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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