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Spinks TE, Walters R, Feeley TW, Albright HW, Jordan VS, Bingham J, Burke TW. Improving cancer care through public reporting of meaningful quality measures. Health Aff (Millwood) 2011; 30:664-72. [PMID: 21471487 DOI: 10.1377/hlthaff.2011.0089] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Historically, quality measures for cancer have followed a different route than overall quality measures in the health care system. Many specialized cancer treatment centers were exempt from standard reporting on quality measures because of the complexity of cancer. Additionally, it has been difficult to create meaningful quality measures for cancer because the disease can strike so many different organs; is discovered at and progresses through different stages; and is treated using different modalities, such as surgery, radiation, and chemotherapy. Over the past decade the National Quality Forum, a nonprofit organization dedicated to bettering the quality of US health care, has endorsed measures of quality for cancer providers and patients. The Affordable Care Act of 2010, which has sections specific to cancer reporting, will also further the development and public reporting of cancer quality measures-important steps in improving the delivery of cancer care.
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Albright HW, Feeley TW. A cancer center puts the new approach to work. HARVARD BUSINESS REVIEW 2011; 89:61-62. [PMID: 21939128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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53
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Albright HW, Moreno M, Feeley TW, Walters R, Samuels M, Pereira A, Burke TW. The implications of the 2010 Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act on cancer care delivery. Cancer 2010; 117:1564-74. [PMID: 21472704 DOI: 10.1002/cncr.25725] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 09/12/2010] [Accepted: 09/20/2010] [Indexed: 11/08/2022]
Abstract
In March 2010, President Obama signed into law the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. This legislation attempts to address cost control and improve the quality of healthcare in the United States. Cancer is a major health problem in the United States and the leading cause of death for Americans under the age of 80. Therefore, cancer care providers need to be fully engaged in ongoing discussions regarding quality measurement and care delivery. With the optimum level of collaboration and support, the proposals in the legislation can be properly structured to deliver improved access to care via better delivery systems, as well as more appropriate reimbursement to advance the prevention and treatment of cancer.
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Feeley TW, Fly HS, Albright H, Walters R, Burke TW. A method for defining value in healthcare using cancer care as a model. J Healthc Manag 2010; 55:399-412. [PMID: 21166323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Value-based healthcare delivery is being discussed in a variety of healthcare forums. This concept is of great importance in the reform of the US healthcare delivery system. Defining and applying the principles of value-based competition in healthcare delivery models will permit future evaluation of various delivery applications. However, there are relatively few examples of how to apply these principles to an existing care delivery system. In this article, we describe an approach for assessing the value created when treating cancer patients in a multidisciplinary care setting within a comprehensive cancer center. We describe the analysis of a multidisciplinary care center that treats head and neck cancers, and we attempt to examine how this center integrates with Porter and Teisberg's (2006) concept of value-based competition based on the results analysis. Using the relationship between outcomes and costs as the definition of value, we developed a methodology to analyze proposed outcomes for a population of patients treated using a multidisciplinary approach, and we matched those outcomes to the costs of the care provided. We present this work as a model for defining value for a subset of patients undergoing active treatment. The method can be applied not only to head and neck treatments, but to other modalities as well. Public reporting of this type of data for a variety of conditions can lead to improved competition in the healthcare marketplace and, as a result, improve outcomes and decrease health expenditures.
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Abstract
Improving the prediction of successful ventilator weaning and extubation is a goal that all Intensivists and perioperative physicians strive for. The successful wean and extubation of ventilated patients decreases hospital length of stay and associated costs, but more importantly it also reduces patient morbidity and mortality. This review evaluates traditional and novel indices used in the assessment for ventilatory wean readiness. Novel equipment such as the Bicore pulmonary monitor and the CO2 SMO Plus are now available on the market to assess and monitor ventilator weaning and may offer some value in this process. We also review the non-respiratory factors affecting weaning and the role of the bedside nurse and respiratory therapist. Resolution of the pulmonary compromise and an understanding of respiratory physiology, used in conjunction with monitored indices of weaning parameters in a consistent fashion will continue to improve our success rates of ventilator weaning and extubation.
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Wallace SK, Ewer MS, Price KJ, Feeley TW. Outcome and cost implications of cardiopulmonary resuscitation in the medical intensive care unit of a comprehensive cancer center. Support Care Cancer 2002; 10:425-9. [PMID: 12136227 DOI: 10.1007/s00520-002-0353-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Intensive care unit (ICU) resources are frequently utilized in the supportive care of hospitalized patients with cancer. Patients with cancer reportedly have poor outcomes from cardiopulmonary resuscitation (CPR). The goal of this study was to evaluate the effectiveness and patient care costs of CPR applied to patients already receiving life support in an ICU. The medical records of patients who developed cardiac arrest and underwent CPR in the ICU of a comprehensive cancer center between 1993 and 2000 were reviewed. ICU charges after the first episode of CPR were analyzed. There were 5,196 admissions to the ICU during this time; 406 (8%) of the patients underwent CPR; 67% had hematologic malignancies or had undergone hematopoietic stem cell transplantation: 256 patients (63%) died at the time of the arrest, and in 150 (37%) spontaneous circulation was restored. There were 104 patients (26%) who survived more than 24 hours but ultimately died during their hospitalization; their mean time to death was 4.3 days (95% confidence interval [CI] 2.9-5.6), and mean ICU charges were $45,877 (95% CI $24,802-$66,952). Seven patients (2%) survived to be discharged. Patients who survived after CPR and were discharged from the hospital were those who had acute ventricular dysrhythmias and were resuscitated promptly. The application of CPR to cancer patients receiving life support is costly and typically does not lead to long-term survival. Cancer patients requiring admission to an ICU should receive full supportive care short of resuscitation. Providing assurances that care will remain appropriate, aggressive, and in accordance with the patient's and family's wishes can optimize compassionate care while avoiding futile life-sustaining interventions.
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Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer 2001; 92:1905-12. [PMID: 11745264 DOI: 10.1002/1097-0142(20011001)92:7<1905::aid-cncr1708>3.0.co;2-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite advances in cardiopulmonary resuscitation and the education of its providers, survival remains dismal for cancer patients suffering in-hospital cardiac arrest. In an effort to determine if characteristics of cardiac arrest would represent a useful parameter for prognostication and recommendations regarding the suitability of ongoing resuscitation for various groups, this review was undertaken for patients who experienced in-hospital cardiac arrest. METHODS A retrospective study of data gathered between January 1993 and December 1997 was undertaken in a 518-bed comprehensive cancer center. The records of 243 inpatients who experienced cardiac arrest and received cardiopulmonary resuscitation were reviewed, and their course observed until hospital discharge or death. RESULTS Sixteen of 73 patients (22%) who had sudden, unanticipated cardiac arrests survived to be discharged from the hospital; however, none (0 of 171) of the patients who experienced an anticipated cardiac arrest survived (P < 0.001). Logistic regression analysis revealed that anticipated cardiac arrest associated with metabolic derangement was an independent predictor of hospital mortality. CONCLUSIONS Patients experiencing an anticipated cardiac arrest, the course of which could not be interrupted through aggressive management in an intensive care unit, have an extremely poor prognosis. Ongoing resuscitative measures in these patients need not be routinely provided. The authors suggest an algorithm for resuscitation that evaluates the characteristics of the arrest as a prognostic factor. This algorithm should be implemented once progressive deterioration spirals toward cardiac arrest that cannot be prevented. Such an approach should avoid painful and costly interventions that are futile with the present techniques of cardiopulmonary resuscitation.
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58
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Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer 2001. [DOI: 10.1002/1097-0142(20011001)92:7%3c1905::aid-cncr1708%3e3.0.co;2-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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59
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Feeley TW. Perioperative Care. Anesth Analg 1998. [DOI: 10.1213/00000539-199804000-00063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Electrocardiography was the first application of electronic monitoring to anesthesia care. The detection of arrhythmias remains the most important use of this technology today. Several predisposing factors tend to emerge when perioperative arrhythmias are evaluated. These are the anesthetic given, the site of surgery, abnormalities of blood gases or electrolytes, tracheal intubation, reflexes such as vagal slowing and the oculocardiac reflex, stimulation of the central nervous system, the presence of preexisting heart disease, and the use of intracardiac devices. In the evaluation of cardiac arrhythmias, several facts need to be determined. The most important is to determine if there is an underlying complication of anesthesia and surgery that may explain the arrhythmia. In addition, it is vital to evaluate the heart rate, the regularity, the number of P waves per QRS, and the configuration of the QRS. The anesthesiologist needs to determine whether the rhythm is dangerous to the patient and whether it requires treatment. Prompt evaluation and management of perioperative arrhythmias reduce anesthetic morbidity and mortality. This article reviews the causes and pharmacological treatment of major abnormalities of atrial and ventricular cardiac arrhythmias occurring in the perioperative period.
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61
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Peterson KL, DeCampli WM, Feeley TW, Starnes VA. Blood loss and transfusion requirements in cystic fibrosis patients undergoing heart-lung or lung transplantation. J Cardiothorac Vasc Anesth 1995; 9:59-62. [PMID: 7536482 DOI: 10.1016/s1053-0770(05)80056-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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62
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Propst JW, Siegel LC, Feeley TW. Effect of aprotinin on transfusion requirements during repeat sternotomy for cardiac transplantation surgery. Transplant Proc 1994; 26:3719-21. [PMID: 7527985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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63
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McConnell MS, Finn JC, Feeley TW. Tension hydrothorax during laparoscopy in a patient with ascites. Anesthesiology 1994; 80:1390-3. [PMID: 8010483 DOI: 10.1097/00000542-199406000-00027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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65
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Feeley TW. Management of perioperative dysrhythmias. MIDDLE EAST JOURNAL OF ANAESTHESIOLOGY 1993; 12:225-43. [PMID: 8289746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This paper reviews cardiac dysrhythmias occurring in the perioperative period. Electrocardiography was the first application of electronic monitoring to anesthesia care. The detection of dysrhythmias remains the most important use of this technology today. While the description of dysrhythmias dates back to the early 1900's, the first large series was reported in 1936. Early descriptions of the kinds seen and the predisposing factors have changed little in the past 50 years. Several factors tend to emerge when one evaluates perioperative dysrhythmias. These are the anesthetic given, the site of surgery, abnormalities of blood gases or electrolytes, tracheal intubation, reflexes such as vagal slowing and the oculocardiac reflex, stimulation of the central nervous system the presence of pre-existing heart disease, and the use of intracardiac devices. In the evaluation of cardiac dysrhythmias several facts need to be determined. The most important is to determine if there is an underlying complication of anesthesia and surgery which may explain the dysrhythmia. In addition, one needs to evaluate the heart rate, the regularity, the number of P waves per QRS, and the configurations of the QRS. The anesthesiologist needs to determine whether the rhythm is dangerous to the patient and whether it requires treatment. The two major abnormalities of sinus rhythm are sinus bradycardia and the sinus tachycardia. Sinus bradycardia can be due to hypoxia, vagal stimulation, drug effects, a high sympathetic block or an acute myocardial infarction. Sinus tachycardia can be due pain, light anesthesia, hypovolemia, sepsis, hypoxia, hypercapnia and drug effects. The major atrial dysrhythmias are paroxysmal atrial tachycardia, atrial fibrillation and atrial flutter. Each require treatment if perfusion is impaired or if the heart rate is persistently elevated. The new agents esmolol and adenosine are particularly useful in managing atrial dysrhythmias. The major ventricular dysrhythmias are ventricular premature contractions, ventricular tachycardia and ventricular fibrillation. The later two demand emergency management with DC cardioversion when perfusion is impaired. The major abnormality of conduction is complete heart block which usually requires emergency treatment in the perioperative period. Prompt evaluation and management of perioperative dysrhythmias reduce anesthetic morbidity and mortality.
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66
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Feeley TW. The anesthesiologist's role in cardiac transplantation. MIDDLE EAST JOURNAL OF ANAESTHESIOLOGY 1993; 12:257-70. [PMID: 8289748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Cardiac transplantation has become an increasingly common operation and many patients who have transplanted hearts may require anesthetic care at any time. Management of the recipient is similar to managing any patient with severe cardiac failure before the new heart is implanted. Following transplantation the problems are those of the denervated heart and the problems associated with the immunosuppressive agents used for transplantation.
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67
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Feeley TW, Rinsky LA. Use of aprotinin to reduce intraoperative bleeding. West J Med 1993; 159:189-92. [PMID: 7692676 PMCID: PMC1022232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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68
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Abstract
The preservation of vascular integrity and blood flow is essential for vital functions. The dynamic equilibrium between bleeding and clotting can be set awry by stimulation of the inflammatory or immune response or by unchecked activation of the coagulation or fibrinolytic systems. It is through greater understanding of the complex interplay between these pathways that we are able to develop agents that can, with increasing specificity, manipulate coagulation and restore hemostasis.
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Feeley TW, Keating D, Nishimura T. Independent lung ventilation using high-frequency ventilation in the management of a bronchopleural fistula. Anesthesiology 1988; 69:420-2. [PMID: 3046438 DOI: 10.1097/00000542-198809000-00025] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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70
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Alagesan K, Nunn JF, Feeley TW, Heneghan CP. Comparison of the respiratory depressant effects of halothane and isoflurane in routine surgery. Br J Anaesth 1987; 59:1070-9. [PMID: 3117082 DOI: 10.1093/bja/59.9.1070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Respiratory depression has been studied in 21 patients anaesthetized with either halothane and nitrous oxide, or isoflurane and nitrous oxide while undergoing routine surgery. Spontaneous ventilation was preserved and the end-tidal concentrations of the two volatile anaesthetics were at approximately equal MAC-multiples. The minute volume of pulmonary ventilation was not significantly different for the two anaesthetics, but tidal volume was significantly greater and frequency significantly lower with isoflurane. Arterial and end-tidal PCO2 were consistently lower in the patients receiving isoflurane, the difference being significant in many of the sub-groups. There was no evidence of a progressive increase in PCO2 with either anaesthetic during surgery lasting up to 225 min. Mean values for PCO2, however, tended to be well above the normal reference range, with mean arterial PCO2 in the range 7.2-8.6 kPa.
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71
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Halperin B, Feeley TW, Mihm FG, Guthaner DF. Utility of Portable Chest X-ray. Chest 1987. [DOI: 10.1378/chest.91.3.470-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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72
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Feeley TW, Minty BD, Scudder CM, Jones JG, Royston D, Teng NN. The effect of human antiendotoxin monoclonal antibodies on endotoxin-induced lung injury in the rat. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1987; 135:665-70. [PMID: 3548509 DOI: 10.1164/arrd.1987.135.3.665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A model of endotoxin-induced lung injury was developed in the rat. We found that 24 h after intravenously administered endotoxin (3 mg/kg) there was increased clearance of the isotope 99mTcDTPA from the lung to blood, increased neutrophils in the lung in bronchoalveolar lavage, and increased levels of products of peroxidation of lipids and nucleic acid in the serum. Using this model, we evaluated the effect of pretreatment of rats with a human monoclonal antibody specific to the core glycolipid that is common to all endotoxins. We found that pretreatment prevented the increased clearance of 99mTcDTPA from the lung, as well as the increase in lipid peroxidation products in the serum. The antibody did not prevent increased neutrophil accumulation in the lung. The findings suggest that the administration of human antiendotoxin monoclonal antibodies prior to endotoxemia may prevent some of the changes in the lung associated with endotoxin.
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73
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Amene PC, Sladen RN, Feeley TW, Fisher R. Hypercapnia during total parenteral nutrition with hypertonic dextrose. Crit Care Med 1987; 15:171-2. [PMID: 3100138 DOI: 10.1097/00003246-198702000-00020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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74
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Mihm FG, Feeley TW, Jamieson SW. Thermal dye double indicator dilution measurement of lung water in man: comparison with gravimetric measurements. Thorax 1987; 42:72-6. [PMID: 3616974 PMCID: PMC460606 DOI: 10.1136/thx.42.1.72] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The thermal dye double indicator dilution technique for estimating lung water was compared with gravimetric analyses in nine human subjects who were organ donors. As observed in animal studies, the thermal dye measurement of extravascular thermal volume (EVTV) consistently overestimated gravimetric extravascular lung water (EVLW), the mean (SEM) difference being 3.43 (0.59) ml/kg. In eight of the nine subjects the EVTV -3.43 ml/kg would yield an estimate of EVLW that would be from 3.23 ml/kg under to 3.37 ml/kg over the actual value EVLW at the 95% confidence limits. Reproducibility, assessed with the standard error of the mean percentage, suggested that a 15% change in EVTV can be reliably detected with repeated measurements. One subject was excluded from analysis because the EVTV measurement grossly underestimated its actual EVLW. This error was associated with regional injury observed on gross examination of the lung. Experimental and clinical evidence suggest that the thermal dye measurement provides a reliable estimate of lung water in diffuse pulmonary oedema states.
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75
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Calcagni DE, Mihm FG, Feeley TW, Halperin BD, Rosenthal MH. The thermal-dye method of lung water measurement is reliable at a low cardiac output. J Surg Res 1986; 41:286-92. [PMID: 3762135 DOI: 10.1016/0022-4804(86)90038-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The measurement of lung water by the thermal-dye double indicator dilution technique was evaluated in dogs with normal and edematous lungs during a state of reduced cardiac output. The technique used cold indocyanine green dye to measure extravascular thermal volume (EVTV) as an estimate of extravascular lung water (EVLW). Anesthesia was maintained with pentobarbital. In 15 of 21 animals, pulmonary edema was first induced with oleic acid (0.75 to 0.18 ml/kg). Cardiac output (CO) was then decreased by a combination of propranolol and slow exsanguination (mean CO reduction to 36% of baseline). Extravascular lung water produced in this model ranged from 1.4 to 30.2 ml/kg. Predetermination measurements of EVTV correlated closely with EVLW as determined by gravimetric analysis (EVTV = 1.1 EVLW + 4.7 ml/kg, n = 21, r = 0.93, P less than 0.001). Thermodilution cardiac output measured in the abdominal aorta (used in the calculation of the EVTV) correlated well with simultaneous measurements of cardiac output by both indocyanine green dye dilution and pulmonary artery thermodilution (r = 0.86 and r = 0.88, respectively, pretermination). The thermal-dye technique appears to provide an accurate reflection of lung water in normal and edematous lungs, even in the presence of a low cardiac output.
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