The Effect of Anesthesia Type on Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement.

OBJECTIVES: To assess postoperative outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) either under general anesthesia (GA) or monitored anesthesia care (MAC) as the primary anesthetic. DESIGN: A retrospective, propensity-matched, cohort study, with univariate logistic regression to assess postoperative outcomes. SETTING: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). PARTICIPANTS: The study comprised 559 patients who underwent a TAVR procedure under GA or MAC. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After propensity score matching, there were no significant differences between the two cohorts in age, sex, race, body mass index, functional status, American Society of Anesthesiologists physical status, and other comorbidities. There were no significant differences in 30-day mortality between the two cohorts, or in the number of complications at 30 days. However, hospital length of stay was significantly shorter in the MAC cohort compared with the GA cohort. CONCLUSIONS: Patients undergoing TAVR under MAC may have similar 30-day mortality and complications, but shorter hospital length of stay, than patients undergoing TAVR under GA.

Inpatient imaging utilization: trends of the past decade.

OBJECTIVE: We have previously reported inpatient imaging utilization trends at our institution from fiscal year (FY) 1984 through FY 2002. In this study, we assessed the trends in imaging utilization for inpatients from FY 2003 through FY 2012. MATERIALS AND METHODS: In this institutional review board-approved retrospective study performed at a 793-bed tertiary care academic institution, we reviewed imaging utilization in adult inpatients from October 1, 2002, through September 30, 2012 (FY 2003 through FY 2012), and recorded the gross number of imaging studies coded by modality (conventional [radiography and fluoroscopy], ultrasound, nuclear medicine, CT, and MRI) and associated relative value units (RVUs). We used linear regression to assess trends in number of imaging studies and RVUs per case-mix-adjusted admission (CMAA). RESULTS: The total number of imaging studies, as well as the number of CT, nuclear medicine, and conventional studies adjusted for case mix, decreased (p=0.02, p=0.0006, p=0.0008, and p=0.001, respectively); CT per CMAA increased until FY 2009 and then decreased through FY 2012. Utilization of ultrasound and MRI did not change significantly (p=0.15 and p=0.22, respectively). Unadjusted global RVUs increased until FY 2009 and then showed a slight decrease through FY 2012 (p=0.04), whereas RVUs per CMAA did not change significantly (p=0.18). CONCLUSION: After decades of continued rise, imaging utilization for inpatients significantly decreased by most measures between FY 2009 and FY 2012. Future studies to evaluate the contribution of various factors to this decline, including efforts to reduce inappropriate use of imaging and concerns about potential harms of radiation exposure, may be helpful in optimizing imaging utilization and resource planning.

The meaningful use regulations in information technology: what do they mean for quality improvement in hospitals?

If provider organizations are serious about improving quality and efficiency, they must advance their electronic health record capabilities far beyond just meeting the U.S. federal regulations.

Shared decision-making - Creating pathways and models of care.

Shared decision-making (SDM) is an essential element providing patient-centered perioperative care. Newer value-based healthcare models, defined as patient-centered outcomes versus the cost required to achieve these outcomes, will necessitate the use of metrics that reflect the alignment of treatment decisions with patient preferences and goals. The heart of a successful SDM conversation is ensuring this alignment. Accountability for ensuring high quality SDM perioperatively is not clearly assigned. By learning methodologies to successfully incorporate SDM into clinical practice, anesthesiologists can increase the value of care they provide to their patients. The ideal means of achieving SDM within the complexity of modern medicine is not yet certain.

Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement.

To prepare for the increasing numbers of older adults undergoing surgery, the American College of Surgeons (ACS) has recently launched the Geriatric Surgery Verification Program with the goal of encouraging the creation of centers of geriatric surgery. Meanwhile, the Society for Perioperative Assessment and Quality Improvement (SPAQI) has published recommendations for the preoperative management of frailty, which state that teams should actively screen for frailty before surgery and that pathways, including geriatric comanagement, shared decision-making, and multimodal prehabilitation, should be embedded in routine care to help improve patient outcomes. Both SPAQI and the ACS advocate for a multidisciplinary approach to improve the value of care for older adults undergoing surgery. However, the best way to implement geriatric services in the surgical setting is yet to be determined. In this statement, we will describe the SPAQI recommendations for launching a geriatric surgery center and the process by which its value should be assessed over time.

Multifaceted approach to reducing unnecessary red blood cell utilization.

Strong organizational leadership,experienced project leaders,and the engagement of front-line stakeholders are critical elements for performance improvement efforts. A holistic approach,including incentives, feedback, a collaborative interdisciplinary process, decision support, and education may be necessary to change clinician behavior. A multifaceted performance improvement effort can lead to dramatic improvement in value for patients and society.

Interest in and perceived barriers to flexible-track residencies in general surgery: a national survey of residents and program directors.

OBJECTIVE: The American Board of Surgery now permits general surgery residents to complete their clinical training over a 6-year period. Despite this new policy, the level of interest in flexible scheduling remains undefined. We sought to determine why residents and program directors (PDs) are interested in flexible tracks and to understand implementation barriers. DESIGN: National survey. SETTING: All United States general surgery residency programs that participate in the Association of Program Directors in Surgery listserv. PARTICIPANTS: PDs and categorical general surgery residents in the United States. MAIN OUTCOME MEASURES: Attitudes about flexible tracks in surgery training. A flexible track was defined as a schedule that allows residents to pursue nonclinical time during residency with resulting delay in residency completion. RESULTS: Of the 748 residents and 81 PDs who responded, 505 residents and 45 PDs were supportive of flexible tracks (68% vs 56%, p = 0.03). Residents and PDs both were interested in flexible tracks to pursue research (86% vs 82%, p = 0.47) and child bearing (69% vs 58%, p = 0.13), but residents were more interested in pursuing international work (74% vs 53%, p = 0.004) and child rearing (63% vs 44%, p = 0.02). Although 71% of residents believe that flexible-track residents would not be respected as the equal of other residents, only 17% of PDs indicated they would not respect flexible-track residents (p < 0.001). CONCLUSION: Most residents and PDs support flexible tracks, although they differ in their motivation and perceived barriers. This finding lends support to the new policy of the American Board of Surgery.

Proposed checklist of hospital interventions to decrease the incidence of healthcare-associated Clostridium difficile infection.

BACKGROUND: The incidence and severity of Clostridium difficile infection (CDI) are increasing, and previously described interventions for controlling the spread of CDI are not easily generalized to multiple healthcare institutions. OBJECTIVE: We tested prevention and treatment bundles to decrease the incidence of CDI and the mortality associated with CDI at our hospital. DESIGN: Observational before-after study of adult patients admitted to a tertiary care, university-affiliated hospital during the period from January 2004 through December 2008. METHODS: In January 2006, we launched an educational campaign and introduced a prevention bundle-a series of specific processes aimed at preventing the transmission of C. difficile among hospitalized patients, including enhanced isolation practices, laboratory notification procedures, and steps coordinating infection control and environmental services activities. In April 2006, we implemented a treatment bundle-a set of hospital-wide treatment practices aimed at minimizing the risk of serious CDI complications. We tracked quarterly incidence rates and case-fatality rates for healthcare-associated CDI cases at our hospital. Our main outcome was the healthcare-associated CDI incidence rate, measured as the number of healthcare-associated cases of CDI per 1,000 patient-days. RESULTS: We followed patients for a total of 1,047,849 patient-days. The healthcare-associated CDI incidence rates fell from an average of 1.10 cases per 1,000 patient-days before intervention to 0.66 cases per 1,000 patient-days after intervention. This statistically significant decrease amounts to a 40% reduction in incidence after the intervention. CONCLUSIONS: Our intervention was successful in reducing the incidence of CDI at our hospital. On the basis of our experience, we propose the use of a checklist of hospital interventions to decrease the incidence of healthcare-associated CDI.