Patient-specific Predictors of Surgical Delay in a Large Tertiary-care Hospital Operating Room.

PURPOSE: The purpose of this study was to describe patient-specific factors predictive of surgical delay in elective surgical cases. DESIGN: Retrospective cohort study. METHODS: Data were extracted retrospectively from the electronic health record of 32,818 patients who underwent surgery at a large academic hospital in Los Angeles between May 2012 and April 2017. Following bivariate analysis of patient-specific factors and surgical delay, statistically significant predictors were entered into a logistic regression model to determine the most significant predictors of surgical delay. FINDINGS: Predictors of delay included having monitored anesthesia care (odds ratio [OR], 1.28; 95% confidence intervals [CI], 1.20-1.36), American Society of Anesthesiologist class 3 or above (OR, 1.21; 95% CI, 1.15-1.28), African American race (OR, 1.25; 95% CI, 1.12-1.39), renal failure (OR, 1.20; 95% CI, 1.09-1.32), steroid medication (OR, 1.13; 95% CI, 1.04-1.23) and Medicaid (OR,1.18; 95%CI, 1.09-1.30) or medicare insurance (OR, 1.14; 95% CI, 1.07-1.21). Six surgical specialties also increased the odds of delay. Obesity and cardiovascular anesthesia decreased the odds of delay. CONCLUSIONS: Certain patient-specific factors including type of insurance, health status, and race were associated with surgical delay. Whereas monitored anesthesia care anesthesia was predictive of a delay, cardiovascular anesthesia reduced the odds of delay. Additionally, obese patients were less likely to experience a delay. While the electronic health record provided a large amount of detailed information, barriers existed to accessing meaningful data.

Cost analysis of removing pediatric ureteral stents with and without a retrieval string.

BACKGROUND: Indwelling ureteral stents are commonly placed in urologic surgeries where optimal urinary drainage is necessary. In the pediatric population, removing a stent without retrieval string (SWOS) requires a secondary operation and additional anesthetic exposure. Although these burdens can be mitigated through the placement of a stent with retrieval string (SWS), fears of complications may prevent widespread adoption of this practice by pediatric urologists. OBJECTIVE: The authors sought to assess the differential cost of removing SWS and SWOS. It was hypothesized that costs associated with removing SWS are significantly lower than those associated with removing SWOS, without increasing complications. STUDY DESIGN: A retrospective chart review was performed on pediatric patients undergoing common urologic surgeries with concurrent stent placement at a single tertiary referral center. Charges and healthcare costs surrounding the removal of ureteral stents were evaluated using the institution-specific ratio of cost to charges, by estimating lost wages, and by exploring differences in poststent healthcare-related events that incur additional cost. RESULTS: A total of 109 patients with a median age of 5 years (range: 6 months-20 years) were reviewed. A total of 29 patients had SWS, and 80 had SWOS. The theoretical cost of SWS removal in clinic was $400.48 compared with $2290.86 ± $119.30 for operative removal of SWOS, with mean difference of $1890.38 (P < 0.01). The mean stent duration of SWOS was 34.0 ± 13.2 days vs. 10.1 ± 4.9 days for SWS (P < 0.01). Subgroup analysis of the ureteral reconstruction group showed no difference in any complications (35% vs 27%, respectively), early dislodgment (7% vs 7%, respectively) or costly healthcare utilization (23% vs 20%, respectively) among patients with SWOS compared with those with SWS. In SWS group with early dislodgment, neither required a secondary procedure. DISCUSSION: With rising healthcare expenditures, physicians must be able to provide cost-effective treatment while not compromising safety or outcomes. Unlike prior analyses of cost related to the type of the stent used, the present study specifically reviewed costs of removing SWS versus SWOS and evaluated rates of costly complications. The study findings provide a preliminary basis for advocating the more economical use of SWS when indicated. Lack of power and heterogeneity of the groups need to be addressed in future analyses with larger, matched cohorts. CONCLUSION: Removal of SWS is more cost-effective than that of SWOS while maintaining similar safety outcomes and should be considered in certain pediatric urology cases to decrease healthcare cost. SWS should be preferred for uncomplicated ureteroscopy, but benefits are less certain in ureteral reconstruction; further studies are needed.

Patient Portal Usage in Pediatric Urology: Is it Meaningful Use for Everyone?

INTRODUCTION: The Affordable Care Act promotes multiple directives for meaningful use of the Electronic Health Record, such as patient/provider portals, to increase patient engagement. Although portal use is common within adult healthcare, little information exists regarding pediatric portal use. We examined pediatric urology patient portal enrollment and activation patterns at a tertiary pediatric hospital in Southern California by race/ethnicity, preferred language, gender, and residential region. METHODS: Retrospective Electronic Health Record analysis of enrollment in patient portal from January 2010 to May 2016 among 10,464 patients with at least one outpatient urology clinic visit. Differences in adoption rates were examined using logistic regression for the following categories: activated (or caregiver activated); code accepted not activated; declined; or activated/then deactivated. RESULTS: Overall, 46.5% of patients/caregivers activated the portal. Primarily Spanish-speaking patients were less likely to activate (OR 0.25, p <.001) than English-speaking patients. Males (OR 0.89, p =.004); those self-identifying racially as Other (not White, Asian, or African American) (OR 0.47, p <.001); and Hispanic patients (OR 0.49, p <.001) were less likely to activate. Suburban patients were up to 3 times more likely to activate portals than central urban patients depending on the region (OR 2.94, p <.001). Multivariate logistic regression demonstrated Spanish-speaking patients were 3 times less likely to activate while controlling for demographic and region variables. CONCLUSIONS: Primary language and socioeconomic factors may be significant barriers to portal adoption. Patient education to reduce these barriers may increase portal acceptance and increase meaningfulness to the portal for patients/parents and providers.

Community Health Workers and Use of mHealth: Improving Identification of Pregnancy Complications and Access to Care in the Dominican Republic.

This article presents the feasibility and acceptability of using mobile health technology by community health workers (CHWs) in San Juan Province, Dominican Republic, to improve identification of pregnancy complications and access to care for pregnant women. Although most women in the Dominican Republic receive four antenatal care visits, poor women and adolescents in remote areas are more likely to have only one initial prenatal visit to verify the pregnancy. This community-based research began when community leaders raised concern about the numbers of their mothers who died in childbirth annually; San Juan's maternal mortality rate is 144/100,000 compared to the Caribbean rate of 85/100,000. Eight CHWs in three communities were taught to provide third-trimester antenatal assessment, upload the data on a mobile phone application, send the data to the local physician who monitored data for "red flags," and call directly if a mother had an urgent problem. Fifty-two pregnant women enrolled, 38 were followed to delivery, 95 antenatal care postintake were provided, 2 urgent complications required CHW home management of mothers, and there were 0 deaths. Stakeholders endorsed acceptability of intervention. Preliminary data suggest CHWs using mobile health technology is feasible, linking underserved and formal health care systems with provision of primary care in mothers' homes.

Predictors of Readiness for Hospital Discharge After Birth: Building Evidence for Practice.

BACKGROUND: Preparation for hospital discharge after birth became a global concern when hospitals in many developing countries began implementing shorter lengths of stay for uncomplicated deliveries. A mother's perceived readiness for hospital discharge may be influenced by many factors that can ultimately shape postdischarge outcomes. AIMS: The purpose of this study was to explore the antepartum, intrapartum, and postpartum predictors of discharge readiness, including nursing educational practices that are predictive of postpartum mothers' perceptions of readiness for hospital discharge. METHODS: The Adaptation to Transitions conceptual framework guided the descriptive correlational study design and measures. A purposive sample of 185 English- and Spanish-speaking postpartum mothers who experienced an uneventful vaginal or cesarean birth of a healthy infant completed demographic, quality of discharge teaching, and readiness for hospital discharge questionnaires prior to discharge. RESULTS: Mothers with three or more children, delivery mode, bottle-feeding, the delivery of education, and the difference between educational content received and needed, were significant predictors that accounted for 42% of the variance in readiness for hospital discharge (R2 = 0.42, F[10,174] = 14.52, p < .001). Nurses' skill in teaching and educational content received were significant predictors even with parity, feeding, and delivery mode in the model. LINKING EVIDENCE TO ACTION: The relationship between quality of discharge teaching and discharge readiness provides evidence of the critical role nurses have in the discharge preparation process. Nurse education programs and evidence-based guidelines should be designed to enhance patient education focused on the adequacy and delivery of teaching content.