Clinicians' Perceptions of Futile or Potentially Inappropriate Care and Associations with Avoidant Behaviors and Burnout.

Background: Futile or potentially inappropriate care (futile/PIC) for dying inpatients leads to negative outcomes for patients and clinicians. In the setting of rising end-of-life health care costs and increasing physician burnout, it is important to understand the causes of futile/PIC, how it impacts on care and relates to burnout. Objectives: Examine causes of futile/PIC, determine whether clinicians report compensatory or avoidant behaviors as a result of such care and assess whether these behaviors are associated with burnout. Design: Online, cross-sectional questionnaire. Setting/Subjects: Clinicians at two academic hospitals in New York City. Methods: Respondents were asked the frequency with which they observed or provided futile/PIC and whether they demonstrated compensatory or avoidant behaviors as a result. A validated screen was used to assess burnout. Measurements: Descriptive statistics, odds ratios, linear regressions. Results: Surveys were completed by 349 subjects. A majority of clinicians (91.3%) felt they had provided or "possibly" provided futile/PIC in the past six months. The most frequent reason cited for PIC (61.0%) was the insistence of the patient's family. Both witnessing and providing PIC were statistically significantly (p < 0.05) associated with compensatory and avoidant behaviors, but more strongly associated with avoidant behaviors. Provision of PIC increased the likelihood of avoiding the patient's loved ones by a factor of 2.40 (1.82-3.19), avoiding the patient by a factor of 1.83 (1.32-2.55), and avoiding colleagues by a factor of 2.56 (1.57-4.20) (all p < 0.001). Avoiding the patient's loved ones (ß = 0.55, SE = 0.12, p < 0.001), avoiding the patient (ß = 0.38, SE = 0.17; p = 0.03), and avoiding colleagues (ß = 0.78, SE = 0.28; p = 0.01) were significantly associated with burnout. Conclusions: Futile/PIC, provided or observed, is associated with avoidance of patients, families, and colleagues and those behaviors are associated with burnout.

Association of Perceived Futile or Potentially Inappropriate Care With Burnout and Thoughts of Quitting Among Health-Care Providers.

BACKGROUND: Futile or potentially inappropriate care (futile/PIC) has been suggested as a factor contributing to clinician well-being; however, little is known about this association. OBJECTIVE: To determine whether futile/PIC provision is associated with measures of clinician well-being. DESIGN: Cross-sectional, self-administered, online questionnaire. SETTING: Two New York City Hospitals. PARTICIPANTS: Attending physicians, residents, nurses, and physician assistants in the fields of internal medicine, surgery, neurology, or intensive care. EXPOSURE(S): Provision of perceived futile/PIC. MEASUREMENTS: Main outcomes included (1) clinician burnout, measured using the Physician Worklife Study screen; (2) clinician depression, measured using the Patient Health Questionnaire; and (3) intention to quit, measured using questions assessing thoughts of quitting and how seriously it is being considered. RESULTS: Of 1784 clinicians who received surveys, 349 participated. Across all clinicians, 91% reported that they either had or had possibly provided futile/PIC to a patient. Overall, 43.4% of clinicians screened positive for burnout syndrome, 7.8% screened positive for depression, and 35.5% reported thoughts of leaving their job as a result of futile/PIC. The amount of perceived futile/PIC provided was associated with burnout (odds ratio [OR] 3.8 [16-30 patients vs 1-2 patients]; 95% confidence interval [CI]: 1.1-12.8) and having thoughts of quitting (OR, 7.4 [16-30 patients vs 1-2 patients]; 95% CI: 2.0-27), independent of depression, position, department, and the number of dying patients cared for. CONCLUSIONS: A large majority of clinicians report providing futile/PIC, and such care is associated with measures of clinician well-being, including burnout and intention to quit.

Defining the Learning Curve for Hip Arthroscopy: A Threshold Analysis of the Volume-Outcomes Relationship.

BACKGROUND: Hip arthroscopy has emerged as a successful option for the treatment of femoroacetabular impingement and related hip disorders, but the procedure is technically challenging. PURPOSE: To define the learning curve through which surgeons become proficient at hip arthroscopy. STUDY DESIGN: Cohort study; level of evidence, 3. METHODS: The authors identified hip arthroscopy procedures performed by surgeons through a New York State database (Statewide Planning and Research Cooperative System) and followed those cases for additional hip surgery (total hip arthroplasty, hip resurfacing, or ipsilateral hip arthroscopy) within 5 years of the original procedure. Career volume for each case was calculated as the number of hip arthroscopy procedures that the surgeon had performed. Volume strata were identified via the stratum-specific likelihood ratio method. A Cox proportional hazards model was used to measure the effect of surgeon career volume on risk of additional hip surgery, adjusting for the following patient characteristics: age, sex, race/ethnicity, insurance type, and concurrent diagnosis of hip osteoarthritis. RESULTS: Among 8041 hip arthroscopies performed by 251 surgeons, 989 (12.3%) cases underwent additional hip surgery within 5 years. Four strata of surgeon career volume associated with distinct frequencies of reoperation were identified: cases in the lowest stratum (0-97) had the highest frequency of additional surgery (15.4%). Frequencies declined for cases in the medium (98-388), high (389-518), and highest (≥519) strata (13.8%, 10.1%, and 2.6%, respectively). There was an increased risk of subsequent surgery in each stratum when compared with the highest stratum (hazard ratio [95% CI]: low volume, 3.22 [2.29-4.54]; medium, 3.40 [2.41-4.82]; high, 2.81 [1.86-4.25]; P < .0001 for all). Patients with a diagnosis of hip osteoarthritis had increased risk of subsequent hip arthroplasty or resurfacing (2.46 [2.09-2.89], P < .0001) . Risk also increased with age: 30 to 39 vs ≤29 years (5.12 [3.29-8.00], P < .0001), 40 to 49 vs ≤29 years (11.30 [7.43-17.190], P < .0001), ≥50 vs ≤29 years (18.39 [12.10-27.96], P < .0001). Increased age and osteoarthritis were not risk factors for revision hip arthroscopy. CONCLUSION: The learning curve for hip arthroscopy was unexpectedly demanding. Cases performed by surgeons with career volumes ≥519 had significantly lower risk of subsequent hip surgery than those performed by lower-volume surgeons.

Risk of failure of primary hip arthroscopy-a population-based study.

The aims of this study are (i) to report on the rates of subsequent surgery following hip arthroscopy and (ii) to identify prognostic variables associated with revision surgery, survival rates and complication rates. The Statewide Planning and Research Cooperative System database, a census of hospital admissions and ambulatory surgery in New York State, was used to identify cases of primary hip arthroscopy. Demographic information and rates of subsequent revision hip arthroscopy or arthroplasty were collected. The risks were modeled with use of age, sex, procedure and surgeon volume as risk factors. Survival analyses were also performed, and 30-day complication was recorded. We identified 8267 procedures in 7836 patients from 1998 to 2012. Revision surgery occurred in 1087 cases (13.2%) at a mean of 1.7 ± 1.6 (mean ± SD) years. Revision arthroscopy accounted for 311 cases (3.8%), and arthroplasty for 796 (9.7%) cases. Survival analysis showed a 2-year survival rate of 88.1%, 5-year of 80.7% and 10-year of 74.9%. Regression analysis revealed that age >50 years [hazard ratio (HR) 2.09; confidence interval (CI) 1.82-2.39, P < 0.01] and a diagnosis of osteoarthritis (HR 2.72; CI 2.21-3.34, P < 0.01) were associated with increased risk of re-operation. Labral repair was associated with a lower risk of re-operation (HR 0.71; CI 0.54-0.93, P = 0.01). Finally, higher surgeon volume (>164 cases/year) resulted in a lower risk of re-operation versus lower volume (<102 cases/year) (HR 0.42; CI 0.32-0.54, P < 0.01). The 30-day complication rate was 0.2%. Older age and pre-existing osteoarthritis increased the likelihood of re-operation following hip arthroscopy, whereas performing a labral repair and having the procedure performed by a higher-volume surgeon lowered the risk of re-operation.

Nutrition Quality of US School Snack Foods: A First Look at 2011-2014 Bid Records in 8 School Districts.

BACKGROUND: As part of the Healthy, Hunger-Free Kids Act, snacks, and desserts sold in K-12 schools as of the 2014-2015 school year are required to meet the "Smart Snacks" nutritional guidelines. Although studies exist in tracking progress in local and national efforts, the proportion of snack food procured by school districts compliant with the Smart Snacks standard prior to its full implementation is unknown. METHODS: We repurposed a previously untapped database, Interflex, of public bid records to examine the nutritional quality of snacks and desserts procured by school districts. We selected 8 school districts with at least 90% complete data each year during 2011-2012, 2012-2013, and 2013-2014 school years and at locations across different regions of the United States. We quantified the amount of calories and sugar of each product contained in the won bids based on available online sources and determined whether the produce complied with Smart Snack guidelines. RESULTS: In all 8 districts (snack expenditure analyzed ranging from $152,000 to $4.4 million), at least 50% of snack bids were compliant with the US Department of Agriculture Smart Snacks standard during the 2013-2014 school year. Across sampled districts, we observed a general trend in lower caloric density (kcal per product) and sugar density (grams of sugar per product) over a 3-year period. CONCLUSIONS: Many districts across the country have made headway in complying with the Smart Snack guidelines, though gaps remain.