Association of Cataract Surgical Outcomes With Late Surgeon Career Stages: A Population-Based Cohort Study

Risk Factors for Legal Blindness in 237 Japanese Patients with Exogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential risk factors for visual prognosis in Japanese patients with exogenous endophthalmitis.

METHODS

In this retrospective observational multicenter cohort study, risk factors for legal blindness at 12 weeks after treatment initiation were evaluated based on patient characteristics, initial BCVA, causative events, pathogens, ocular symptoms, duration from symptom onset to initial treatment, and selected treatments.

RESULTS

Overall, 23.1% of eyes developed legal blindness. The six risk factors for legal blindness were presence of eye pain, pathogen identification, poor BCVA at the initial visit, longer duration from symptom onset to initial treatment, type of causative event, and type of causative pathogen. Regarding the type of causative pathogen, coagulase-negative staphylococci was associated with a better visual impairment outcome.

CONCLUSION

Exogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatment, as well as other advances in medical knowledge and technology.

Should we screen aging physicians for cognitive decline?

OBJECTIVES

To synthesize evidence relevant for informed decisions concerning cognitive testing of older physicians.

METHODS

Relevant literature was systematically searched in Medline, EMBASE, PsycInfo, and ERIC, with key findings abstracted and synthesized.

RESULTS

Cognitive abilities of physicians may decline in an age range where they are still practicing. Physician competence and clinical performance may also decline with age. Cognitive scores are lower in physicians referred for assessment because of competency or performance concerns. Many physicians do not accurately self-assess and continue to practice despite declining quality of care; however, perceived cognitive decline, although not an accurate indicator of ability, may accelerate physicians' decision to retire. Physicians are reluctant to report colleagues' cognitive problems. Several issues should be considered in implementing cognitive screening. Most cognitive assessment tools lack normative data for physicians. Scientific evidence linking cognitive test results with physician performance is limited. There is no known level of cognitive decline at which a doctor is no longer fit to practice. Finally, relevant domains of cognitive ability vary across medical specialties.

CONCLUSION

Physician cognitive decline may impact clinical performance. If cognitive assessment of older physicians is to be implemented, it should consider challenges of cognitive test result interpretation.

Duration of consultant experience and patient outcome following acute medical unit admission: an observational cohort study

BACKGROUND

The effect of the duration of consultant experience on clinical outcomes in the acute medical unit (AMU) model remains unknown.

METHODS

Unscheduled AMU admissions (n=66,929) admitted by 56 consultant physicians between 2017 and 2020 to two large teaching hospital AMUs in Lothian, Scotland were examined. The associations of consultant experience on AMU with patient discharge, mortality, readmission and postdischarge death were calculated adjusting for clinical acuity, pathology and comorbidity.

RESULTS

Increasing consultant experience was associated with a continuous increase in likelihood of early AMU discharge (odds ratio (OR) 1.08; 95% confidence interval (CI) 1.07-1.10; p<0.001 per 5 years' experience), which persisted after adjustment for confounders (OR 1.06; 95% CI: 1.01-1.11; p=0.01). There was no association with early readmission, death after discharge or 30-day inpatient mortality. The marginal effect estimate translates into 31 (95% CI: 25-36), 41 (95% CI: 30-53) and 52 (95% CI: 35-71) additional safe discharges per 1,000 admissions for clinicians of 15, 20 and 25 years' experience, respectively compared with those recently completing training.

CONCLUSIONS

Increasing consultant physician experience associates with early safe discharge after AMU admission. These data suggest that the support and retention of experienced clinicians is vital if escalating pressures on unscheduled medical care are to be addressed.

Physicians' clinical experience and its association with healthcare quality: a systematised review

BACKGROUND AND PURPOSE

There is conflicting evidence regarding whether physicians' clinical experience affects healthcare quality. Knowing whether an association exists and which dimensions of quality might be affected can help healthcare services close quality gaps by tailoring improvement initiatives according to physicians' clinical experience. Here, we present a systematised review that aims to assess the potential association between physicians' clinical experience and different dimensions of healthcare quality.

METHODS

We conducted a systematised literature review, including the databases MEDLINE, Embase, PsycINFO and PubMed. The search strategy involved combining predefined terms that describe physicians' clinical experience with terms that describe different dimensions of healthcare quality (ie, safety, clinical effectiveness, patient-centredness, timeliness, efficiency and equity). We included relevant, original research published from June 2004 to November 2020.

RESULTS

Fifty-two studies reporting 63 evaluations of the association between physicians' clinical experience and healthcare quality were included in the final analysis. Overall, 27 (43%) evaluations found a positive or partially positive association between physicians' clinical experience and healthcare quality; 22 (35%) found no association; and 14 (22%) evaluations reported a negative or partially negative association. We found a proportional association between physicians' clinical experience and quality regarding outcome measures that reflect safety, particularly in the surgical fields. For other dimensions of quality, no firm evidence was found.

CONCLUSION

We found no clear evidence of an association between measures of physicians' clinical experience and overall healthcare quality. For outcome measures related to safety, we found that physicians' clinical experience was proportional with safer care, particularly in surgical fields. Our findings support efforts to secure adequate training and supervision for early-career physicians regarding safety outcomes. Further research is needed to reveal the potential subgroups in which gaps in quality due to physicians' clinical experience might exist.

Clinical Characteristics and Outcomes in 314 Japanese Patients with Bacterial Endophthalmitis: A Multicenter Cohort Study from J-CREST

Bacterial endophthalmitis is an intraocular infection that causes rapid vison loss. Pathogens can infect the intraocular space directly (exogenous endophthalmitis (ExE)) or indirectly (endogenous endophthalmitis (EnE)). To identify predictive factors for the visual prognosis of Japanese patients with bacterial endophthalmitis, we retrospectively examined the bacterial endophthalmitis characteristics of 314 Japanese patients and performed statistics using these clinical data. Older patients, with significantly more severe clinical symptoms, were prevalent in the ExE group compared with the EnE group. However, the final best-corrected visual acuity (BCVA) was not significantly different between the ExE and EnE groups. Bacteria isolated from patients were not associated with age, sex, or presence of eye symptoms. Genus Streptococcus, Streptococcus pneumoniae, and Enterococcus were more prevalent in ExE patients than EnE patients and contributed to poor final BCVA. The presence of eye pain, bacterial identification, and poor BCVA at baseline were risk factors for final visual impairment.

Comparing cataract surgery complication rates in veterans receiving VA and community care

OBJECTIVES

To compare 90-day postoperative complication rates between Veterans receiving cataract surgery in VA vs Community Care (CC) during the first year of implementation of the Veterans Choice Act.

DATA SOURCES

Fiscal Year (FY) 2015 VA and CC outpatient data from VA's Corporate Data Warehouse (CDW) 10/01/14-9/30/15). FY14 data were used to obtain baseline clinical information prior to surgery.

STUDY DESIGN

Retrospective one-year study using secondary data to compare 90-day complication rates following cataract surgery (measured using National Quality Forum (NQF) criteria) in VA vs CC. NQF defines major complications from a specified list of Current Procedural Terminology (CPT) codes. We ran a series of logistic regression models to predict 90-day complication rates, adjusting for Veterans' sociodemographic characteristics, comorbidities, preoperative ocular conditions, eye risk group, and type of cataract surgery (classified as routine vs complex).

DATA COLLECTION

We linked VA and CC users through patient identifiers obtained from the CDW files. Our sample included all enrolled Veterans who received outpatient cataract surgery either in the VA or through CC during FY15. Cataract surgeries were identified through CPT codes 66 984 (routine) and 66 982 (complex).

PRINCIPAL FINDINGS

Of the 83,879 cataract surgeries performed in FY15, 31 percent occurred through CC. Undergoing complex surgery and having a high-risk eye (based on preoperative ocular conditions) were the strongest clinical predictors of 90-day postoperative complications. Overall, we found low complication rates, ranging from 1.1 percent in low-risk eyes to 3.6 percent in high-risk eyes. After adjustment for important confounders (eg, race, rurality, and preoperative ocular conditions), there were no statistically significant differences in 90-day complication rates between Veterans receiving cataract surgery in VA vs CC.

CONCLUSIONS

As more Veterans seek care through CC, future studies should continue to monitor quality of care across the two care settings to help inform VA's "make vs buy decisions."