Can We Do That Here? Establishing the Scope of Surgical Practice at a New Safety-Net Community Hospital Through a Transparent, Collaborative Review of Physician Privileges.

PROBLEM DEFINITION: Stewarding of physician privileges wisely is imperative, but no guidelines exist for how to incorporate system-level factors in privileging decisions. A newly opened, safety-net community hospital tailored the scope of surgical practice through review of physician privileges. Martin Luther King, Jr. Community Hospital is a public-private partnership, safety-net institution in South Los Angeles that opened in July 2015. It has 131 beds, including a 28-bed emergency department, a 20-bed ICU, and 5 operating rooms. Staff privileging decisions were initially based only on physicians' training and experience, but this resulted in several cases that tested the boundaries of what a small community hospital was prepared to handle. ITERATION AND PIVOTS: A collaborative, transparent process to review physician privileges was developed. This began with physician-only review of procedure lists, followed by a larger, multidisciplinary group to assess system-level factors. Specific questions were used to guide discussion, and unanimous approval from all stakeholders was required to include a procedure. An initial list of 558 procedures across 11 specialties was reduced to 321 (57.5%). No new cases that fall outside these new boundaries have arisen. KEY INSIGHTS: An inclusive process was crucial for obtaining buy-in and establishing cultural norms. Arranging transfer agreements remains a significant challenge. NEXT STEPS: Accumulation of institutional experience continues through regular performance reviews. As this hospital's capabilities mature, a blueprint has been established for expanding surgical scope of practice based explicitly on system-level factors.

PEP Talk: Prostate Education Program, "Cutting Through the Uncertainty of Prostate Cancer for Black Men Using Decision Support Instruments in Barbershops".

The objective of this study was to investigate the effectiveness of using decision support instruments (DSI) to assist African-American (AA) men in making a prostate cancer (CaP) screening decision. This nonrandomized pretest-posttest comparison study assessed two DSI that were either culturally tailored or culturally nonspecific. CaP knowledge, intention to screen, and preferences were assessed before and after exposure to DSI using a convenience sample of 120 AA men aged 40 years and above. Participants interested in screening were referred to healthcare providers through a community-based patient navigator to obtain prostate-specific antigen (PSA) testing. We followed up 3 months after to determine if participants screened for CaP. CaP knowledge increased following exposure to both DSI in equivalent proportions. While similar proportions of men ultimately intended on having a PSA test following both DSI, bivariate analysis revealed that the culturally tailored DSI demonstrated a statistically significant increase in intention to screen. Participants' degree of certainty in their decision-making process with regard to CaP screening increased following the culturally tailored DSI (p < .001). The majority of participants planned on discussing CaP screening with a healthcare provider upon completion of the study. Barbershop-based health education can change the knowledge, preferences, intentions, and behaviors of this at-risk population. At 3 months follow-up, half (n = 58) of the participants underwent PSA testing, which led to the diagnosis of CaP in one participant. Community-led interventions for CaP, such as cluster-randomized designs in barbershops, are needed to better assess the efficacy of DSI in community settings.

Prostate Cancer Foundation Screening Guidelines for Black Men in the United States.

BACKGROUND: In the United States, Black men are at highest risk for being diagnosed with and dying from prostate cancer. Given this disparity, we examined relevant data to establish clinical prostate-specific antigen (PSA) screening guidelines for Black men in the United States. METHODS: A comprehensive literature search identified 1848 unique publications for screening. Of those screened, 287 studies were selected for full-text review, and 264 were considered relevant and form the basis for these guidelines. The numbers were reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: Three randomized controlled trials provided Level 1 evidence that regular PSA screening of men 50 to 74 years of age of average risk reduced metastasis and prostate cancer death at 16 to 22 years of follow-up. The best available evidence specifically for Black men comes from observational and modeling studies that consider age to obtain a baseline PSA, frequency of testing, and age when screening should end. Cohort studies suggest that discussions about baseline PSA testing between Black men and their clinicians should begin in the early 40s, and data from modeling studies indicate prostate cancer develops 3 to 9 years earlier in Black men compared with non-Black men. Lowering the age for baseline PSA testing to 40 to 45 years of age from 50 to 55 years of age, followed by regular screening until 70 years of age (informed by PSA values and health factors), could reduce prostate cancer mortality in Black men (approximately 30% relative risk reduction) without substantially increasing overdiagnosis. CONCLUSIONS: These guidelines recommend that Black men should obtain information about PSA screening for prostate cancer. Among Black men who elect screening, baseline PSA testing should occur between ages 40 and 45. Depending on PSA value and health status, annual screening should be strongly considered. (Supported by the Prostate Cancer Foundation.).

Changes in serum prostate-specific antigen levels and the identification of prostate cancer in a large managed care population.

OBJECTIVE: To determine whether the rate of change in total serum prostate-specific antigen (PSA) levels accurately detects prostate cancer and to evaluate whether it adds any predictive value to a single measurement of serum PSA alone, in general practice settings. MATERIALS AND METHODS: A retrospective cohort of 219,388 community-dwelling men, aged ≥45 years, enrolled in the Kaiser Permanente Southern California health plan, with no history of prostate cancer and at least three PSA measurements, were followed from 1 January 1998 to 31 December 2007, for the development of biopsy-confirmed prostate cancer. Annual percent changes in total serum PSA levels were estimated using linear mixed models. The accuracy of prostate cancer prediction was assessed for prostate cancer overall and for aggressive disease (Gleason score ≥7) and compared with that of a single measure of PSA level using area under the receiver-operating characteristic curves (AUCs). RESULTS: The men in this cohort experienced a mean change of 2.9% in PSA levels per year and the rate of change in PSA increased modestly with age (P ≤ 0.001). Annual percent changes in PSA accurately predicted the presence of prostate cancer (AUC = 0.963) and aggressive disease (AUC = 0.955) and had more predictive accuracy for aggressive disease than did a single measurement of PSA alone (AUC = 0.727). CONCLUSIONS: Longitudinal measures of PSA improve the accuracy of aggressive prostate cancer detection when compared with a single measurement of PSA alone. Findings from this study provide insight into the usefulness of PSA velocity as a detection marker for aggressive prostate cancer.

Cost-effectiveness of Prostate Health Index for prostate cancer detection.

OBJECTIVE: • To evaluate the cost-effectiveness of early prostate cancer detection with the Beckman Coulter Prostate Health Index (phi) (not currently available in the USA) adding to the serum prostate-specific antigen (PSA) test compared with the PSA test alone from the US societal perspective. PATIENTS AND METHODS: • Phi was developed as a combination of PSA, free PSA, and a PSA precursor form [-2]proPSA to calculate the probability of prostate cancer and was used as an aid in distinguishing prostate cancer from benign prostatic conditions for men with a borderline PSA test (e.g. PSA 2-10 ng/mL or 4-10 ng/mL) and non-suspicious digital rectal examination. • We constructed a Markov model with probabilistic sensitivity analysis to estimate expected costs and utilities of prostate cancer detection and consequent treatment for the annual prostate cancer screening in the male population aged 50-75 years old. • The transition probabilities, health state utilities and prostate cancer treatment costs were derived from the published literature. The diagnostic performance of phi was obtained from a multi-centre study. Diagnostic related costs were obtained from the 2009 Medicare Fee Schedule. • Cost-effectiveness was compared between the strategies of PSA test alone and PSA plus phi under two PSA thresholds (≥2 ng/mL and ≥4 ng/mL) to recommend a prostate biopsy. RESULTS: • Over 25 annual screening cycles, the strategy of PSA plus phi dominated the PSA-only strategy using both thresholds of PSA ≥2 ng/mL and PSA ≥4 ng/mL, and was estimated to save $1199 or $443, with an expected gain of 0.08 or 0.03 quality adjusted life years, respectively. • The probabilities of PSA plus phi being cost effective were approximately 77-70% or 78-71% at a range of $0-$200,000 willingness to pay using PSA thresholds ≥2 ng/mL and ≥4 ng/mL, respectively. CONCLUSION: • The strategy PSA plus phi may be an important strategy for prostate cancer detection at both thresholds of PSA ≥2 ng/mL and PSA ≥4 ng/mL to recommend a prostate biopsy compared with using PSA alone.

Moving urologic disparities research from evidence synthesis to translational research: a dynamic, multidisciplinary approach to tackling inequalities in urology.

Disparities in urology are well-documented but less is known about the role of translational research within existing interventional models to address inequalities. In this narrative review, we utilize an accepted framework of the process of translational research in mitigating disparities to investigate current translational and interventional urologic programs that bridge the gap. Three established, disparity-focused urologic interventional programs were identified and are highlighted in depth. Finally, we extrapolate from these findings to provide 10 policy relevant implications to help move urologic disparities research from evidence synthesis to translational research.

Comprehension, utility, and preferences of prostate cancer survivors for visual timelines of patient-reported outcomes co-designed for limited graph literacy: meters and emojis over comics.

OBJECTIVE: Visual timelines of patient-reported outcomes (PRO) can help prostate cancer survivors manage longitudinal data, compare with population averages, and consider future trajectories. PRO visualizations are most effective when designed with deliberate consideration of users. Yet, graph literacy is often overlooked as a design constraint, particularly when users with limited graph literacy are not engaged in their development. We conducted user testing to assess comprehension, utility, and preference of longitudinal PRO visualizations designed for prostate cancer survivors with limited literacy. MATERIALS AND METHODS: Building upon our prior work co-designing longitudinal PRO visualizations with survivors, we engaged 18 prostate cancer survivors in a user study to assess 4 prototypes: Meter, Words, Comic, and Emoji. During remote sessions, we collected data on prototype comprehension (gist and verbatim), utility, and preference. RESULTS: Participants were aged 61-77 (M = 69), of whom half were African American. The majority of participants had less than a college degree (95%), had inadequate health literacy (78%), and low graph literacy (89%). Among the 4 prototypes, Meter had the best gist comprehension and was preferred. Emoji was also preferred, had the highest verbatim comprehension, and highest rated utility, including helpfulness, confidence, and satisfaction. Meter and Words both rated mid-range for utility, and Words scored lower than Emoji and Meter for comprehension. Comic had the poorest comprehension, lowest utility, and was least preferred. DISCUSSION: Findings identify design considerations for PRO visualizations, contributing to the knowledge base for visualization best practices. We describe our process to meaningfully engage patients from diverse and hard-to-reach groups for remote user testing, an important endeavor for health equity in biomedical informatics. CONCLUSION: Graph literacy is an important design consideration for PRO visualizations. Biomedical informatics researchers should be intentional in understanding user needs by involving diverse and representative individuals during development.

Epidemiology of bone fracture across the age span in blacks and whites.

BACKGROUND: Gender and racial disparities in injury mortality have been well established, but less is known regarding differences in fracture-related hospitalizations across the age span. METHODS: Cross-sectional analysis of annual incident fracture hospital admissions used statewide acute care hospital discharge data (Statewide Program and Research Cooperative System) for non-Hispanic White (n = 138,763) and non-Hispanic Black (n = 19,588) residents of New York State between 2000 and 2002. US census data with intercensal estimates were used to ascertain the population at risk. Gender- and race-specific incident fracture was calculated in 5-year age intervals. The χ test was used to analyze categorical variables. RESULTS: Mechanisms of injury vary by race and gender in their relative contribution to injury-related fractures across the age span. Black males exhibited higher fracture incidence until approximately age 62, while incidence in women diverged around age 45. Total motor vehicle traffic-related fracture hospitalization is bimodal in Whites but not in Blacks. Over the life span, all groups exhibited bimodal pedestrian fractures with pedestrian fractures accounting for 8.8% and 2.5% of all fractures in Blacks and Whites, respectively. Racial disparities were present from preschool through age 70. Violence-related fractures were 10 times higher in Blacks, accounting for 18.2% of hospitalizations. Black males exhibit higher fracture incidence due to violence by age 5 and higher gun violence by age 10; both remain elevated through age 75. CONCLUSIONS: Despite historical studies demonstrating higher bone density in Blacks, this study found racial disparities with increased fracture risk in both Black children and adults across most nonfall-related injury mechanisms examined.

Differences in Implementation Outcomes of a Shared Decision-Making Program for Men with Prostate Cancer between an Academic Medical Center and County Health Care System.

BACKGROUND: Shared decision making (SDM) has long been advocated as the preferred way for physicians and men with prostate cancer to make treatment decisions. However, the implementation of formal SDM programs in routine care remains limited, and implementation outcomes for disadvantaged populations are especially poorly described. We describe the implementation outcomes between academic and county health care settings. METHODS: We administered a decision aid (DA) for men with localized prostate cancer at an academic center and across a county health care system. Our implementation was guided by the Consolidated Framework for Implementation Research and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. We assessed the effectiveness of the DA through a postappointment patient survey. RESULTS: Sites differed by patient demographic/clinical characteristics. Reach (DA invitation rate) was similar and insensitive to implementation strategies at the academic center and county (66% v. 60%, P = 0.37). Fidelity (DA completion rate) was also similar at the academic center and county (77% v. 80%, P = 0.74). DA effectiveness was similar between sites, except for higher academic center ratings for net promoter for the doctor (77% v. 37%, P = 0.01) and the health care system (77% v. 35%, P = 0.006) and greater satisfaction with manner of care (medians 100 v. 87.5, P = 0.04). Implementation strategies (e.g., faxing of patients' records and meeting patients in the clinic to complete the DA) represented substantial practice changes at both sites. The completion rate increased following the onset of reminder calls at the academic center and the creation of a Spanish module at the county. CONCLUSIONS: Successful DA implementation efforts should focus on patient engagement and access. SDM may broadly benefit patients and health care systems regardless of patient demographic/clinical characteristics.

A comparative analysis of serious injury and illness among homeless and housed low income residents of New York City.

BACKGROUND: Delivery of effective primary, secondary, and tertiary injury prevention in homeless populations is complex and could be greatly aided by an improved understanding of contributing factors. METHODS: Injury and health conditions were examined for hospitalized New York City homeless persons (n = 326,073) and low socioeconomic status (SES) housed residents (n = 1,202,622) using 2000 to 2002 New York statewide hospital discharge data (Statewide Program and Research Cooperative System). Age- and gender-adjusted odds ratios with 95% confidence intervals were calculated within age groups of 0.1 years to 9 years, 10 years to 19 years, 20 years to 64 years, and ≥65 years, with low SES housed as the comparison group. RESULTS: Comorbid conditions, injury, and injury mechanisms varied by age, gender, race or ethnicity, and housing status. Odds of unintentional injury in homeless versus low SES housed were higher in younger children aged 0 years to 9 years (1.34, 1.27-1.42), adults (1.13, 1.09-1.18), and elderly (1.25, 1.20-1.30). Falls were increased by 30% in children, 14% in adolescents or teenagers, and 47% in the elderly. More than one-quarter (26.9%) of fall hospitalizations in homeless children younger than 5 years were due to falls from furniture with more than threefold differences observed in both 3 year and 4 year olds (p = 0.0001). Several comorbid conditions with potential to complicate injury and postinjury care were increased in homeless including nutritional deficiencies, infections, alcohol and drug use, and mental disorders. CONCLUSIONS: Although homelessness presents unique, highly complex social and health issues that tend to overshadow the need for and the value of injury prevention, this study highlights potentially fruitful areas for primary, secondary, and tertiary prevention.

Health promotion in barbershops: balancing outreach and research in African American communities.

Promoting health and preventing illness among African American men, who die disproportionately from preventable diseases, is a challenging health disparity that has seen limited progress. However, focusing our efforts in places outside of traditional clinical and community settings such as the barbershop has shown promise for ameliorating these disparities. In particular, barbershop-based health promotion as conducted by the Black Barbershop Health Outreach Program has successfully reached nearly 10,000 men nationwide through a grassroots, volunteer-driven effort. At the same time, researchers have begun to conduct formal clinical trials in barbershops in order to explore interventions targeting this at-risk population. Herein, we describe, in brief a review of barbershop-based health promotion and the experience of this novel community-based organization. We argue for continuing to integrate evaluation and research using community-partnered principles into successful grassroots initiatives without dulling the practical impact of these programs is a crucial next step as we move beyond simply acknowledging health disparities and seek to find solutions.

Cardiovascular disease control through barbershops: design of a nationwide outreach program.

OBJECTIVES: To review the success of barbershops as vehicles for health promotion and outline the Black Barbershop Health Outreach Program (BBHOP), a rapidly growing, replicable model for health promotion through barbershops. METHODS: BBHOP was established by clinicians in order to enhance community level awareness of and empowerment for cardiometabolic disorders such as diabetes and cardiovascular disease. At coordinated events utilizing existing infrastructures as well as culturally and gender-specific health promotion, BBHOP volunteers screen for diabetes and hypertension and reinforce lifestyle recommendations for the prevention of cardiometabolic disorders from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Patrons with abnormal findings are referred to participating physicians or health care facilities. We performed a selective review of the literature in order to place this model for health promotion in the context of previous efforts in barbershops. BBHOP is among several successful programs that have sought to promote health in barbershops. Combining a grassroots organization approach to establishing a broad-based network of volunteers and partner agencies with substantial marketing expertise and media literacy, the BBHOP has screened more than 7000 African American men in nearly 300 barbershops from more than 20 cities across 6 states. CONCLUSIONS: The BBHOP is an effective method for community level health promotion and referral for cardio-metabolic diseases, especially for AA men, one of the nation's most vulnerable populations.

Geographic and Institutional Trends in Ambulatory Surgery in the State of California, 2012-2014.

Although geographic variation in health care services is well established, relatively less is known about ambulatory surgical procedures in California. Thus, we sought to describe statewide trends according to geographic and institutional factors. Using the California Office of State Health Planning and Development Ambulatory Surgery and Hospital Utilization datasets, overall and per-capita procedure rates by county and institution were calculated and compared across 2012 to 2014. There was substantial variation in services provided at the county level (Range: 49-382,142 cases/county). Among the 10 largest counties, there was a more than 2-fold difference in case volume per capita; across all counties, a 50-fold variation was observed. Changes in county population size and surgical case volume were correlated only if Los Angeles, the most populous and highest-volume county in the state, was excluded as an outlier. In the first year of California's full Medicaid expansion, Medicaid ambulatory surgery cases increased 29 per cent and self-pay cases decreased 16 per cent. The top 10 facilities by volume experienced substantial volatility in case volume over two years, ranging from -19.6 to +11.5 per cent. Geographic differences in rates of ambulatory surgery may be related to population shifts, but this was not uniformly true. The factors driving this variation and its impact on patient care warrant further investigation.

The Medicare Prescription Drug Improvement and Modernization Act: prescription drugs and academic medicine.

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) provides universally available prescription drug benefits to elderly and disabled Medicare beneficiaries for the first time. This paper first discusses three controversial features of this legislation: (1) the form of the prescription drug benefit package; (2) the use of competing private plans; and (3) the uncertainty about the future cost of the new prescription drug benefit. The paper then evaluates the implications for academic medicine of the prescription drug benefit and other MMA legislative provisions aimed at improving the quality of medical practice and shifting away from acute care. Ultimately, the health of seniors and the efficient use of public funds in the new prescription drug benefit depend centrally on the prescribing practices of physicians. Academic medicine should turn its attention to training the next generation of physicians to be more effective agents and advocates for their patients in their use of pharmaceuticals.

Association of breast cancer with papillary lesions identified at percutaneous image-guided breast biopsy.

BACKGROUND: The management of papillary lesions identified on image-guided breast biopsy remains controversial. In the literature, data regarding papillary lesions are limited because of small sample sizes. The purpose of this study was to identify the prevalence of atypical ductal hyperplasia and malignancy associated with papillary lesions identified on image-guided breast biopsy. METHODS: This study is a retrospective review of 9,310 consecutive image-guided biopsies performed at our institution between January 1996 and November 2003. Patients were included if they underwent an excisional biopsy after a papillary lesion was diagnosed on image-guided biopsy. RESULTS: Papillary lesions were identified in 153 (2%) of the 9,310 image-guided biopsies performed, and 87 of these patients underwent subsequent excisional biopsy at our institution. Breast cancer (in situ or invasive) was identified in 15 patients (17%), and 16 patients (18%) had atypical ductal hyperplasia identified at excisional biopsy. CONCLUSIONS: These data suggest that excisional biopsy should be considered when a papillary lesion is identified at percutaneous image-guided breast biopsy. The final surgical pathology may impact the treatment plan, risk reduction, and/or surveillance for more than a third of patients diagnosed with a papillary lesion on image-guided biopsy.

Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Data used for evaluating quality of medical care need to be of high reliability to ensure valid quality assessment and benchmarking. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) has continually emphasized the collection of highly reliable clinical data through its program infrastructure. STUDY DESIGN: We provide a detailed description of the various mechanisms used in ACS NSQIP to assure collection of high quality data, including training of data collectors (surgical clinical reviewers) and ongoing audits of data reliability. For the 2005 through 2008 calendar years, inter-rater reliability was calculated overall and for individual variables using percentages of agreement between the data collector and the auditor. Variables with > 5% disagreement are flagged for educational efforts to improve accurate collection. Cohen's kappa was estimated for selected variables from the 2007 audit year. RESULTS: Inter-rater reliability audits show that overall disagreement rates on variables have fallen from 3.15% in 2005 (the first year of public enrollment in ACS NSQIP) to 1.56% in 2008. In addition, disagreement levels for individual variables have continually improved, with 26 individual variables demonstrating > 5% disagreement in 2005, to only 2 such variables in 2008. Estimated kappa values suggest substantial or almost perfect agreement for most variables. CONCLUSIONS: The ACS NSQIP has implemented training and audit procedures for its hospital participants that are highly effective in collecting robust data. Audit results show that data have been reliable since the program's inception and that reliability has improved every year.