Healthcare Quality Measurement in Orthopaedic Surgery: Current State of the Art

Improving quality of care in arthroplasty is of increasing importance to payors, hospitals, surgeons, and patients. Efforts to compel improvement have traditionally focused measurement and reporting of data describing structural factors, care processes (or ‘quality measures’), and clinical outcomes. Reporting structural measures (eg, surgical case volume) has been used with varying degrees of success. Care process measures, exemplified by initiatives such as the Surgical Care Improvement Project measures, are chosen based on the strength of randomized trial evidence linking the process to improved outcomes. However, evidence linking improved performance on Surgical Care Improvement Project measures with improved outcomes is limited. Outcome measures in surgery are of increasing importance as an approach to compel care improvement with prominent examples represented by the National Surgical Quality Improvement Project. Although outcomes-focused approaches are often costly, when linked to active benchmarking and collaborative activities, they may improve care broadly. Moreover, implementation of computerized data systems collecting information formerly collected on paper only will facilitate benchmarking. In the end, care will only be improved if these data are used to define methods for innovating care systems that deliver better outcomes at lower or equivalent costs

Living with COVID-19 and preparing for future pandemics: revisiting lessons from the HIV pandemic

In April, 2020, just months into the COVID-19 pandemic, an international group of public health researchers published three lessons learned from the HIV pandemic for the response to COVID-19, which were to: anticipate health inequalities, create an enabling environment to support behavioural change, and engage a multidisciplinary effort. We revisit these lessons in light of more than 2 years’ experience with the COVID-19 pandemic. With specific examples, we detail how inequalities have played out within and between countries, highlight factors that support or impede the creation of enabling environments, and note ongoing issues with the scarcity of integrated science and health system approaches. We argue that to better apply lessons learned as the COVID-19 pandemic matures and other infectious disease outbreaks emerge, it will be imperative to create dialogue among polarised perspectives, identify shared priorities, and draw on multidisciplinary evidence

Association Between a Serotonin Transporter Gene Variant and Hopelessness Among Men in the Heart and Soul Study

Hopelessness is associated with mortality in patients with cardiac disease even after accounting for severity of depression. We sought to determine whether a polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) is associated with increased hopelessness, and whether this effect is modified by sex, age, antidepressant use or depression in patients with coronary heart disease. We conducted a cross-sectional study of 870 patients with stable coronary heart disease. Our primary outcomes were hopelessness score (range 0-8) and hopeless category (low, moderate and high) as measured by the Everson hopelessness scale. Analysis of covariance and ordinal logistic regression were used to examine the independent association of genotype with hopelessness. Compared to patients with l/l genotype, adjusted odds of a higher hopeless category increased by 35% for the l/s genotype and 80% for s/s genotype (p-value for trend = 0.004). Analysis of covariance demonstrated that the effect of 5-HTTLPR genotype on hopelessness was modified by sex (.04), but not by racial group (p = 0.63). Among men, odds of higher hopeless category increased by 40% for the l/s genotype and by 2.3-fold for s/s genotype (p-value p < 0.001), compared to no effect in the smaller female sample (p = 0.42). Results stratified by race demonstrated a similar dose-response effect of the s allele on hopelessness across racial groups. We found that the 5-HTTLPR is independently associated with hopelessness among men with cardiovascular disease

Expert-augmented machine learning.

Machine learning is proving invaluable across disciplines. However, its success is often limited by the quality and quantity of available data, while its adoption is limited by the level of trust afforded by given models. Human vs. machine performance is commonly compared empirically to decide whether a certain task should be performed by a computer or an expert. In reality, the optimal learning strategy may involve combining the complementary strengths of humans and machines. Here, we present expert-augmented machine learning (EAML), an automated method that guides the extraction of expert knowledge and its integration into machine-learned models. We used a large dataset of intensive-care patient data to derive 126 decision rules that predict hospital mortality. Using an online platform, we asked 15 clinicians to assess the relative risk of the subpopulation defined by each rule compared to the total sample. We compared the clinician-assessed risk to the empirical risk and found that, while clinicians agreed with the data in most cases, there were notable exceptions where they overestimated or underestimated the true risk. Studying the rules with greatest disagreement, we identified problems with the training data, including one miscoded variable and one hidden confounder. Filtering the rules based on the extent of disagreement between clinician-assessed risk and empirical risk, we improved performance on out-of-sample data and were able to train with less data. EAML provides a platform for automated creation of problem-specific priors, which help build robust and dependable machine-learning models in critical applications

Physician Use of Advance Care Planning Discussions in a Diverse Hospitalized Population

Two decades after the Patient Self Determination Act it is unknown how often physicians have advance care planning (ACP) discussions with hospitalized patients. The objective of this study is to investigate use of ACP discussions in a multi-ethnic, multi-lingual hospitalized population. Cross-sectional communication study of hospitalized patients. The Participants are 369 patients at one urban county hospital and one academic medical center. Interventions are not applicable. Participants were asked at baseline and a post-discharge interview whether hospital physicians had discussed either (a) what type of treatment they would want if they could not make decisions for themselves or (b) whether they would want cardiopulmonary resuscitation if needed. We compared patient characteristics for those who did and did not have an ACP discussion. Only 151 (41%) participants reported an ACP discussion. Rates of ACP were low across ethnic, language, education and age groups. In a multivariate model, scoring higher on a co-morbidity scale was associated with higher odds of reporting having had an ACP discussion during hospitalization; this finding remained after adjusting for time period and site of data collection. Multiethnic, multi-lingual hospitalized patients reported low rates of ACP discussions with their physicians regardless of ethnicity, English proficiency, education level or age

Do Hospitalists or Physicians with Greater Inpatient HIV Experience Improve HIV Care in the Era of Highly Active Antiretroviral Therapy? Results from a Multicenter Trial of Academic Hospitalists

Background. Little is known about the effect of provider type and experience on outcomes, resource use, and processes of care of hospitalized patients with human immunodeficiency virus (HIV) infection. Hospitalists are caring for this population with increasing frequency. Methods. Data from a natural experiment in which patients were assigned to physicians on the basis of call cycle was used to study the effects of provider type—that is, hospitalist versus non hospitalist—and HIV-specific inpatient experience on resource use, outcomes, and selected measures of processes of care at 6 academic institutions. Administrative data, inpatient interviews, 30-day follow-up interviews, and the National Death Index were used to measure outcomes. Results. A total of 1207 patients were included in the analysis. There were few differences in resource use, outcomes, and processes of care by provider type and experience with HIV-infected inpatients. Patients who received hospitalist care demonstrated a trend toward increased length of hospital stay compared with patients who did not receive hospitalist care (6.0 days vs. 5.2 days; Pp .13). Inpatient providers with moderate experience with HIV-infected patients were more likely to coordinate care with outpatient providers (odds ratio, 2.40; Pp .05) than were those with the least experience with HIV-infected patients, but this pattern did not extend to providers with the highest level of experience. Conclusion. Provider type and attending physician experience with HIV-infected inpatients had minimal effect on the quality of care of HIV-infected inpatients. Approaches other than provider experience, such as the use of multidisciplinary inpatient teams, may be better targets for future studies of the outcomes, processes of care, and resource use of HIV-infected inpatients

Characteristics of intensive care units in Michigan: Not an open and closed case

OBJECTIVE: Delivery of critical care by intensivists has been recommended by several groups. Our objective was to understand the delivery of critical care physician services in Michigan and the role of intensivists and nonintensivist providers in providing care. DESIGN: Descriptive questionnaire. PARTICIPANTS AND SETTING: Intensive care unit (ICU) directors and nurse managers at 96 sites, representing 115 ICUs from 72 hospitals in Michigan. MEASUREMENTS AND RESULTS: The primary outcome measure was the percentage of sites utilizing a closed vs. an open model of ICU care. Secondary outcome measures included the percentage of ICUs utilizing a high-intensity service model, hospital size, ICU size, type of clinician providing care, and clinical activities performed. Twenty-four (25%) sites used a closed model of intensive care, while 72 (75%) had an open model of care. Hospitals with closed ICUs were larger and had larger ICUs than sites with open ICUs ( P < 0.05). Hospitalists serving as attending physicians were strongly associated with an open ICU (odds ratio [OR] = 12.2; 95% confidence interval [CI] = 2.5-60.2), as was the absence of intensivists in the group (OR = 12.2; 95%CI = 1.4-105.8), while ICU and hospital size were not associated. At 18 sites (20%) all attendings were board certified in Critical Care. Sixty sites had less than 50% board-certified attending physicians. CONCLUSIONS: The closed intensivist-led model of intensive care delivery is not in widespread use in Michigan. In the absence of intensivists, alternate models of care, including the hospitalist model, are frequently used. Journal of Hospital Medicine 2010;5:4–9. © 2010 Society of Hospital Medicine.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/64903/1/567_ftp.pd