Patient-Reported Outcomes for Breast Cancer.

Patient-reported outcomes (PROs) provide insight into how patients perceive health and treatment effects, how treatments impact outcomes, and are helpful in determining how disease and surgical interventions impact many aspects of a patients' life. Commonly utilized metrics include survival and disease control, degree of recovery and functional status, access to treatment, treatment-related complications, health-related quality of life, and long-term consequences of therapy. The key to value-based, patient-centered health care is systematically incorporating patient input into the measures that they consider to be the most important outcomes for a particular medical condition while minimizing costs of care. This manuscript reviews the development and validation of multiple available PROs in breast surgical oncology and reconstruction, their impact in improving patient-physician communication and treatment outcome, and potential for impacting reimbursement. The implementation of PROs can be complex and challenging and care must be taken to minimize the potential for survey fatigue by patients and the potential financial burden for implementation, maintenance, and analyses of collected data. Because there is an increased emphasis in providing high-value care for cancer patients, the widespread incorporation of transparent breast-specific PROs stratified by treatments received and disease stage will be essential in delivering exceptional quality care.

Communication Skills Training for Physicians Improves Patient Satisfaction.

BACKGROUND: Skilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted. OBJECTIVE: We aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience. DESIGN: This was an observational study. SETTING: The study was conducted at a large, multispecialty academic medical center. PARTICIPANTS: Participants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014. INTERVENTION: An 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationship-centered model. MAIN MEASURES: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction. KEY RESULTS: Following the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p < 0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p = 0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p = 0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4 ± 12.7 vs. 124 ± 11.9, p < 0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3 months. CONCLUSIONS: System-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions.

Health care's service fanatics.

The Cleveland Clinic has long had a reputation for medical excellence. But in 2009 the CEO acknowledged that patients did not think much of their experience there and decided to act. Since then the Clinic has leaped to the top tier of patient-satisfaction surveys, and it now draws hospital executives from around the world who want to study its practices. The Clinic's journey also holds Lessons for organizations outside health care that must suddenly compete by creating a superior customer experience. The authors, one of whom was critical to steering the hospital's transformation, detail the processes that allowed the Clinic to excel at patient satisfaction without jeopardizing its traditional strengths. Hospital leaders: Publicized the problem internally. Seeing the hospital's dismal service scores shocked employees into recognizing that serious flaws existed. Worked to understand patients' needs. Management commissioned studies to get at the root causes of dissatisfaction. Made everyone a caregiver. An enterprisewide program trained everyone, from physicians to janitors, to put the patient first. Increased employee engagement. The Clinic instituted a "caregiver celebration" program and redoubled other motivational efforts. Established new processes. For example, any patient, for any reason, can now make a same-day appointment with a single call. Set patients' expectations. Printed and online materials educate patients about their stays--before they're admitted. Operating a truly patient-centered organization, the authors conclude, isn't a program; it's a way of life.

Complicated skin and soft-tissue infections: diagnostic approach and empiric treatment options.

Skin and soft-tissue infections are common and generally are uncomplicated at the time of initial presentation. However, these infections can worsen quickly when there are delays in presentation and treatment. Upon encountering these infections, physicians must respond quickly with an appropriate therapeutic plan and be aware of trends in microbial resistance in order to optimize patient care.

Nosocomial infections adversely affect the outcomes of patients with serious intraabdominal infections.

BACKGROUND: Patients with serious intraabdominal infections (IAI) who subsequently acquire nosocomial infections (NI) have been shown to have adverse outcomes. We evaluated factors that put patients at risk for developing NI and examined the effect of the NI on outcomes. METHODS: This study was a retrospective review of NI among 168 patients diagnosed with IAI over a seven-year period. RESULTS: Sixty-six patients (39.3%) developed 98 NI (23 urinary tract, 20 surgical site, 19 pneumonia, 14 bloodstream, 12 recurrent peritonitis, seven intravascular catheter-related, and three enteric). There were 35 males and 31 females. Patients with NI were older (56.0 +/- 18.3 vs. 47.0 +/- 15.6 years, p = 0.001), had a higher admission APACHE II score (10.7 +/- 6.1 vs. 7.5 +/- 5.1 points, p = 0.001), and more often had concomitant medical diagnoses (27.3% vs. 12.7%, OR = 2.57, 95% CI: 1.159-5.69, p = 0.018) than those who did not develop infection. Antimicrobial resistance among the IAI was higher in the NI group (19.7 vs. 5.9%, OR = 3.93, 95% CI: 1.41-10.93, p = 0.006). Patients who developed NI had an increased mortality rate (27.0% vs. 4.0%, OR = 8.87, 95% CI: 2.82-27.86, p < or = 0.0001), longer hospital stay (24.7 +/- 19.5 vs. 11.7 +/- 8.1 days, p < or = 0.0001), required more days of intravenous antibiotics (11.5 +/- 8.0 vs. 7.6 +/- 4.4 days, p < or = 0.0001), and were more likely to be admitted to an intensive care unit (54.5% vs. 25.5%, OR = 3.51, 95% CI: 1.82-6.77, p < or = 0.0001). Multivariate analysis demonstrated that antimicrobial resistance and an APACHE II score of > or = 10 independently predicted the development of a nosocomial infection. Age >/= 50 years, APACHE II score > or = 10, or the presence of a NI independently predicted death. CONCLUSIONS: The development of NI following treatment of an IAI significantly affects mortality, hospital length of stay, and treatment. Early recognition and treatment of these infections, combined with strategies to prevent NI, may be important to improve outcomes in this patient population.

The false negative technetium-99m-sestamibi scan in patients with primary hyperparathyroidism: correlation with clinical factors and operative findings.

False negative (FN) results limit the efficacy of technetium-99m-sestamibi scanning for parathyroid localization. We determined the incidence of FN results and attempted to correlate it with clinical and operative findings. One hundred forty-six patients underwent parathyroidectomy; 89 had primary hyperparathyroidism (76 single adenoma and 13 multiglandular disease) and underwent sestamibi scanning. The false negative rate was 22 per cent with an overall sensitivity of 77 per cent and a positive predictive value of 99 per cent. Patients with single adenomas were more likely to have a true positive scan than those with multiglandular disease [83% vs 38%; odds ratio (OR) = 7.754, 95% confidence interval (CI) = 2.184-27.524; P < or = 0.0001]. Inferior adenomas (90% vs 59%; OR = 6.261, 95% CI = 2.037-19.243; P < or = 0.0001) and larger adenomas (1422.3 +/- 1576.2 vs 474.6 +/- 193.2 g; P < or = 0.0001) were more likely to be detected by sestamibi imaging. Patients with normal preoperative calcium levels were more likely to have an FN sestamibi scan. Sestamibi parathyroid imaging is limited by a 22 per cent FN rate and is less accurate for detecting abnormal parathyroid tissue in patients with small adenomas, multiglandular disease, superior adenomas, or preoperative normocalcemia.

Post-parathyroidectomy hypocalcemia: incidence, risk factors, and management.

The purpose of this study was to evaluate the incidence and severity of hypocalcemia after parathyroidectomy and delineate its risk factors. Data was retrieved from a prospective database. Patients with postoperative hypocalcemia were identified and risk factors were investigated including primary versus renal hyperparathyroidism (HPT), preoperative calcium, parathyroid hormone (PTH) and alkaline phosphatase levels, gland weight, pathology, extent of surgery, and reoperative surgery. Of the 162 patients who underwent parathyroidectomy, 84 (52%) were hypocalcemic postoperatively: 55 (42%) of 132 patients with primary and 29 (97%) of 30 patients with renal HPT (P = 0.0001). Patients with renal HPT had more profound hypocalcemia with a mean +/- SD calcium of 7.34 mg/dL +/- 1.07 versus 7.76 mg/dL +/- 0.59 for patients with primary HPT (P < 0.05). Symptoms were present in 28 (51%) of 55 patients with primary and 13 (45%) of 29 patients with renal HPT. Only three (2%) patients with primary compared to 29 (97%) with renal HPT were treated with intravenous calcium. The average length of stay for hypocalcemic patients was 0.7 days for primary HPT versus 4.7 days for renal HPT (P < 0.0005). Patients with primary HPT who underwent subtotal parathyroidectomy had significantly lower postoperative calcium levels (7.95 mg/dL +/- 0.64) than patients who had a single or double adenoma removed (8.49 mg/dL +/- 0.79) (P = 0.036). No other factor was predictive of postoperative hypocalcemia. Patients with renal HPT develop profound postoperative hypocalcemia requiring intravenous calcium and vitamin D therapy. Hypocalcemia in patients with primary HPT develop less severe hypocalcemia that is amenable to outpatient oral calcium therapy and should be routinely initiated following subtotal parathyroidectomy.

The REDE Model of Healthcare Communication: Optimizing Relationship as a Therapeutic Agent.

The REDE model is a conceptual framework for teaching relationship-centered healthcare communication. Based on the premise that genuine relationships are a vital therapeutic agent, use of the framework has the potential to positively influence both patient and provider. The REDE model applies effective communication skills to optimize personal connections in three primary phases of Relationship: Establishment, Development and Engagement (REDE). This paper describes the REDE model and its application to a typical provider-patient interaction.

HCAHPS Survey Results: Impact of Severity of Illness on Hospitals' Performance on HCAHPS Survey Results.

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is used by the Centers of Medicare and Medicaid (CMS) to assess inpatient satisfaction. HCAHPS survey results are publicly reported, and performance began to affect CMS reimbursement to hospitals as of FY2013. However, the impact of severity of illness on patients' self-reported inpatient satisfaction as measured by HCAHPS survey scores remains unknown. OBJECTIVE: To determine the impact of severity of illness on patients' self-reported inpatient satisfaction. DESIGN: The All Patient-Refined, Diagnosis Related Group (APR-DRG) classifies every patient into one of four levels of severity of illness. We evaluated the impact of APR-DRG severity of illness on five HCAHPS domains, two reputation and two environmental questions, using linear regression analysis. SETTING: Adult inpatients discharged from a large, academic, tertiary care hospital. PATIENTS: 37,223 patients' HCAHPS survey data were combined with their APR-DRG severity of illness rating over a 39-month period between April 2008 and June 2011. MEASUREMENTS: HCAHPS scores. RESULTS: Higher severity of illness was consistently and inversely associated with lower patients' self-reported perception of inpatient hospital satisfaction as measured by HCAHPS scores. For each one-unit increase in severity of illness, the average HCHAPS scores across all five domains were approximately 3 percent lower. CONCLUSIONS: Hospitals treating patients with a higher severity of illness will have lower HCAHPS scores, potentially leading these hospitals to receive lower reimbursement from CMS. Conversely, hospitals with lower severity of illness will receive greater reimbursement. Failure to adequately adjust for severity of illness is a serious flaw in the current HCAHPS reporting system that should be corrected.

Surgical complications impact patient perception of hospital care.

BACKGROUND: Public reporting of the Hospital Consumer Assessment of Healthcare Providers and Systems survey is designed to produce data on patients' perceptions of the quality of hospital care. The aim of this study was to assess the impact of complications on patient responses to Hospital Consumer Assessment of Healthcare Providers and Systems "top-box" (most favorable) scores. STUDY DESIGN: All patients who underwent a colorectal procedure from October 2009 to June 2012 at a single center were included. Patient complications were categorized as major, minor, or no complications and "surgical technique" or "medical." Chi-square and Wilcoxon rank sum tests were used to compare binary and ordinal top-box scores, respectively. RESULTS: One thousand four hundred and nine surveys were collected for 1,233 patients (mean age 53 ± 15.7 years; 701 [52.2%] females) who underwent 955 (67.8%) major abdominal, 114 (8.1%) anorectal, and 340 (24.1%) stoma-related operations. There were 195 (13.8%) major and 396 (28.1%) minor complications. There were 159 (11.3%) technique complications and 411 (29.2%) medical complications. Patients without any complications were more likely to recommend the hospital than those with complications (p = 0.023) irrespective of type of complication (minor vs major; p = 0.72 or technique vs medical; p = 0.5). Responsiveness of hospital staff was also reported as higher for patients without complications (p = 0.0003) and the type of complication did not influence this assessment (minor vs major; p = 0.71 and technique vs medical; p = 0.95). CONCLUSIONS: The occurrence of any complication after colorectal surgery adversely impacts patients' self-reported perceptions of hospital care as measured by Hospital Consumer Assessment of Healthcare Providers and Systems. An instrument that more accurately reflects patients' assessment of quality in the context of variations in patient, disease, and surgical factors is required.

Impact of isolation on hospital consumer assessment of healthcare providers and systems scores: is isolation isolating?

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was used to measure the effect of isolation on patient satisfaction. Isolated patients reported lower scores for questions regarding physician communication and staff responsiveness. Overall scores for these domains were lower in isolated than in nonisolated patients.

Defining the volume-quality debate: is it the surgeon, the center, or the training?

The quality movement in health care is ubiquitous in our society. The volume-quality debate is a central component of this that affects surgeons. In colorectal surgery and other fields, studies have demonstrated improved outcomes for patients having care provided at higher volume centers. What is unclear about this relationship however, is whether this improvement is related to the center, the surgeon, or the surgeon's training and experience. Some studies have tried to better examine this relationship and have suggested that limitations in administrative data may exaggerate the impact of a high-volume center. The use of crude mortality as the primary outcome instead of more specific outcomes such as cancer recurrence, inadequate risk data, and the failure to account for clustering of cases are other important limitations. Although higher volume likely equates to higher quality in some form, this may be more related to surgeon-specific factors rather than high-volume centers alone. The role of subspecialization, especially colorectal-trained surgeons with a high individual case volume may be the most important predictor of higher quality in colorectal surgery. This relationship may be especially important for the treatment of rectal cancer. The relationship of volume to outcomes is difficult to understand, and to appropriately answer these questions will require the collection and analysis of comprehensive, risk-adjusted data after adequate outcome measures are defined. This will only occur with significant institutional support, and a commitment to follow outcomes longitudinally and implement necessary changes to improve outcomes.

Predictors and outcome of readmission after laparoscopic intestinal surgery.

BACKGROUND: Previous studies have failed to identify predictors of early readmission after major intestinal operations. The objectives of this study were to determine readmission rates, outcomes, and predictors of readmission for patients undergoing laparoscopic colon and rectal operations. METHODS: Patients readmitted (PR) to the hospital within 30 days of discharge after laparoscopic colon and rectal operations were identified from a prospectively maintained database. The PR group was compared with patients that were not readmitted (NR). Outcomes and variables related to readmission were evaluated. RESULTS: There were 820 consecutive elective laparoscopic colon and rectal operations performed over a 5-year period, with adequate follow-up data for 787 cases. Seventy-nine (10%) patients were readmitted. There was no difference in the age, sex, surgeon, or type of operation between the PR and NR groups. The most common causes for readmission were bowel obstruction (19%), ileus (18%), intra-abdominal abscess (14%), and anastomotic leak (9%). Overall mean (median) length of stay (LOS) for the index admission was 3.7 +/- 4.3 (3.0) days. Patients in the PR group had a trend toward a longer index admission LOS than the NR group (5.4 +/- 8.8 [3.0] versus 3.5 +/- 3.3 [3.0], p = 0.068). Univariate analysis demonstrated that patients with inflammatory bowel disease, pulmonary comorbidities, and steroid use were more likely to be readmitted. Multivariate analysis confirmed that inflammatory bowel disease and pulmonary comorbidity are independent risk factors for readmission. CONCLUSIONS: Early readmission after laparoscopic colon and rectal operations is not associated with early discharge. Identification of specific patient characteristics indicating risk for early readmission may allow for selective changes in perioperative care or discharge criteria to avoid unexpected readmission. An erratum to this article can be found at

Fetal evaluation for transport by ultrasound performed by air medical teams: A case series.

The air medical team has limited options when evaluating the obstetrical patient and assessing fetal health during air transport to a high-risk obstetrical unit. Traditionally, physical examination and a Doppler stethoscope have been used to determine fetal heart rates and movement. However, with the advent of portable ultrasound technology, new information about the mother and child are available to the air medical crew. The Fetal Evaluation for Transport with Ultrasound (FETUS) is a screening examination that consists of an evaluation of the fetal heart rate, position, and movement and general condition of the placenta. The examination can be repeated in flight with no acoustic distortion from rotor noise. The additional information can be advantageous when transport decisions need to be made or when conditions do not allow Doppler stethoscope use.

Intubated pediatric patients requiring transport: a review of patients, indications, and standards.

INTRODUCTION: We could not find any studies of nontertiary care facilities performing intubation for patients requiring transport to definitive pediatric care. The purpose of our study was to determine the current practices of pediatric airway management in the prehospital and transport environments. METHODS: A retrospective analysis of all patients younger than 16 years transported by our flight program during a 2-year period served as the population of interest. The flight records (RN and MD documentation) for intubated patients were analyzed for medications, methods, outcomes, and other descriptive endpoints. As a matter of program policy, all pediatric transports are subjected to peer review in the performance improvement committee. RESULTS: During the review period, 732 patients younger than 16 years (range: 30 days to 15 years) were transported by our flight program. Of the 148 (20%) patients intubated for airway control, 81 were boys (55%), and 67 were girls (45%). Sixteen percent were younger than 1 year, 24% were 1 to 2 years old, 18% were 3 to 5, 20% were 6 to 11, and 22% were 12 to 15. Indicators for intubation included unresponsiveness or arrest, 42 (28%); seizures, 38 (26%); respiratory failure, 28 (19%); decreased level of consciousness (LOC), 14 (9%); airway protection, 13 (9%); combativeness, 11 (7%); and other, 2 (1%). Children were intubated most frequently by the referring physician (92 children, 62% of patients). The flight crew performed 49 (33%) intubations, and EMS staff performed seven (5%). Three children were nasally intubated. Significant variation occurred in medications used, endotracheal tube size and position, and nasogastric decompression. No single group performed better or worse than the others in our review. CONCLUSION: Variability exists in the application of pediatric airway management techniques, including pharmacologic modes and intubation indications.