Better Patient Care At High-Quality Hospitals May Save Medicare Money And Bolster Episode-Based Payment Models

US policy makers are making efforts to simultaneously improve the quality of and reduce spending on health care through alternative payment models such as bundled payment. Bundled payment models are predicated on the theory that aligning financial incentives for all providers across an episode of care will lower health care spending while improving quality. Whether this is true remains unknown. Using national Medicare fee-for-service claims for the period 2011-12 and data on hospital quality, we evaluated how thirty- and ninety-day episode-based spending were related to two validated measures of surgical quality-patient satisfaction and surgical mortality. We found that patients who had major surgery at high-quality hospitals cost Medicare less than those who had surgery at low-quality institutions, for both thirty- and ninety-day periods. The difference in Medicare spending between low- and high-quality hospitals was driven primarily by postacute care, which accounted for 59.5 percent of the difference in thirty-day episode spending, and readmissions, which accounted for 19.9 percent. These findings suggest that efforts to achieve value through bundled payment should focus on improving care at low-quality hospitals and reducing unnecessary use of postacute care.

Training surgical residents for a career in academic global surgery: a novel training model

Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path. Brigham and Women's Hospital has established a specialized global surgery track within the general surgery residency program to develop academic leaders in this growing area of need and opportunity. Here we describe our experience with the design and development of the program followed by practical applications and lessons learned from our early experiences.

Survey of the American College of Surgeons scholarship recipients: a story of generating academic leaders

BACKGROUND

The objective of this survey was to provide a review of the American College of Surgeons (ACS) scholarship activity.

STUDY DESIGN

The domestic ACS scholarship recipient survey was electronically transmitted twice to awardees from 1987 to 2007 (n=253). Themes of the survey included type of practice, activities during scholarship period, success of peer review funding, and the role of mentors. All survey responses were evaluated using SPSS version 20.

RESULTS

There were 123 total responses, with 108 separate respondents (94, 1 award; 13, 2 awards; 1, 3 awards). The group averaged 11.8 years in clinical practice, with the majority (90.2%) having an academic appointment. Seventy-seven percent of respondents were on a tenure track, and almost three-quarters (72.4%) of the respondents hold a major leadership position. In terms of research, 67.5% of respondents have received extramural funding; 10.6% have received patents. The average number of publications related to their funded research is 19.2 (range 0 to 180). Most respondents perform peer review of research (73.2%), learned about the peer review process during their funding period (82.1%), and mentor medical students (88.6%). The average number of students currently mentored is 6.4; the average total trainees mentored is 13. Despite the significant research responsibilities of respondents, they still spend more time performing clinical care (49.2%) than research (30.4%).

CONCLUSIONS

The ACS scholarship has a significant impact on the recipient's academic career, even in the setting of increasing clinical burdens. This program also appears to tangentially identify surgeons who become leaders in academic surgery.

Hospital variation in sphincter preservation for elderly rectal cancer patients

BACKGROUND

The primary goal of an operation for rectal cancer is to cure cancer and, where possible, preserve continence. A wide range of sphincter preservation rates have been reported. This study evaluated hospital variation in the use of low anterior resection (LAR), local excision (LE), and abdominoperineal resection (APR) in the treatment of elderly rectal cancer patients.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare linked data, we identified 4959 patients older than 65 y with stage I-III rectal cancer diagnosed from 2000-2005 who underwent operative intervention at one of 370 hospitals. We evaluated the distribution of hospital-specific procedure rates and used generalized mixed models with random hospital effects to examine the influence of patient characteristics and hospital on operation type, using APR as a reference.

RESULTS

The median hospital performed APR on 33% of elderly patients with rectal cancer. Hospital was a stronger predictor of LAR receipt than any patient characteristic, explaining 32% of procedure choice, but not a strong predictor of LE, explaining only 3.8%. Receipt of LE was primarily related to tumor size and tumor stage, which combined explained 31% of procedure variation.

CONCLUSIONS

Receipt of LE is primarily determined by patient characteristics. In contrast, the hospital where surgery is performed significantly influences whether a patient undergoes an LAR or APR. Understanding the factors that cause this institutional variation is crucial to ensuring equitable availability of sphincter preservation.

Master surgeons' operative teaching philosophies: a qualitative analysis of parallels to learning theory

OBJECTIVES

Practicing within the Halstedian model of surgical education, academic surgeons serve dual roles as physicians to their patients and educators of their trainees. Despite this significant responsibility, few surgeons receive formal training in educational theory to inform their practice. The goal of this work was to gain an understanding of how master surgeons approach teaching uncommon and highly complex operations and to determine the educational constructs that frame their teaching philosophies and approaches.

DESIGN

Individuals included in the study were queried using electronically distributed open-ended, structured surveys. Responses to the surveys were analyzed and grouped using grounded theory and were examined for parallels to concepts of learning theory.

SETTING

Academic teaching hospital.

PARTICIPANTS

Twenty-two individuals identified as master surgeons.

RESULTS

Twenty-one (95.5%) individuals responded to the survey. Two primary thematic clusters were identified: global approach to teaching (90.5% of respondents) and approach to intraoperative teaching (76.2%). Many of the emergent themes paralleled principles of transfer learning theory outlined in the psychology and education literature. Key elements included: conferring graduated responsibility (57.1%), encouraging development of a mental set (47.6%), fostering or expecting deliberate practice (42.9%), deconstructing complex tasks (38.1%), vertical transfer of information (33.3%), and identifying general principles to structure knowledge (9.5%).

CONCLUSIONS

Master surgeons employ many of the principles of learning theory when teaching uncommon and highly complex operations. The findings may hold significant implications for faculty development in surgical education.

Postgame analysis: using video-based coaching for continuous professional development

BACKGROUND

The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance.

STUDY DESIGN

Four complex operations performed by surgeons of varying experience--a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience--were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded.

RESULTS

The sessions focused on operative technique--both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident's technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings.

CONCLUSIONS

Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development.

The role of perioperative hyperglycemia in postoperative infections

In the past decade, convincing evidence has emerged that perioperative glycemic control in certain settings, especially cardiac surgery and the surgical ICU, can decrease morbidity and mortality. It remains unclear, however, if hypoglycemia is a cause of death or marker of patient acuity. It is clear, however, that the particular intensive glycemic control protocol matters because the rate of hypoglycemia varies across protocols and institutions. The best current evidence for tight control rests in the population of surgical patients needing more than 5 days of critical care. Many questions still remain, such as the optimum blood sugar or the best protocol to implement glucose control, minimizing hypoglycemia. Further information will become available from the Normogylcemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation trial, currently enrolling patients in a prospective randomized trial to answer some of these outstanding questions. Maintaining euglycemia postoperatively is a simple and actionable step that could decrease the risk of postoperative infections and postoperative mortality.

Pancreatic PEComa (sugar tumor): MDCT and EUS features

CONTEXT

PEComas (tumors showing perivascular epithelioid cell differentiation) of the pancreas are exceedingly rare.

CASE REPORT

We herein report on a 60-year-old female who noticed a bulge in her right upper quadrant while exercising. Subsequent multidetector-row CT scan showed a 3.5 cm well-defined, encapsulated, hypovascular, solid tumor in the body of the pancreas. Endoscopic ultrasound demonstrated a mixed hypo- and hyper-echoic, well-defined, heterogeneous tumor.

CONCLUSIONS

Although three pancreatic PEComas (sugar tumors) have been described previously, to the best of our knowledge, this is the first report of a pancreatic PEComa with illustration of its multidetector-row CT and endoscopic ultrasound features in the radiological literature.

Nonoperative management of patients with a diagnosis of high-grade small bowel obstruction by computed tomography

OBJECTIVE

To determine the natural history and treatment of high-grade small bowel obstruction (HGSBO). Small bowel obstruction is a frequent complication of abdominal surgery. Complete and strangulating obstructions are managed operatively while partial obstructions receive a trial of nonoperative therapy. The management and outcome of patients with HGSBO diagnosed by computed tomography (CT) has not been examined.

DESIGN

Retrospective medical record review. Outcomes for nonoperative vs operative management were analyzed using Fisher exact and log-rank tests.

SETTING

Tertiary care referral center.

PATIENTS

One thousand five hundred sixty-eight consecutive patients admitted from the emergency department with a diagnosis of small bowel obstruction between 2000 and 2005 by CT criteria.

MAIN OUTCOME MEASURES

Recurrence of symptoms and complications.

RESULTS

One hundred forty-five patients (9%) with HGSBO were identified, with 88% follow-up (median, 332 days; range, 4-2067 days). Sixty-six (46%) were successfully managed nonoperatively while 79 (54%) required an operation. Length of stay and complications were significantly increased in the operative group (4.7 days vs 10.8 days and 3% vs 23%; P < .001). Nonoperative management was associated with a higher recurrence rate (24% vs 9%; P < .005) and shorter time to recurrence (39 days vs 105 days; P < .005) compared with operative intervention. Computed tomography signs of ischemia, admission laboratory results, and presence of cancer or inflammatory bowel disease were not predictive of an operation.

CONCLUSIONS

Patients with HGSBO by CT can be managed safely with nonoperative therapy; however, they have a significantly higher rate of recurrence requiring readmission or operation within 5 years.

Career satisfaction of women in surgery: perceptions, factors, and strategies

BACKGROUND

With the current and projected shortages of general surgeons, more attention is being paid to the increasing pool of women physicians. This study seeks to understand the variables leading to career satisfaction for women surgeons to better recruit, retain, and support them.

STUDY DESIGN

Eighteen semi-structured interviews of 12 female and 6 male surgeons 2 to 12 years into practice were qualitatively analyzed and converted to coded, categorized data. Significance was derived by Fisher's exact test. Participants were recruited by snowball sampling.

RESULTS

Our sample represents a highly satisfied group of female and male surgeons. Although both women and men describe with equal frequency having made career tradeoffs for personal and family time, and vice versa, women far more frequently than men cite reasons related to their personal time, predictable time, and family relationships as why they are currently satisfied with their career (34.1% versus 8.7%; p < 0.05). Both cite being satisfied by career content equally. When describing strategies used in developing a successful surgical career, women most frequently cite social networks as a key to success (88% versus 12% by men; p < 0.05), and men more frequently cite reasons related to training (29% versus 0% by women; p < 0.05) and compensation (24% versus 0% by women; p < 0.05).

CONCLUSIONS

Although both men and women make tradeoffs of career for family and family for career, women's perception of satisfaction comes from viewing their surgical career within the broader context of their lives. Women might be attracted to a career that acknowledges and values the whole person beyond the surgeon, and could benefit from work infrastructures that enhance networking.

Novel presentation of a familial pancreatic cancer syndrome

INTRODUCTION

Earlier detection of pancreatic cancer may help identify patients for whom surgical intervention could provide cure or prolong life. In this article, we report the occurrence of breast cancer, melanoma, squamous cell carcinoma of the alveolar ridge, colon cancer, a desmoid tumor of the abdominal wall, and pancreatic adenocarcinoma in a 65-year-old woman. She was identified as having the familial atypical multiple mole melanoma-pancreatic cancer syndrome (FAMMM-PC) with a germline p16 mutation at amino acid position 15.

DISCUSSION

Patients with this syndrome traditionally present with multiple nevi and melanoma, and a subset also present with other cancers, including pancreatic cancer; however, no FAMMM-PC patient has yet been described with this constellation of cancers, including squamous cell carcinoma of the alveolar ridge and a desmoid tumor. Recognition of the tumors this population of patients is susceptible to developing and their genetic associations can help guide the surgeon in screening, surveillance, and eventually prevention of many of these cancers.

Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness

BACKGROUND

New technologies are available to reduce or prevent retained surgical sponges (RSS), but their relative cost effectiveness are unknown. We developed an empirically calibrated decision-analytic model comparing standard counting against alternative strategies: universal or selective x-ray, bar-coded sponges (BCS), and radiofrequency-tagged (RF) sponges.

METHODS

Key model parameters were obtained from field observations during a randomized-controlled BCS trial (n = 298), an observational study of RSS (n = 191,168), and clinical experience with BCS (n approximately 60,000). Because no comparable data exist for RF, we modeled its performance under 2 alternative assumptions. Only incremental sponge-tracking costs, excluding those common to all strategies, were considered. Main outcomes were RSS incidence and cost-effectiveness ratios for each strategy, from the institutional decision maker's perspective.

RESULTS

Standard counting detects 82% of RSS. Bar coding prevents > or =97.5% for an additional $95,000 per RSS averted. If RF were as effective as bar coding, it would cost $720,000 per additional RSS averted (versus standard counting). Universal and selective x-rays for high-risk operations are more costly, but less effective than BCS-$1.1 to 1.4 million per RSS event prevented. In sensitivity analyses, results were robust over the plausible range of effectiveness assumptions, but sensitive to cost.

CONCLUSION

Using currently available data, this analysis provides a useful model for comparing the relative cost effectiveness of existing sponge-tracking strategies. Selecting the best method for an institution depends on its priorities: ease of use, cost reduction, or ensuring RSS are truly "never events." Given medical and liability costs of >$200,000 per incident, novel technologies can substantially reduce the incidence of RSS at an acceptable cost.

Impact of radiologic intervention on mortality in necrotizing pancreatitis: the role of organ failure

BACKGROUND

Our group previously reported that organ failure and mortality in necrotizing pancreatitis (NP) are not different between patients with infected and sterile necrosis. Since that report, management of this disease has evolved to include image-guided percutaneous catheter drainage (PCD) to improve morbidity and mortality. We evaluated the effect of PCD on mortality in NP.

DESIGN

Retrospective analysis.

SETTING

Tertiary care referral center.

PATIENTS

A total of 689 consecutive patients treated for acute pancreatitis between 2001 and 2005, of whom 64 (9.3%) had pancreatic necrosis documented on contrast-enhanced computed tomography.

MAIN OUTCOME MEASURES

Mortality and organ failure.

RESULTS

In the 64 patients with documented NP, overall mortality was 16%. Thirty-six patients (56%) had organ failure according to the Atlanta classification. Compared with patients with sterile necrosis, those with infected necrosis did not have an increased prevalence of organ failure or increased need for intubation, pressors, or dialysis but had an increased mortality. Mortality in patients treated conservatively was 1 of 29 (3%); in those with PCD alone, 6 of 11 (55%); in those with PCD and surgery, 2 of 17 (12%); and in those with surgery alone, 1 of 7 (14%). All patients treated with PCD alone had organ failure, whereas 10 (59%) of those with PCD and surgery had organ failure.

CONCLUSION

The use of PCD did not improve the mortality of NP among patients with organ failure.

Distal pancreatectomy is not associated with increased perioperative morbidity when performed as part of a multivisceral resection

PURPOSE

To evaluate the indications for and the outcomes from distal pancreatectomy.

METHODS

Retrospective chart review of 171 patients who underwent distal pancreatectomy at Brigham and Women's Hospital between January 1996 and August 2005.

RESULTS

Nearly one-third of distal pancreatectomies were performed as part of an en bloc resection for a contiguous or metastatic tumor. Fifty-six percent of the patients underwent a standard distal pancreatectomy +/- splenectomy (group 1), whereas 44% of distal pancreatic resections included additional organs or contiguous intraperitoneal or retroperitoneal tumor (group 2). The overall post-operative complication rate was 37%; the most common complication was pancreatic duct leak (23%). When compared to patients undergoing standard distal pancreatectomy, those with a more extensive resection including multiple viscera and/or metastatic or contiguous tumor resection had no significant difference in overall complication rate (35% v. 39%, p = 0.75), leak rate (25% v. 20%, p = 0.47), new-onset insulin-dependent diabetes mellitus (3% v. 4%, p = 1.0), and mortality (2% v. 4%, p = 0.656).

CONCLUSION

This series includes a large number of patients in whom distal pancreatectomy was performed as part of a multivisceral resection or with en bloc resection of contiguous tumor. Complications were no different in these patients when compared to patients undergoing straightforward distal pancreatectomy.

The evolution of health care in America

The evolution of health care in America had its beginnings even before the founding of the nation. This article divides the evolution of American health care into six historical periods: (1) the charitable era, (2) the origins of medical education era, (3) the insurance era, (4) the government era, (5) the managed care era, and (6) the consumerism era.

Severe acute gastrointestinal graft-vs-host disease: an emerging surgical dilemma in contemporary cancer care

OBJECTIVE

To determine the natural history of and guidelines for the surgical management of severe acute gastrointestinal (GI) graft-vs-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT).

DESIGN

Case series from a prospective database.

SETTING

Tertiary care referral center/National Cancer Institute-designated Comprehensive Cancer Center.

PATIENTS

A total of 63 of 2065 patients (3%) undergoing HSCT for hematologic malignancies from February 1997 to March 2005 diagnosed clinically with severe (stage 3 or 4) acute GI GVHD. Main Outcome Measure Percutaneous or surgical intervention. Perforation, obstruction, ischemia, hemorrhage, and abscess were considered surgically correctable problems.

RESULTS

Severe acute GI GVHD was diagnosed in 63 patients (median age at HSCT, 47.6 years) at a median of 23 days after HSCT. Clinical diagnosis was confirmed histologically in 84% of patients. On computed tomography and/or magnetic resonance images, 64% had bowel wall thickening, 20% had a normal-appearing bowel, and 16% had nonspecific findings; none had evidence of perforation, obstruction, or abscess. All were initially treated with immunosuppression. Only 1 patient (1.6%) required intervention, undergoing a nontherapeutic laparotomy for worsening abdominal pain. A total of 83% of patients have died (median time to death from HSCT, 119 days; from GI GVHD diagnosis, 85 days). None who underwent an autopsy died of a surgically correctable cause.

CONCLUSIONS

This series represents a large single-center experience with GI GVHD reviewed from a surgical perspective. Operative intervention was rarely required. Therefore, mature surgical judgment is necessary to confirm the absence of surgically reversible problems, thus avoiding unnecessary operations in this challenging patient population.

[Surgical volume. An American perspective]

Due to an increasing interest in patient safety and quality health care, many studies attempt to show a relationship between procedural volume at the institutional and individual level and patient outcome. Despite the correlation between number of surgeons and institutional volume in major operative procedures such as coronary artery bypass graft, pancreatic resection, and esophagectomy, these parameters are likely to be proxy for individual factors such as experience and structural aspects. In general the relationship between case numbers and results is more convincing in cancer surgery than for cardiovascular procedures, and risk adjustment may play an important role for interpreting results of the various studies. Exact thresholds cannot be determined and thus remain speculative. It appears difficult to implement practical changes based on the observations, because the etiology and causality of the relationship between volume and outcome are still not understood. The simple focus on volume does not apply to measurements of quality but can be a starting point for further studies to identify more specific factors associated with surgical quality.

Multivariable Predictors of Postoperative Venous Thromboembolic Events after General and Vascular Surgery: Results from the Patient Safety in Surgery Study

BACKGROUND

Venous thromboembolism (VTE) is a potentially preventable postoperative complication. Accurate risk prediction is an essential first step toward limiting serious, and sometimes fatal, postoperative VTE. We sought to develop and test a model to predict patients at high risk for postoperative VTE.

STUDY DESIGN

Data from the Patient Safety in Surgery (PSS) Study were used to develop and test a predictive model of VTE using multiple logistic regression analyses.

RESULTS

VTE occurred in 1,162 of 183,069 (0.63%) patients undergoing vascular and general surgical procedures. The 30-day mortality in patients who suffered a VTE was 11.19%. Fifteen variables independently associated with increased risk of VTE included patient factors (female gender, higher American Society of Anesthesiologists class, ventilator dependence, preoperative dyspnea, disseminated cancer, chemotherapy within 30 days, and > 4 U packed red blood cell transfusion in the 72 hours before operation), preoperative laboratory values (albumin < 3.5 mg/dL, bilirubin > 1.0 mg/dL, sodium > 145 mmol/L, and hematocrit < 38%), and operative characteristics (type of surgical procedure, emergency operation, work relative value units, and infected/contaminated wounds). These variables were used to develop a predictive model for postoperative VTE (c-index = 0.7647) and a risk score that can be used in the preoperative assessment of patients undergoing major operations.

CONCLUSIONS

Venous thromboembolic events after noncardiac operations are relatively infrequent but highly lethal. Important multivariable risk factors for VTE in this setting were identified in the large PSS database. The risk-prediction scoring system, developed by using the logistic regression odds ratios, helps to identify patients at risk for postoperative VTE and to institute appropriate perioperative prophylactic measures.

Liver-specific functional studies in a microfluidic array of primary mammalian hepatocytes

Nearly half a billion dollars in resources are lost each time a drug candidate is withdrawn from the market by the Food and Drug Administration (FDA) for reasons of liver toxicity. The number of late-phase drug developmental failures due to liver toxicity could potentially be reduced through the use of hepatocyte-based systems capable of modeling the response of in vivo liver tissue to toxic insults. With this article, we report progress toward the goal of realizing an array of primary hepatocytes for use in high-throughput liver toxicity studies. Described herein is the development of a 64 (8 x 8) element array of microfluidic wells capable of supporting micropatterned primary rat hepatocytes in coculture with 3T3-J2 fibroblasts. Each of the wells within the array was continuously perfused with medium and oxygen in a nonaddressable format. The key features of the system design and fabrication are described, including the use of two microfluidic perfusion networks to provide the coculture with an independent and continuous supply of cell culture medium and oxygen. Also described are the fabrication techniques used to selectively pattern hepatocytes and 3T3-J2 fibroblasts within the wells of the array. The functional studies used to demonstrate the synthetic and metabolic capacity of the array are outlined in this article. These studies demonstrate that the hepatocytes contained within the array are capable of continuous, steady-state albumin synthesis (78.4 microg/day, sigma = 3.98 microg/day, N = 8) and urea production (109.8 microg/day, sigma = 11.9 microg/day, N = 8). In the final section of the article, these results are discussed as they relate to the final goal of this research effort, the development of an array of primary hepatocytes for use in physiologically relevant toxicology studies.

Predicting Future Staffing Needs at Teaching Hospitals

OBJECTIVE

To develop a model to predict future staffing for the surgery service at a teaching hospital.

SETTING

Tertiary hospital.

INTERVENTIONS

A computer model with potential future variables was constructed. Some of the variables were distribution of resident staff, fellows, and physician extenders; salary/wages; work hours; educational value of rotations; work units, inpatient wards, and clinics; future volume growth; and efficiency savings. Outcomes Number of staff to be hired, staffing expense, and educational impact.

RESULTS

On a busy general surgery service, we estimated the impact of changes in resident work hours, service growth, and workflow efficiency in the next 5 years. Projecting a reduction in resident duty hours to 60 hours per week will require the hiring of 10 physician assistants at a cost of $1 134 000, a cost that is increased by $441 000 when hiring hospitalists instead. Implementing a day of didactic and simulator time (10 hours) will further increase the costs by $568 000. A 10% improvement in the efficiency of floor care, as might be gained by advanced information technology capability or by regionalization of patients, can mitigate these expenses by as much as 21%. On the other hand, a modest annual growth of 2% will increase the costs by $715 000 to $2 417 000.

CONCLUSIONS

To simply replace residents with alternative providers requires large amounts of human and fiscal capital. The potential for simple efficiencies to mitigate some of this expense suggests that traditional patterns of care in teaching hospitals will have to change in response to educational mandates.

Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients

BACKGROUND

Communication breakdowns are a common threat to surgical safety, but there are little data to guide initiatives to improve communication.

STUDY DESIGN

In surgeon-review of 444 surgical malpractice claims from 4 liability insurers, we identified 60 cases involving communication breakdowns resulting in harm to patients. Two surgeon-reviewers analyzed these cases to identify common characteristics and associated factors. Based on identified patterns, potential interventions to prevent communication breakdowns were developed and their potential impact was assessed.

RESULTS

The 60 cases involved 81 communication breakdowns, occurring in the preoperative (38%), intraoperative (30%), and postoperative periods (32%). Seventy-two percent of cases involved one communication breakdown. The majority of breakdowns were verbal communications (92%) involving 1 transmitter and 1 receiver (64%). Attending surgeons were the most common team member involved. Status asymmetry (74%) and ambiguity about responsibilities (73%) were commonly associated factors. Forty-three percent of communication breakdowns occurred with handoffs and 39% with transfers in the patient's location. The most common communication breakdowns involved residents failing to notify the attending surgeon of critical events and a failure of attending-to-attending handoffs. Proposed interventions could prevent 45% to 73% of communication breakdowns in this cases series.

CONCLUSIONS

Serious communication breakdowns occur across the continuum of care, typically result from a failure in verbal communication between a surgical attending and another caregiver, and often involve ambiguity about responsibilities. Interventions to prevent these breakdowns should involve: defined triggers that mandate communication with an attending surgeon; structured handoffs and transfer protocols; and standard use of read-backs.

An Apgar score for surgery

BACKGROUND

Surgical teams have not had a routine, reliable measure of patient condition at the end of an operation. We aimed to develop an Apgar score for the field of surgery, an outcomes score that teams could calculate at the end of any general or vascular surgical procedure to accurately grade a patient's condition and chances of major complications or death.

STUDY DESIGN

We derived our surgical score in a retrospective analysis of data from medical records and the National Surgical Quality Improvement Program for 303 randomly selected patients undergoing colectomy at Brigham and Women's Hospital, Boston. The primary outcomes measure was incidence of major complication or death within 30 days of operation. We validated the score in two prospective, randomly selected cohorts: 102 colectomy patients and 767 patients undergoing general or vascular operations at the same institution.

RESULTS

A 10-point score based on a patient's estimated amount of blood loss, lowest heart rate, and lowest mean arterial pressure during general or vascular operations was significantly associated with major complications or death within 30 days (p < 0.0001; c-index = 0.72). Of 767 general and vascular surgery patients, 29 (3.8%) had a surgical score <or= 4. Major complications or death occurred in 17 of these 29 patients (58.6%) within 30 days. By comparison, among 220 patients with scores of 9 or 10, only 8 (3.6%) experienced major complications or died (relative risk 16.1; 95% CI, 7.6-34.0; p < 0.0001).

CONCLUSIONS

A simple score based on blood loss, heart rate, and blood pressure can be useful in rating the condition of patients after general or vascular operations.

Making the operating room of the future safer

There is an increasing demand for interventions to improve patient safety, but there is limited data to guide such reform. In particular, because much of the existing research is outcome-driven, we have a limited understanding of the factors and process variations that influence safety in the operating room. In this article, we start with an overview of safety terminology, suggesting a model that emphasizes "safety" rather than "error" and that can encompass the spectrum of events occurring in the operating room. Next, we provide an introduction to techniques that can be used to understand safety at the point of care and we review the data that exists relating such studies to improved outcomes. Future work in this area will need to prospectively study the processes and factors that impact patient safety and vulnerability in the operating room.

Making the Operating Room of the Future Safer

There is an increasing demand for interventions to improve patient safety, but there is limited data to guide such reform. In particular, because much of the existing research is outcome-driven, we have a limited understanding of the factors and process variations that influence safety in the operating room. In this article, we start with an overview of safety terminology, suggesting a model that emphasizes “safety” rather than “error” and that can encompass the spectrum of events occurring in the operating room. Next, we provide an introduction to techniques that can be used to understand safety at the point of care and we review the data that exists relating such studies to improved outcomes. Future work in this area will need to prospectively study the processes and factors that impact patient safety and vulnerability in the operating room.

Post-gastric bypass hyperinsulinism with nesidioblastosis: subtotal or total pancreatectomy may be needed to prevent recurrent hypoglycemia

Symptomatic hyperinsulinemic hypoglycemia and pancreatic nesidioblastosis have recently been described in a small series of patients after gastric bypass surgery for morbid obesity. In the limited published reports of patients with this condition, hyperinsulinism and nesidioblastosis have been managed with distal or subtotal pancreatectomy, with the extent of resection guided by calcium angiography. However, nesidioblastosis may involve the pancreas diffusely, and limited pancreatic resections may predispose patients to further hypoglycemic episodes. We have treated two patients with refractory hyperinsulinism and symptomatic hypoglycemia after successful gastric bypass surgery. One patient underwent an approximately 80% pancreatectomy with good results but subsequently experienced recurrent drop attacks and fainting from hyperinsulinism; a completion pancreatectomy via a pancreaticoduodenectomy was then required. A second patient had profound hyperinsulinemic hypoglycemia and was treated successfully with a subtotal (95%) pancreatectomy. Our experience, the third published report of post-gastric bypass nesidioblastosis, suggests that the risk of recurrent symptomatic hyperinsulinism after limited pancreatectomy is significant and relative euglycemia may be achieved with subtotal or total pancreatectomy.

Incidence, Patterns, and Prevention of Wrong-Site Surgery

HYPOTHESIS

We hypothesized that wrong-site surgery is infrequent and that a substantial proportion of such incidents are not preventable by current site-verification protocols.

DESIGN

Case series and survey of site-verification protocols.

SETTING

Hospitals and a malpractice liability insurer.

PATIENTS AND OTHER PARTICIPANTS

All wrong-site surgery cases reported to a large malpractice insurer between 1985 and 2004.

MAIN OUTCOME MEASURES

Incidence, characteristics, and causes of wrong-site surgery and characteristics of site-verification protocols.

RESULTS

Among 2,826,367 operations at insured institutions during the study period, 25 nonspine wrong-site operations were identified, producing an incidence of 1 in 112,994 operations (95% confidence interval, 1 in 76,336 to 1 in 174,825). Medical records were available for review in 13 cases. Among reviewed claims, patient injury was permanent-significant in 1, temporary-major in 2, and temporary-minor or temporary-insignificant in 10. Under optimal conditions, the Joint Commission on Accreditation of Healthcare Organizations Universal Protocol might have prevented 8 (62%) of 13 cases. Hospital protocol design varied significantly. The protocols mandated 2 to 4 personnel to perform 12 separate operative-site checks on average (range, 5-20). Five protocols required site marking in cases that involved nonmidline organs or structures; 6 required it in all cases.

CONCLUSIONS

Wrong-site surgery is unacceptable but exceedingly rare, and major injury from wrong-site surgery is even rarer. Current site-verification protocols could have prevented only two thirds of the examined cases. Many protocols involve considerable complexity without clear added benefit.

A prospective study of patient safety in the operating room

BACKGROUND

To better understand the operating room as a system and to identify system features that influence patient safety, we performed an analysis of operating room patient care using a prospective observational technique.

METHODS

A multidisciplinary team comprised of human factors experts and surgeons conducted prospective observations of 10 complex general surgery cases in an academic hospital. Minute-to-minute observations were recorded in the field, and later coded and analyzed. A qualitative analysis first identified major system features that influenced team performance and patient safety. A quantitative analysis of factors related to these systems features followed. In addition, safety-compromising events were identified and analyzed for contributing and compensatory factors.

RESULTS

Problems in communication and information flow, and workload and competing tasks were found to have measurable negative impact on team performance and patient safety in all 10 cases. In particular, the counting protocol was found to significantly compromise case progression and patient safety. We identified 11 events that potentially compromised patient safety, allowing us to identify recurring factors that contributed to or mitigated the overall effect on the patient's outcome.

CONCLUSIONS

This study demonstrates the role of prospective observational methods in exposing critical system features that influence patient safety and that can be the targets for patient safety initiatives. Communication breakdown and information loss, as well as increased workload and competing tasks, pose the greatest threats to patient safety in the operating room.

Resistance to change in surgical residency: an ethnographic study of work hours reform

BACKGROUND

Although the practical challenges to work hour restrictions have been the focus of much discussion, cultural resistance to such change has received less attention. Surgical residency has its own unique social structure, and we hypothesized that challenges to this would provide impediments to successful implementation of duty hours reform.

STUDY DESIGN

We used ethnographic research methods to study the efforts at work hour restriction over a 15-month period before the introduction of the Accreditation Council for Graduate Medical Education regulations. These methods, validated for studying institutional change, build on intense periods of observation. Records of observations are then analyzed and coded to uncover cultural and political challenges. The frequency of successful hand-offs in sign-out situations between day and night float residents was measured as an objective index of success.

RESULTS

Practical issues were addressed initially by scheduling adjustments including creating a night float system. The hand-offs that this system required, however, were successful only 14% of the time. Subsequent steps to address the challenge to resident identity by top-down support of a new definition of professionalism increased the number of successful hand-offs to 39%. Finally, a reduction in a noted hierarchy violation led to successful hand-offs 79% of the time.

CONCLUSIONS

These results demonstrate that practical solutions alone may not be a sufficient basis for change in surgical residency. While we face other challenges to the traditional surgical culture, attention to social and political issues may enhance the success of our efforts.

The volume-outcome relationship: don't believe everything you see

This paper investigates methodological limitations of the volume-outcome relationship. A brief overview of quality measurement is followed by a discussion of two important aspects of the relationship.

Hospital Volume versus Outcome: An Unusual Example of Bivariate Association

The Leapfrog Group, a consortium of more than 100 large employers, purchasing coalitions, and states that collectively provide health insurance to more than 33 million people, convened in 2000 with the goal of using market forces to improve the quality of healthcare. The resulting Leapfrog initiative suggested selective referral of complex procedures to high-volume hospitals and set volume thresholds for five procedures. This was based on the hypothesis that low-volume hospitals have higher mortality, which can be viewed in simplified statistical terms as the hypothesis that the binomial p is a decreasing function of n. The analysis of the correlation between hospitals' standardized mortality ratios (SMR, i.e., the ratio of observed to expected deaths) and hospitals' procedural volumes is revealing about the volume/mortality hypothesis. This presents an unusual pedagogic example in which the detection of correlation in the presence of nonlinear dependence is of primary interest, and thus the Pearson correlation is ideally suited. The frequently preferred nonparametric measures of bivariate association are inappropriate as they are unable to discriminate between correlation and dependence.

Risk factors and outcomes of pancreatitis after open heart surgery

BACKGROUND

We sought to analyze the risk factors and natural history associated with post-cardiac surgery acute pancreatitis.

METHODS

Retrospective analysis of all patients having undergone cardiac surgery at our hospital between January 1, 1992, and October 1, 2001.

RESULTS

A total of 10,249 cardiac operations were performed. Thirty-nine (0.4%) patients developed postoperative pancreatitis. There was a higher incidence during the period spanning 1992 through 1996 than 1997 through 2001 (0.6% versus 0.2%, P< .05). Patients with pancreatitis had longer postoperative length of stay (51+/-5 days versus 10+/-1 days, P<.05) and a greater in-hospital mortality rate (28% versus 4%, P<.05) than patients who did not develop pancreatitis. A history of alcohol abuse, cardiac surgery performed during 1992 to 1996, increased cardiopulmonary bypass time, and increased cross-clamp time were independent risk factors for the development of pancreatitis. Multiple-organ failure was an independent predictor for death among patients with pancreatitis.

CONCLUSIONS

Although the frequency of post-cardiac surgery pancreatitis is diminishing, it is still associated with significant mortality.