Cutting Edge Developments in Spine Surgery at the University of Missouri.

The treatment of spinal pathologies has evolved significantly from the times of Hippocrates and Galen to the current era. This evolution has led to the development of cutting-edge technologies to improve surgical techniques and patient outcomes. The University of Missouri Health System is a high-volume, tertiary care academic medical center that serves a large catchment area in central Missouri and beyond. The Department of Neurosurgery has sought to integrate the best available technologies to serve their spine patients. These technological advancements include intra-operative image guidance, robotic spine surgery, minimally invasive techniques, motion preservation surgery, and interdisciplinary care of metastatic disease to the spine. These advances have resulted in safer surgeries with enhanced outcomes at the University of Missouri. This integration of innovation demonstrates our tireless commitment to ensuring excellence in the comprehensive care of a diverse range of patients with complex spinal pathologies.

Use of Electronic Patient Messaging by Pregnant Patients Receiving Prenatal Care at an Academic Health System: Retrospective Cohort Study.

Background: The COVID-19 pandemic accelerated telemedicine and mobile app use, potentially changing our historic model of maternity care. MyChart is a widely adopted mobile app used in health care settings specifically for its role in facilitating communication between health care providers and patients with its messaging function in a secure patient portal. However, previous studies analyzing portal use in obstetric populations have demonstrated significant sociodemographic disparities in portal enrollment and messaging, specifically showing that patients who have a low income and are non-Hispanic Black, Hispanic, and uninsured are less likely to use patient portals. Objective: The study aimed to estimate changes in patient portal use and intensity in prenatal care before and during the pandemic period and to identify sociodemographic and clinical disparities that continued during the pandemic. Methods: This retrospective cohort study used electronic medical record (EMR) and administrative data from our health system's Enterprise Data Warehouse. Records were obtained for the first pregnancy episode of all patients who received antenatal care at 8 academically affiliated practices and delivered at a large urban academic medical center from January 1, 2018, to July 22, 2021, in Chicago, Illinois. All patients were aged 18 years or older and attended ≥3 clinical encounters during pregnancy at the practices that used the EMR portal. Patients were categorized by the number of secure messages sent during pregnancy as nonusers or as infrequent (≤5 messages), moderate (6-14 messages), or frequent (≥15 messages) users. Monthly portal use and intensity rates were computed over 43 months from 2018 to 2021 before, during, and after the COVID-19 pandemic shutdown. A logistic regression model was estimated to identify patient sociodemographic and clinical subgroups with the highest portal nonuse. Results: Among 12,380 patients, 2681 (21.7%) never used the portal, and 2680 (21.6%), 3754 (30.3%), and 3265 (26.4%) were infrequent, moderate, and frequent users, respectively. Portal use and intensity increased significantly over the study period, particularly after the pandemic. The number of nonusing patients decreased between 2018 and 2021, from 996 of 3522 (28.3%) in 2018 to only 227 of 1743 (13%) in the first 7 months of 2021. Conversely, the number of patients with 15 or more messages doubled, from 642 of 3522 (18.2%) in 2018 to 654 of 1743 (37.5%) in 2021. The youngest patients, non-Hispanic Black and Hispanic patients, and, particularly, non-English-speaking patients had significantly higher odds of continued nonuse. Patients with preexisting comorbidities, hypertensive disorders of pregnancy, diabetes, and a history of mental health conditions were all significantly associated with higher portal use and intensity. Conclusions: Reducing disparities in messaging use will require outreach and assistance to low-use patient groups, including education addressing health literacy and encouraging appropriate and effective use of messaging.

An Effective Academic Medical Center-Based Strategy to Enhance Diversity Among Nurse Researchers.

The Connell-Jones Endowed Chair Diversity Nursing Research Scholars Program was created to promote engagement in nursing research and scholarship among nurses of color. Preliminary evaluation suggests that the program was widely beneficial, resulting in enrollment in doctoral education for some. Establishing opportunities that promote exposure and participation in nursing research and scholarship among nurses of color helps cultivate cohorts of diverse nurses armed to address health disparities through the advancement of nursing knowledge.

Establishing a Pediatric Health Equity, Diversity, and Inclusion Research Review Process.

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

Accelerating Climate Action Through Academic Health Systems: Leadership's Call to Duty.

This Viewpoint makes the case for academic health systems to lead the way on climate change action in the US, including planning to reduce greenhouse gas emissions, educating current and future clinicians, and communicating with their patients and communities.

Surgeon compensation in academic medicine.

Academic surgery is the best career one could ever aspire to have; however, given the long duration of training and the anticipated education debt, surgeon compensation has not kept pace with the compensation of other comparable careers. As surgeon compensation has experienced increased downward pressure, it has become of growing importance to those in academic medicine/surgery. Competitive compensation is necessary, even if not sufficient, for successful faculty recruitment and retention. The optimal compensation system should encourage the best possible patient care, inspire teamwork, maximize the department's or physician practice's ability to recruit and retain faculty, support all missions, and be viewed as equitable and transparent. The goal of an optimal compensation system is to have faculty minds focused on things other than compensation-those elements of their job that are most important, such as career development, multidisciplinary clinical programs, research, and education. One way to ensure that compensation stays in the background for academic surgeons is for leadership to keep this front and center. Compensation plans can influence behavior and time management and affect the clinical, academic, and educational contributions of surgeons and physicians of all specialties. As we strive to optimize the productivity and engagement of a health system's most valuable resource-those who deliver surgical care and create new knowledge-compensation is an important variable in need of constant attention.

Operationalizing Equity, Inclusion, and Access in Research Practice at a Large Academic Institution.

INTRODUCTION: Healthcare advances are hindered by underrepresentation in prospective research; sociodemographic, data, and measurement infidelity in retrospective research; and a paucity of guidelines surrounding equitable research practices. OBJECTIVE: The Joint Research Practices Working Group was created in 2021 to develop and disseminate guidelines for the conduct of inclusive and equitable research. METHODS: Volunteer faculty and staff from two research centers at the University of Pennsylvania initiated a multi-pronged approach to guideline development, including literature searches, center-level feedback, and mutual learning with local experts. RESULTS: We developed guidelines for (1) participant payment and incentives; (2) language interpretation and translation; (3) plain language in research communications; (4) readability of study materials; and (5) inclusive language for scientific communications. Key recommendations include (1) offer cash payments and multiple payment options to participants when required actions are completed; (2) identify top languages of your target population, map points of contact, and determine available interpretation and translation resources; (3) assess reading levels of materials and simplify language, targeting 6th- to 8th-grade reading levels; (4) improve readability through text formatting and style, symbols, and visuals; and (5) use specific, humanizing terms as adjectives rather than nouns. CONCLUSIONS: Diversity, inclusion, and access are critical values for research conduct that promotes justice and equity. These values can be operationalized through organizational commitment that combines bottom-up and top-down approaches and through partnerships across organizations that promote mutual learning and synergy. While our guidelines represent best practices at one time, we recognize that practices evolve and need to be evaluated continuously for accuracy and relevance. Our intention is to bring awareness to these critical topics and form a foundation for important conversations surrounding equitable and inclusive research practices.

Addressing anti-black racism in an academic preterm birth initiative: perspectives from a mixed methods case study.

BACKGROUND: Growing recognition of racism perpetuated within academic institutions has given rise to anti-racism efforts in these settings. In June 2020, the university-based California Preterm Birth Initiative (PTBi) committed to an Anti-Racism Action Plan outlining an approach to address anti-Blackness. This case study assessed perspectives on PTBi's anti-racism efforts to support continued growth toward racial equity within the initiative. METHODS: This mixed methods case study included an online survey with multiple choice and open-ended survey items (n = 27) and key informant interviews (n = 8) of leadership, faculty, staff, and trainees working within the initiative. Survey and interview questions focused on perspectives about individual and organizational anti-racism competencies, perceived areas of initiative success, and opportunities for improvement. Qualitative interview and survey data were coded and organized into common themes within assessment domains. RESULTS: Most survey respondents reported they felt competent in all the assessed anti-racism skills, including foundational knowledge and responding to workplace racism. They also felt confident in PTBi's commitment to address anti-Blackness. Fewer respondents were clear on strategic plans, resources allocated, and how the anti-racism agenda was being implemented. Suggestions from both data sources included further operationalizing and communicating commitments, integrating an anti-racism lens across all activities, ensuring accountability including staffing and funding consistent with anti-racist approaches, persistence in hiring Black faculty, providing professional development and support for Black staff, and addressing unintentional interpersonal harms to Black individuals. CONCLUSIONS: This case study contributes key lessons which move beyond individual-level and theoretical approaches towards transparency and accountability in academic institutions aiming to address anti-Black racism. Even with PTBi's strong commitment and efforts towards racial equity, these case study findings illustrate that actions must have sustained support by the broader institution and include leadership commitment, capacity-building via ongoing coaching and training, broad incorporation of anti-racism practices and procedures, continuous learning, and ongoing accountability for both short- and longer-term sustainable impact.

Workplace Harassment, Cyber Incivility, and Climate in Academic Medicine.

Importance: The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender). Objective: To evaluate academic medical culture, faculty mental health, and their relationship. Design, Setting, and Participants: A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health. Exposures: Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status. Main Outcomes and Measures: Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health. Results: Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis. Conclusions and Relevance: High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.

Disparities in Hypoxemia Detection by Pulse Oximetry Across Self-Identified Racial Groups and Associations With Clinical Outcomes.

OBJECTIVES: To assess disparities in hypoxemia detection by pulse oximetry across self-identified racial groups and associations with clinical outcomes. DESIGN: Observational cohort study from May 5, 2018, to December 31, 2020. SETTING: Three academic medical centers in the United States. PATIENTS: Adults greater than or equal to 18 years who self-identified as White, Black, Asian, or American Indian admitted to the ICU or undergoing surgery during inpatient hospitalization with simultaneous measurements of pulse oximetry-estimated oxygen saturation and arterial blood gas-derived oxygen saturation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable models were employed to assess the relationships between race, occult hypoxemia (i.e., arterial blood gas-derived oxygen saturation < 88% despite pulse oximetry-estimated oxygen saturation ≥ 92%), and clinical outcomes of hospital mortality and hospital-free days. One-hundred twenty-eight-thousand two-hundred eighty-five paired pulse oximetry-estimated oxygen saturation-arterial blood gas-derived oxygen saturation measurements were included from 26,603 patients. Pulse oximetry-estimated oxygen saturation on average overestimated arterial blood gas-derived oxygen saturation by 1.57% (1.54-1.61%). Black, Asian, and American Indian patients were more likely to experience occult hypoxemia during hospitalization (estimated probability 6.2% [5.1-7.6%], 6.6% [4.9-8.8%], and 6.6% [4.4-10.0%], respectively) compared with White patients (3.6% [3.4-3.8%]). Black patients had increased odds of occult hypoxemia compared with White patients after adjustment (odds ratio, 1.65; 1.28-2.14; p < 0.001). Differences in occult hypoxemia between Asian and American Indian patients compared with White patients were not significant after adjustment (odds ratio, 1.53; 0.95-2.47; p = 0.077 and odds ratio, 1.31; 0.80-2.16; p = 0.288, respectively). Occult hypoxemia was associated with increased odds of mortality in surgical (odds ratio, 2.96; 1.20-7.28; p = 0.019) and ICU patients (1.36; 1.03-1.80; p = 0.033). Occult hypoxemia was associated with fewer hospital-free days in surgical (-2.5 d [-3.9 to -1.2 d]; p < 0.001) but not ICU patients (0.4 d [-0.7 to 1.4 d]; p = 0.500). CONCLUSIONS: Occult hypoxemia is more common in Black patients compared with White patients and is associated with increased mortality, suggesting potentially important outcome implications for undetected hypoxemia. It is imperative to validate pulse oximetry with expanded racial inclusion.

Impact of the COVID-19 pandemic on workplace violence at an academic emergency department.

STUDY OBJECTIVES: COVID-19 brought unique challenges; however, it remains unclear what effect the pandemic had on violence in healthcare. The objective of this study was to identify the impact of the pandemic on workplace violence at an academic emergency department (ED). METHODS: This mixed-methods study involved a prospective descriptive survey study and electronic medical record review. Within our hospital referral region (HRR), the first COVID-19 case was documented on 3/11/2020 and cases peaked in mid-November 2020. We compared the monthly HRR COVID-19 case rate per 100,000 people to the rate of violent incidents per 1000 ED visits. Multidisciplinary ED staff were surveyed both pre/early-pandemic (April 2020) and mid/late-pandemic (December 2020) regarding workplace violence experienced over the prior 6-months. The study was deemed exempt by the Mayo Clinic Institutional Review Board. RESULTS: There was a positive association between the monthly HRR COVID-19 case rate and rate of violent ED incidents (r = 0.24). Violent incidents increased overall during the pandemic (2.53 incidents per 1000 visits) compared to the 3 months prior (1.13 incidents per 1000 visits, p < .001), as well as compared to the previous year (1.24 incidents per 1000 patient visits, p < .001). Survey respondents indicated a higher incidence of assault during the pandemic, compared to before (p = .019). DISCUSSION: Incidents of workplace violence at our ED increased during the pandemic and there was a positive association of these incidents with the COVID-19 case rate. Our findings indicate health systems should prioritize employee safety during future pandemics.

Rapid Development and Deployment of an Intensivist-Led Venovenous Extracorporeal Membrane Oxygenation Cannulation Program.

OBJECTIVES: To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program. DESIGN: A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program. SETTING: An adult ICU in a tertiary academic medical center in Camden, NJ. PATIENTS: Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation. INTERVENTIONS: Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists. MEASUREMENTS AND MAIN RESULTS: Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1). CONCLUSIONS: There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.

Utilization of lean project management principles and health informatics to reduce operating room delays in a vascular surgery practice.

OBJECTIVES: Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service. METHODS: First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation. RESULTS: 57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders. CONCLUSIONS: Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.

Underrepresented Women Leaders: Lasting Impact of Gender Homophily in Surgical Faculty Networks.

OBJECTIVE: Despite the increase of women in surgical fields and resources toward advancing women, there is no corresponding increased representation of women in higher academic ranks and leadership. The following hypotheses are explored: 1) men and women build/maintain different relationship networks and 2) women are not similarly included within the organization and do not receive the same sponsorship as male counterparts. STUDY DESIGN: Prospective observational study. METHODS: Three months of prospective, passive organizational network data of full-time faculty at an academic medical center were collected by analysis of deidentified internal email communication logs. Data were analyzed and strength of network relationships was assessed using algorithms measuring the tie, or connection, score. Data analysis was performed with standard statistical methods and multivariable regression models, comparing network relationships based on gender and academic rank. RESULTS: Among 345 full-time faculties from surgical departments, 45.2% were female Assistant Professors, but only 9.8% were female full Professors. Men had 55% more network relationships with other men than women had with men. Gender homophily was particularly pronounced at the higher academic ranks. Men compared to women in higher ranks had 157% more network relationships to other men in lower ranks. Multivariable regression models suggested direct association of these gender differences in relationships with more women in lower academic ranks. CONCLUSION: Higher academic rank can be predicted by male gender, tenure, and number of meaningful relationships. Women are underrepresented at the leadership level in surgical departments. Gender homophily is present in collaboration networks among academic surgeons and is associated with impeded female career advancement. LEVEL OF EVIDENCE: 2 Laryngoscope, 132:20-25, 2022.

Female Leadership in Academic Plastic Surgery: A Comprehensive Analysis.

BACKGROUND: Gender equity remains to be realized in academic plastic and reconstructive surgery. The purpose of this study was to measure the proportion of women in leadership roles in academic plastic and reconstructive surgery to verify where gender gaps may persist. METHODS: Six markers of leadership were analyzed: academic faculty rank, manuscript authorship, program directorship, journal editor-in-chief positions, society board of directors membership, and professional society membership. Descriptive statistics were performed, and chi-square tests were used to compare categorical variables. RESULTS: About 16 percent to 19 percent of practicing plastic surgeons are female, as measured by the percentage of female faculty and American Society of Plastic Surgeons members. Female plastic surgeons comprised 18.9 percent (n = 178) of the faculty from 88 academic plastic surgery institutions, and represented 9.9 percent of full professors and 10.8 percent of chiefs. Nineteen institutions had no female faculty. Women were first authors in 23.4 percent of publications and senior author in 14.7 percent of publications. No journal studied had a female editor-in-chief. Of the examined plastic and reconstructive societies, the proportion of women on the board of directors ranged from 16.7 percent to 23.5 percent. CONCLUSIONS: The proportion of female program directors, first manuscript authors, and board members of certain societies is commensurate with the number of women in the field, suggesting an evolving landscape within the specialty. However, women remain underrepresented in many other leadership roles, heralding the work that remains to ensure gender parity exists for those pursuing leadership roles in the field of plastic and reconstructive surgery.

Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center.

OBJECTIVE: To assess changes in inpatient transfusion utilization and patient outcomes with implementation of a comprehensive patient blood management (PBM) program at a large US medical center. PATIENTS AND METHODS: This is an observational study of graduated PBM implementation for hospitalized adults (age ≥18 years) from January 1, 2010, through December 31, 2017, at two integrated hospital campuses at a major academic US medical center. Allogeneic transfusion utilization and clinical outcomes were assessed over time through segmented regression with multivariable adjustment comparing observed outcomes against projected outcomes in the absence of PBM activities. RESULTS: In total, 400,998 admissions were included. Total allogeneic transfusions per 1000 admissions decreased from 607 to 405 over the study time frame, corresponding to an absolute risk reduction for transfusion of 6.0% (95% confidence interval [CI]: 3.6%, 8.3%; P<.001) and a 22% (95% CI: 6%, 37%; P=.006) decrease in the rate of transfusions over projected. The risk of transfusion decreased for all blood components except cryoprecipitate. Transfusion reductions were experienced for all major surgery types except liver transplantation, which remained stable over time. Hospital length of stay (multiplicative increase in geometric mean 0.85 [95% CI: 0.81, 0.89]; P<.001) and incident in-hospital adverse events (absolute risk reduction: 1.5% [95% CI: 0.1%, 3.0%]; P=.04) were lower than projected at the end of the study time frame. CONCLUSION: Patient blood management implementation for hospitalized patients in a large academic center was associated with substantial reductions in transfusion utilization and improved clinical outcomes. Broad-scale implementation of PBM in US hospitals is feasible without signal for patient harm.