Enhanced Recovery After Surgery in Patients Implanted with Left Ventricular Assist Device.

INTRODUCTION: We sought to develop and implement a comprehensive enhanced recovery after surgery (ERAS) protocol for patients implanted with a left ventricular assist device (LVAD). METHODS AND RESULTS: In this article, we describe our approach to the development and phased implementation of the protocol. Additionally, we reviewed prospectively collected data for patients who underwent LVAD implantation at our institution from February 2019 to August 2020. To compare early outcomes in our patients before and after protocol implementation, we dichotomized patients into two 6-month cohorts (the pre-ERAS and ERAS cohorts) separated from each other by 6 months to allow for staff adoption of the protocol. Of the 115 LVAD implants, 38 patients were implanted in the pre-ERAS period and 46 patients in the ERAS period. Preoperatively, the patients` characteristics were similar between the cohorts. Postoperatively, we observed a decrease in bleeding (chest tube output of 1006 vs 647.5 mL, P < .001) and blood transfusions (fresh frozen plasma 31.6% vs 6.7%, P = .04; platelets 42.1% vs 8.7%, P = .001). Opioid prescription at discharge were 5-fold lower with the ERAS approach (P < .01). Furthermore, the number of patients discharged to a rehabilitation facility decreased significantly (20.0% vs 2.4%, P = .02). The index hospitalization length of stay and survival were similar between the groups. CONCLUSIONS: ERAS for patients undergoing LVAD implantation is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. In this article, we describe the details of the protocol and early positive changes in clinical outcomes. Further studies are needed to evaluate benefits of an ERAS protocol in an LVAD population.Lay Summary: Enhanced recovery after surgery (ERAS) is the implementation of standardized clinical pathways that ensures the use of best practices and decreased variation in perioperative care. Multidisciplinary teams work together on ERAS, thereby enhancing communication among health care silos. ERAS has been used for more than 30 years by other surgical services and has been shown to lead to a decreased length of stay, fewer complications, lower mortality, fewer readmissions, greater job satisfaction, and lower costs. Our goal was to translate these benefits to the perioperative care of complex patients with a left ventricular assist device. Early results suggest that this goal is possible; we have observed a decrease in transfusions, discharge on opioids, and discharge to a rehabilitation facility.

Health plan quality-of-care information is undermined by voluntary reporting.

BACKGROUND: Most health services in the United States are delivered by managed care organizations (MCOs). Publicly available, plan-specific performance information is required to adequately assess healthcare quality provided. Using women's health indicators, we compared performance results for MCOs and evaluated whether those MCOs that publicly report quality-of-care (QOC) results demonstrate better QOC than those plans that restrict public access to data. METHODS: Data from the Health Plan Employer Data and Information Set (HEDIS) for commercial MCOs in 1998 were analyzed for women's QOC indicators. Plan-specific, regional, and national performances were analyzed and results compared to established benchmarks. Public-reporting plans were compared to plans that restrict access to QOC information. Linear regression was used to identify determinants of health plan performance including public release of information. RESULTS: Commercial MCOs had wide variations in QOC indicators and, on average, failed to attain national health goals for most women's health indicators analyzed. Plans that restricted public access to QOC information had poorer performance than those that did not (p<0.05). Results suggest that whether a plan publicly releases its performance information is highly associated with health plan performance even after taking into account other factors. CONCLUSIONS: The voluntary aspect of reporting and the ability of health plans to restrict public access is allowing poorer performing health plans to escape public scrutiny. Variations in QOC have clinical significance and, if publicly available, would enable individuals to select high-quality healthcare products. The ability of health plans to restrict public information is not consistent with the 1973 Health Maintenance Organization Act requiring public information on health plan quality. A national strategy to ensure that QOC information is available on all healthcare systems is past due.

When the physician-researcher gets cancer: understanding cancer, its treatment, and quality of life from the patient's perspective.

The authors, both medical researchers, describe their personal experiences with cancer, its treatment, and its effects on their lives. They discuss the "eight Ds" that represent their concerns as they navigated this permanent disruption in their lives: diagnosis, dying, discomfort, disability, drug and other treatment effects, dependency, doubt, and death. They also discuss the beneficial effects that cancer has had on their lives and end with suggestions for clinicians and outcomes researchers who seek to assess and improve quality of life among persons with cancer.

Inflammatory myofibroblastic tumor of the gastroesophageal junction in childhood.

We report a unusual case of an inflammatory myofibroblastic tumor arising at the gastroesophageal junction in a 14-year-old girl. The bland histologic appearance with concurrent infiltration into adjacent structures made diagnostic interpretation difficult, but suggested a neoplastic process. A literature review was undertaken to address diagnostic and management issues raised in this case. Although the anatomic location was unusual, clinical, grass, histopathologic, and immunohistochemical data substantiated the diagnosis of inflammatory myofibroblastic tumor. The bland histologic appearance was consistent with the most widely accepted view of inflammatory myofibroblastic tumor as a low-grade neoplasm. Wide surgical excision was performed. This is considered the preferred treatment given the potential risk of recurrence and aggressive behavior, most frequently noted with extrapulmonary disease. Although inflammatory myofibroblastic tumor represents an heterologous spectrum of benign to malignant neoplastic proliferations, the prognosis is good in casts with benign histologic features.

Performance indicators in women's health: incorporating women's health in the health plan employer data and information set (HEDIS).

The Health plan Employer Data and Information Set (HEDIS) is limited in its scope of women's health-related performance measures. Realizing this, the National Committee for Quality Assurance developed the Women's Health Measurement Advisory Panel (MAP) to expand and develop HEDIS measures to better represent women's health issues. This paper outlines the development of several new women's health-related performance measures and highlights the complexities of creating new measures to assess the quality of care provided to women through our nation's managed care organizations.