Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model.

BACKGROUND: Laborist practice models are associated with lower rates of cesarean delivery than individual private practice models in several studies; however, this effect is not uniform. Further exploration of laborist models may help us better understand the observed decrease in rates of cesarean delivery in some hospitals that implement a laborist model. OBJECTIVE: Our objective was to evaluate the degree of variation in rates of primary cesarean delivery by individual laborists within a single institution that uses a laborist model. In addition, we sought to evaluate whether differences in rates of cesarean delivery resulted in different maternal or short-term neonatal outcomes. STUDY DESIGN: At this teaching institution, one laborist (either a generalist or maternal-fetal medicine attending physician) is directly responsible for labor and delivery management during each shift. No patients are followed in a private practice model nor are physicians incentivized to perform deliveries. We retrospectively identified all laborists who delivered nulliparous, term women with cephalic singletons at this institution from 2007 to 2014. Overall and individual primary cesarean delivery rates were reported as percentages with exact Pearson 95% confidence intervals. Laborists were grouped by tertile as having low, medium, or high rates of cesarean delivery. Characteristics of the women delivered, indications for cesarean delivery, and short-term neonatal outcomes were compared between these groups. A binomial regression model of cesarean delivery was estimated, where the relative rates of each laborist compared with the lowest-unadjusted laborist rate were calculated; a second model was estimated to adjust for patient-level maternal characteristics. RESULTS: Twenty laborists delivered 2224 nulliparous, term women with cephalic singletons. The overall cesarean delivery rate was 24.1% (95% confidence interval 21.4-26.8). In an unadjusted binomial model, the overall effect of individual laborist was significant (P < .001), and a 2.9-fold (1.5-5.4, P = .001) variation between the cesarean delivery rates of the greatest (35.9%) and lowest (12.5%) physicians was observed. When adjusted for hypertensive disease, gestational age at delivery, race, and maternal age, the physician effect remained overall significant (P = .0265) with the difference between physicians expanding to 3.58 (1.72-7.47, P <. 001). Between groups of laborists with low, medium, and high rates of cesarean delivery, patient demographics and clinical characteristics of the population managed were clinically similar and not different statistically. The primary indication for cesarean delivery did not differ between groups. Similarly there were no differences in short-term neonatal outcomes, including Apgar scores, arterial cord blood pH, or the incidence of neonatal encephalopathy. CONCLUSION: The 3-fold variation in cesarean delivery rates between laborists at the same institution without observed differences in patient characteristics or short-term neonatal outcomes draws attention to the impact of individual physician decision-making on cesarean delivery rates even within a laborist care model. Further exploration of the role of individual physician decision-making on cesarean rates may help to better elucidate the effect of the laborist model.

Intentions for risk-reducing surgery among high-risk women referred for BRCA1/BRCA2 genetic counseling.

OBJECTIVE: Genetic testing for breast and ovarian cancer susceptibility is now part of routine clinical practice. Although rates of risk-reducing surgery following genetic testing have been increasing, little is known about attitudes toward risk-reducing surgery in women prior to genetic counseling and testing. This study examines correlates of patient intentions to undergo risk-reducing mastectomy (RRM) and risk-reducing oophorectomy (RRO). METHODS: Participants were 696 women, ages 21-85, who sought breast cancer gene 1 and 2 (BRCA1/2) genetic counseling and had at least a 10% risk of carrying a mutation. The sample included women who were affected with breast or ovarian cancer and unaffected women with a known familial BRCA1/2 mutation. Participants completed a precounseling telephone questionnaire. RESULTS: Prior to receiving genetic counseling, 23.3% of participants were considering RRM and 42.5% were considering RRO. Variables that were independently associated with RRM intentions were cancer-specific distress (OR = 1.14, 95% CI = 1.03-1.26), perceived risk of breast cancer (OR = 1.16, 95% CI = 1.05-1.28), education (OR = 1.76, 95% CI = 1.03-2.99), and age (OR = 0.96, 95% CI = 0.95-0.98). Predictors of RRO intentions were perceived risk for ovarian cancer (OR = 1.25, 95% CI = 1.14-1.37), perceived risk of carrying a BRCA1/2 mutation (OR = 1.74, 95% CI = 1.15-2.62), marital status (OR = 1.92, 95% CI = 1.34-2.76), and age (OR = 1.02, 95% CI = 1.00-1.03). CONCLUSIONS: Because precounseling intentions predict subsequent risk-reducing surgery decisions, this study identified patient factors associated with surgical intentions. These factors reinforce the critical role for pretest genetic counseling in communicating accurate risk estimates and management options, and addressing psychosocial concerns, to facilitate informed decision making regarding RRM and RRO.

The influence of a Vascular Surgery Hospitalist program on physician and patient satisfaction, resident education, and resource utilization.

A number of surgery practice models have been developed to address general and trauma surgeon workforce shortages and on-call issues and to improve surgeon satisfaction. These include the creation of acute or urgent care surgery services and "surgical hospitalist" programs. To date, no practice models corresponding to those developed for general and trauma surgeons have been proposed to address these same issues among vascular surgeons or other surgical subspecialists. In 2003, our practice established a Vascular Surgery Hospitalist program. Since its inception nearly a decade ago, it has undergone several modifications. We reviewed hospital administrative databases and surveys of faculty, residents, and patients to evaluate the program's impact. Benefits of the Vascular Surgery Hospitalist program include improved surgeon satisfaction, resource utilization, timeliness of patient care, communication among referring physicians and ancillary staff, and resident teaching/supervision. Elements of this program may be applicable to a variety of surgical subspecialty settings.

Real-time patient experience surveys of hospitalized medical patients.

BACKGROUND: Real-time feedback about patients' perceptions of the quality of the care they are receiving could provide physicians the opportunity to address concerns and improve these perceptions as they occur, but physicians rarely if ever receive feedback from patients in real time. OBJECTIVE: To evaluate if real-time patient feedback to physicians improves patient experience. DESIGN: Prospective, randomized, quality-improvement initiative. SETTING: University-affiliated, public safety net hospital. PARTICIPANTS: Patients and hospitalist physicians on general internal medicine units. INTERVENTION: Real-time daily patient feedback to providers along with provider coaching and revisits of patients not reporting optimal satisfaction with their care. MEASUREMENTS: Patient experience scores on 3 provider-specific questions from daily surveys on all patients and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and percentiles on randomly selected patients. RESULTS: Changes in HCAHPS percentile ranks were substantial (communication from doctors: 60th percentile versus 39th, courtesy and respect of doctors: 88th percentile versus 23rd, doctors listening carefully to patients: 95th percentile versus 57th, and overall hospital rating: 87th percentile versus 6th (P = 0.02 for overall differences in percentiles), but we found no statistically significant difference in the top box proportions for the daily surveys or the HCAHPS survey. The median [interquartile range] top box score for the overall hospital rating question on the HCAHPS survey was higher in the intervention group than in the control group (10 [9, 10] vs 9 [8, 10], P = 0.04). CONCLUSIONS: Real-time feedback, followed by coaching and patient revisits, seem to improve patient experience.

Randomized noninferiority trial of telephone versus in-person genetic counseling for hereditary breast and ovarian cancer.

PURPOSE: Although guidelines recommend in-person counseling before BRCA1/BRCA2 gene testing, genetic counseling is increasingly offered by telephone. As genomic testing becomes more common, evaluating alternative delivery approaches becomes increasingly salient. We tested whether telephone delivery of BRCA1/2 genetic counseling was noninferior to in-person delivery. PATIENTS AND METHODS: Participants (women age 21 to 85 years who did not have newly diagnosed or metastatic cancer and lived within a study site catchment area) were randomly assigned to usual care (UC; n = 334) or telephone counseling (TC; n = 335). UC participants received in-person pre- and post-test counseling; TC participants completed all counseling by telephone. Primary outcomes were knowledge, satisfaction, decision conflict, distress, and quality of life; secondary outcomes were equivalence of BRCA1/2 test uptake and costs of delivering TC versus UC. RESULTS: TC was noninferior to UC on all primary outcomes. At 2 weeks after pretest counseling, knowledge (d = 0.03; lower bound of 97.5% CI, -0.61), perceived stress (d = -0.12; upper bound of 97.5% CI, 0.21), and satisfaction (d = -0.16; lower bound of 97.5% CI, -0.70) had group differences and confidence intervals that did not cross their 1-point noninferiority limits. Decision conflict (d = 1.1; upper bound of 97.5% CI, 3.3) and cancer distress (d = -1.6; upper bound of 97.5% CI, 0.27) did not cross their 4-point noninferiority limit. Results were comparable at 3 months. TC was not equivalent to UC on BRCA1/2 test uptake (UC, 90.1%; TC, 84.2%). TC yielded cost savings of $114 per patient. CONCLUSION: Genetic counseling can be effectively and efficiently delivered via telephone to increase access and decrease costs.

Long-term psychosocial outcomes of BRCA1/BRCA2 testing: differences across affected status and risk-reducing surgery choice.

BACKGROUND: Numerous studies have documented the short-term impact of BRCA1/BRCA2 (BRCA1/2) testing; however, little research has examined the long-term impact of testing. We conducted the first long-term prospective study of psychosocial outcomes in a U.S. sample of women who had BRCA1/2 testing. METHODS: Participants were 464 women who underwent genetic testing for BRCA1/2 mutations. Prior to testing, we measured sociodemographics, clinical variables, and cancer specific and general distress. At long-term follow-up (Median = 5.0 years; Range = 3.4-9.1 years), we assessed cancer-specific and genetic testing distress, perceived stress, and perceived cancer risk. We evaluated the impact of BRCA1/2 test result and risk-reducing surgery on long-term psychosocial outcomes. RESULTS: Among participants who had been affected with breast or ovarian cancer, BRCA1/2 carriers reported higher genetic testing distress (ß = 0.41, P < 0.0001), uncertainty (ß = 0.18, P < 0.0001), and perceived stress (ß = 0.17, P = 0.005) compared with women who received negative (i.e., uninformative) results. Among women unaffected with breast/ovarian cancer, BRCA1/2 carriers reported higher genetic testing distress (ß = 0.39, P < 0.0001) and lower positive testing experiences (ß = 0.25, P = 0.008) than women with negative results. Receipt of risk-reducing surgery was associated with lower perceived cancer risk (P < 0.0001). CONCLUSIONS: In this first prospective long-term study in a U.S. sample, we found modestly increased distress in BRCA1/2 carriers compared with women who received uninformative or negative test results. Despite this modest increase in distress, we found no evidence of clinically significant dysfunction. IMPACT: Although a positive BRCA1/2 result remains salient among carriers years after testing, testing does not seem to impact long-term psychologic dysfunction.