An Integrated Process for Co-Developing and Implementing Written and Computable Clinical Practice Guidelines.

The goal of this article is to describe an integrated parallel process for the co-development of written and computable clinical practice guidelines (CPGs) to accelerate adoption and increase the impact of guideline recommendations in clinical practice. From February 2018 through December 2021, interdisciplinary work groups were formed after an initial Kaizen event and using expert consensus and available literature, produced a 12-phase integrated process (IP). The IP includes activities, resources, and iterative feedback loops for developing, implementing, disseminating, communicating, and evaluating CPGs. The IP incorporates guideline standards and informatics practices and clarifies how informaticians, implementers, health communicators, evaluators, and clinicians can help guideline developers throughout the development and implementation cycle to effectively co-develop written and computable guidelines. More efficient processes are essential to create actionable CPGs, disseminate and communicate recommendations to clinical end users, and evaluate CPG performance. Pilot testing is underway to determine how this IP expedites the implementation of CPGs into clinical practice and improves guideline uptake and health outcomes.

Surgical Episodes of Care for Price Transparency Using the Episode Grouper for Medicare.

OBJECTIVE: To explore the use of an episode grouper to more accurately identify the complete set of surgical services typically provided in a surgical episode of care and the corresponding range of prices, using colectomy for cancer as the example. BACKGROUND: Price transparency is an important policy issue that will require surgeons to better understand the components and cost of care. METHODS: This study uses the Episode Grouper for Medicare business logic to construct colectomy surgical episodes of care for cancer using Medicare claims data for the Boston Hospital Referral Region from 2012 to 2015. Descriptive statistics show the mean reimbursement based on patient severity and stage of surgery, along with the number of unique clinicians billing for care and the mix of services provided. RESULTS: The Episode Grouper for Medicare episode grouper identified 3182 colectomies in Boston between 2012 and 2015, with 1607 done for cancer. The mean Medicare allowed amount per case is $29,954 and varies from $26,605 to $36,850 as you move from low to high-severity cases. The intrafacility stage is the most expensive ($23,175 on average) compared with the pre ($780) and post ($6,479) facility stages. There is tremendous heterogeneity in the service mix. CONCLUSIONS: Episode groupers are a potentially valuable tool for identifying variations in service mix and teaming patterns that correlate with a total price. By looking at patient care holistically, stakeholders can identify opportunities for price transparency and care redesign that have heretofore been hidden.

Trauma system funding: implications for the surgeon health policy advocate.

BACKGROUND: Trauma systems improve mortality for the most severely injured patients; however, these systems are managed by individual states with different funding mechanisms, which can lead to inconsistencies in the quality of care. This study compiles trauma system legislation and regulations of funding sources and creates a trauma funding categorization system. Such data help to inform the systems of trauma care delivery within and between states. METHODS: Online searches of state statutes were performed to establish the presence of legislative code to establish a trauma system, the presence of legislative code that funds these trauma systems, and the amount of funding that was allocated to each state's trauma system in fiscal year 2016 to 2017. Following this, each state's trauma system was contacted via email and telephone to further obtain this information. RESULTS: Specific state legislation creating a trauma system was identified in 48 states (96%). Data for categorization of trauma system funding were obtained in 30 states (60%). Of these 30 states, 29 have legislation funding their trauma systems. 17 states funded their trauma systems through general appropriations legislation, 10 states used percentages of fines from criminal and misdemeanor offenses, and 7 states used fees and taxes. New York state does not have any specific funding legislation. Individual state financial contributions to state trauma systems ranged from $55 000 to $25 899 450, annually. DISCUSSION: There is a limited amount of trauma system funding details available, and among these there is wide variation of funding source types and amounts allotted toward trauma systems. It is difficult to obtain and summate legislative information for use for surgical health policy advocacy efforts. Further study and method development to disseminate comprehensive and comparative legislative and regulatory data and information to physicians and other trauma system stakeholders are needed. LEVEL OF EVIDENCE: III, economic and valued-based evaluation; analyses based on limited alternatives and costs; poor estimates.

The American College of Surgeons Response to the COVID-19 Pandemic (Part II) : Advocacy and Public Policy.

From the onset of the COVID-19 global pandemic of 2020, the American College of Surgeons (ACS) has been a leader in disseminating credible information on the clinical and scientific aspects of the disease. As governmental regulations enforced the closure of hospitals and operating rooms to elective surgical cases as part of its "shelter-in-place" public lockdown policies, the ACS brought specialty societies together to create guidelines to protect patients and preserve surgical quality. Federal agencies made available financial aid programs to mitigate the economic impact of the outbreak. The division of advocacy and health policy of the ACS made certain that the interests of surgeons and their patients were served. Steven Wexner, member of the Board of Regents of the ACS interviewed the medical directors of the division, Frank Opelka in quality and health policy, and Patrick Bailey in advocacy, for their stories of how the College responded to the many health and public policy issues that came before Congress and governmental agencies during the pandemic.

Association of Patient-reported Experiences and Surgical Outcomes Among Group Practices: Retrospective Cohort Study.

OBJECTIVE: The aim of the study was to determine the association of patient-reported experiences (PREs) and risk-adjusted surgical outcomes among group practices. BACKGROUND: The Centers for Medicare and Medicaid Services required large group practices to submit PREs data for successful participation in the Physician Quality Reporting System (PQRS) using the Consumer Assessment of Healthcare Providers and Systems for PQRS survey. Whether these PREs data correlate with perioperative outcomes remains ill defined. METHODS: Operations between January 1, 2014 and December 31, 2016 in the American College of Surgeons' National Surgical Quality Improvement Program registry were merged with 2015 Consumer Assessment of Healthcare Providers and Systems for PQRS survey data. Hierarchical logistic models were constructed to estimate associations between 7 subscales and 1 composite score of PREs and 30-day morbidity, unplanned readmission, and unplanned reoperation, separately, while adjusting for patient- and procedure mix. RESULTS: Among 328 group practices identified, patients reported their experiences with clinician communication the highest (mean ±â€Šstandard deviation, 82.66 ±â€Š3.10), and with attention to medication cost the lowest (25.96 ±â€Š5.14). The mean composite score was 61.08 (±6.66). On multivariable analyses, better PREs scores regarding medication cost, between-visit communication, and the composite score of experience were each associated with 4% decreased odds of morbidity [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.92-0.99], readmission (OR 0.96, 95% CI 0.93-0.99), and reoperation (OR 0.96, 95% CI 0.93-0.99), respectively. In sensitivity analyses, better between-visit communication remained significantly associated with fewer readmissions. CONCLUSIONS: In these data, patients' report of better between-visit communication was associated with fewer readmissions. More sensitive, surgery-specific PRE assessments may reveal additional unique insights for improving the quality of surgical care.

Transitioning from Practice to Health Care Administration: The Later Years.

Since the late 1800s, the role of the physician has evolved substantially beyond mainstream clinical medicine. As fee for service models expanded in the 1980s, resulting in an unsustainable financial crisis in health care, senior physicians stepped up to provide essential input and expertise to administrators on a national level. This model of physician-administrator has evolved to include dual-degree physicians who are equipped with specialized knowledge even at the outset of their career. As physicians are now vital members of health care administration, many will feel the need to transition from clinical practice to a new position where they can effect change on a larger scale. This article will provide insight into such transitions and dual-career pathways and discuss important considerations when faced with this juncture in one's career.

Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters.

OBJECTIVE: Our objective was to determine whether abscess size can be used as a discriminating factor to guide management of patients with diverticular abscesses. MATERIALS AND METHODS: We performed a word search of our CT database between July 2001 and July 2002 for the CT diagnosis of diverticulitis. CTs were retrospectively reviewed as consensus opinion of two reviewers. CTs were evaluated for presence of an abscess, its location, maximum diameter, and feasibility of percutaneous abscess drainage. Abscesses were categorized into smaller than 3 cm and larger than or equal to 3 cm, and the management of these groups was compared. RESULTS: Thirty-one abscesses were noted in 30 (17%) of 181 patients with a CT diagnosis of diverticulitis. Twenty-two (73%) of 30 patients had 23 abscesses, all of which were smaller than 3 cm and were treated and resolved with antibiotics alone (p < 0.001). Eight (36%) of 22 required surgical treatment. Eight (26%) of 31 abscesses had a maximum diameter larger than or equal to 3 cm. Four (50%) of eight patients with abscesses 3.4-4.1 cm were treated with antibiotics alone. Four (50%) of eight abscesses, all larger than 4.1 cm, were treated with CT-guided drainage and one abscess required repeat drainage. After resolution of symptoms, surgery was performed in five (62.5%) of eight of the larger abscesses. CONCLUSION: Patients with abscesses smaller than 3 cm in size can be treated with antibiotics alone and, in some cases, as outpatients, and may not uniformly require surgery. This is also likely true for patients with abscesses 3-4 cm in size, although our results in this group were limited by a small sample size. Patients with abscesses larger than or equal to 4 cm can be managed with CT-guided abscess drainage followed by referral for surgical treatment.