Impact of Viral PCR Positive Nasal Swabs (Non Covid-19) on Outcomes Following Cardiac Surgery.

Viral bronchiolitis is a relative contraindication to elective pediatric cardiac surgery. Nasopharyngeal swab utilizing polymerase chain reaction (PCR) screening for viruses known to cause bronchiolitis are commonly available. The objective of this study was to evaluate clinical outcomes in patients with nasopharyngeal viral PCR positive findings at the time of cardiac surgery. Retrospective review from January 2013 to May 2019 for patients with virus detected by PCR on nasopharyngeal swabs at the time of cardiac surgery. Single ventricle and two ventricle patients were compared to control group of age and procedure matched patients viral negative at the time of surgery. Outcome measures included OR extubation, reintubation, hospital length of stay, and mortality. For two ventricle patients (n = 81; control group = 165), there was no statistical difference in any outcome variable (OR extubation 74% vs 72%; p = 0.9; reintubation 9% vs 11% vs; p = 0.7; hospital length of stay 5 days (1-46) vs 4 days (2-131); p = 0.4; mortality 2 vs 1; p = 0.3). For single ventricle patients, there was no statistical difference in any outcome variable (OR extubation 81% vs 76%; p = 0.6; reintubation 14% vs 21% vs; p = 0.5; hospital length of stay 9.5 days (3-116) vs 15 days (2-241); p = 0.1; mortality 0 vs 3; (p = 0.6)). PCR is a sensitive test that fails to predict which patients will proceed to have a clinically significant infection. Viral bronchiolitis remains a relative risk factor for cardiac surgery; presence of detectable virus via nasopharyngeal swab with limited clinical symptoms may not be a contraindication to cardiac surgery.

Measuring teamwork in health care settings: a review of survey instruments.

BACKGROUND: Teamwork in health care settings is widely recognized as an important factor in providing high-quality patient care. However, the behaviors that comprise effective teamwork, the organizational factors that support teamwork, and the relationship between teamwork and patient outcomes remain empirical questions in need of rigorous study. OBJECTIVE: To identify and review survey instruments used to assess dimensions of teamwork so as to facilitate high-quality research on this topic. RESEARCH DESIGN: We conducted a systematic review of articles published before September 2012 to identify survey instruments used to measure teamwork and to assess their conceptual content, psychometric validity, and relationships to outcomes of interest. We searched the ISI Web of Knowledge database, and identified relevant articles using the search terms team, teamwork, or collaboration in combination with survey, scale, measure, or questionnaire. RESULTS: We found 39 surveys that measured teamwork. Surveys assessed different dimensions of teamwork. The most commonly assessed dimensions were communication, coordination, and respect. Of the 39 surveys, 10 met all of the criteria for psychometric validity, and 14 showed significant relationships to nonself-report outcomes. CONCLUSIONS: Evidence of psychometric validity is lacking for many teamwork survey instruments. However, several psychometrically valid instruments are available. Researchers aiming to advance research on teamwork in health care should consider using or adapting one of these instruments before creating a new one. Because instruments vary considerably in the behavioral processes and emergent states of teamwork that they capture, researchers must carefully evaluate the conceptual consistency between instrument, research question, and context.

From striving to thriving: systems thinking, strategy, and the performance of safety net hospitals.

BACKGROUND: Safety net hospitals (SNH) have, on average, experienced declining financial margins and faced an elevated risk of closure over the past decade. Despite these challenges, not all SNHs are weakening and some are prospering. These higher-performing SNHs provide substantial care to safety net populations and produce sustainable financial returns. PURPOSE: Drawing on the alternative structural positioning and resource-based views, we explore strategic management as a source of performance differences across SNHs. METHODOLOGY/APPROACH: We employ a mixed-method design, blending quantitative and qualitative data and analysis. We measure financial performance using hospital operating margin and quantitatively evaluate its relationship with a limited set of well-defined structural positions. We further evaluate these structures and also explore the internal resources of SNHs based on nine in-depth case studies developed from site visits and extensive interviews. FINDINGS: Quantitative results suggest that structural positions alone are not related to performance. Comparative case studies suggest that higher-performing SNH differ in four respects: (1) coordinating patient flow across the care continuum, (2) engaging in partnerships with other providers, (3) managing scope of services, and (4) investing in human capital. On the basis of these findings, we propose a model of strategic action related to systems thinking--the ability to see wholes and interrelationships rather than individual parts alone. PRACTICE IMPLICATIONS: Our exploratory findings suggest the need to move beyond generic strategies alone and acknowledge the importance of underlying managerial capabilities. Specifically, our findings suggest that effective strategy is a function of both the internal resources (e.g., managers' systems-thinking capability) and structural positions (e.g., partnerships) of organizations. From this perspective, framing resources and positioning as distinct alternatives misses the nuances of how strategic advantage is actually achieved.

Hospital performance, the local economy, and the local workforce: findings from a US National Longitudinal Study.

BACKGROUND: Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity. METHODS AND FINDINGS: We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004-2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare's "Value-Based Purchasing" program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p<0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p<0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007--4 years after public reporting began--hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement. CONCLUSIONS: Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare's hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.

Beyond satisfaction scores: exploring emotionally adverse patient experiences.

OBJECTIVES: Although improving the average patient experience is at the center of recent efforts to make cancer care more patient centered, extreme experiences may be more informative for quality improvement. Little is known about the most deeply dissatisfying experiences that predispose disengagement and negatively influence patient outcomes. We sought to establish a framework for emotionally adverse patient experiences and identify the range of common causes. STUDY DESIGN: Qualitative study including in-depth interviews and free-text survey comments. METHODS: Thematic analysis of 20 open-ended patient interviews and 2389 free-text survey comments collected in a medical center's cancer clinics. RESULTS: Emotionally adverse experiences were rarely reported in survey comments (96; 4.0%) but more frequently discussed in interviews (12 interview participants). Such experiences were identified through explicit statements of negative emotion, language, syntax, and tone. Among these rare comments, hostility as an indicator was easiest to identify, whereas passive expressions of fear or hopelessness were less reliably identified. We identified 3 mutually inclusive high-level domains of triggers of negative emotion-system issues, technical processes, and interpersonal processes-and 10 themes within those domains. There was wide variation in the causes of emotionally adverse experiences and evidence of a complex interplay of patient expectations and preconditions that influenced the perception of negative experiences. CONCLUSIONS: This study presents a taxonomy for classifying emotionally adverse patient experiences expressed in free-text format. Further research should test how perceptions of adverse experiences correspond to recorded ratings of patient satisfaction and subsequent enrollment or utilization.

Race/Ethnicity and patient confidence to self-manage cardiovascular disease.

BACKGROUND: Minority populations bear a disproportionate burden of chronic disease, due to higher disease prevalence and greater morbidity and mortality. Recent research has shown that several factors, including confidence to self-manage care, are associated with better health behaviors and outcomes among those with chronic disease. OBJECTIVE: To examine the association between minority status and confidence to self-manage cardiovascular disease (CVD). STUDY SAMPLE: Survey respondents admitted to 10 hospitals participating in the "Expecting Success" program, with a diagnosis of CVD, during January-September 2006 (n = 1107). RESULTS: Minority race/ethnicity was substantially associated with lower confidence to self-manage CVD, with 36.5% of Hispanic patients, 30.7% of Black patients, and 16.0% of white patients reporting low confidence (P < 0.001). However, in multivariate analysis controlling for socioeconomic status and clinical severity, minority status was not predictive of low confidence. CONCLUSIONS: Although there is an association between race/ethnicity and confidence to self-manage care, that relationship is explained by the association of race/ethnicity with socioeconomic status and clinical severity.

Inpatient Hospital Factors and Resident Time With Patients and Families.

OBJECTIVES: To define hospital factors associated with proportion of time spent by pediatric residents in direct patient care. METHODS: We assessed 6222 hours of time-motion observations from a representative sample of 483 pediatric-resident physicians delivering inpatient care across 9 pediatric institutions. The primary outcome was percentage of direct patient care time (DPCT) during a single observation session (710 sessions). We used one-way analysis of variance to assess a significant difference in the mean percentage of DPCT between hospitals. We used the intraclass correlation coefficient analysis to determine within- versus between-hospital variations. We compared hospital characteristics of observation sessions with ≥12% DPCT to characteristics of sessions with <12% DPCT (12% is the DPCT in recent resident trainee time-motion studies). We conducted mixed-effects regression analysis to allow for clustering of sessions within hospitals and accounted for correlation of responses across hospital. RESULTS: Mean proportion of physician DPCT was 13.2% (SD = 8.6; range, 0.2%-49.5%). DPCT was significantly different between hospitals (P < .001). The intraclass correlation coefficient was 0.25, indicating more within-hospital than between-hospital variation. Observation sessions with ≥12% DPCT were more likely to occur at hospitals with Magnet designation (odds ratio [OR] = 3.45, P = .006), lower medical complexity (OR = 2.57, P = .04), and higher patient-to-trainee ratios (OR = 2.48, P = .05). CONCLUSIONS: On average, trainees spend <8 minutes per hour in DPCT. Variation exists in DPCT between hospitals. A less complex case mix, increased patient volume, and Magnet designation were independently associated with increased DPCT.

Informal Peer Interaction and Practice Type as Predictors of Physician Performance on Maintenance of Certification Examinations.

IMPORTANCE: Physicians can demonstrate mastery of the knowledge that supports continued clinical competence by passing a maintenance of certification examination (MOCEX). Performance depends on professional learning and development, which may be enhanced by informal routine interactions with colleagues. Some physicians, such as those in solo practice, may have less opportunity for peer interaction, thus negatively influencing their examination performance. OBJECTIVE: To determine the relationship among level of peer interaction, group and solo practice, and MOCEX performance. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal cohort study of 568 surgeons taking the 2008 MOCEX. Survey responses reporting the level of physicians' peer interactions and their practice type were related to MOCEX scores, controlling for initial qualifying examination scores, practice type, and personal characteristics. EXPOSURES: Solo practice and amount of peer interaction. MAIN OUTCOMES AND MEASURES: Scores on the MOCEX and pass-fail status. RESULTS: Of the 568 surgeons in the study sample, 557 (98.1%) passed the examination. Higher levels of peer interaction were associated with a higher score (ß = 0.91 [95% CI, 0.31-1.52]) and higher likelihood of passing the examination (odds ratio, 2.58 [1.08-6.16]). Physicians in solo (vs group) practice had fewer peer interactions (ß = -0.49 [95% CI, -0.64 to -0.33), received lower scores (ß = -1.82 [-2.94 to -0.82]), and were less likely to pass the examination (odds ratio, 0.22 [0.06-0.77]). Level of peer interaction moderated the relationship between solo practice and MOCEX score; solo practitioners with high levels of peer interaction achieved an MOCEX performance on a par with that of group practitioners. CONCLUSIONS AND RELEVANCE: Physicians in solo practice had poorer MOCEX performance. However, solo practitioners who reported high levels of peer interaction performed as well as those in group practice. Peer interaction is important for professional learning and quality of care.

Strained local and state government finances among current realities that threaten public hospitals' profitability.

This study demonstrates that some safety-net hospitals--those that provide a large share of the care to low-income, uninsured, and Medicaid populations--survived and even thrived before the recent recession. We analyzed the financial performance and governance of 150 hospitals during 2003-07. We found, counterintuitively, that those directly governed by elected officials and in highly competitive markets were more profitable than other safety-net hospitals. They were financially healthy primarily because they obtained subsidies from state and local governments, such as property tax transfers or supplemental Medicaid payments, including disproportionate share payments. However, safety-net hospitals now face a new market reality. The economic downturn, slow recovery, and politics of deficit reduction have eroded the ability of local governments to support the safety net. Many safety-net hospitals have not focused on effective management, cost control, quality improvement, or services that attract insured patients. As a result, and coupled with new uncertainties regarding Medicaid expansion stemming from the recent Supreme Court decision on the Affordable Care Act, many are likely to face increasing financial and competitive pressures that may threaten their survival.