Disparities in Health Care Delivery Systems.

Racial disparities in health care systems exist in all phases of health care delivery. The Affordable Care Act has been unable to completely mitigate disparities in health care as the root cause (ie, socioeconomic inequality) remains unaddressed. Uninsured status, lack of transportation, high costs, health literacy, provider unavailability, lack of trust in the health system, and implicit bias block minority populations from obtaining deserved quality care. With the COVID-19 crisis, increased sensitivity and development of innovative approaches to provide accessibly and quality health care are necessary.

Effective Educational Approaches to Training Physicians About Lung Cancer Screening.

In 2013, the U.S. Preventative Services Task Force recommended low-dose computed tomography (LDCT) for lung cancer screening (LCS) after a national trial demonstrated a 20% reduction in lung cancer mortality with LDCT. Implementation of LCS employing LDCT depends heavily on physician education regarding multiple factors, including eligibility criteria, potential benefits and harms, and shared decision-making. To date, there are no studies of educational approaches for teaching physicians about LCS. This study aims to assess the feasibility and effectiveness of implementing an interactive, group-based learning (GBL) curriculum to teach physicians about LCS. A prospective study was conducted at two nearby institutions from 2017 to 2019 comparing GBL with a lecture format as measured by total knowledge about LCS, acceptability of the educational format, and ease of implementation. We surveyed participants regarding total knowledge and format acceptance. Results were compared to determine whether GBL is an effective and feasible educational strategy for LDCT and LCS education. Residents and faculty participating in GBL demonstrated greater total knowledge compared with residents and faculty participating in the lecture format. Participants in both cohorts preferred a mix of GBL and lecture formats. All participants believed that GBL facilitates implementation of LCS better than lecture-based learning. GBL is an effective and feasible approach for educating physicians about LCS, though it is more time- and resource-intensive than a lecture approach. However, healthcare providers believe GBL will facilitate implementation of LCS more than lectures.

Adherence to annual lung cancer screening with low-dose CT scan in a diverse population.

PURPOSE: Our aim was to develop a novel approach for lung cancer screening among a diverse population that integrates the Centers for Medicare and Medicaid Services (CMS) recommended components including shared decision making (SDM), low-dose CT (LDCT), reporting of results in a standardized format, smoking cessation, and arrangement of follow-up care. METHODS: Between October of 2015 and March of 2018, we enrolled patients, gathered data on demographics, delivery of SDM, reporting of LDCT results using Lung-RADS, discussion of results, and smoking cessation counseling. We measured adherence to follow-up care, cancer diagnosis, cancer treatment, and smoking cessation at 2 years after initial LDCT. RESULTS: We enrolled 505 patients who were 57% African American, 30% Caucasian, 13% Hispanic, < 1% Asian, and 61% were active smokers. All participants participated in SDM, 88.1% used a decision aid, and 96.1% proceeded with LDCT. Of 496 completing LDCT, all received a discussion about results and follow-up recommendations. Overall, 12.9% had Lung-RADS 3 or 4, and 3.2% were diagnosed with lung cancer resulting in a false-positive rate of 10.7%. All 48 patients with positive screens but no cancer diagnosis adhered to follow-up care at 1 year, but only 35.4% adhered to recommended follow-up care at 2 years. The annual follow-up for patients with negative lung cancer screening results (Lung-RADS 1 and 2) was only 23.7% after one year and 2.8% after 2 years. All active smokers received smoking cessation counseling, but only 11% quit smoking. CONCLUSION: The findings show that an integrated lung cancer screening program can be safely implemented in a diverse population, but adherence to annual screening is poor.

The University of Pennsylvania Medical School Commencement of 1889: Aequanimitas and the Agnew Clinic.

Academic commencements ceremonies usually do not result in memorable occasions and once ended usually are forgotten. Not so for the University of Pennsylvania's School of Medicine commencement on May 1,1889, which was marked by an address by William Osler, the retirement of the renowned Professor of Surgery, D. Hayes Agnew, and the presentation to the University of Thomas Eakins' remarkable masterpiece, "The Agnew Clinic." Osler had been on the faculty of the University for 5 years and in his keynote address, Aequanimitas, he laid out 2 elements, imperturbability and equanimity, that he stated would "make or mar" the lives of the students he was addressing. His words and message that day have continued to resonate for medical students and many others up to the present day. Osler ended his address on a more somber note, seemingly surprising the assembled, by announcing his imminent departure from the University. He would soon be one of the 4 founders of the Johns Hopkins Hospital along with fellow Penn faculty member, Howard Kelly. Osler was not the only one on the verge of leaving as this commencement also marked the end of the career of D. Hayes Agnew. To honor him on this occasion of his retirement the 3 classes of medical students had commissioned Eakins to paint a portrait of their revered professor, which was presented on this commencement day and accepted by Trustee Dr S. Weir Mitchell on behalf of the University. The day was indeed one to be remembered.

Aiding shared decision making in lung cancer screening: two decision tools.

BACKGROUND: Shared decision making (SDM) preceding lung cancer screening is important for populations that are underrepresented in lung cancer screening trials. Current evidence-based guidelines; however, do not address personal risk and outcomes in underrepresented populations. This study compared two SDM decision aids (Option Grids and Shouldiscreen.com) for SDM efficacy, decision regret and knowledge. METHODS: We conducted a prospective trial of lung cancer screening patients (N = 237) randomized to SDM with Option Grids or Shouldiscreen.com. To evaluate the SDM process after lung cancer screening, patients answered two questionnaires: CollaboRATE and Decision Regret. Patients also completed a questionnaire to test their knowledge of lung cancer screening. RESULTS: Patients were predominantly African American (61.6%), though multiple races, varying education levels and equal genders were represented. Patients in both Option Grids and Shouldiscreen.com groups reported favorable SDM experiences (P = 0.60) and equivalent knowledge about lung cancer screening (P = 0.43). Patients using Shouldiscreen.com had less knowledge regarding the potential complications of subsequent testing (P = 0.02). Shouldiscreen.com patients had increased regret regarding their decision to pursue screening (P = 0.02). CONCLUSIONS: Option Grids and Shouldiscreen.com both facilitated a meaningful SDM process. However, Option Grids patients experienced decreased decision regret and enhanced knowledge of the potential complications of screening.

Thymic Neuroendocrine Tumors and Thymic Carcinoma: Demographics, Treatment, and Survival.

OBJECTIVE: Although rare, thymic neuroendocrine tumors (TNET) and thymic carcinoma (TC) are the most common thymic nonthymomatous malignancies; their survival outcomes have not been thoroughly compared. We analyzed the clinical, treatment, and survival characteristics of TNET and TC. METHODS: We retrospectively identified patients with a histologic diagnosis of TNET or TC in the National Cancer Database (2004 to 2015). Exclusion criteria were age <18 years and unstaged tumors. Descriptive statistics, survival analysis, and multivariable Cox regression analyses were used in elucidating associations. RESULTS: One thousand four hundred eighty-nine patients were included (TNET: 19.8%). Patients with TNET were significantly younger (57 vs 62.5 years), more likely to be male (70.5% vs 60.0%), and have localized tumors (45.4% vs 32.3%). Patients with TC more frequently underwent chemotherapy (56.1% vs 34.9%), radiation (56.9% vs 39.3%), and trimodality therapy (21.3% vs 11.5%), while resection rates were similar (55.3% vs 58.3%). The 5-year survival was 62% for TNET and 52% for TC, but comparable following multivariable adjustment. Age, stage, and Charlson-Deyo score were negative predictors of survival, while surgery and trimodality therapy were positive predictors. On subanalysis, adjuvant radiation therapy (ART) improved the survival of margin-positive tumors and was an independent predictor of survival for both tumor types (hazard ratio = 0.5). CONCLUSIONS: Our analysis of the largest series of TNET and TC showed a survival rate surpassing 50% at 5 years. These outcomes seem to be influenced by surgical resection and ART. Standardized staging and surgical protocols including lymph node sampling are still warranted to better elucidate the treatment algorithm of these tumors.

Examining Gender Differences in Lung Cancer Screening.

It is unknown if gender influences outcome of lung cancer screening with Low Dose CT (LDCT), especially with frequent and continued underrepresentation of women in clinical trials. We examined a balanced cohort of men and women with the hypothesis that there would be no difference in participation or results between men and women undergoing lung cancer screening. In an urban, academic medical center, we prospectively collected data on patients referred for lung cancer screening from October 2015 to August 2018. We studied gender, age, ethnicity, level of education and smoking history. We measured results of LDCT using Lung-RADS reporting system. 546 patients underwent LDCT between October 2015 and August 2018. 279 (51%) were female and 267 (49%) were males. Age, education status or smoking patterns did not significantly differ between females and males There was a significant difference between males and females in the distribution of LDCT results (p = 0.05). 81 females and 105 males were diagnosed with Lung-RADS 1; 99 females and 92 males with Lung-RADS 2; 15 females and 8 males with Lung-RADS 3; 19 females and 11 males with Lung-RADS 4. Overall, 10 females (3.5%) and 3 males (1.1%) were diagnosed with lung cancer (risk difference 2.4, 95% CI-0.0006-0.05, p = 0.09). Women are often underrepresented in clinical trials. Preliminary results from our lung cancer screening program demonstrate equal participation and equal benefit from the screening program. Long term data is needed to study survival benefit.

An Enhanced Shared Decision Making Model to Address Willingness and Ability to Undergo Lung Cancer Screening and Follow-Up Treatment in Minority Underserved Populations.

Failure to address willingness and ability to undergo lung cancer treatment before lung cancer screening could cause patients unnecessary anxiety, cost and care. We employed an enhanced shared decision making (SDM) model to address willingness and ability to undergo lung cancer screening of low dose CT (LDCT) scanning. We hypothesized that enhanced SDM was feasible and did not discourage patients from undergoing lung cancer screening. We performed a prospective study of patients referred for lung cancer screening. We measured adherence to the LCS protocol, including consent to discuss lung cancer treatment if cancer is found and direct questions to patients about willingness and ability to undergo lung cancer treatment. We measured race, gender, adherence to the consent process and questions regarding willingness and ability to undergo lung cancer treatment and subsequent uptake of LDCT. All 190 patients have a documented SDM visit addressing the risks and benefits of lung cancer screening and consented to discuss lung cancer treatment if lung cancer is diagnosed. One hundred and seventy-nine (179) of 190 (94%) answered yes to being willing and able to undergo lung cancer treatment. One hundred and eighty-seven (187) patients underwent LDCT (98.4%). Discussion about willingness and ability to undergo lung cancer treatment should be an essential component of a SDM discussion prior to LDCT. This study demonstrated that an enhanced SDM experience is feasible in a clinical setting. Furthermore, patients proceeded with LDCT following the enhanced SDM process.

Endoscopy after esophagectomy: Safety demonstrated in a porcine model.

BACKGROUND: Endoscopy is useful in assessing conduit ischemia and anastomotic leaks after esophagectomy but poses a theoretical threat of anastomotic disruption. We used a porcine model to evaluate the safety of endoscopy after esophagectomy. METHODS: We performed esophagectomies in 10 live pigs and performed endoscopy with progressive air insufflation and continuous intraluminal pressure monitoring. We stopped insufflation when the intraluminal pressure reached a plateau. We assessed the integrity of the conduit and anastomosis via endoscopy. We also performed pulse oximetry of the stomach and Doppler velocimetry of the right gastroepiploic artery on 5 live pigs to study the effects of endoscopic gastric insufflation. RESULTS: With gentle air insufflation, there was no measurable increase in intraluminal pressure, disruption of the conduit or anastomosis, or significant gastric distension. With progressive insufflation, the intraluminal pressure reached a plateau at a maximum of 8.7 ± 2.1 cm H2O (95% confidence interval, 7.2-10.2). At this plateau, air leaked retrograde via the mouth, which prevented further gastric distension. There were no significant changes in oxyhemoglobin saturation along various regions in the stomach even with maximal insufflation sustained for 10 minutes. There was a momentary reduction in gastroepiploic flow from 12.0 ± 1.0 [95% confidence interval, 10.8-13.2] mL/min/100 g to 9.6 ± 1.5 [95% confidence interval, 7.8-11.4] mL/min/100 g immediately after maximal insufflation, but flow recovered to 11 ± 1.3 [9.6, 12.8] mL/min/100 g after 10 minutes of sustained insufflation. CONCLUSIONS: Endoscopy after esophagectomy with gentle or maximal air insufflation results in safe endoluminal pressures and minimal disturbance of blood flow and oxygenation.

Assuring survival of safety-net surgical patients.

BACKGROUND: Survival of surgical inpatients is a key quality metric. Patient, surgeon, and system factors all contribute to inpatient mortality, and sophisticated risk adjustment is required to assess outcomes. When the mortality of general surgery patients was determined to be high at a safety-net hospital, a comprehensive approach was undertaken to improve patient survival. METHODS: General surgical service line mortality was measured in the database of the University HealthSystem Consortium from January 2013 through June 2015. Ten best practices were implemented sequentially to decrease observed and/or increase expected mortality. University HealthSystem Consortium mortality rank, observed, expected, and observed/expected index as well as early deaths were compared with control charts for 30 months. RESULTS: University HealthSystem Consortium general surgery mortality improved from the bottom decile to the top quartile, while Case Mix Index increased from 2.48 to 2.82 (P < .05). Observed mortality decreased from 3.39 to 2.35%. Expected mortality increased from 1.40 to 2.73% (P < .05). The observed/expected mortality index decreased from 2.43 to 0.86 (P < .05). Early deaths decreased from 0.52 to 0% (P < .05). CONCLUSION: Risk-adjusted mortality and early deaths decreased significantly over 30 months in general surgery patients. Systematic implementation of quality best practices was associated with improved survival of general surgery patients at a safety-net medical center.

Clinical pathway for esophagectomy improves perioperative nutrition.

BACKGROUND: Clinical pathways reduce hospitalization and costs in colorectal and pancreatic cancer. We describe creating an esophagectomy pathway and analyze its implementation and effects. METHODS: We documented the process of developing an esophagectomy clinical pathway. We performed a retrospective review of prospectively collected data on 12 patients before pathway implementation and 12 patients after. RESULTS: Pathway Implementation: more patients were presented at tumor board (9 pathway vs. 2 pre-pathway; p=0.012) and chose their postoperative care facility before surgery (8 vs. 0; p=0.0013) OUTCOMES: There were no changes in mortality (0 vs. 0), major complications (5 vs. 5), hospitalization (median 9.5 vs. 12 days; p=0.82), and total charges ($ 98,395 vs. $ 96,946; p=0.96). Pathway patients lost significantly less weight preoperatively (2.3% vs. 7.6%; p=0.01) and perioperatively (6.3% vs. 12%; p=0.02). CONCLUSIONS: This is the first study to report the process of designing and implementing an esophagectomy pathway. While there was no significant decrease in mortality, complications, hospitalization, or charges, our pathway significantly decreased pre- and perioperative weight loss, which we attribute to coordinated patient education and care.

Transforming Patient Value: Comparison of Hospital, Surgical, and General Surgery Patients.

BACKGROUND: Patient value (V) is enhanced when quality (Q) is increased and cost (C) is diminished (V = Q/C). However, calculating value has been inhibited by a lack of risk-adjusted cost data. The aim of this analysis was to measure patient value before and after implementation of quality improvement and cost reduction programs. STUDY DESIGN: Multidisciplinary efforts to improve patient value were initiated at a safety-net hospital in 2012. Quality improvement focused on adoption of multiple best practices, and minimizing practice variation was the strategy to control cost. University HealthSystem Consortium (UHC) risk-adjusted quality (patient mortality + safety + satisfaction + effectiveness) and cost (length of stay + direct cost) data were used to calculate patient value over 3 fiscal years. Normalized ranks in the UHC Quality and Accountability Scorecard were used in the value equation. RESULTS: For all hospital patients, quality scores improved from 50.3 to 66.5, with most of the change occurring in decreased mortality. Similar trends were observed for all surgery patients (42.6 to 48.4) and for general surgery patients (30.9 to 64.6). For all hospital patients, cost scores improved from 71.0 to 2.9. Similar changes were noted for all surgical (71.6 to 27.1) and general surgery (85.7 to 23.0) patients. Therefore, value increased more than 30-fold for all patients, 3-fold for all surgical patients, and almost 8-fold for general surgery patients. CONCLUSIONS: Multidisciplinary quality and cost efforts resulted in significant improvements in value for all hospitalized patients as well as general surgery patients. Mortality improved the most in general surgery patients, and satisfaction was highest among surgical patients.