Longitudinal Trends in 30-Day Mortality Between Multi-Site and Single-Site Surgeons.

BACKGROUND: Quality leaders are concerned that creation of multi-hospital health systems may lead to surgeons traveling to and from distant hospitals and thus to more fragmented surgical care and worse outcomes for their patients. Despite this concern, little empirical data exist on outcomes of multi-site versus single-site surgeons. METHODS: Using national Medicare data, we assessed trends in the number of multi-site vs. single-site surgeons from 2011 to 2016. We performed a multivariable regression analysis to compare overall 30-day mortality differences, stratified by system and rural status, and examined trends over time. RESULTS: The number of multi-site surgeons and the percentage of multi-site surgeons per hospital decreased over time (24.2%-19.0%; 44.3%-41.8%). Overall, multi-site surgeons had lower 30-day mortality than single-site surgeons (2.24% vs 2.50%, P < 0.01). When stratified by system status, multi-site surgeons performed better in-system (2.47% vs 2.58%, P < 0.01); by rural status, multi-site surgeons had lower mortality in non-rural hospitals (2.42% vs 2.51%, P < 0.01). The statistically significant but small mortality advantage of multi-site versus single-site surgeons decreased over time, such that by 2016 there was no difference in outcomes between multi-site and single-site surgeons. CONCLUSION: For the majority of study years, multi-site surgeons had lower 30-day mortality than single-site surgeons, but this trend narrowed until outcomes were equivalent by 2016. Surgeons operating at multiple hospitals can provide surgical care to patients without any evidence of increased mortality.

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.

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.

Experience with Designing and Implementing a Bundled Payment Program for Total Hip Replacement.

BACKGROUND: Bundled payments, also known as episode-based payments, are intended to contain health care costs and promote quality. In 2011 a bundled payment pilot program for total hip replacement was implemented by an integrated health care delivery system in conjunction with a commercial health plan subsidiary. In July 2015 the Centers for Medicare & Medicaid Services (CMS) proposed the Comprehensive Care for Joint Replacement Model to test bundled payment for hip and knee replacement. METHODS: Stakeholders were identified and a structure for program development and implementation was created. An Oversight Committee provided governance over a Clinical Model Subgroup and a Financial Model Subgroup. RESULTS: The pilot program included (1) a clinical model of care encompassing the period from the preoperative evaluation through the third postoperative visit, (2) a pricing model, (3) a program to share savings, and (4) a patient engagement and expectation strategy. Compared to 32 historical controls-patients treated before bundle implementation-45 post-bundle-implementation patients with total hip replacement had a similar length of hospital stay (3.0 versus 3.4 days, p=.24), higher rates of discharge to home or home with services than to a rehabilitation facility (87% versus 63%), similar adjusted median total payments ($22,272 versus $22,567, p=.43), and lower median posthospital payments ($704 versus $1,121, p=.002), and were more likely to receive guideline-consistent care (99% versus 95%, p=.05). DISCUSSION: The bundled payment pilot program was associated with similar total costs, decreased posthospital costs, fewer discharges to rehabilitation facilities, and improved quality. Successful implementation of the program hinged on buy-in from stakeholders and close collaboration between stakeholders and the clinical and financial teams.

Reducing the Risk of Delayed Colorectal Cancer Diagnoses Through an Ambulatory Safety Net Collaborative.

BACKGROUND: An estimated 12 million adults in the United States experience delayed diagnoses and other diagnostic errors annually. Ambulatory safety nets (ASNs) are an intervention to reduce delayed diagnoses by identifying patients with abnormal results overdue for follow-up using registries, workflow redesign, and patient navigation. The authors sought to co-design a collaborative and implement colorectal cancer (CRC) ASNs across various health care settings. METHODS: A working group was convened to co-design implementation guidance, measures, and the collaborative model. Collaborative sites were recruited through a medical professional liability insurance program and chose to begin with developing an ASN for positive at-home CRC screening or overdue surveillance colonoscopy. The 18-month Breakthrough Series Collaborative ran from January 2022 to July 2023, with sites continuing to collect data while sustaining their ASNs. Data were collected from sites monthly on patients in the ASN, including the proportion that was successfully contacted, scheduled, and completed a follow-up colonoscopy. RESULTS: Six sites participated; four had an operational ASN at the end of the Breakthrough Series, with the remaining sites launching three months later. From October 2022 through February 2024, the Collaborative ASNs collectively identified 5,165 patients from the registry as needing outreach. Among patients needing outreach, 3,555 (68.8%) were successfully contacted, 2,060 (39.9%) were scheduled for a colonoscopy, and 1,504 (29.1%) completed their colonoscopy. CONCLUSION: The Collaborative successfully identified patients with previously abnormal CRC screening and facilitated completion of follow-up testing. The CRC ASN Implementation Guide offers a comprehensive road map for health care leaders interested in implementing CRC ASNs.

The Patient Safety Adoption Framework: A Practical Framework to Bridge the Know-Do Gap.

OBJECTIVES: Many patient safety initiatives fail to be adopted and implemented, even when proven effective. This creates the well-recognized know-do gap, referring to the discrepancy between what healthcare workers know should be done based on evidence and what takes place in practice. We aimed to develop a framework to improve the adoption and implementation of patient safety initiatives. METHODS: We conducted a background literature review followed by qualitative interviews with patient safety leaders to identify barriers and facilitators to adoption and implementation. Inductive thematic analysis was used to generate themes that informed the development of the framework. We used a consensus-building approach to co-create the framework and guidance tool with an Ad Hoc Committee made up of subject-matter experts and patient family advisors. The framework was tested for utility, feasibility, and acceptability through qualitative interviews. RESULTS: The Patient Safety Adoption Framework contains 5 domains and 6 subdomains. The domains are leadership (subdomains: prioritization, accountability, governance), culture and context, process (subdomains: co-creation, high reliability, engagement), meaningful measurement, and person-centeredness. A guidance tool was developed to provide practical guidance for improvement teams using the framework. Testing affirmed the framework and guidance tool with a high degree of acceptability, feasibility, and utility among implementers and subject-matter experts. CONCLUSIONS: The Patient Safety Adoption Framework provides the essential components necessary to facilitate the adoption and implementation of patient safety initiatives. The framework offers a roadmap for healthcare organizations striving to close the know-do gap.

High-reliability organisation principles implemented in dentistry.

Introduction/objectives Successful dentistry inherently requires high-reliability and situational awareness to provide consistent high-quality care. However, treatment errors still occur in dentistry as they do in medicine. The importance of avoiding error is elevated for dentistry due to the increased frequency of irreversible procedures in each patient interaction compared to non-surgical specialties in medicine. Although a universal protocol for time-out exists, wrong-site procedures are a persistent healthcare issue in dentistry.Data By implementing high-reliability organisations (HROs) principles to dentistry, improved safety and quality can be achieved.Sources There are five essential principles that HROs have been observed to adhere to: preoccupation with failure; situational awareness/sensitivity to operations; a reluctance to simplify; deference to expertise; and commitment to resilience. Deep examination of the potential vulnerabilities in dentistry, using HRO ideology will create effective process improvement strategies. It fosters a culture of accountability using systematic problem-solving as opposed to condemnation.Study selection Implementation of HRO principles will improve the existing universal time-out process, while placing quality and performance at the central focus of strategic success.Conclusions Dentists can adopt these HRO principles into their practices to create effective process improvement strategies.

Serious Illness Care Programme-contextual factors and implementation strategies: a qualitative study.

OBJECTIVES: The Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients' values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three 'real-world' health system SICP initiatives. METHODS: We employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey. RESULTS: Analysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians' attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities. CONCLUSIONS: Health systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.

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.

Communication Tools to Support Advance Care Planning and Hospital Care During the COVID-19 Pandemic: A Design Process.

The COVID-19 pandemic has exposed the medical and social vulnerability of an unprecedented number of people. Consequently, there has never been a more important time for clinicians to engage patients in advance care planning (ACP) discussions about their goals, values, and preferences in the event of critical illness. An evidence-based communication tool-the Serious Illness Conversation Guide-was adapted to address COVID-related ACP challenges using a user-centered design process: convening relevant experts to propose initial guide adaptations; soliciting feedback from key clinical stakeholders from multiple disciplines and geographic regions; and iteratively testing language with patient actors. With feedback focused on sharing risk about COVID-19-related critical illness, recommendations for treatment decisions, and use of person-centered language, the team also developed conversation guides for inpatient and outpatient use. These tools consist of open-ended questions to elicit perception of risk, goals, and care preferences in the event of critical illness, and language to convey prognostic uncertainty. To support use of these tools, publicly available implementation materials were also developed for clinicians to effectively engage high-risk patients and overcome challenges related to the changed communication context, including video demonstrations, telehealth communication tips, and step-by-step approaches to identifying high-risk patients and documenting conversation findings in the electronic health record. Well-designed communication tools and implementation strategies can equip clinicians to foster connection with patients and promote shared decision making. Although not an antidote to this crisis, such high-quality ACP may be one of the most powerful tools we have to prevent or ameliorate suffering due to COVID-19.

Public reporting and pay for performance in hospital quality improvement.

BACKGROUND: Public reporting and pay for performance are intended to accelerate improvements in hospital care, yet little is known about the benefits of these methods of providing incentives for improving care. METHODS: We measured changes in adherence to 10 individual and 4 composite measures of quality over a period of 2 years at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative, including 207 facilities that simultaneously participated in a pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services; we then compared the pay-for-performance hospitals with the 406 hospitals with public reporting only (control hospitals). We used multivariable modeling to estimate the improvement attributable to financial incentives after adjusting for baseline performance and other hospital characteristics. RESULTS: As compared with the control group, pay-for-performance hospitals showed greater improvement in all composite measures of quality, including measures of care for heart failure, acute myocardial infarction, and pneumonia and a composite of 10 measures. Baseline performance was inversely associated with improvement; in pay-for-performance hospitals, the improvement in the composite of all 10 measures was 16.1% for hospitals in the lowest quintile of baseline performance and 1.9% for those in the highest quintile (P<0.001). After adjustments were made for differences in baseline performance and other hospital characteristics, pay for performance was associated with improvements ranging from 2.6 to 4.1% over the 2-year period. CONCLUSIONS: Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.

Outcomes of care by hospitalists, general internists, and family physicians.

BACKGROUND: The hospitalist model is rapidly altering the landscape for inpatient care in the United States, yet evidence about the clinical and economic outcomes of care by hospitalists is derived from a small number of single-hospital studies examining the practices of a few physicians. METHODS: We conducted a retrospective cohort study of 76,926 patients 18 years of age or older who were hospitalized between September 2002 and June 2005 for pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction at 45 hospitals throughout the United States. We used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians. RESULTS: As compared with patients cared for by general internists, patients cared for by hospitalists had a modestly shorter hospital stay (adjusted difference, 0.4 day; P<0.001) and lower costs (adjusted difference, $268; P=0.02) but a similar inpatient rate of death (odds ratio, 0.95; 95% confidence interval [CI], 0.85 to 1.05) and 14-day readmission rate (odds ratio, 0.98; 95% CI, 0.91 to 1.05). As compared with patients cared for by family physicians, patients cared for by hospitalists had a shorter length of stay (adjusted difference, 0.4 day; P<0.001), and the costs (adjusted difference, $125; P=0.33), rate of death (odds ratio, 0.95; 95% CI, 0.83 to 1.07), and 14-day readmission rate (odds ratio, 0.95; 95% CI, 0.87 to 1.04) were similar. CONCLUSIONS: For common inpatient diagnoses, the hospitalist model is associated with a small reduction in the length of stay without an adverse effect on rates of death or readmission. Hospitalist care appears to be modestly less expensive than that provided by general internists, but it offers no significant savings as compared with the care provided by family physicians.

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.

Patient and clinician experience of a serious illness conversation guide in oncology: A descriptive analysis.

BACKGROUND/OBJECTIVE: Oncology guidelines recommend earlier communication with patients about prognosis and goals-of-care in serious illness. However, current evidence leaves gaps in our understanding of the experience of these conversations. This analysis evaluates the patient and clinician experience of a conversation using a Serious Illness Conversation Guide (SICG). DESIGN/SETTING: Secondary analysis from a cluster-randomized clinical trial in a northeastern cancer center. PARTICIPANTS: Physicians, advanced practice clinicians, and patients with advanced cancer who received the intervention. INTERVENTION: SICG, clinician training, systems-changes. MAIN OUTCOMES AND MEASURES: The patient questionnaire assessed perceptions of the conversation and impact on anxiety, hopefulness, peacefulness, sense of control over medical decisions, closeness with their clinician, and behaviors. The clinician questionnaire assessed feasibility, acceptability, and impact on satisfaction in their role. RESULTS: We enrolled 54 clinicians and 163 patients; 41 clinicians and 118 patients had a SICG discussion. Most patients described the conversation as worthwhile (79%) and reported no change or improvement in their sense of peacefulness, hopefulness, and anxiety (on average 79%); 56% reported feeling closer with their clinician. Qualitative patient data described positive behavior changes, including enhanced planning for future care and increased focus on personal priorities. Nearly 90% of clinicians agreed that the SICG facilitated timely, effective conversations, and 70% reported increased satisfaction in their role. CONCLUSION: Conversations using a SICG were feasible, acceptable, and were associated with positive experiences for both patients and clinicians in oncology in ways that align with national recommendations for serious illness communication. This trial is registered at ClinicalTrials.gov: NCT01786811 https://clinicaltrials.gov/ct2/show/NCT01786811.

Effect of the Serious Illness Care Program on Health Care Utilization at the End of Life for Patients with Cancer.

Objectives: To determine the effect of the Serious Illness Care Program on health care utilization at the end of life in oncology. Design: Analysis of the secondary outcome of health care utilization as part of a cluster-randomized clinical trial that ran from 2012 to 2016. Clinicians in the intervention group received training, coaching, and system supports to have discussions with patients using a Serious Illness Conversation Guide (SICG); clinicians in the control arm followed usual care. Setting/Subject: Patients with advanced cancer who died within two years of enrollment at the Dana-Farber Cancer Institute. Measurement: Health care utilization was abstracted from the electronic medical record using the National Quality Forum (NQF)-endorsed indicators of aggressive cancer care at the end of life and scored from 0 to 6 (one point for each aggressive indicator); t tests and chi-square tests were used to determine differences between intervention and control patients. Results: The charts of 159 patients who died were reviewed. Neither the main outcome of mean number of aggressive indicators (0.9 vs. 0.9, p = 0.84) nor the proportion of patients with any aggressive care (49% intervention [95% CI: 40-57] vs. 54% control [95% CI: 42-67]) differed between patients in the intervention and control groups. Conclusion: In this analysis of a secondary outcome from a randomized clinical trial of the Serious Illness Care Program, intervention and control patients had similar end-of-life health care utilization as measured by the mean number of NQF-endorsed indicators. Future research efforts should focus on studying the strategies by which communication about patients' prognosis, values, and goals leads to personalized care plans.

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.

Perioperative beta-blocker therapy and mortality after major noncardiac surgery.

BACKGROUND: Despite limited evidence from randomized trials, perioperative treatment with beta-blockers is now widely advocated. We assessed the use of perioperative beta-blockers and their association with in-hospital mortality in routine clinical practice. METHODS: We conducted a retrospective cohort study of patients 18 years of age or older who underwent major noncardiac surgery in 2000 and 2001 at 329 hospitals throughout the United States. We used propensity-score matching to adjust for differences between patients who received perioperative beta-blockers and those who did not receive such therapy and compared in-hospital mortality using multivariable logistic modeling. RESULTS: Of 782,969 patients, 663,635 (85 percent) had no recorded contraindications to beta-blockers, 122,338 of whom (18 percent) received such treatment during the first two hospital days, including 14 percent of patients with a Revised Cardiac Risk Index (RCRI) score of 0 and 44 percent with a score of 4 or higher. The relationship between perioperative beta-blocker treatment and the risk of death varied directly with cardiac risk; among the 580,665 patients with an RCRI score of 0 or 1, treatment was associated with no benefit and possible harm, whereas among the patients with an RCRI score of 2, 3, or 4 or more, the adjusted odds ratios for death in the hospital were 0.88 (95 percent confidence interval, 0.80 to 0.98), 0.71 (95 percent confidence interval, 0.63 to 0.80), and 0.58 (95 percent confidence interval, 0.50 to 0.67), respectively. CONCLUSIONS: Perioperative beta-blocker therapy is associated with a reduced risk of in-hospital death among high-risk, but not low-risk, patients undergoing major noncardiac surgery. Patient safety may be enhanced by increasing the use of beta-blockers in high-risk patients.

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.