Steroid hormone-inducible biosensor based on EGFP-tagged and environmental application.

Steroid hormones as a class of emerging organic pollutant and high concern, due to their potential risks for human and environmental. Accurate analytical methods of steroid hormones are necessary in quantifying and monitoring. Biosensor is a promising technique. In this study, though part of 3α-HSD DNA to construct a regulatory plasmid and with the EGFP reporter gene to generate a reporter plasmid. Separately transformed into Escherichia coli strain BL21 and extracted the cell lysates as novel biosensor reagents. Analyzed the total amounts of steroid hormones in water, sediment, and soil samples using biosensor reagents, and compared these results with those obtained by HPLC. In summary, detection method using an EGFP reporter that can detect trace amounts of steroid hormones to reached fg/L. The optimal reaction time range and temperature were 30 min and 30 °C, respectively, while the most suitable organic solvent for the steroid hormone was 100% ethanol, up to 96-well plate format. This method is very suitable for high-throughput detection of environmental steroid hormone pollutants.

Scientometric analysis and scientific trends on microplastics research.

In recent years, the environmental pollution of microplastics has attracted much attention. To date, there have been a lot of researches on microplastics and a series of studies published. In this study, by bibliometric analysis method to evaluated the development and evolution on microplastics research trends and hot spots. A total of 2872 literature information was collected from the Web of Science (2004-2020), which was used for bibliometric visual analysis by CiteSpace. It was possible to see the contributing countries, institutions, authors, keywords, and future study directions in the microplastics sectors by looking at the visual representation of the results. (1) Since 2004, scientific advancements in this sector have advanced significantly, with a significant increase in speed since 2012. (2) China and the United States are the world's leading researchers in microplastics. (3) The study of microplastics was multidisciplinary, comprising researchers from the fields of ecology, chemistry, molecular biology, environmental science, and oceanography. (4) In recent years, researchers have concentrated their attention on the distribution and toxicity of microplastics in the environment, as well as their coupled pollution with heavy metal contaminants. In conclusion microplastics study in environmental science has become increasingly popular in recent years. Topics include dispersion, toxicity, and coupled pollution with heavy metal pollutants. Researchers in a wide range of fields are involved in microplastics research. Furthermore, policies and regulations about microplastics in global were summarized, and membrane technology has potential to remove microplastics from water. The above findings help to clearly grasp the content and development trend of microplastics research, point out the future research direction for scholars, and promote microplastics research and pollution prevention and control.

Effects of saline-alkali stress on bacterial and fungal community diversity in Leymus chinensis rhizosphere soil.

The salinization of grassland in arid and semi-arid areas is a serious environmental issue in China. Halophytes show extreme salt tolerance and are grown in saline-alkaline environments. Their rhizosphere microorganisms contribute significantly to plant stress tolerance. To study bacterial and fungal community structure changes in Chinese ryegrass (Leymus chinensis) rhizosphere soil under salt and alkali stress, pot experiments were conducted with different salt and alkali stress intensities. High-throughput sequencing was conducted, and the microbial diversity, community structure, and driving factors were analyzed in rhizosphere soil. The salinization of grassland in arid and semi-arid areas is a serious environmental issue in China. Halophytes show extreme salt tolerance and grow in saline-alkaline environments. A total of 549 species of bacteria from 28 phyla and 250 species from 11 phyla of fungi were detected in the rhizosphere soil of Leymus chinensis with different saline-alkali gradients. Alpha diversity analysis along saline-alkali gradients showed that bacterial community richness and diversity were the highest in the moderate saline-alkali group (pH = 8.28, EC = 160.4 µS·cm-1), while fungi had high richness and diversity in the control group (pH = 7.35, EC = 134.5 µS·cm-1). The bacteriophyta Proteobacteria, Acidobacteria, Plantomycetes, and the eumycota Ascomycota, Basidiomycota, and Glomeromycota were found with relative abundances of more than 10%. Saline-alkali gradients had significant effects on the abundance of the bacterial and fungal groups in the rhizosphere. The distribution of bacterial colony structure was not significant at the species level (P > 0.05). However, there were significant differences in the distribution of fungal structure and considerable differences in the composition of fungal species among the moderate saline-alkali group, severe saline-alkali group, and control group (P < 0.05). Correlation analysis showed that the bacterial phylum Gemmatimonadetes had a highly significant positive correlation with pH and EC (P < 0. 01). Saline-alkali stress significantly inhibited the abundance of the bacteria Latescibacteria, Cyanobacteria, and Bacteroides, and the fungi Zoopagomycota, Mortierllomycota, and Cryptomycota (P < 0. 05). Compared with fungi, bacterial community composition was most closely correlated with soil salinization. This report provided new insights into the responses of relationships between rhizosphere soil microorganisms and salt and alkali tolerance of plants.

A predictive score for progression of COVID-19 in hospitalized persons: a cohort study.

Accurate prediction of the risk of progression of coronavirus disease (COVID-19) is needed at the time of hospitalization. Logistic regression analyses are used to interrogate clinical and laboratory co-variates from every hospital admission from an area of 2 million people with sporadic cases. From a total of 98 subjects, 3 were severe COVID-19 on admission. From the remaining subjects, 24 developed severe/critical symptoms. The predictive model includes four co-variates: age (>60 years; odds ratio [OR] = 12 [2.3, 62]); blood oxygen saturation (<97%; OR = 10.4 [2.04, 53]); C-reactive protein (>5.75 mg/L; OR = 9.3 [1.5, 58]); and prothrombin time (>12.3 s; OR = 6.7 [1.1, 41]). Cutoff value is two factors, and the sensitivity and specificity are 96% and 78% respectively. The area under the receiver-operator characteristic curve is 0.937. This model is suitable in predicting which unselected newly hospitalized persons are at-risk to develop severe/critical COVID-19.

Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates.

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices' successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

Effect of SARS-CoV-2 Infection on the Microbial Composition of Upper Airway.

METHODS: Forty-four COVID-19 patients (severe/critical: N = 8, non-severe: N = 36) were examined by next generation sequencing (NGS) of nasopharyngeal test paper to observe the effect of novel coronavirus infection to the microbial composition in upper airway. RESULTS: In these nasopharyngeal test paper samples, 38 kinds of bacteria, 10 kinds of viruses except SARS-CoV-2, nine kinds of fungi and three kinds of atypical pathogens had been found. There was some difference in microbial composition in the upper airway between severe and non-severe cases. SUMMARY: These results are important for us to study the effect of SARS-CoV-2 on the local microbial composition of upper airway and prevent opportunistic infection in severe patients.

Impact of Risk Adjustment Using Clinical vs Administrative Data on Hospital Sepsis Mortality Comparisons.

BACKGROUND: A reliable risk-adjusted sepsis outcome measure could complement current national process metrics by identifying outlier hospitals and catalyzing additional improvements in care. However, it is unclear whether integrating clinical data into risk adjustment models identifies similar high- and low-performing hospitals compared with administrative data alone, which are simpler to acquire and analyze. METHODS: We ranked 200 US hospitals by their Centers for Disease Control and Prevention Adult Sepsis Event (ASE) mortality rates and assessed how rankings changed after applying (1) an administrative risk adjustment model incorporating demographics, comorbidities, and codes for severe illness and (2) an integrated clinical and administrative model replacing severity-of-illness codes with laboratory results, vasopressors, and mechanical ventilation. We assessed agreement between hospitals' risk-adjusted ASE mortality rates when ranked into quartiles using weighted kappa statistics (к). RESULTS: The cohort included 4 009 631 hospitalizations, of which 245 808 met ASE criteria. Risk-adjustment had a large effect on rankings: 22/50 hospitals (44%) in the worst quartile using crude mortality rates shifted into better quartiles after administrative risk adjustment, and a further 21/50 (42%) of hospitals in the worst quartile using administrative risk adjustment shifted to better quartiles after incorporating clinical data. Conversely, 14/50 (28%) hospitals in the best quartile using administrative risk adjustment shifted to worse quartiles with clinical data. Overall agreement between hospital quartile rankings when risk-adjusted using administrative vs clinical data was moderate (к = 0.55). CONCLUSIONS: Incorporating clinical data into risk adjustment substantially changes rankings of hospitals' sepsis mortality rates compared with using administrative data alone. Comprehensive risk adjustment using both administrative and clinical data is necessary before comparing hospitals by sepsis mortality rates.

Preliminary evidence from a multicenter prospective observational study of the safety and efficacy of chloroquine for the treatment of COVID-19.

Effective therapies are urgently needed for the SARS-CoV-2 pandemic. Chloroquine has been proved to have antiviral effect against coronavirus in vitro. In this study, we aimed to assess the efficacy and safety of chloroquine with different doses in COVID-19. In this multicenter prospective observational study, we enrolled patients older than 18 years old with confirmed SARS-CoV-2 infection excluding critical cases from 12 hospitals in Guangdong and Hubei Provinces. Eligible patients received chloroquine phosphate 500 mg, orally, once (half dose) or twice (full dose) daily. Patients treated with non-chloroquine therapy were included as historical controls. The primary endpoint is the time to undetectable viral RNA. Secondary outcomes include the proportion of patients with undetectable viral RNA by day 10 and 14, hospitalization time, duration of fever, and adverse events. A total of 197 patients completed chloroquine treatment, and 176 patients were included as historical controls. The median time to achieve an undetectable viral RNA was shorter in chloroquine than in non-chloroquine (absolute difference in medians -6.0 days; 95% CI -6.0 to -4.0). The duration of fever is shorter in chloroquine (geometric mean ratio 0.6; 95% CI 0.5 to 0.8). No serious adverse events were observed in the chloroquine group. Patients treated with half dose experienced lower rate of adverse events than with full dose. Although randomized trials are needed for further evaluation, this study provides evidence for safety and efficacy of chloroquine in COVID-19 and suggests that chloroquine can be a cost-effective therapy for combating the COVID-19 pandemic.

Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients.

Importance: Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions. Objective: To evaluate the association of establishing team-based primary care with patient health care use and costs. Design, Setting, and Participants: We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018. Exposures: Practices participated in a 4-year learning collaborative that created and supported team-based primary care. Main Outcomes and Measures: Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care. Results: Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P < .001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P = .003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P = .02). Conclusions and Relevance: While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.

Overuse and insurance plan type in a privately insured population.

OBJECTIVES: A substantial portion of healthcare spending is wasted on services that do not directly improve patient health and that cause harm in some cases. Features of health insurance coverage, including enrollment in high-deductible health plans (HDHPs) or health maintenance organizations (HMOs), may provide financial and nonfinancial mechanisms to potentially reduce overuse of low-value healthcare services. STUDY DESIGN: Using 2009 to 2013 administrative data from 3 large commercial insurers, we examined patient characteristics and health insurance plan types associated with overuse of 6 healthcare services identified by the Choosing Wisely campaign. METHODS: We explored associations between overuse and patient characteristics using multivariate logistic regression models, including patient age, gender, enrollment in an HMO, enrollment in an HDHP, an indicator of primary care fragmentation, and number of outpatient visits as explanatory variables. RESULTS: Measurement of services highlighted as potential overuse by the Choosing Wisely recommendations revealed low to moderate prevalence, depending on the service. HMO coverage and enrollment in HDHPs were significantly associated with differences in prevalence of all 6 services, albeit differently in terms of the direction of the effects. Primary care fragmentation was significantly associated with higher rates of overuse. CONCLUSIONS: Neither HDHPs nor HMO plans, with their closed networks and referral requirements, consistently reduced overuse, although HMO plans were never associated with higher rates of overuse. As policy makers seek levers for reducing low-value healthcare utilization, health insurance plan features may prove a valuable target, although the effect may be complicated by other factors.

Measuring overuse with electronic health records data.

OBJECTIVES: To measure overuse of low-value care using electronic health record (EHR) data and manual chart review and to evaluate whether certain low-value services are better captured using EHR data. STUDY DESIGN: We implemented algorithms to extract performance on 13 Choosing Wisely-identified healthcare services using EHR data at a large physician practice group between 2011 and 2013. METHODS: We calculated rates of overuse using automated EHR extracts. We manually reviewed the charts for 200 cases of overuse for each measure to determine if they had clinical risk factors that could explain use of the low-value service and then calculated adjusted rates of overuse. We explored trends in overuse for each low-value service in the 3-year duration using logistic regression. RESULTS: Unadjusted rates of overuse ranged from 0.2% to 92%. Automated EHR extracts and manual chart review identified explanatory risk factors for most measures, although the magnitude varied: for some measures (eg, bone densitometry exam for women younger than 65 years), manual chart review did not identify many additional risks (3.0%). In contrast, in patients who had sinus computed tomography or an antibiotic prescription for uncomplicated acute rhinosinusitis, manual chart review identified more explanatory risk factors (22.5%) than the automated EHR extract (9.5%). Adjusted rates of overuse ranged from 0.2% to 61.9%. Eight services demonstrated a statistically significant decrease in overuse over 3 years, while 1 increased significantly. CONCLUSIONS: The use of EHR data, both extracted and manually abstracted, provides an opportunity to more accurately and reliably identify overuse of low-value healthcare services.

Payer Type and Low-Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations.

OBJECTIVE: To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care. DATA SOURCES: 2009-2011 national Medicare and commercial insurance administrative data. DESIGN: We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics. METHODS: We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these. PRINCIPAL FINDINGS: Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians. CONCLUSIONS: Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.

Trends in Beverage Consumption Among Children and Adults, 2003-2014.

OBJECTIVE: This study aimed to provide the most recent national estimates for beverage consumption among children and adults in the United States. METHODS: Dietary data were collected from 18,600 children aged 2 to 19 years and from 27,652 adults aged ≥ 20 years in the 2003 to 2014 National Health and Nutrition Examination Survey. Total beverage and sugar-sweetened beverage (SSB) consumption was measured by 24-hour dietary recall. RESULTS: From 2003 to 2014, per capita consumption of all beverages declined significantly among children (473.8-312.6 calories; P < 0.001) and adults (425.0-341.1 calories; P < 0.001). In the 2013-2014 survey, 60.7% of children and 50.0% of adults drank SSBs on a given day, which is significantly lower than 2003-2004, when 79.7% of children and 61.5% of adults reported drinking SSBs. From 2003 to 2014, per capita consumption of SSBs declined from 224.6 calories to 132.5 calories (P < 0.001) for children and from 190.4 calories to 137.6 calories (P < 0.001) for adults. The absolute levels for the percentage of SSB drinkers and per capita consumption of SSBs were highest among black, Mexican American, and non-Mexican Hispanic children, adolescents, and young adults for all years of the study. CONCLUSIONS: Overall, beverage and SSB consumption declined for children and adults from 2003 to 2014. The levels of consumption are highest among black, Mexican American, and non-Mexican Hispanic participants.

End-of-Life Experience of Older Adults Dying of End-Stage Renal Disease: A Comparison With Cancer.

CONTEXT: Older adults with end-stage renal disease (ESRD) are a rapidly growing group of seriously ill patients. Yet, despite a mortality rate almost twice that of cancer, less is known about the impact of ESRD on patients' end-of-life experience. OBJECTIVE: To compare the end-of-life experience of older adults who died of ESRD vs. cancer. METHODS: We used data from the Health and Retirement Study, a nationally representative survey of older adults. Our sample included 1883 Health and Retirement Study participants who died of cancer or ESRD between 2000 and 2010 and their family respondents. We compared advance care planning, treatment intensity, and symptoms between the two groups and used propensity score weighting to adjust for differences by diagnosis. RESULTS: Among propensity-weighted cohorts, older adults with ESRD, compared with similar patients with cancer, were less likely to have end-of-life instructions (adjusted proportions 38.5% vs. 49.7%; P = 0.005) and were more likely to die in the hospital (53.5% vs. 29.0%; P < 0.001) and to use the intensive care unit in the last two years of life (57.1% vs. 37.0%; P < 0.001). Decedents with ESRD and cancer had similarly high rates of moderate or severe pain (53.7% vs. 57.8%; P = 0.34) and all other symptoms. CONCLUSION: Older adults dying of ESRD had lower rates of advance care planning and higher treatment intensity near the end of life than similar patients dying of cancer; both groups had similarly high rates of symptoms. Efforts are needed to make treatment more supportive and alleviate suffering for older adults with ESRD and their families near the end of life.

The influence of fasudil on renal proximal tubular cell epithelial-mesenchymal transition induced by parathormone.

BACKGROUND: Renal fibrosis is a common pathway through which a variety of chronic kidney diseases progress to end-stage renal disease. Epithelial-mesenchymal transition (EMT) of renal proximal tubular cells is one of the most important factors in renal fibrosis. This study investigates if fasudil could influence EMT of renal proximal tubular cells. METHODS: HK-2 cells in passage 3-4 were used for all experiments. The cells were divided into five groups and treated with different concentrations of PTH and then observe cellular morphological changes at 0, 24 and 48 h using an inverted microscope and investigate the expression of the epithelial cell marker E-cadherin and the renal fibroblast marker α-smooth muscle actin (α-SMA). RESULTS: PTH significantly induced EMT, fasudil-inhibited EMT induced by PTH to different degrees, and the inhibitory effect of fasudil was most pronounced at 20 µmol/L. CONCLUSION: Monitoring PTH levels, early prevention and control of hyperparathyroidism and reducing the concentration of PTH are important means to improve prognosis and delay the progression of chronic kidney disease. Fasudil can restrain EMT induced by PTH; this conclusion provides experimental data for the application of fasudil in the clinical prevention and treatment of renal fibrosis.

Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes.

OBJECTIVE: To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes. METHODS: We developed and administered a management measurement instrument using structured telephone interviews with both the primary nurse and physician managers at 53 diverse hospitals across the United States. A trained interviewer scored the managers' interview responses based on management practices that ranged from most reactive (lowest scores) to most proactive (highest scores). We established instrument validity by conducting site visits among a subsample of 11 hospitals and established reliability using interrater comparison. Using a factor analysis, we identified three themes of management competencies: management of unit culture, patient flow, and nursing. We constructed patient-level regressions to assess the independent association between these management themes and maternal outcomes. RESULTS: Proactive management of unit culture and nursing was associated with a significantly higher risk of primary cesarean delivery in low-risk patients (relative risk [RR] 1.30, 95% CI 1.02-1.66 and RR 1.47, 95% CI 1.13-1.92, respectively). Proactive management of unit culture was also associated with a significantly higher risk of prolonged length of stay (RR 4.13, 95% CI 1.98-8.64), postpartum hemorrhage (RR 2.57, 95% CI 1.58-4.18), and blood transfusion (RR 1.87, 95% CI 1.12-3.13). Proactive management of patient flow and nursing was associated with a significantly lower risk of prolonged length of stay (RR 0.23, 95% CI 0.12-0.46 and RR 0.27, 95% CI 0.11-0.62, respectively). CONCLUSION: Labor and delivery unit management varies dramatically across and within hospitals in the United States. Some proactive management practices may be associated with increased risk of primary cesarean delivery and maternal morbidity. Other proactive management practices may be associated with decreased risk of prolonged length of stay, indicating a potential opportunity to safely improve labor and delivery unit efficiency.

Perception of Safety of Surgical Practice Among Operating Room Personnel From Survey Data Is Associated With All-cause 30-day Postoperative Death Rate in South Carolina.

OBJECTIVE: To evaluate whether the perception of safety of surgical practice among operating room (OR) personnel is associated with hospital-level 30-day postoperative death. BACKGROUND: The relationship between improvements in the safety of surgical practice and benefits to postoperative outcomes has not been demonstrated empirically. METHODS: As part of the Safe Surgery 2015: South Carolina initiative, a baseline survey measuring the perception of safety of surgical practice among OR personnel was completed. We evaluated the relationship between hospital-level mean item survey scores and rates of all-cause 30-day postoperative death using binomial regression. Models were controlled for multiple patient, hospital, and procedure covariates using supervised principal components regression. RESULTS: The overall survey response rate was 38.1% (1793/4707) among 31 hospitals. For every 1 point increase in the hospital-level mean score for respect [adjusted relative risk (aRR) 0.78, 95% CI 0.65-0.93, P = 0.0059], clinical leadership (aRR 0.86, 95% CI 0.74-0.9932, P = 0.0401), and assertiveness (aRR 0.71, 95% CI 0.54-0.93, P = 0.01) among all survey respondents, there were associated decreases in the hospital-level 30-day postoperative death rate after inpatient surgery ranging from 14% to 29%. Higher hospital-level mean scores for the statement, "I would feel safe being treated here as a patient," were associated with significantly lower hospital-level 30-day postoperative death rates (aRR 0.83, 95% CI 0.70-0.97, P = 0.02). Although most findings seen among all OR personnel were seen among nurses, they were often absent among surgeons. CONCLUSIONS: Perception of OR safety of surgical practice was associated with hospital-level 30-day postoperative death rates.

Relationship Between Operating Room Teamwork, Contextual Factors, and Safety Checklist Performance.

BACKGROUND: Studies show that using surgical safety checklists (SSCs) reduces complications. Many believe SSCs accomplish this by enhancing teamwork, but evidence is limited. Our study sought to relate teamwork to checklist performance, understand how they relate, and determine conditions that affect this relationship. STUDY DESIGN: Using 2 validated tools for observing and coaching operating room teams, we evaluated the association between checklist performance with surgeon buy-in and 4 domains of surgical teamwork: clinical leadership, communication, coordination, and respect. Hospital staff in 10 South Carolina hospitals observed 207 procedures between April 2011 and January 2013. We calculated levels of checklist performance, buy-in, and measures of teamwork, and evaluated their relationship, controlling for patient and case characteristics. RESULTS: Few teams completed most or all SSC items. Teams more often completed items considered procedural "checks" than conversation "prompts." Surgeon buy-in, clinical leadership, communication, a summary measure of teamwork overall, and observers' teamwork ratings positively related to overall checklist completion (multivariable model estimates from 0.04, p < 0.05 for communication to 0.17, p < 0.01 for surgeon buy-in). All measures of teamwork and surgeon buy-in related positively to completing more conversation prompts; none related significantly to procedural checks (estimates from 0.10, p < 0.01 for communication to 0.27, p < 0.001 for surgeon buy-in). Patient age was significantly associated with completing the checklist and prompts (p < 0.05); only case duration was positively associated with performing more checks (p < 0.10). CONCLUSIONS: Surgeon buy-in and surgical teamwork characterized by shared clinical leadership, open communication, active coordination, and mutual respect were critical in prompting case-related conversations, but not in completing procedural checks. Findings highlight the importance of surgeon engagement and high-quality, consistent teamwork for promoting checklist use and ensuring a safe surgical environment.

Impact of the Cincinnati Aligning Forces for Quality Multi-Payer Patient Centered Medical Home Pilot on Health Care Quality, Utilization, and Costs.

To evaluate the potential for a patient-centered medical home initiative to reduce utilization and cost while improving quality, we examined a natural experiment involving 11 primary care practices in Cincinnati, Ohio, that participated in the Aligning Forces for Quality Multi-Payer Patient Centered Medical Home pilot. Our research design involved difference-in-difference analyses, comparing changes in utilization, costs, and quality between patients attributed to pilot practices compared with those attributed to a matched comparison cohort after 2 years of active engagement by the practices. The Cincinnati pilot was associated with a reduction of ambulatory care-sensitive emergency department visits of approximately 0.7 per 1,000 member months or approximately 22.6% (p = .01). While there was a reduction in total costs of care of $7,679 per 1,000 member months, the difference did not reach statistical significance. After 2 years of the pilot, lipid testing in diabetics had increased by 2.7 percentage points (a 3.3% improvement; p < .0001). Patient-centered medical homes have the potential to improve the quality of care and reduce emergency department use but expectations for cost control in a relatively short time horizon and absent other changes may be unrealistic.