What Should "Shopping" Look Like in Actual Practice?

In health care, lack of transparency about the cost of health care services to patients during clinical encounters has contributed to increased costs and high out-of-pocket expenses. Federal policy has responded to the need for more transparency and spurred discussion about ethics and the clinician's role in being transparent with patients at the point of service. This article investigates and encourages state, private market, and federal policy efforts to address what health care costs patients. This article also applies the ethical framework of principlism to cases and considers what a "shoppable service" model would demand of clinicians in practice.

U.S. medical school admissions and enrollment practices: status of LGBTQ inclusivity.

CONTEXT: The failure to collect information on lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity in healthcare and medical education is a part of a systemic problem that limits academic medical institutions' ability to address LGBTQ health disparities. OBJECTIVES: To determine whether accurate sexual and gender minority (SGM) demographic data is being consistently collected for all US medical schools during admissions and enrollment, and whether differences exist between collection practices at osteopathic and allopathic schools. METHODS: Secure, confidential electronic were sent via email in July 2019 to 180 osteopathic (n=42) and allopathic (n=138) medical schools identified through the American Association of Colleges of Osteopathic Medicine Student Guide to Osteopathic Medical Colleges database and the American Association of Medical Colleges Medical School Admissions Requirements database. The nine question survey remained open through October 2019 and queried for; (1) the ability of students to self report SGM status during admissions and enrollment; and (2) availability of SGM specific resources and support services for students. Chi square analysis and the test for equality of proportions were performed. RESULTS: Seventy five of 180 (41.7%) programs responded to the survey; 74 provided at least partial data. Of the 75 respondent schools, 55 (73.3%) allowed applicants to self report a gender identity other than male or female, with 49 (87.5%) of those being allopathic schools compared with 6 (31.6%) osteopathic schools. Similarly, 15 (20.0%) allowed applicants to report sexual orientation, with 14 (25.5%) of those being allopathic schools compared with one (5.3%) osteopathic school. Fifty four of 74 (73.0%) programs allowed matriculants to self report a gender identity other than male or female; 11 of 74 (14.7%) allowed matriculants to report sexual orientation. CONCLUSIONS: Demographics collection practices among American medical education programs that responded to our survey indicated that they undervalued sexual orientation and gender identity, with osteopathic programs being less likely than allopathic programs to report inclusive best practices in several areas. American medical education programs, and their supervising bodies, must update their practices with respect to the collection of sexual orientation and gender identity demographics as part of a holistic effort to address SGM health disparities.

A Call for LGBTQ Content in Graduate Medical Education Program Requirements.

A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health-related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.

Changes in health insurance coverage, access to care, and health services utilization by sexual minority status in the United States, 2013-2018.

OBJECTIVE: To examine the changes in health insurance coverage, access to care, and health services utilization among nonelderly sexual minority and heterosexual adults between pooled years 2013-2014 and 2017-2018. DATA SOURCES: Data on 3223 sexual minorities (lesbians, gay men, bisexual individuals, and other nonheterosexual populations) and 86 181 heterosexuals aged 18-64 years were obtained from the 2013, 2014, 2017, and 2018 National Health Interview Surveys. STUDY DESIGN: Unadjusted and regression-adjusted estimates compared changes in health insurance status, access to care, and health services utilization for nonelderly adults by sexual minority status. Regression-adjusted changes were obtained from logistic regression models controlling for demographic and socioeconomic characteristics. PRINCIPAL FINDINGS: Uninsurance declined for both sexual minority adults (5 percentage points, P < .05) and heterosexual adults (2.5 percentage points, P < .001) between 2013-2014 and 2017-2018. Reductions in uninsurance for sexual minority and heterosexual adults were associated with increases in Medicaid coverage. Sexual minority and heterosexual adults were also less likely to report unmet medical care in 2017-2018 compared with 2013-2014. Low-income adults (regardless of sexual minority status) experienced relatively large increases in Medicaid coverage and substantial improvements in access to care over the study period. The gains in coverage and access to care across the study period were generally similar for heterosexual and sexual minority adults. CONCLUSIONS: Sexual minority and heterosexual adults have experienced improvements in health insurance coverage and access to care in recent years. Ongoing health equity research and public health initiatives should continue to monitor health care access and the potential benefits of recent health insurance expansions by sexual orientation and sexual minority status when possible.

Patient satisfaction survey scores are not an appropriate metric to differentiate performance among anesthesiologists.

STUDY OBJECTIVE: With the focus of patient-centered care in healthcare organizations, patient satisfaction plays an increasingly important role in healthcare quality measurement. We sought to determine whether an automated patient satisfaction survey could be effectively used to identify outlying anesthesiologists. DESIGN: Retrospective Observational Study. SETTING: Vanderbilt University Medical Center (VUMC). MEASUREMENTS: Patient satisfaction data were obtained between October 24, 2016 and November 1, 2017. A multivariable ordered probit regression was conducted to evaluate the relationship between the mean scores of responses to Likert-scale questions on SurveyVitals' Anesthesia Patient Satisfaction Questionnaire 2. Fixed effects included demographics, clinical variables, providers and surgeons. Hypothesis tests to compare each individual anesthesiologist with the median-performing anesthesiologist were conducted. MAIN RESULTS: We analyzed 10,528 surveys, with a 49.5% overall response rate. Younger patient (odds ratio (OR) 1.011 [per year of age]; 95% confidence interval (CI) 1.008 to 1.014; p < 0.001), regional anesthesia (versus general anesthesia) (OR 1.695; 95% CI 1.186 to 2.422; p = 0.004) and daytime surgery (versus nighttime surgery) (OR 1.795; 95% CI 1.091 to 2.959; p = 0.035) were associated with higher satisfaction scores. Compared with the median-ranked anesthesiologist, we found the adjusted odds ratio for an increase in satisfaction score ranged from 0.346 (95% CI 0.158 to 0.762) to 1.649 (95% CI 0.687 to 3.956) for the lowest and highest scoring providers, respectively. Only 10.10% of anesthesiologists at our institution had an odds ratio for satisfaction with a 95% CI not inclusive of 1. CONCLUSIONS: Patient satisfaction is impacted by multiple factors. There was very little information in patient satisfaction scores to discriminate the providers, after adjusting for confounding. While patient satisfaction scores may facilitate identification of extreme outliers among anesthesiologists, there is no evidence that this metric is useful for the routine evaluation of individual provider performance.

Price Transparency: Empowering Patient Choice and Promoting Provider Competition.

In light of recent health policy efforts to promote price transparency, this perspective reviews the challenges and benefits of price transparency. These price transparency efforts include the recent executive order and associated rulemaking directing providers to disclose negotiated and out-of-pocket costs for "shoppable" healthcare services. First, we explore the previous efforts of states and health plans targeted at price transparency, reviewing lessons for future implementation. Second, we address the value of price transparency in light of various policy concerns and objections. Finally, we jointly hypothesize potential effects of and opportunities presented by price transparency for patients, physicians, and other healthcare industry stakeholders.

A Model for Improving Health Care Quality for Transgender and Gender Nonconforming Patients.

PROBLEM DEFINITION: Transgender and gender nonconforming (TGNC) populations are disproportionately affected by limited health care access and poor health outcomes and commonly report discrimination and mistreatment in health care settings. Despite these disparities, comprehensive approaches to improve the quality of health care of TGNC patient populations are currently lacking. INITIAL APPROACH: The Vanderbilt Program for LGBTQ Health has developed a multifaceted, community-engaged approach to improve the quality of health care of TGNC patients, which includes the creation of a transgender patient advocacy program, a community advisory board, and a transgender health clinic. To support the continuous quality improvement of transgender health care, the program is currently piloting a novel multilevel monitoring and evaluation (M&E) system to collect information at the individual patient visit and health systems levels. NEXT STEPS: The next steps for Vanderbilt's community-engaged M&E system are to identify the clinics and health services most used by TGNC patients and assess the level of patient satisfaction in each area. This process will support the identification of high- and low-performing clinics and health services and allow for targeted delivery of trainings to improve the quality of culturally competent health care TGNC patients receive systemwide. CONCLUSION: In collaboration with TGNC patient populations and community stakeholders, Vanderbilt has created a model to improve the quality of both transition- and non-transition-related health care at the systems level that can be adopted by other health care systems nationally.

Trans-specific Geriatric Health Assessment (TGHA): An inclusive clinical guideline for the geriatric transgender patient in a primary care setting.

There is a growing concern in the field of geriatric medicine that transgender health is often overlooked and under-reported. Not only does this impact the health and safety of the aging transgender community, but it also often influences the ability of physicians to provide high-quality evidence-based care. This article reviews the current knowledge base for geriatric transgender health and aims to organize evidence-based clinical recommendations for the primary care provider. Our proposed guideline, the Trans-specific Geriatric Health Assessment (TGHA), highlights areas of current clinical practice that do not address the geriatric transgender experience and modifies them to include trans-specific clinical recommendations found in the literature. The TGHA emphasizes topics such as cognitive function, vision and hearing, gait and stability, nutrition, sleep, functional/social status, urogenital health, psychiatric health, hormone replacement therapy, cancer screening, disease prevention and advanced care planning. Our review also addresses the limitations of certain clinical topics and where there is significant need for supportive research.

Machine Learning Can Improve Estimation of Surgical Case Duration: A Pilot Study.

Operating room (OR) utilization is a significant determinant of hospital profitability. One aspect of this is surgical scheduling, which depends on accurate predictions of case duration. This has been done historically by either the surgeon based on personal experience, or by an electronic health record (EHR) based on averaged historical means for case duration. Here, we compare the predicted case duration (pCD) accuracy of a novel machine-learning algorithm over a 3-month period. A proprietary machine learning algorithm was applied utilizing operating room factors such as patient demographic data, pre-surgical milestones, and hospital logistics and compared to that of a conventional EHR. Actual case duration and pCD (Leap Rail vs EHR) was obtained at one institution over the span of 3 months. Actual case duration was defined as time between patient entry into an OR and time of exit. pCD was defined as case time allotted by either Leap Rail or EHR. Cases where Leap Rail was unable to generate a pCD were excluded. A total of 1059 surgical cases were performed during the study period, with 990 cases being eligible for the study. Over all sub-specialties, Leap Rail showed a 7 min improvement in absolute difference between pCD and actual case duration when compared to conventional EHR (p < 0.0001). In aggregate, the Leap Rail method resulted in a 70% reduction in overall scheduling inaccuracy. Machine-learning algorithms are a promising method of increasing pCD accuracy and represent one means of improving OR planning and efficiency.

Feasibility Assessment of a Pre-Hospital Automated Sensing Clinical Documentation System.

Clinical documentation in the pre-hospital setting is challenged by limited resources and fast-paced, high-acuity. Military and civilian medics are responsible for performing procedures and treatments to stabilize the patient, while transporting the injured to a trauma facility. Upon arrival, medics typically give a verbal report from memory or informal source of documentation such as a glove or piece of tape. The development of an automated documentation system would increase the accuracy and amount of information that is relayed to the receiving physicians. This paper discusses the 12-week deployment of an Automated Sensing Clinical Documentation (ASCD) system among the Nashville Fire Department EMS paramedics. The paper examines the data collection methods, operational challenges, and perceptions surrounding real-life deployment of the system. Our preliminary results suggest that the ASCD system is feasible for use in the pre-hospital setting, and it revealed several barriers and their solutions.

Validation of a Sequential Organ Failure Assessment Score using Electronic Health Record Data.

The sequential organ failure assessment (SOFA) score is a scoring system commonly used in critical care to assess severity of illness. Automated calculation of the SOFA score using existing electronic health record data would broaden its applicability. We performed a manual validation of an automated SOFA score previously developed at our institution. A retrospective analysis of a random subset of 300 patients from a previously published randomized trial of critically ill adults was performed, with manual validation of SOFA scores from the date of initial intensive care unit admission. Spearman's rank correlation coefficient, weighted Cohen's kappa, and Bland-Altman plots were used to assess agreement between manual and electronic versions of SOFA scores and between manual and electronic versions of their individual components. There was high agreement between manual and electronic SOFA scores (Spearman's rank correlation coefficient = 0.90, 95% CI 0.87-0.93). Renal and respiratory components had lower agreement (weighted Cohen's kappa = 0.63, 95% CI 0.53-0.73 for renal; weighted Cohen's kappa = 0.77, 95% CI 0.70-0.84 for respiratory). The area under the receiver operating characteristic curve (AUC) for 30-day in-hospital mortality was 0.77 (95% CI 0.68-0.84) for manual SOFA scores and 0.75 (95% CI 0.66-0.83) for automated SOFA scores. Automatic calculation of SOFA scores from the electronic health record is feasible and correlates highly with manually calculated SOFA scores. Both have similar predictive value for 30-day in-hospital mortality.

Decision Support Tool Improves Real and Perceived Anesthesiology Resident Relief Equity.

BACKGROUND: The Accreditation Council of Graduate Medical Education requires monitoring of resident clinical and educational hours but does not require tracking daily work patterns or duty hour equity. Lack of such monitoring may allow for inequity that affects resident morale. No defined system for resident relief of weekday operating room (OR) clinical duties existed at our institution, leaving on-call residents to independently decide daily relief order. We developed an automated decision support tool (DST) to improve equitable decision making for clinical relief and assessed its impact on real and perceived relief equity. METHODS: The DST sent a daily e-mail to the senior resident responsible for relief decisions. It contained a prioritized relief list of noncall residents who worked in the OR beyond 5 PM the prior clinical day. We assessed actual relief equity using the number of times a resident worked in the OR past 5:30 PM on 2 consecutive weekdays as our outcome, adjusting for the mean number of open ORs each day between 5:00 PM and 6:59 PM in our main OR areas. We analyzed 14 months of data before implementation and 16 months of data after implementation. We assessed perceived relief equity before and after implementation using a questionnaire. RESULTS: After implementing the DST, the percentage of residents held 2 consecutive weekdays over the total of resident days worked decreased from 1.33% to 0.43%. The percentage of residents held beyond 5:30 PM on any given day decreased from 18.09% to 12.64%. Segmented regression analysis indicated that implementation of the DST was associated with a reduction in biweekly time series of residents kept late 2 days in a row, independent of the mean number of ORs in use. Surveyed residents reported the DST aided their ability to make equitable relief decisions (pre 60% versus post 94%; P = .0003). Eighty-five percent of residents strongly agreed that a prioritized relief list based on prior day work hours after 5 PM aided their decision making. After implementation, residents reported fewer instances of working past 5 PM within the past month (P < .005). CONCLUSIONS: A DST systematizing the relief process for anesthesiology residents was associated with a lower frequency of residents working beyond 5:30 PM in the OR on 2 consecutive days. The DST improved the perceived ability to make equitable relief decisions by on-call senior residents and residents being relieved. Success with this tool allows for broader applications in resident education, enabling enhanced monitoring of resident experiences and support for OR assignment decisions.

The Association between State Policy Environments and Self-Rated Health Disparities for Sexual Minorities in the United States.

A large body of research has documented disparities in health and access to care for lesbian, gay, and bisexual (LGB) people in the United States. Less research has examined how the level of legal protection afforded to LGB people (the state policy environment) affects health disparities for sexual minorities. This study used data on 14,687 sexual minority adults and 490,071 heterosexual adults from the 2014⁻2016 Behavioral Risk Factor Surveillance System to document differences in health. Unadjusted state-specific prevalence estimates and multivariable logistic regression models were used to compare poor/fair self-rated health by gender, sexual minority status, and state policy environments (comprehensive versus limited protections for LGB people). We found disparities in self-rated health between sexual minority adults and heterosexual adults in most states. On average, sexual minority men in states with limited protections and sexual minority women in states with either comprehensive or limited protections were more likely to report poor/fair self-rated health compared to their heterosexual counterparts. This study adds new findings on the association between state policy environments and self-rated health for sexual minorities and suggests differences in this relationship by gender. The associations and impacts of state-specific policies affecting LGB populations may vary by gender, as well as other intersectional identities.

Sources of Variation in Anesthetic Drug Costs.

BACKGROUND: Increasing attention has been focused on health care expenditures, which include anesthetic-related drug costs. Using data from 2 large academic medical centers, we sought to identify significant contributors to anesthetic drug cost variation. METHODS: Using anesthesia information management systems, we calculated volatile and intravenous drug costs for 8 types of inpatient surgical procedures performed from July 1, 2009, to December 31, 2011. For each case, we determined patient age, American Society of Anesthesiologists (ASA) physical status, gender, institution, case duration, in-room provider, and attending anesthesiologist. These variables were then entered into 2 fixed-effects linear regression models, both with logarithmically transformed case cost as the outcome variable. The first model included duration, attending anesthesiologist, patient age, ASA physical status, and patient gender as independent variables. The second model included case type, institution, patient age, ASA physical status, and patient gender as independent variables. When all variables were entered into 1 model, redundancy analyses showed that case type was highly correlated (R = 0.92) with the other variables in the model. More specifically, a model that included case type was no better at predicting cost than a model without the variable, as long as that model contained the combination of attending anesthesiologist and case duration. Therefore, because we were interested in determining the effect both variables had on cost, 2 models were created instead of 1. The average change in cost resulting from each variable compared to the average cost of the reference category was calculated by first exponentiating the ß coefficient and subtracting 1 to get the percent difference in cost. We then multiplied that value by the mean cost of the associated reference group. RESULTS: A total of 5504 records were identified, of which 4856 were analyzed. The median anesthetic drug cost was $38.45 (25th percentile = $23.23, 75th percentile = $63.82). The majority of the variation was not described by our models-35.2% was explained in the model containing case duration, and 32.3% was explained in the model containing case type. However, the largest sources of variation our models identified were attending anesthesiologist, case type, and procedure duration. With all else held constant, the average change in cost between attending anesthesiologists ranged from a cost decrease of $41.25 to a cost increase of $95.67 (10th percentile = -$19.96, 90th percentile = +$20.20) when compared to the provider with the median value for mean cost per case. The average change in cost between institutions was significant but minor ($5.73). CONCLUSIONS: The majority of the variation was not described by the models, possibly indicating high per-case random variation. The largest sources of variation identified by our models included attending anesthesiologist, procedure type, and case duration. The difference in cost between institutions was statistically significant but was minor. While many prior studies have found significant savings resulting from cost-reducing interventions, our findings suggest that because the overall cost of anesthetic drugs was small, the savings resulting from interventions focused on the clinical practice of attending anesthesiologists may be negligible, especially in institutions where access to more expensive drugs is already limited. Thus, cost-saving efforts may be better focused elsewhere.

Tracheostomy risk factors and outcomes after severe traumatic brain injury.

OBJECTIVE: To determine risk factors associated with tracheostomy placement after severe traumatic brain injury (TBI) and subsequent outcomes among those who did and did not receive a tracheostomy. METHODS: This retrospective cohort study compared adult trauma patients with severe TBI (n = 583) who did and did not receive tracheostomy. A multivariable logistic regression model assessed the associations between age, sex, race, insurance status, admission GCS, AIS (Head, Face, Chest) and tracheostomy placement. Ordinal logistic regression models assessed tracheostomy's influence on ventilator days and ICU LOS. To limit immortal time bias, Cox proportional hazards models assessed mortality at 1, 3 and 12-months. RESULTS: In this multivariable model, younger age and private insurance were associated with increased probability of tracheostomy. AIS, ISS, GCS, race and sex were not risk factors for tracheostomy placement. Age showed a non-linear relationship with tracheostomy placement; likelihood peaked in the fourth decade and declined with age. Compared to uninsured patients, privately insured patients had an increased probability of receiving a tracheostomy (OR = 1.89 [95% CI = 1.09-3.23]). Mortality was higher in those without tracheostomy placement (HR = 4.92 [95% CI = 3.49-6.93]). Abbreviated injury scale-Head was an independent factor for time to death (HR = 2.53 [95% CI = 2.00-3.19]), but age, gender and insurance were not. CONCLUSIONS: Age and insurance status are independently associated with tracheostomy placement, but not with mortality after severe TBI. Tracheostomy placement is associated with increased survival after severe TBI.

Electronically Mediated Time-out Initiative to Reduce the Incidence of Wrong Surgery: An Interventional Observational Study.

BACKGROUND: "Wrong surgery" is defined as wrong site, wrong operation, or wrong patient, with estimated incidence up to 1 per 5,000 cases. Responding to national attention on wrong surgery, our objective was to create a care redesign intervention to minimize the rate of wrong surgery. METHODS: The authors created an electronic system using existing intraoperative electronic documentation to present a time-out checklist on large in-room displays. Time-out was dynamically interposed as a forced-function documentation step between "patient-in-operating room" and "incision." Time to complete documentation was obtained from audit logs. The authors measured the postimplementation wrong surgery rate and used Bayesian methods to compare the pre- and postimplementation rates at our institution. Previous probabilities were selected using wrong surgery rate estimates from the observed performance reported in the literature to generate previous probabilities (4.24 wrong surgeries per 100,000 cases). RESULTS: No documentation times exceeded 5 min; 97% of documentation tasks were completed within 2 min. The authors performed 243,939 operations over 5 yr using the system, with zero wrong surgeries, compared with 253,838 operations over 6 yr with two wrong surgeries before implementation. Bayesian analysis suggests an 84% probability that the postimplementation wrong rate is lower than baseline. However, given the rarity of wrong surgery in our sample, there is substantial uncertainty. The total system-development cost was $34,000, roughly half the published cost of one weighted median settlement for wrong surgery. CONCLUSION: Implementation of a forced-completion electronically mediated time-out process before incision is feasible, but it is unclear whether true performance improvements occur.

A perioperative consult service results in reduction in cost and length of stay for colorectal surgical patients: evidence from a healthcare redesign project.

BACKGROUND: A major restructuring of perioperative care delivery is required to reduce cost while improving patient outcomes. In a test implementation of this notion, we developed and implemented a perioperative consult service (PCS) for colorectal surgery patients. METHODS: A 6-month planning process was undertaken to engage key stakeholders from surgery, nursing, and anesthesia in a healthcare redesign project that resulted in the creation of a PCS to implement a coordinated clinical pathway. After Institutional Review Board (IRB) approval, data were collected for all elective colorectal procedures for three phases: phase 0 (pre-implementation; 1/2014-6/2014), phase 1 (7/2014-10/2014), and phase 2 (11/2014-10/2015). Length of stay (primary endpoint; LOS), total hospital cost, use of clinical pathway components, markers of functional recovery, and readmission and reoperation rates were analyzed. Outcomes and patient characteristics among phases were compared by two-tailed t tests and Wilcoxon rank-sum tests. Categorical variables were analyzed by chi-square and Fisher's exact tests. RESULTS: We studied 544 patients (phase 0 = 179; phase 1 = 124; phase 2 = 241), with 365 consecutive patients being cared for in the redesigned care structure. Median LOS was reduced and sustained after implementation (phase 0, 4.24 days; phase 1, 3.32 days; phase 2, 3.32 days, P < 0.01 phase 0 v. phases 1 and 2), and mean LOS was reduced in phase 2 (phase 0, 5.26 days; phase 1, 4.93 days; phase 2, 4.36 days, P < 0.01 phase 0 v. phase 2). Total hospital cost was reduced by 17 % (P = 0.05, median). Application of clinical pathway components was higher in phases 1 and 2 compared to phase 0 (P < 0.01 for all components except anti-emetics); measures of functional recovery improved with successive phases. Reoperation and 30-day readmission rates were no different in phase 1 or phase 2 compared to phase 0 (P > 0.15). CONCLUSIONS: Restructuring of perioperative care delivery through the launch of a PCS-reduced LOS and total cost in a significant and sustainable fashion for colorectal surgery patients. Based on the success of this care redesign project, hospital administration is funding expansion to additional services.