Smartphone-based Assessment of Preoperative Decision Conflict and Postoperative Physical Activity Among Patients Undergoing Cancer Surgery: A Prospective Cohort Study.

OBJECTIVE: To determine the prevalence of clinically significant decision conflict (CSDC) among patients undergoing cancer surgery and associations with postoperative physical activity, as measured through smartphone accelerometer data. BACKGROUND: Patients with cancer face challenging treatment decisions, which may lead to CSDC. CSDC negatively affects patient-provider relationships, psychosocial functioning, and health-related quality of life; however, physical manifestations of CSDC remain poorly characterized. METHODS: Adult smartphone-owners undergoing surgery for breast, skin-soft-tissue, head-and-neck, or abdominal cancer (July 2017-2019) were approached. Patients downloaded the Beiwe application that delivered the Decision Conflict Scale (DCS) preoperatively and collected smartphone accelerometer data continuously from enrollment through 6 months postop-eratively. Restricted-cubic-spline regression, adjusting for a priori potential confounders (age, type of surgery, support status, and postoperative complications) was used to determine trends in postoperative daily physical activity among patients with and without CSDC (DCS score >25/100). RESULTS: Among 99 patients who downloaded the application, 85 completed the DCS (86% participation rate). Twenty-three (27%) reported CSDC. These patients were younger (mean age 48.3 years [standard deviation 14.2]-vs-55.0 [13.3], P = 0.047) and more frequently lived alone (22%-vs-6%, P = 0.042). There were no differences in preoperative physical activity (115.4 minutes [95%CI 90.9, 139.9]-vs-110.8 [95%CI 95.7, 126.0], P = 0.753). Adjusted postoperative physical activity was lower among patients reporting CSDC at 30 days (difference 33.1 minutes [95%CI 5.93,60.2], P = 0.017), 60 days 35.5 [95%CI 8.50, 62.5], P = 0.010 and 90 days 31.8 [95%CI 5.44, 58.1], P = 0.018 postoperatively. CONCLUSIONS: CSDC was prevalent among patients who underwent cancer surgery and associated with lower postoperatively daily physical activity. These data highlight the importance of addressing modifiable decisional needs of patients through enhanced shared decision-making.

Comparison of General Surgical Practice Size and Setting in 2017 vs 2013 in the US.

Importance: As health care delivery markets have changed and new payment models have emerged, physicians in many specialties have consolidated their practices, but whether this consolidation has occurred in surgical practices is unknown. Objective: To examine changes in the size of surgical practices, market-level factors associated with this consolidation, and how place of service for surgical care delivery varies by practice size. Design, Setting, and Participants: A cross-sectional study of Medicare Data on Provider Practice and Specialty from January 1 to December 31, 2013, compared with January 1 to December 31, 2017, was conducted on all general surgeon practices caring for patients enrolled in Medicare in the US. Data analysis was performed from November 4, 2019, to January 9, 2020. Exposures: Practice sizes in 2013 and 2017 were compared relative to hospital market concentration measured by the Herfindahl-Hirschman Index in the hospital referral region. Main Outcomes and Measures: The primary outcome was the change in size of surgical practices over the study period. Secondary outcomes included change in surgical practice market concentration and the place of service for provision of surgical care stratified by surgical practice size. Results: From 2013 to 2017, the number of surgical practices in the US decreased from 10 432 to 8451. The proportion of surgeons decreased in practices with 1 (from 26.2% to 17.4%), 2 (from 8.3% to 6.6%), and 3 to 5 (from 18.0% to 16.5%) surgeons, and the proportion of surgeons in practices with 6 or more surgeons increased (from 47.6% to 59.5%). Hospital concentration was associated with an increase in the size of the surgical practice. Each 10% increase in the hospital market concentration was associated with an increase of 0.204 surgeons (95% CI, 0.020-0.388 surgeons; P = .03) per practice from 2013 to 2017. Similarly, a 10% increase in the hospital-level HHI was associated with an increase in the surgical practice HHI of 0.023 (95% CI, 0.013-0.033; P < .001). Large surgical practices increased their share of Medicare services provided from 36.5% in 2013 to 45.6% in 2017. Large practices (31.3% inpatient in 2013 to 33.1% in 2017) were much more likely than small practices (19.0% inpatient in 2013 to 17.7% in 2017) to be based in hospital settings and this gap widened over time. Conclusions and Relevance: Surgeons have increasingly joined larger practices over time, and there has been a significant decrease in solo, small, and midsize surgical practices. The consolidation of surgeons into larger practices appears to be associated with hospital market concentration in the same market. Although overall care appears to be more hospital based for larger practices, the association between the consolidation of surgical practices and patient access and outcomes should be studied.

Correction to: Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers.

In the original version of the article, Dominique Vervoort's last name was misspelled. It is correct as reflected here. The original article has been updated.

Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers.

BACKGROUND: The Surgical Safety Checklist (SSC) has been shown to reduce perioperative complications across global health systems. We sought to assess perceptions of the SSC and suggestions for its improvement among medical students, trainees, and early career providers. METHODS: From July to September 2019, a survey assessing perceptions of the SSC was disseminated through InciSioN, the International Student Surgical Network comprising medical students, trainees, and early career providers pursuing surgery. Individuals with ≥2 years of independent practice after training were excluded. Respondents were categorized according to any clinical versus solely non-clinical SSC exposure. Logistic regression was used to evaluate associations between clinical/non-clinical exposure and promoting future use of the SSC, adjusting for potential confounders/mediators: training level, human development index, and first perceptions of the SSC. Thematic analysis was conducted on suggestions for SSC improvement. RESULTS: Respondent participation rate was 24%. Three hundred and eighteen respondents were included in final analyses; 215 (67%) reported clinical exposure and 190 (60%) were promoters of future SSC use. Clinical exposure was associated with greater odds of promoting future SSC use (aOR 1.81 95% CI [1.03-3.19], p = 0.039). A greater proportion of promoters reported "Improved Operating Room Communication" as a goal of the SSC (0.21 95% CI [0.15-0.27]-vs.-0.12 [0.06-0.17], p = 0.031), while non-promoters reported the SSC goals were "Not Well Understood" (0.08 95% CI [0.03-0.12]-vs.-0.03 [0.01-0.05], p = 0.032). Suggestions for SSC improvement emphasized context-specific adaptability and earlier formal training. CONCLUSIONS: Clinical exposure to the SSC was associated with promoting its future use. Earlier formal clinical training may improve perceptions and future use among medical students, trainees, and early career providers.

Effects Of A Communication-And-Resolution Program On Hospitals' Malpractice Claims And Costs.

To promote communication with patients after medical injuries and improve patient safety, numerous hospitals have implemented communication-and-resolution programs (CRPs). Through these programs, hospitals communicate transparently with patients after adverse events; investigate what happened and offer an explanation; and, when warranted, apologize, take responsibility, and proactively offer compensation. Despite growing consensus that CRPs are the right thing to do, concerns over liability risks remain. We evaluated the liability effects of CRP implementation at four Massachusetts hospitals by examining before-and-after trends in claims volume, cost, and time to resolution and comparing them to trends among nonimplementing peer institutions. CRP implementation was associated with improved trends in the rate of new claims and legal defense costs at some hospitals, but it did not significantly alter trends in other outcomes. None of the hospitals experienced worsening liability trends after CRP implementation, which suggests that transparency, apology, and proactive compensation can be pursued without adverse financial consequences.

Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Programs.

Through communication-and-resolution programs, hospitals and liability insurers communicate with patients when adverse events occur; investigate and explain what happened; and, where appropriate, apologize and proactively offer compensation. Using data recorded by program staff members and from surveys of involved clinicians, we examined case outcomes of a program used by two academic medical centers and two of their community hospitals in Massachusetts in the period 2013-15. The hospitals demonstrated good adherence to the program protocol. Ninety-one percent of the program events did not meet compensation eligibility criteria, and those events that did were not costly to resolve (the median payment was $75,000). Only 5 percent of events led to malpractice claims or lawsuits. Clinicians were supportive of the program but desired better communication about it from staff members. Our findings suggest that communication-and-resolution programs will not lead to higher liability costs when hospitals adhere to their commitment to offer compensation proactively.

Measuring Adverse Events in Hospitalized Patients: An Administrative Method for Measuring Harm.

CONTEXT: Current methods for tracking harm either require costly full manual chart review (FMCR) or rely on proxy methods that have questionable accuracy. We propose an administrative measure of harm detection that uses electronically captured data. OBJECTIVE: Determine the level of agreement on harm event occurrence when harm is detected based on an administrative harm measurement tool (AHMT) compared with FMCR. DESIGN: A retrospective chart review was used to measure the level of agreement in harm detection between an AHMT that uses electronically captured data and a FMCR. SETTING: The inpatient hospital setting was used. PATIENTS: Approximately 771 medical records from 5 hospitals were reviewed. MAIN OUTCOME MEASURES: Measures of positive predictive value, negative predictive value, weighted sensitivity, weighted specificity, and concordance were used to evaluate agreement between the 2 methods. RESULTS: Although there was agreement at the harm-event level, the results were not all as high as desired: adjusted sensitivity 65%, adjusted specificity 85%, positive predictive value (PPV) 59%, negative predictive value (NPV) 88%, and concordance 75%. The patient-level results show greater agreement: adjusted sensitivity 95%, adjusted specificity 86%, PPV 61%, NPV 99%, and concordance 81%. CONCLUSION: The AHMT is sufficiently accurate for use as a within hospital tool to reliably detect and track harm. Nevertheless, it is not recommended as a tool to make comparisons across institutions, which has policy and payment implications. Further research using administrative harm detection, including the use of a broader set of measures and electronic health records, is needed.

Can social media be used as a hospital quality improvement tool?

Many hospitals wish to improve their patients' experience of care. To learn whether social media could be used as a tool to engage patients and to identify opportunities for hospital quality improvement (QI), we solicited patients' narrative feedback on the Baystate Medical Center Facebook page during a 3-week period in 2014. Two investigators used directed qualitative content analysis to code comments and descriptive statistics to assess the frequency of selected codes and themes. We identified common themes, including: (1) comments about staff (17/37 respondents, 45.9%); (2) comments about specific departments (22/37, 59.5%); (3) comments on technical aspects of care, including perceived errors and inattention to pain control (9/37, 24.3%); and (4) comments describing the hospital physical plant, parking, and amenities (9/37, 24.3%). A small number (n = 3) of patients repeatedly responded, accounting for 30% (45/148) of narratives. Although patient feedback on social media could help to drive hospital QI efforts, any potential benefits must be weighed against the reputational risks, the lack of representativeness among respondents, and the volume of responses needed to identify areas of improvement.

Attitudes of hospital leaders toward publicly reported measures of health care quality.

IMPORTANCE: Public reporting of quality is considered a key strategy for stimulating improvement efforts at US hospitals; however, little is known about the attitudes of hospital leaders toward existing quality measures. OBJECTIVES: To describe US hospital leaders' attitudes toward hospital quality measures found on the Centers for Medicare & Medicaid Services' Hospital Compare website, assess use of these measures for quality improvement, and examine the association between leaders' attitudes and hospital quality performance. DESIGN, SETTING, AND PARTICIPANTS: We mailed a 21-item questionnaire from January 1 through September 31, 2012, to senior hospital leaders from a stratified random sample of 630 US hospitals, including equal numbers with better-than-expected, as-expected, and worse-than-expected performance on mortality and readmission measures. MAIN OUTCOMES AND MEASURES: We assessed levels of agreement with statements concerning quality measures, examined use of measures for improvement activities, and analyzed the association between leaders' attitudes and hospital performance. RESULTS: Of 630 hospitals surveyed, 380 (60.3%) responded. For each of the mortality, readmission, process, and patient experience measures, more than 70% of hospitals agreed with the statement that "public reporting stimulates quality improvement activity at my institution"; agreement for measures of cost and volume was 65.2% and 53.3%, respectively. A similar pattern was observed for the statement that "our hospital is able to influence performance on this measure"; agreement for processes of care and patient experience measures was 96.4% and 94.2%, respectively. A total of 89.7% of hospitals agreed that the hospital's reputation was influenced by patient experience measures; agreement was 77.4% for mortality, 69.9% for readmission, 76.3% for process measures, 66.1% for cost measures, and 54.0% for volume measures. A total of 87.1% of hospitals reported incorporating performance on publicly reported measures into their hospital's annual goals, whereas 90.2% reported regularly reviewing the results with the hospital's board of trustees and 94.3% with senior clinical and administrative leaders. When compared with chief executive officers and chief medical officers, respondents who identified themselves as chief quality officers or vice presidents of quality were less likely to agree that public reporting stimulates quality improvement and that measured differences are large enough to differentiate among hospitals. CONCLUSIONS AND RELEVANCE: Hospital leaders indicated that the measures reported on the Hospital Compare website exert strong influence over local planning and improvement efforts. However, they expressed concerns about the clinical meaningfulness, unintended consequences, and methods of public reporting.

Impact of cardiac telemetry on patient safety and cost.

BACKGROUND: With the impetus for healthcare reform and the imperative for healthcare organizations to improve efficiency and reduce waste, it is valuable to examine high-volume procedures and practices in order to identify potential overuse. At the same time, organizations must ensure that improved efficiency does not inadvertently reduce patient safety. METHODS: We undertook a multicenter analysis of the use of adult cardiac telemetry outside of the intensive care unit or step-down units at 4 teaching hospitals to determine the percentage of monitoring days that were not justified by an accepted indication and the monetary costs associated with these nonindicated days. We also assessed the safety of eliminating monitoring on days when it was not justified by looking at the incidence of arrhythmias. RESULTS: We found that in 35% of telemetry days, telemetry use was not supported by an accepted set of clinical indications. The incidence of arrhythmias on nonindicated days was low (3.1 per 100 days of monitoring per nonindicated day),and the arrhythmias detected were clinically insignificant. Eliminating monitoring on nonindicated days could save a minimum of $53 per patient per day. The average 400-bed hospital with a conservative estimate of 5000 nonindicated patientdays per year could save $250,000 per year. CONCLUSION: Reducing the use of telemetry on nonindicated days may provide an opportunity for institutions to safely reduce cost as well as staff time and effort, while maintaining and potentially increasing patient safety.

Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease.

CONTEXT: Systemic corticosteroids are beneficial for patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD); however, their optimal dose and route of administration are uncertain. OBJECTIVE: To compare the outcomes of patients treated with low doses of steroids administered orally to those treated with higher doses administered intravenously. DESIGN, SETTING, AND PATIENTS: A pharmacoepidemiological cohort study conducted at 414 US hospitals involving patients admitted with acute exacerbation of COPD in 2006 and 2007 to a non-intensive care setting and who received systemic corticosteroids during the first 2 hospital days. MAIN OUTCOME MEASURES: A composite measure of treatment failure, defined as the initiation of mechanical ventilation after the second hospital day, inpatient mortality, or readmission for acute exacerbation of COPD within 30 days of discharge. Length of stay and hospital costs. RESULTS: Of 79,985 patients, 73,765 (92%) were initially treated with intravenous steroids, whereas 6220 (8%) received oral treatment. We found that 1.4% (95% confidence interval [CI], 1.3%-1.5%) of the intravenously and 1.0% (95% CI, 0.7%-1.2%) of the orally treated patients died during hospitalization, whereas 10.9% (95% CI, 10.7%-11.1%) of the intravenously and 10.3% (95% CI, 9.5%-11.0%) of the orally treated patients experienced the composite outcome. After multivariable adjustment, including the propensity for oral treatment, the risk of treatment failure among patients treated orally was not worse than for those treated intravenously (odds ratio [OR], 0.93; 95% CI, 0.84-1.02). In a propensity-matched analysis, the risk of treatment failure was significantly lower among orally treated patients (OR, 0.84; 95% CI, 0.75-0.95), as was length of stay and cost. Using an adaptation of the instrumental variable approach, increased rate of treatment with oral steroids was not associated with a change in the risk of treatment failure (OR for each 10% increase in hospital use of oral steroids, 1.00; 95% CI, 0.97-1.03). A total of 1356 (22%) patients initially treated with oral steroids were switched to intravenous therapy later in the hospitalization. CONCLUSION: Among patients hospitalized for acute exacerbation of COPD low-dose steroids administered orally are not associated with worse outcomes than high-dose intravenous therapy.

Mortality rates as a measure of quality and safety, "caveat emptor".

The objective of this study was to demonstrate the impact of a single ICD-9 (International Statistical Classification of Diseases and Related Health Problems, Version 9) code on the observed-to-expected mortality ratios for acute care hospitals, calculated using administrative data. The study was a retrospective analysis of mortality data and prospective measurement of the impact of a change in coding on expected mortality rates. Measurement included overall mortality observed-to-expected mortality index for 2 hospitals and rate of use of the palliative care ICD-9 code. The main result was that both retrospective and prospective applications of this single ICD-9 code significantly reduced observed-to-expected mortality ratios. Both regulators and hospitals need to be aware of the impact of the quality of coding on publicly reported quality and patient safety data.

One system's journey in creating a disclosure and apology program.

BACKGROUND: Patients experience adverse events more frequently than the public appreciates. A number of health systems have led the movement toward open, prompt, and compassionate disclosure of adverse events. IMPLEMENTATION: In 2006 Baystate Health (BH) formed a disclosure advisory committee to design and implement an enhanced program to support prompt and skillful disclosure of adverse events. The proposed model for a disclosure and apology program resembled a consultation service, similar to a hospital ethics consultation service. BH hired an outside trainer to teach coaches/facilitators. Emotional support services were formalized and expanded not only for patients and families but also clinicians. THE EXPERIENCE SO FAR: Implementation of a formal disclosure and apology program has placed internal pressure on the organization to more promptly determine causality of adverse events and to respond to patient/family requests for information and/or assistance. Root causes and degree of system culpability are often not clear early after an event and sometimes are debated among the clinical team and the trained coaches/facilitators and risk managers. DISCUSSION: After a medical error, patients and families expect the organization to make changes to the system to prevent other patients from being harmed by the same mistake. To minimize the chance that patients and families feel that their suffering has been "in vain," health care systems will need to put systems in place to deliver on the promise to reduce the risk of future harm. Some of the challenges in sustaining such a program include the ability to promptly investigate, to accurately determine liability, to communicate empathetically even if unable to meet all patient/family expectations, and to ensure establishment of a just culture.

Public reporting of hospital quality: recommendations to benefit patients and hospitals.

Public reporting of hospital performance holds tremendous promise for improving the care provided by hospitals. To date, however, consumers have failed to embrace public reporting, despite considerable efforts to promote it. We review a number of reasons that public reporting has failed to live up to expectations, and we make 10 recommendations to improve the value of public reporting for both patients and hospitals. We also review 3 leading performance reporting programs to evaluate how well they adhere to these recommendations.