health Geography
University of Liverpool

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Between Dec 2013 and Dec 2015 there was an increase of 41% in the number of acute patients delayed being discharged from hospital. If we compare the previous year of data –Dec 2012- Dec 2014 – there was only a 10% increase. 2015 saw one of the largest annual spikes in mortality rates for almost 50 years – we wanted to explore if there was any correlation between these two trends.

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Substituting Less Well Trained Assistants For Nurses Increased Hospital Mortality

MedicalResearch.com Interview with:

Dr Linda H Aiken PhD, FAAN, FRCN, RN Claire M. Fagin Leadership Professor in Nursing Professor of Sociology, School of Arts & Sciences Director, Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing Center for Health Outcomes and Policy Research Philadelphia, PA 19104

Dr Linda H Aiken

Dr Linda H Aiken PhD, FAAN, FRCN, RN
Claire M. Fagin Leadership Professor in Nursing
Professor of Sociology, School of Arts & Sciences
Director, Center for Health Outcomes and Policy Research
University of Pennsylvania School of Nursing
Center for Health Outcomes and Policy Research
Philadelphia, PA 19104

MedicalResearch.com: What is the background for this study?

Response: The idea that adding lower skilled and lower wage caregivers to hospitals instead of increasing the number of professional nurses could save money without adversely affecting care outcomes is intuitively appealing to mangers and policymakers but evidence is lacking on whether this strategy is safe or saves money.
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LEAN Principles Improved Surgical Safety, Outcomes and Efficiency

MedicalResearch.com Interview with:
Vishal Sarwahi, MD, senior author
Associate Surgeon-in-Chief
Chief, Spinal Deformity and Pediatric Orthopaedics
Billie and George Ross center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery
Cohen’s Children Medical Center
Northwell Hofstra School of Medicine and

Stephen F. Wendolowski Research Assistant Pediatric Orthopaedics Cohen Children’s Medical Center New Hyde Park, NY, 11040

Stephen F. Wendolowski

Stephen F. Wendolowski
Research Assistant
Pediatric Orthopaedics
Cohen Children’s Medical Center
New Hyde Park, NY, 11040

MedicalResearch.com: What is LEAN?

Response: LEAN is a management principle that supports the concept of continuous improvement through small incremental changes to not only improve efficiency, but also quality. Particularly, we took interest in the 5S’s – Sort, Simplify, Sweep, Standardize, and Self-Discipline. We felt that Sort, Simplify, and Standardize were the most relevant to surgery.

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Quality of Outpatient Care Has Not Consistently Improved Over Last Decade

MedicalResearch.com Interview with:

David Michael Levine M.D.,M.A. Division of General Internal Medicine and Primary Care Brigham and Women’s Hospital Boston, Massachusetts

Dr. David Levine

David Michael Levine M.D.,M.A.
Division of General Internal Medicine and Primary Care
Brigham and Women’s Hospital
Boston, Massachusetts

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: About a decade ago, researchers showed that Americans only received half of recommended health care. Since then, national, regional, and local initiatives have attempted to improve quality and patient experience, but there is incomplete information about whether such efforts have been successful.

We found that over the past decade the quality of outpatient care has not consistently improved, while patient experience has improved.

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Hospital Wide Crew Resource Management Training Improves Communication and Teamwork

MedicalResearch.com Interview with:

Dr. Susan Moffatt-Bruce, MD PhD Cardiothoracic surgeon Associate professor of surgery and assistant professor of molecular virology, immunology and medical genetics The Ohio State University Wexner Medical Center Columbus, OH

Dr. Moffatt-Bruce

Dr. Susan Moffatt-Bruce, MD PhD
Cardiothoracic surgeon
Associate professor of surgery and assistant professor of molecular virology, immunology and medical genetics
The Ohio State University Wexner Medical Center
Columbus, OH

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Crew Resource Management (CRM), a training for all health care providers, including doctors, nurses, staff and students, focusing on team communication, leadership, and decision-making practices, was implemented throughout a large academic health system – across eight departments spanning three hospitals and two campuses. All those in the health system, inclusive of those that took the training, took a survey measuring perceptions of workplace patient safety culture both before CRM implementation and about 2 years after. Safety culture was significantly improved after Crew Resource Management training, with the strongest effects in participant perception of teamwork and communication. This study was the first health-system wide CRM implementation reported in the literature.

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More ICU Use in Hospitals With Worse Quality of Care for Heart Failure or MI

MedicalResearch.com Interview with:

Thomas Valley, MD, MSc Fellow, Pulmonary and Critical Care University of Michigan Ann Arbor, MI 48109-2800

Dr. Thomas Valley

Thomas Valley, MD, MSc
Fellow, Pulmonary and Critical Care
University of Michigan
Ann Arbor, MI 48109-2800

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Hospitalizations for cardiovascular condition such as acute myocardial infarction (AMI) and heart failure (HF) are incredibly common and costly. Yet, about 20% of hospitalized patients with these conditions receive substandard care. We assessed whether there was an association between the quality of care a hospital provided for AMI or heart failure and how frequently a hospital used the ICU. We found that hospitals with the highest rates of ICU use for AMI or HF delivered worse quality of care and had higher 30-day mortality for these conditions.

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Weekend-Admitted Patients With Non-STEMI Heart Attacks Have Longer Admissions and Higher Mortality

MedicalResearch.com Interview with:

Sahil Agrawal MD, Heart and Vascular Center St. Luke’s University Health Network Bethlehem, PA 18015

Dr. Sahil Agrawal

Sahil Agrawal MD, MD
Heart and Vascular Center

St. Luke’s University Health Network
Bethlehem, PA 18015

MedicalResearch.com: What is the background for this study?

Dr. Agrawal: Patients admitted on a weekend have previously been known to have poorer outcomes compared to patients admitted on weekdays for various acute illnesses. With the advent of early fibrinolytic therapy and subsequently, emergent primary percutaneous coronary interventions (PCI), such discrepancies in outcomes have been largely resolved for ST-segment elevation myocardial infarctions (STEMI). In contrast, treatment of non-ST segment elevation myocardial infarction (NSTEMI) has remained less stringent such that invasive coronary angiography and potential intervention is often delayed for those presenting on a weekend rather than a week day. According to current ACC/AHA guidelines for NSTEMI, an early invasive strategy (EIS) is the preferred method of management unless barred by presence of contraindications (comorbid conditions) or patients’ preference. We were interested in investigating differences in utilization of EIS between patients admitted on a weekend versus those admitted on a weekday for an NSTEMI, and to evaluate the impact of such differences on in-hospital mortality in such patients.

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Computerized Triggers May Help Prevent Delays in X-Ray Reports

MedicalResearch.com Interview with:

Daniel R. Murphy, M.D., M.B.A. Assistant Professor - Interim Director of GIM at Baylor Clinic Department of Medicine Health Svc Research & General Internal Medicine Baylor College of Medicine Houston, TX

Dr. Daniel Murphy

Daniel R. Murphy, M.D., M.B.A.
Assistant Professor – Interim Director of GIM at Baylor Clinic
Department of Medicine
Health Svc Research & General Internal Medicine
Baylor College of Medicine
Houston, TX

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Murphy: Electronic health records (EHRs) have improved communication in health care, but they have not eliminated the problem of patients failing to receive appropriate and timely follow up after abnormal test results. For example, after a chest x-ray result where a radiologist identifies a potentially cancerous mass and suggests additional evaluation, about 8% of patients do not receive follow-up imaging or have a visit with an appropriate specialist within 30 days. Identifying patients experiencing a delay with traditional methods, like randomly reviewing charts, is not practical. Fortunately, EHRs collect large amounts of data each day that can be useful in automating the process of identifying such patients.

We evaluated whether an electronic “trigger” algorithm designed to detect delays in follow up of abnormal lung imaging tests could help medical facilities identify patients likely to have experienced a delay. Of 40,218 imaging tests performed, the trigger found 655 with a possible delay. Reviewing a subset of these records showed that 61% were truly delays in care that required action. We also found that the trigger had a sensitivity of 99%, indicating that it missed very few actual delays.

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Mobility Program During Hospitalization Improved Post-Discharge Ambulation

MedicalResearch.com Interview with:
Cynthia J. Brown, MD, MSPH, AGSF
Parrish Professor of Medicine and Director,
Division of Gerontology, Geriatrics, and Palliative Care
Comprehensive Center for Healthy Aging
University of Alabama at Birmingham
Birmingham, Alabama 35294

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Brown: Low mobility is common during hospitalization and associated with loss of activities of daily living ability and community mobility. The objective of this study was to examine the impact of an in-hospital mobility program on post-hospital function and community mobility. Brown and colleagues, using a single blind randomized trial design, found that a mobility program that included offering assistance with ambulation linked with a behavioral intervention that focused on goal setting and addressing mobility barriers prevented loss of community mobility one month after hospital discharge. Those who received usual care experienced a clinically significant decline in community mobility. Functional status as measured by activities of daily living was not significantly different between the usual care and mobility program groups either before or after the hospitalization. Because low mobility in the hospital is associated with adverse outcomes including functional decline and nursing home placement even after controlling for illness severity and comorbid illness, these findings have potentially significant clinical implications.

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Fluorescent Marker May Help Improve Cleanliness of Hospital Surfaces

MedicalResearch.com Interview with:

Gabriele Messina, MD  Dr.PH  MSc Research Professor of Public Health University of Siena Department of Molecular and Developmental Medicine Area of Public Health. Room: 2057 Siena, Italy

Dr. Gabriele Messina

Gabriele Messina, MD  Dr.PH  MSc
Research Professor of Public Health
University of Siena
Department of Molecular and Developmental Medicine
Area of Public Health. Room: 2057
Siena, Italy

MedicalResearch.com: What is the background for this study?

Dr. Messina:  Studies conducted in the 1970s and 1980s conferred to environmental surfaces a marginal role in the transmission of health care associated infections (HAIs). Today, it is demonstrated that several pathogens such as C. difficile, VRE (Vancomycin-resistant Enterococcus) and MRSA (Methicillin-resistant Staphylococcus aureus) can survive even for months on inanimate surfaces. Up to 40% of HAIs can be spread by the hands of doctors and hospital staff after touching infected patient and/or contaminated surfaces; furthermore, people hospitalized in rooms previously occupied by patients infected by microorganism that can persist on surfaces present an increased  risk to develop HAIs.

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What Else Can Be Done To Reduce Medical Errors?

MedicalResearch.com Interview with:

Michael Daniel The Johns Hopkins University School of Medicine M.D. Candidate 2016

Michael Daniel

Michael Daniel
The Johns Hopkins University School of Medicine
M.D. Candidate 2016

Michael G. Daniel is a graduating medical student at the Johns Hopkins School of Medicine. He will be attending the Osler Internal Medicine Residency Training Program next year at the Johns Hopkins Hospital. His research focus is on Patient Safety, Quality, and Outcomes improvement.

Summary:

Medical error ranks as the third leading cause of death in the United States, but is not recognized in national vital statistics because of a flawed reporting process. Using recent studies on preventable medical error and extrapolating the results to the 2013 U.S. hospital admissions we calculated a mortality rate or 251,454 deaths per year.

MedicalResearch.com: What made you want to research this topic?

Response: I decided to study medicine because I wanted to improve patient health. However, I realized that improving patient health is not only about curing a disease but is sometimes about fixing the way we deliver healthcare.

MedicalResearch.com: Is this news surprising to you?

Response: Yes, because all previous estimates of medical error were much lower and when I started the research I couldn’t use the CDC statistics to get current data.

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Breast Cancer Surgery: Reoperations Less Frequent in High Volume Centers

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

Dr. Art Sedrakyan

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.

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Fully Integrated Electronic Records Linked to Fewer Inpatient Adverse Effects

MedicalResearch.com Interview with:

Mr. Noel Eldridge Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality

Mr. Noel Eldridge

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.

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Mortality After Lung Cancer Resection Steadily Decreasing

Carlos E. Bravo Iñiguez, M.D. Clinical Research Fellow in Thoracic Oncology Brigham and Women´s Hospital (BWH)/Harvard Medical School (HMS) Department of Surgery, Division of Thoracic Surgery Center for Surgery and Public Health Boston, MA, 02115

Dr. Bravo

MedicalResearch.com Interview with:
Carlos E. Bravo Iñiguez, M.D.
Clinical Research Fellow in Thoracic Oncology
Brigham and Women´s Hospital (BWH)/Harvard Medical School (HMS)
Department of Surgery, Division of Thoracic Surgery
Center for Surgery and Public Health
Boston, MA, 02115

Medical Research: What is the background for this study? What are the main findings?

Dr. Bravo: The National Lung Screening Trial (NLST) determined the ability of low-dose computed tomography (LDCT) scans to reduce Lung Cancer specific mortality by 20% in high-risk patients. This reduction was partly dependent on the low surgical mortality experienced at the major academic centers, centers that were pioneers in minimally invasive lobectomy techniques.

In December 2013, The United States Preventive services task force (USPTF) endorsed annual low-dose computed tomography screening for Americans between ages 55 to 80 years who have 30 pack-years of smoking history and have smoked within 15 years.

On April 30th, 2014 the Centers for Medicare and Medicaid Services expressed concerns and raised skepticism as to whether the benefit of implementing a Lung Cancer Screening Program for the Medicare population could be maintained nationwide.  Specifically, they doubted low mortality and morbidity rates achieved by the NLST in the elderly patients could be maintained throughout the United States and across a broad range of hospital settings.

Medical Research: What are the main findings? 

Dr. Bravo: Mortality after lung resection has been decreasing over the past five decades. We analyzed a nationally validated database intended to measure and improve quality of surgical care – The American College of Surgeons National Surgical Quality improvement Program (ACS-NSQIP)- in order to find this answer.

The Overall Mortality rate was 2.34%. This included academic and community hospitals. Further analysis showed a significant difference on this rate depending on surgical technique: 3.13% for those undergoing Open thoracotomy lobectomy and 1.19% for those who underwent minimally invasive video-assisted Thoracoscopic lobectomy. Morbidity rate was 19.9% consistent with other recent prospective clinical trials. 

Medical Research: What should clinicians and patients take away from your report?

Dr. Bravo: These results showed that current operative mortality is not limited to pioneering centers in minimally invasive surgery or large academic centers but has now pervaded centers participating in the ACS-NSQIP database. Briefly, 8% of US hospitals providing adult care participate in the database. They include a mixture of academic centers and community hospitals with 29% of participants defined as non teaching hospitals and 31% having fewer than 500 licensed beds.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Bravo: Prospective data collection in the context of the recently implemented lung cancer screening program will be necessary to further refine screening criteria and implementation strategies. Also, results of ongoing randomized trials on sublobar resections for Lung cancer can favorably impact the results of the screening program reducing even more the morbidity and mortality.

Citation:

Thirty-Day Mortality After Lobectomy in Elderly Patients Eligible for Lung Cancer Screening

Bravo Iñiguez, Carlos E. et al.
The Annals of Thoracic Surgery Published Online:October 22, 2015

Carlos E. Bravo Iñiguez, M.D. (2015). Mortality After Lung Cancer Resection Steadily Decreasing 

Studies Evaluates Outcomes of Carotid Artery Stenting in Real World Settings

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.  
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Mission of Safety Net Hospitals Prevents Streamlining Health Care

Richard S. Hoehn, MD Division of Transplant Surgery Department of Surgery, University of Cincinnati School of Medicine Cincinnati, OHMedicalResearch.com Interview with:
Richard S. Hoehn, MD
Division of Transplant Surgery
Department of Surgery
University of Cincinnati School of Medicine
Cincinnati, OH

Medical Research: What is the background for this study? What are the main findings?

Dr. Hoehn: Safety-net hospitals are hospitals that either have a stated purpose of maintaining an “open door policy” to all patients, regardless of their ability to pay, or simply have a significantly high burden of patients with Medicaid or no insurance. As healthcare policy and reimbursement change to focus on both “quality” metrics as well as cost containment, these hospitals may find themselves in a precarious situation. Current literature suggests that increased safety-net burden corresponds to inferior surgical outcomes. If this is true, safety-net hospitals will have inferior outcomes and suffer more financial penalties than other centers. This decrease in resources may adversely affect patient care, leading to even worse outcomes and further financial penalties, potentially creating a downward spiral that exacerbates disparities in surgical care that already exist in our country.

Medical Research: What are the main findings?

Dr. Hoehn: Our study analyzed 9 major surgical operations using the University HealthSystem Consortium clinical database, which represents 95% of academic medical centers in the United States. We sought to determine the effect of patient and hospital characteristics on the inferior outcomes at safety-net hospitals. As expected, we found that safety-net hospitals had higher rates of patients who were of black race, of lowest socioeconomic status, had government insurance, had extreme severity of illness, and needed emergent operations. They also had the highest rates of post-operative mortality, 30-day readmissions, and highest costs associated with care.

Next we performed a multivariate analysis controlling for patient age, race, socioeconomic status, and severity of illness, as well as hospital procedure-specific volume. Using this model, we found that the increased mortality and readmission rates at safety-net hospitals were somewhat reduced, but the increased costs were not affected. Safety-net hospitals still provided surgical care that was 23-35% more expensive, despite controlling for patient characteristics. This suggests that intrinsic hospital characteristics may be responsible for the increased costs at safety-net hospitals.

To further investigate this finding, we analyzed Medicare Hospital Compare data and found that safety-net hospitals performed worse on Surgical Care Improvement Project (SCIP) measures, had higher rates of reported surgical complications, and also had much slower measures of emergency department throughput (time from arrival to evaluation, treatment, admission, etc). This corresponded with our finding that hospital characteristics may be driving increased costs at safety-net hospitals.

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No Clear Standard For Measuring Health Care Quality Improvement Interventions

Megan Colleen McHugh, PhD Research Assistant Professor Center for Healthcare Studies Institute for Public Health and Medicine and Emergency Medicine Northwestern UniversityMedicalResearch.com Interview with:
Megan Colleen McHugh, PhD
Research Assistant Professor
Center for Healthcare Studies
Feinberg Institute for Public Health and Medicine and Emergency Medicine
Northwestern University
 

Medical Research: What is the background for this study? What are the main findings?

Dr. McHugh: There have been many large efforts to improve the delivery of health care in the U.S., for example, the Robert Wood Johnson Foundation’s Aligning Forces for Quality Program and the Institute for Healthcare Improvement’s 100,000 Lives Campaign.  One of the challenges to understanding whether these programs work is that the intervention “dose” – the quality and quantity of the intervention – often varies across different participating sites.

As evaluators of multi-site quality improvement programs, we want to better understand how to measure the dose of a quality improvement intervention at participating sites.  We identified four different approaches to measuring dose.  These approaches resulted in different conclusions about which sites are “low dose” and “high dose” intervention sites.

Medical Research: What should clinicians and patients take away from your report?

Dr. McHugh: The main audience for this paper is program evaluators.  They should take away the following:

1) Variation in dose scores across intervention sites suggests that dose may be a contributor to the effectiveness of a quality improvement intervention.

2) It is feasible to measure the dose of a quality improvement intervention, but measuring QI dose presents many challenges, including subjective decisions about which approach to measurement to use and the need for extensive data collection.

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Distance From Hospital Linked To Worse 30-Day Cardiac Surgery Outcomes

Dr. Ansar Hassan MD PhD Department of Cardiac Surgery New Brunswick Heart Centre Saint John Regional Hospital Saint John, New BrunswicMedicalResearch.com Interview with:
Dr. Ansar Hassan MD PhD
Department of Cardiac Surgery
New Brunswick Heart Centre
Saint John Regional Hospital
Saint John, New Brunswick

Medical Research: What is the background for this study? What are the main findings?

Dr. Hassan: For years, geographic place of residence and one’s proximity to a tertiary care center has been identified as a predictor for access to care.   Little is known regarding the effect of geography on patient outcomes.   The purpose of this study was to explore the relationship between geography and in-hospital / 30-day outcomes among patients undergoing cardiac surgery.  What we found was that despite there being no relationship between geography and in-hospital outcomes, those who lived further away from hospital clearly had worse 30-day outcomes.

Medical Research: What should clinicians and patients take away from your report?

Dr. Hassan: While patients from a differing geographic places of residence appear to have similar in-hospital outcomes following cardiac surgery, their clinical courses following discharge from hospital differ considerably.   Clinicians and patients need to realize that where one lives is tremendously important as it relates to his or her health and that particular attention needs to be paid to cardiac surgery patients who live further away from their tertiary care center, especially within the first 30 days following surgery.

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Hospital Mortality Outcomes Differ After Lung Cancer Surgery Complications

Tyler Grenda, MD House Officer VI Section of General Surgery Department of Surgery University of Michigan

MedicalResearch.com Interview with:
Tyler Grenda, MD
House Officer VI
Section of General Surgery
Department of Surgery
University of Michigan

 

Medical Research: What is the background for this study? What are the main findings?

Dr. Grenda: The main purpose for this study was to better understand the factors underlying differences in mortality rates for hospitals performing lung cancer resection.  The methodology we used included only the highest and lowest mortality hospitals (Commission on Cancer accredited cancer programs) so the sampling frame was specific. There are wide variations in mortality rates across hospitals performing lung cancer resection (overall unadjusted mortality rates were 10.8% vs. 1.6%, respectively.

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Cardiac Arrest Survival Better At Tertiary Care Hospitals

Helle Søholm, MD, PhDDepartment of Cardiology Copenhagen University Hospital Rigshospitalet Denmark MedicalResearch.com Interview with:
Helle Søholm, MD, PhD
Department of Cardiology
Copenhagen University Hospital Rigshospitalet
Denmark
Medical Research: What is the background for this study?

Dr. Søholm: The background of the current study is that previous studies have found higher survival rates after out-of-hospital cardiac arrest and admission to tertiary heart centres for post-resuscitaton care compared with nontertiary hospitals, however the reasons for this difference has only been speculative. The aim of the study was to examine the level-of post-resuscitation care at tertiary heart centers compared with nontertiary hospitals and to associate this with outcome. Only patients without ST-segment elevation myocardial infarction was examined to avoid referral bias.

Medical Research: What are the main findings?

Dr. Søholm: The main findings of the study of 1.078 patients was that the survival in patients admitted to tertiary heart centers was significantly higher compared with survival in patients admitted to nontertiary hospitals even after adjustment for known risk markers including pre-arrest co-morbidity. We found that the adjusted odds of predefined markers of level-of-care differed in both the acute phase after admission, during the intensive care admission and in the workup prior to hospital discharge. The odds of admission to an intensive care unit was 1.8 for patients admitted to a tertiary heart centre. During the intensive care admission the odds of a temporay pacemaker was 6.4, use of vasoactive agents 1.5, acute and late coronary angiography was 10 and 3.8 respectively, neurophysiological examination 1.8, brain computed tomography 1.9, whereas no difference in the odds of therapeutic hypothermia was found. Prior to hospital discharge the odds of a consultation by a cardiologist was 8.6, having an echocardiography was 2.9, and survivors more often had an implantable cardioverter defibrillator implanted (odds 2.1) as compared with patients admitted to nontertiary hospitals.

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Hospitals Vary in Rates of Missed Acute Myocardial Infarction Diagnosis

MedicalResearch.com Interview with:
Philip G. Cotterill PhD
Centers for Medicare & Medicaid Services
Baltimore, MD

Medical Research: What is the background for this study? What are the main findings?

Dr. Cotterill: Chest pain is one of those elusive complaints where patients can seem initially low-risk based on symptoms or risk factors, and subsequently have an acute myocardial infarction (AMI) or die in a short period of time. Using combinations of history and physical examination findings to discriminate patients with serious causes of chest pain is often not possible. In our study, we demonstrated wide variation in the decision to hospitalize Medicare beneficiaries with chest pain – nearly two fold between the lowest (38%) and highest (81%) quintile of hospitals – and that patients treated in hospitals with higher admission rates for chest pain are less likely to have an acute myocardial infarction within 30-days of the index event and less likely to die.

While the findings were statistically significant – differences in outcomes were small: 4 fewer AMIs and 3 fewer deaths per 1,000 patients comparing the highest and lowest admission quintiles. Stated differently, these numbers suggest that if low admitting hospitals were to behave more like high admitting hospitals, 250 patients would need to be admitted to prevent one AMI and 333 cases to prevent one death.

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DVT: Clot Removal Outcomes Better In Hospitals With Higher Volume of Procedures

Riyaz Bashir MD, FACC, RVTProfessor of Medicine Director, Vascular and Endovascular Medicine Department of Medicine Division of Cardiovascular Diseases Temple University Hospital Philadelphia, PA 19140MedicalResearch.com Interview with:
Riyaz Bashir MD, FACC, RVT
Professor of Medicine
Director, Vascular and Endovascular Medicine
Department of Medicine
Division of Cardiovascular Diseases
Temple University Hospital
Philadelphia, PA 19140

Medical Research: What is the background for this study?

Dr. Bashir: Catheter-based thrombus removal also known as Catheter Directed Thrombolysis (CDT) is a minimally invasive therapeutic intervention that has evolved over the past two decades to reduce the incidence of post thrombotic syndrome (PTS), a very frequent and disabling complication of proximal deep vein thrombosis (DVT). Catheter-based thrombus removal has been shown to reduce this lifestyle limiting complication of DVT and as a result we have observed a significant increase in the utilization rates of CDT across United States. Recent nationwide observational data suggests that higher adverse events such as intracranial hemorrhage rates and need for blood transfusions are seen with CDT use.  Nonetheless specific reasons for these findings have not been explored prior to this study.

Medical Research: What are the main findings?

Dr. Bashir: This study showed a significant inverse relationship between the institutional Catheter-based thrombus removal volumes and safety outcomes like death and intracranial hemorrhage. The institutions with higher volume of CDT cases annually (greater than or equal to 6 cases) were associated with lower in-hospital mortality rates and lower intracranial hemorrhage rates as compared to institutions, which performed less than 6 cases annually. This study also showed that at high volume institutions there was no difference in terms of death or intracranial bleeding rates between CDT plus anticoagulation versus anticoagulation alone.

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Compliance With Guidelines Not Linked To Outcomes in Traumatic Brain Injury

Aaron J. Dawes, MD Fellow, VA/RWJF Clinical Scholars Program Division of Health Services Research, University of California Los Angeles Los Angeles, CA 90024MedicalResearch.com Interview with:
Aaron J. Dawes, MD
Fellow, VA/RWJF Clinical Scholars Program
Division of Health Services Research, University of California Los Angeles
Los Angeles, CA 90024

Medical Research: What is the background for this study? What are the main findings?

Dr. Dawes: In the fall of 2013, we formed the Los Angeles County Trauma Consortium, building upon a prior administrative relationship between LA County’s 14 trauma centers. We added health research researchers from UCLA and USC, and shifted the focus of the group from logistical issues to quality improvement. As a first project, our hospitals wanted to know if there was any variation in how traumatic brain injury patients are cared for across the county. Traumatic brain injury accounts for over 1/3 of all injury-related deaths in the U.S. and is the number one reason for ambulance transport to a trauma center in LA County.

When we looked at the data, we found widespread variation in both how these patients were cared for at different hospitals and what happened to them as a result of that care. After adjusting for important differences in patient mix, we found that mortality rates varied by hospital from roughly 25% to 55%. As we tried to explain this variation, we looked into how often hospitals complied with two evidence-based guidelines from the Brain Trauma Foundation, hoping that we could eventually develop an intervention to boost compliance with these recommended care practices. While compliance rates varied even more widely than mortality—from 10 to 65% for intracranial pressure monitoring and 7 to 76% for craniotomy—they did not appear to be associated with risk-adjusted mortality rates. Put simply, we found no connection between how often hospitals complied with the guidelines and how likely their patients were to survive.

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Surgeons Need To Document Why Patient Care May Fall Outside Standard Guidelines

Judy A. Tjoe, MD, FACS Breast Oncology Surgeon Aurora Health Care Milwaukee, WIMedicalResearch.com Interview with:
Judy A. Tjoe, MD, FACS
Breast Oncology Surgeon
Aurora Health Care
Milwaukee, WI

Medical Research: What is the background for this study? What are the main findings?

Dr. Tjoe: Numerous national health organizations have confirmed minimally invasive breast biopsy (MIBB), which uses a percutaneous core needle as opposed to open surgical techniques, as the biopsy procedure of choice when a patient’s diagnostic test reveals a breast lesion suggestive of malignancy. Unfortunately, despite the overwhelming evidence supporting use of MIBB, open breast biopsy rates in the United States remain as high as 24-39%. Our study was designed to determine if measuring individual practice patterns and providing subsequent feedback to surgeons across a large, multihospital healthcare system would improve their adherence to the quality metric of using minimally invasive breast biopsy to diagnose indeterminate breast lesions.

We found that the proportion of studied surgeons (n=46) appropriately adhering to the MIBB quality metric in every instance (i.e. those who achieved 100% adherence) significantly improved from 80.4% to 95.7% (p=0.0196) after receiving feedback on not only their own practice patterns, but those of their blinded peers. As might be expected, the handful of breast-dedicated surgeons (n=4) who cared for nearly half of the analyzed patient population achieved perfect adherence throughout the study, but interestingly, the gains made in total adherence were driven by the general surgeons (n=42), showing that the study’s direct educational efforts were effective in changing practice patterns for the better. These efforts included sending letters describing adherence to the quality metric to individual surgeons and organizational leadership. Continue reading

Residents Participation In Neurosurgery Did Not 30-Day Outcomes

Judy Huang, M.D. Professor of Neurosurgery Program Director, Neurosurgery Residency Program Fellowship Director, Cerebrovascular Neurosurgery Johns Hopkins HospitalMedicalResearch.com Interview with:
Judy Huang, M.D.
Professor of Neurosurgery
Program Director, Neurosurgery Residency Program
Fellowship Director, Cerebrovascular Neurosurgery
Johns Hopkins Hospital

Medical Research: What is the background for this study? What are the main findings?

Dr. Huang: Residents are medical school graduates who are in training programs working alongside and under supervision of more senior physicians, known as attendings. Patients are sometimes wary of having residents assist in their operations, but an analysis of 16,098 brain and spine surgeries performed across the United States finds that resident participation does not raise patient risks for postoperative complications or death.

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Public Outcomes Reporting Linked To Risk Aversion Of Sicker Patients

MedicalResearch.com Interview with:
Stephen W. Waldo, MD
Research Fellow in Medicine
Massachusetts General Hospital

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Waldo: Public reporting is intended to improve outcomes for our patients.  Proponents of public reporting applaud the increased transparency that it offers, allowing both patients and physicians to objectively evaluate health care outcomes for a given institution or individual provider.  Previous research has demonstrated, however, that public reporting of procedural outcomes may create disincentives to provide percutaneous coronary intervention for critically ill patients.  The present study sought to evaluate the association between public reporting of outcomes with procedural management and clinical outcomes among patients with acute myocardial infarction.  As the data demonstrate, public reporting of outcomes is associated with a lower rate of percutaneous revascularization and increased overall in-hospital mortality among patients with an acute myocardial infarction, particularly among those that do not receive percutaneous intervention.  This may reflect risk aversion among physicians in states that participate in public reporting, an unintended consequence of this policy.

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‘Leadership Saves Lives’ Program Aims To Reduce Heart Attack Mortality

Dr. Leslie CurryMedicalResearch.com Interview with:
Leslie Curry PhD, MPH
Senior Research Scientist in and Lecturer in Public Health (Health Policy)
Co-Director, Robert Wood Johnson Clinical Scholars Program
Yale School of Public Health

Medical Research: What is the background for this study? What are the main findings?

Dr. Curry: Quality of care for patients with acute myocardial infarction (AMI) has improved substantially in recent years due to important investments by clinicians and policymakers; however, survival rates across U.S. Hospitals still differ greatly. Evidence suggests links between hospital organizational culture and hospital performance in care of patients with AMI. Yet few studies have attempted to shift organizational culture in order to improve performance, fewer have focused on patient outcomes, and none have addressed mortality for patients with acute myocardial infarction.  We sought to address this gap through a novel longitudinal intervention study, Leadership Saves Lives (LSL). We have a large team of people with backgrounds in nursing, medicine, health care administration and research working in 10 very diverse hospitals across the country in 10 states. All hospitals are members of the Mayo Clinic Care Network and are fully committed to saving lives of patients with heart attacks. Teams of 10-12 clinicians and administrators are devoting substantial energy, expertise and good will to this project.

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Nightcall PCI Procedures Don’t Affect Cardiologists’ Daytime Outcomes

Herbert Aronow, MDMedicalResearch.com Interview with:
Herbert D. Aronow, MD, MPH, FACC, FSCAI, FSVM
Governor, American College of Cardiology (ACC) – Michigan Chapter
Chair, ACC Peripheral Vascular Disease Section
Trustee, Society for Vascular Medicine

Medical Research: What is the background for this study? What are the main findings?

Dr. Aronow: Psychomotor and cognitive performance may be impaired by sleep deprivation.  Interventional cardiologists perform emergent, middle-of-the-night procedures, and may be sleep-deprived as a consequence.  Whether performance of middle-of-the-night percutaneous coronary intervention (PCI) procedures impacts outcomes associated with PCI procedures performed the following day is not known.  Continue reading

Fragmented Post-Surgical Care Leads To Worse Outcomes For Elderly Patients

Thomas C. Tsai, MD, MPH Departments of Surgery and Health Policy and Management Harvard School of Public Health, Boston, Massachusetts MedicalResearch.com Interview with:
Thomas C. Tsai, MD, MPH

Departments of Surgery and Health Policy and Management
Harvard School of Public Health, Boston, Massachusetts

Medical Research: What is the background for this study? What are the main findings?

Dr. Tsai: Emerging evidence is suggesting that fragmented care is associated with higher costs and lower quality. For elderly patients undergoing major surgical procedures, fragmentation of care in the post-discharge period may be especially problematic. We therefore hypothesized that elderly patients receiving fragmented post-discharge care would have worse outcomes. We found that among Medicare patients who are readmitted after a major surgical operation, one in four are readmitted to a different hospital than the one where the original operation was performed. Even taking distance traveled into account, we find that this type of postsurgical care fragmentation is associated with a substantially higher risk of death.

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Sepsis: Hospital Case Volume and Outcomes

Allan J. Walkey, M.D., M.Sc Boston University School of Medicine Pulmonary Center Boston, MassachusettsMedicalResearch.com Interview with:
Allan J. Walkey, M.D., M.Sc
Boston University School of Medicine
Pulmonary Center
Boston, Massachusetts

MedicalResearch.com: What are the main findings of the study?

Dr. Walkey: Thank you for the interest in our study.  Current evidence-based treatments for severe sepsis (ie, infection+systemic inflammatory response+ end organ dysfunction) include specific processes of care rather specific therapeutics.  These processes include early administration of antibiotics, early fluid resuscitation, and lung protective ventilation strategies.  We hypothesized that hospitals with more ‘practice’ at treating patients with severe sepsis may have more effective care processes leading to improved patient outcomes.  We examined more than 15,000 severe sepsis admissions from 124 US academic medical centers. Our findings supported our hypothesis. After adjustment for patient severity of illness and hospital characteristics, mortality in the highest quartile severe sepsis case volume hospitals was 22% and  mortality in lowest severe sepsis case volume hospitals was 29%.  The 7% absolute mortality difference would result in an estimated number needed to treat in high severe sepsis volume hospitals to prevent one death in low case volume hospitals of 14 (though we advise caution in interpretation of a number needed to treat in an observational study). Costs and length of stay were not different across levels of severe sepsis case volume.  Results were robust to multiple subgroup and sensitivity analyses.

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Cardiac Surgery: How Do Short Vacation Breaks by Surgeons Affect Patient Outcomes?

Marco D. Huesch, MBBS, Ph.D., Assistant professor at the USC Sol Price School of Public Policy Adjunct professor with Duke’s School of Medicine and Fuqua School of Business.MedicalResearch.com Interview with:
Marco D. Huesch, MBBS, Ph.D.
Assistant professor at the USC Sol Price School of Public Policy
Adjunct professor with Duke’s School of Medicine and Fuqua School of Business.

MedicalResearch.com: What are the main findings of the study?

Answer: This study asked whether ‘learning by doing’ works backwards too, as ‘forgetting by not doing’. In an nutshell, the answer is ‘no’ among the Californian cardiac surgeons I examined with short breaks of around a month.
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