Event-Based Learning and Improvement: Radiology's Move From Peer Review to Peer Learning.

Over the past 15 years, the radiology community has made great progress moving from a system of score-based peer review to one of peer learning. Much has been learned along the way. In peer learning, cases in which learning opportunities are identified are reviewed solely for the purpose of fostering learning and improvement. This article defines peer learning and peer review and emphasizes the difference; looks back at the 20-year history of score-based peer review and transition to peer learning; outlines the problems with score-based peer review and the key elements of peer learning; discusses the current state of peer learning; and outlines future challenges and opportunities.

Osteopetrosis complicated by multilevel spondylolysis.

Osteopetrosis is a heterogenous group of inheritable disorders which manifests as increased bone density and brittleness. The most common and mildest variant typically presents in adulthood with bone pain and pathologic fractures, including spondylolysis. We present the case of an otherwise healthy, active 17-year-old male with a history of osteopetrosis and 1 year of chronic back pain, found to have multilevel (L1-L4) spondylolysis in the setting of severe diffuse bony sclerosis consistent with osteopetrosis. While single-level spondylolysis is an uncommon complication of osteopetrosis, multilevel spondylolysis in the pediatric population is extremely rare and the genetics of prior cases studies have not been reported. Spondylolysis should be considered as one of the types of fractures that may occur in patients with osteopetrosis.

Evaluation of claims data from a commercial value-based insurance product shows pediatric imaging is not a major driver of overall or pediatric healthcare expenditures.

BACKGROUND: Initiatives to reduce healthcare expenditures often focus on imaging, suggesting that imaging is a major driver of cost. OBJECTIVE: To evaluate medical expenditures and determine if imaging was a major driver in pediatric as compared to adult populations. METHODS: We reviewed all claims data for members in a value-based contract between a commercial insurer and a healthcare system for calendar years 2021 and 2022. For both pediatric (<18 years of age) and adult populations, we analyzed average per member per year (PMPY) medical expenditures related to imaging as well as other categories of large medical expenses. Average PMPY expenditures were compared between adult and pediatric patients. RESULTS: Children made up approximately 20% of members and 21% of member months but only 8-9% of expenditures. Imaging expenditures in pediatric members were 0.2% of the total healthcare spend and 2.9% of total pediatric expenditures. Imaging expenditures per member were seven times greater in adults than children. The rank order of imaging expenditures and imaging modalities was also different in pediatric as compared to adult members. CONCLUSION: Evaluation of claims data from a commercial value-based insurance product shows that pediatric imaging is not a major driver of overall, nor pediatric only, healthcare expenditures.

The Joint Commission's Ongoing Professional Practice Evaluation Process: Costly, Ineffective, and Potentially Harmful to Safety Culture.

OBJECTIVE: To evaluate the estimated labor costs and effectiveness of Ongoing Professional Practice Evaluation (OPPE) processes at identifying outlier performers in a large sample of providers across multiple health care systems and to extrapolate costs and effectiveness nationally. METHODS: Six hospital systems partnered to evaluate their labor expenses related to conducting OPPE. Estimates for mean labor hours and wages were created for the following: data analysts, medical staff office professionals, department physician leaders, and administrative assistants. The total number of outlier performers who were identified by OPPE metrics alone and that resulted in lack of renewal, limitation, or revoking of hospital privileges during the past annual OPPE cycle (2022) was recorded. National costs of OPPE were extrapolated. Literature review of the effect of OPPE on safety culture in radiology was performed. RESULTS: The evaluated systems had 12,854 privileged providers evaluated by OPPE. The total estimated annual recurring labor cost per provider was $50.20. Zero of 12,854 providers evaluated were identified as outlier performers solely through the OPPE process. The total estimated annual recurring cost of administering OPPE nationally was $78.54 million. In radiology over the past 15 years, the use of error rates based on score-based peer review as an OPPE metric has been perceived as punitive and had an adverse effect on safety culture. CONCLUSION: OPPE is expensive to administer, inefficient at identifying outlier performers, diverts human resources away from potentially more effective improvement work, and has been associated with an adverse impact on safety culture in radiology.

Current State of Peer Learning in Radiology: A Survey of ACR Members.

PURPOSE: Peer learning (PL) programs seek to improve upon the limitations of score-based peer review and incorporate modern approaches to improve patient care. The aim of this study was to further understand the landscape of PL among members of the ACR in the first quarter of 2022. METHODS: Members of the ACR were surveyed to evaluate the incidence, current practices, perceptions, and outcomes of PL in radiology practice. The survey was administered via e-mail to 20,850 ACR members. The demographic and practice characteristics of the 1,153 respondents (6%) were similar to those of the ACR radiologist membership and correspond to a normal distribution of the population of radiologists and can therefore be described as representative of that population. Therefore, the error range for the results from this survey is ±2.9% at a 95% confidence level. RESULTS: Among the total sample, 610 respondents (53%) currently use PL, and 334 (29%) do not. Users of PL are younger (mode age ranges, 45-54 years for users and 55-64 years for nonusers; P < .01), more likely to be female (29% vs 23%, P < .05), and more likely to practice in urban settings (52% vs 40%, P = .0002). Users of PL feel that it supports an improved culture of safety and wellness (543 of 610 [89%]) and fosters continuous improvement initiatives (523 of 610 [86%]). Users of PL are more likely than nonusers to identify learning opportunities from routine clinical practice (83% vs 50%, P < .00001), engage in programming inclusive of more team members, and implement more practice improvement projects (P < .00001). PL users' net promoter score of 65% strongly suggests that users of PL are highly likely to recommend the program to colleagues. CONCLUSIONS: Radiologists across a breadth of radiology practices are engaged in PL activities, which are perceived to align with emerging principles of improving health care and enhance culture, quality, and engagement.

The Association Between Central Line-Associated Bloodstream Infection and Central Line Access.

OBJECTIVES: Identifying modifiable risk factors associated with central line-associated bloodstream infections (CLABSIs) may lead to modifications to central line (CL) management. We hypothesize that the number of CL accesses per day is associated with an increased risk for CLABSI and that a significant fraction of CL access may be substituted with non-CL routes. DESIGN: We conducted a retrospective cohort study of patients with at least one CL device day from January 1, 2015, to December 31, 2019. A multivariate mixed-effects logistic regression model was used to estimate the association between the number of CL accesses in a given CL device day and prevalence of CLABSI within the following 3 days. SETTING: A 395-bed pediatric academic medical center. PATIENTS: Patients with at least one CL device day from January 1, 2015, to December 31, 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 138,411 eligible CL device days across 6,543 patients, with 639 device days within 3 days of a CLABSI (a total of 217 CLABSIs). The number of per-day CL accesses was independently associated with risk of CLABSI in the next 3 days (adjusted odds ratio, 1.007; 95% CI, 1.003-1.012; p = 0.002). Of medications administered through CLs, 88% were candidates for delivery through a peripheral line. On average, these accesses contributed a 6.3% increase in daily risk for CLABSI. CONCLUSIONS: The number of daily CL accesses is independently associated with risk of CLABSI in the next 3 days. In the pediatric population examined, most medications delivered through CLs could be safely administered peripherally. Efforts to reduce CL access may be an important strategy to include in contemporary CLABSI-prevention bundles.

Predictive Ability of the Braden QD Scale for Hospital-Acquired Venous Thromboembolism in Hospitalized Children.

PURPOSE: Hospital-acquired venous thromboembolisms (HA-VTEs) are increasingly common in pediatric inpatients and associated with significant morbidity and cost. The Braden QD Scale was created to predict the risk of hospital-acquired pressure injury (HAPI) and is used broadly in children's hospitals. This study evaluated the ability of the Braden QD Total score to predict risk of HA-VTE at a quaternary children's hospital. METHODS: To analyze the predictive potential of the Braden QD Total score and subscores for HA-VTEs, the researchers performed univariate logistic regressions. The increase in a patient's odds of developing an HA-VTE for every 1-point increase in each Braden QD score was evaluated. Each model was evaluated using a 5-fold cross-validated area-under-the-curve of the corresponding receiver operating characteristic curve (AUROC). RESULTS: This study analyzed 27,689 pediatric inpatients. HA-VTE occurred in 135 patients. The odds of HA-VTE incidence increased by 29% (odds ratio 1.29, 95% confidence interval [CI] 1.25-1.34, p < 0.001) for every 1-point increase in a patient's Braden QD Total score. The AUROC was 0.81 (95% CI 0.77-0.85). CONCLUSION: The Braden QD Scale is a predictor for HA-VTE, outperforming its original intended use for predicting HAPI and performing similarly to other HA-VTE predictive models. As the Braden QD Total score is currently recorded in the electronic health records of many children's hospitals, it could be practically and easily implemented as a tool to predict which patients are at risk for HA-VTE.

Serious Experience Events: Applying Patient Safety Concepts to Improve Patient Experience.

Pediatric healthcare systems have successfully decreased patient harm and improved patient safety by adopting standardized definitions, processes, and infrastructure for serious safety events (SSEs). We have adopted those patient safety concepts and used that infrastructure to identify and create action plans to mitigate events in which patient experience is severely compromised. We define those events as serious experience events (SEEs). The purpose of this research brief is to describe SEE definitions, infrastructure used to evaluate potential SEEs, and creation of action plans as well as share our preliminary experiences with the approach.

Patient and family experience with telemedicine and in-person pediatric and obstetric ambulatory encounters throughout 2020, during the COVID-19 epidemic: the distance effect.

BACKGROUND: Telemedicine has grown significantly in recent years, mainly during the COVID-19 pandemic, and there has been a growing body of literature on the subject. Another topic that merits increased attention is differences in patient and family experience between telehealth and in-person visits. To our team's knowledge, this is the first study evaluating pediatric and obstetrics outpatients experience with telemedicine and in-person visit types in an academic maternal and children's hospital, and its correlation with geographic distance from the medical center throughout 2020, during the COVID-19 crisis. METHODS: We aim to evaluate and compare patients' telemedicine and in-person experience for ambulatory encounters based on survey data throughout 2020, during the COVID-19 pandemic, with particular focus on the influence of distance of the patient's home address from the medical facility. A total of 9,322 patient experience surveys from ambulatory encounters (6,362 in-person and 2,960 telemedicine), in a maternal and children's hospital during 2020 were included in this study. The percentage of patients who scored the question "Likelihood to recommend practice" with a maximum 5/5 (top box) score was used to evaluate patient experience. The k-means model was used to create distance clusters, and statistical t-tests were conducted to compare mean distances and Top Box values between telemedicine and in-person models. Logistic regression analysis was used to evaluate the correlation between Top Box scores and patients' distance to the hospital. RESULTS: Top Box likelihood to recommend percentages for in-person and telemedicine were comparable (in-person = 81.21%, telemedicine = 81.70%, p-value = 0.5624). Mean distance from the hospital was greater for telemedicine compared to in-person patients (in-person = 48.89 miles, telemedicine = 61.23 miles, p-value < 0.01). Patients who live farther displayed higher satisfaction scores regardless of the visit type (p-value < 0.01). CONCLUSIONS: There is a direct relationship between the family experience and the distance from the considered medical center, during year 2020, i.e., patients who live farther from the hospital record higher Top Box proportion for "Likelihood to Recommend" than patients who live closer to the medical center, regardless of the approach, in-person or telemedicine.

Factors Influencing Health Equity of Influenza Vaccination in Pediatric Patients.

Social factors can be a determinate for multiple health outcomes. We evaluated the association of numerous social factors on rates of influenza nonvaccination in a large pediatric primary and subspecialty care system. Methods: During the 2019-2020 influenza vaccination season, we calculated the nonvaccination rate for a pediatric healthcare system with both subspecialty and primary care practices. We compared influenza vaccination rates for factors that might affect health equity (patient gender, language preference, health insurance payer category, race and ethnicity, and estimated median household income based on zip code analysis) by creating simultaneous 95% confidence intervals using the Wilson method with continuity correction and a Bonferroni adjustment for the number of categories compared. Results: The overall influenza nonvaccination rate was 58.0% (59,375 not vaccinated of 102,377). Statistically significant differences in nonvaccination rate were present for the following health equity indicators: Spanish (75.6%) and Chinese Dialects (78.0%) > English (55.9%) speaking; Hispanic (70.1%) > many other race and ethnicities; Asian (51%) < many other race and ethnicities; Commercial (53.5%) < Public (71.2%) or Self (81.4%) pay; and lower (67.6%-79.1%) > higher median household income (52.9%-56.4%). Conclusions: Non-English language preference, Hispanic ethnicity, public insurance, and lower median household income are associated with a decreased likelihood of influenza vaccination. We are using these data to inform our key drivers to improve influenza vaccination in our system.

Use of Natural Language Processing (NLP) in Evaluation of Radiology Reports: An Update on Applications and Technology Advances.

Natural language processing (NLP) is focused on the computer interpretation of human language and can be used to evaluate radiology reports and has demonstrated useful applications in essentially all aspects of medical imaging delivery: interpretation of imaging data, improving image acquisition, image analysis, and increasing efficiency of imaging services. This manuscript reviews general technologic approaches to NLP at a level hopefully understandable by clinical radiologists, discusses recent advancements in NLP techniques, and discusses current and potential applications of NLP in radiology.

Performance of a Commonly Used Pressure Injury Risk Model Under Changing Incidence.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) cause patient harm and increase health care costs. We sought to evaluate the performance of the Braden QD Scale-associated changes in HAPI incidence. METHODS: Using electronic health records data from a quaternary children's hospital, we evaluated the association between Braden QD scores and patient risk of HAPI. We analyzed how this relationship changed during a hospitalwide quality HAPI reduction initiative. RESULTS: Of 23,532 unique patients, 108 (0.46%, 95% confidence interval [CI] = 0.38%-0.55%) experienced a HAPI. Every 1-point increase in the Braden QD score was associated with a 41% increase in the patient's odds of developing a HAPI (odds ratio [OR] = 1.41, 95% CI = 1.36-1.46, p < 0.001). HAPI incidence declined significantly following implementation of a HAPI-reduction initiative (ß = -0.09, 95% CI = -0.11 - -0.07, p < 0.001), as did Braden QD positive predictive value (ß = -0.29, 95% CI = -0.44 - -0.14, p < 0.001) and specificity (ß = -0.28, 95% CI = -0.43 - -0.14, p < 0.001), while sensitivity (ß = 0.93, 95% CI = 0.30-1.75, p = 0.01) and the concordance statistic (ß = 0.18, 95% CI = 0.15-0.21, p < 0.001) increased significantly. CONCLUSION: Decreases in HAPI incidence following a quality improvement initiative were associated with (1) significant deterioration in threshold-dependent performance measures such as specificity and precision and (2) significant improvements in threshold-independent performance measures such as the concordance statistic. The performance of the Braden QD Scale is more stable as a tool that continuously measures risk than as a prediction tool.

Effect of Time of Daily Data Collection on the Calculation of Catheter-associated Urinary Tract Infection Rates.

INTRODUCTION: According to the National Healthcare Safety Network (NHSN) definitions for Catheter-associated urinary tract infections (CAUTI) rates, determination of the number of urinary catheter days must occur by calculating the number of catheters in place "for each day of the month, at the same time of day" but does not define at what time of day this occurs. The purpose of this review was to determine if a data collection time of 11 am would yield a greater collection of urinary catheter days than that done at midnight. METHODS: During a 20-month period, the number of urinary catheter days was calculated using once-a-day electronic measurements to identify a urinary catheter presence. We used data collected at 11 am and collected at midnight (our historic default) in comparing the calculated urinary catheter days and resultant CAUTI rates. RESULTS: There were 7,548 patients who had a urinary tract catheter. The number of urinary catheter days captured using the 11 am collection time was 15,425, and using the midnight collection time was 10,234, resulting in a 50.7% increase. The CAUTI rate per 1,000 urinary catheter days calculated using the 11 am collection method was 0.58, and using the midnight collection method was 0.88, a reduced CAUTI rate of 33.6%. CONCLUSION: The data collection time can significantly impact the calculation of urinary catheter days and on calculated CAUTI rates. Variations in how healthcare systems define their denominator per current National Healthcare Safety Network policy may result in significant differences in reported rates.

Development and Implementation of a Real-time Bundle-adherence Dashboard for Central Line-associated Bloodstream Infections.

INTRODUCTION: Central line-associated bloodstream infections (CLABSIs) are the most common hospital-acquired infection in pediatric patients. High adherence to the CLABSI bundle mitigates CLABSIs. At our institution, there did not exist a hospital-wide system to measure bundle-adherence. We developed an electronic dashboard to monitor CLABSI bundle-adherence across the hospital and in real time. METHODS: Institutional stakeholders and areas of opportunity were identified through interviews and data analyses. We created a data pipeline to pull adherence data from twice-daily bundle checks and populate a dashboard in the electronic health record. The dashboard was developed to allow visualization of overall and individual element bundle-adherence across units. Monthly dashboard accesses and element-level bundle-adherence were recorded, and the nursing staff's feedback about the dashboard was obtained. RESULTS: Following deployment in September 2018, the dashboard was primarily accessed by quality improvement, clinical effectiveness and analytics, and infection prevention and control. Quality improvement and infection prevention and control specialists presented dashboard data at improvement meetings to inform unit-level accountability initiatives. All-element adherence across the hospital increased from 25% in September 2018 to 44% in December 2019, and average adherence to each bundle element increased between 2018 and 2019. CONCLUSIONS: CLABSI bundle-adherence, overall and by element, increased across the hospital following the deployment of a real-time electronic data dashboard. The dashboard enabled population-level surveillance of CLABSI bundle-adherence that informed bundle accountability initiatives. Data transparency enabled by electronic dashboards promises to be a useful tool for infectious disease control.

Healthcare Worker Serious Safety Events: Applying Concepts from Patient Safety to Improve Healthcare Worker Safety.

INTRODUCTION: Patient safety has improved pediatric healthcare by defining when patient safety events meet criteria as serious safety events (SSEs). Similar concepts apply to healthcare worker (HCW) safety. We describe the newly designed process for HCW injury reporting, the process for evaluating HCW SSEs, and early experience with the new systems. METHODS: The work to redesign our approach to HCW safety included 2 parts: (1) process flow mapping and redesigning the work for HCW injury reporting; and (2) creating a process to categorize HCW injuries and determine when such injuries rise to a HCW SSE level. We evaluated the mean time per month from HCW injury to reporting and compared those values during the postimplementation time. We also evaluated the team's experience with the first 4 potential HCW SSEs. RESULTS: By improving the process flow, the mean time to reporting decreased significantly from 28 days implementation time-period (September-October 2019) to 9 days during the postimplementation time-period (November 2019-May 2020) (P = 0.0002). Of the first 4 HCW events identified and reviewed as possible HCW SSE events, there were 2 defined as HCW SSE level 4, one defined as a precursor event, and one defined as a nonsafety event. CONCLUSION: Adapting infrastructure and definitions used previously to improve patient safety can improve HCW safety.

Optimizing Professional Practice Evaluation to Enable a Nonpunitive Learning Health System Approach to Peer Review.

Healthcare organizations are focused on 2 different and sometimes conflicting tasks; (1) accelerate the improvement of clinical care delivery and (2) collect provider-specific data to determine the competency of providers. We describe creating a process to meet both of these aims while maintaining a culture that fosters improvement and teamwork. METHODS: We created a new process to sequester activities related to learning and improvement from those focused on individual provider performance. We describe this process, including data on the number and type of cases reviewed and survey results of the participant's perception of the new process. RESULTS: In the new model, professional practice evaluation committees evaluate events purely to identify system issues and human factors related to medical decision-making, resulting in actional improvements. There are separate and sequestered processes that evaluate concerns around an individual provider's clinical competence or behavior. During the first 5 years of this process, 207 of 217 activities (99.5%) related to system issues rather than issues concerning individual provider competence or behavior. Participants perceived the new process as focused on identifying system errors (4.3/5), nonpunitive (4.2/5), an improvement (4.0/5), and helped with engagement in our system and contributed to wellness (4.0/5). CONCLUSION: We believe this sequestered approach has enabled us to achieve both the oversight mandates to ensure provider competence while enabling a learning health systems approach to build the cultural aspects of trust and teamwork that are essential to driving continuous improvement in our system of care.