Building, scaling, and sustaining a learning health system for surgical quality improvement: A toolkit

This article describes how to start, replicate, scale, and sustain a learning health system for quality improvement, based on the experience of the Michigan Surgical Quality Collaborative (MSQC). The key components to operationalize a successful collaborative improvement infrastructure and the features of a learning health system are explained. This information is designed to guide others who desire to implement quality improvement interventions across a regional network of hospitals using a collaborative approach. A toolkit is provided (under Supporting Information) with practical information for implementation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156156/3/lrh210215.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156156/2/lrh210215-sup-0001-supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156156/1/lrh210215_am.pd

Characteristics of Patients Seeking Second Opinions at a Multidisciplinary Colorectal Cancer Clinic

BACKGROUND: Patients seeking second opinions are a challenge for the colorectal cancer provider due to complexity, failed therapeutic relationship with another provider, need for reassurance, and desire for exploration of treatment options. OBJECTIVE: To describe the patient and treatment characteristics of patients seeking initial and second opinions in colorectal cancer care at a multidisciplinary colorectal cancer clinic. DESIGN: Retrospective cohort study SETTINGS:: Prospectively collected clinical registry of a multidisciplinary colorectal cancer clinic. PATIENTS: Patients with colon or rectal cancer seen from 2012-2017. MAIN OUTCOME MEASURES: Data were analyzed for initial vs. second opinion and demographic and clinical characteristics. RESULTS: Of 1711 colorectal cancer patients, 1008 (58.9%) sought an initial opinion, 700 (40.9%) sought a second opinion. As compared to initial opinion patients, second opinion patients were more likely to have Stage IV disease (OR 1.94, 95% CI 1.47-2.58), recurrent disease (OR 1.67, 95% CI 1.13-2.46), and be ages 40-49 (OR 1.47, 95% CI 1.02-2.12). Initial and second opinion cohorts were similar in terms of gender, race, and proportion of colon vs. rectal cancer. Among second opinion patients, 246 (35%) second opinion patients transitioned their care to the multidisciplinary colorectal cancer clinic. LIMITATIONS: We were unable to capture final treatment plan for those patients who did not transfer care to the multidisciplinary colorectal cancer clinic. CONCLUSIONS: Patients seeking a second opinion represent a unique subset of colorectal cancer patients. In general, they are younger, and more likely to have Stage IV or recurrent disease than patients seeking an initial opinion. Although transfer of care to a multidisciplinary colorectal cancer clinic after second opinion is lower than for initial consultations, multidisciplinary colorectal cancer clinics provide an important role for patients with complex disease characteristics and treatment needs. See Video Abstract at http://links.lww.com/DCR/B192

Determinants of Value in Coronary Artery Bypass Grafting

Background Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to$10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation \u3e24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay \u3e14 days (9.3% versus 2.4%, P=0.006), prolonged ventilation (17.6% versus 4.8%, P\u3c0.001), and operative mortality (4.8% versus 0.6%, P=0.001). Mean total episode payments were $51 509 at low-compared with$45 526 at high-value hospitals (P\u3c0.001), driven by higher readmission ($3675 versus$2177, P=0.005), professional ($7462 versus$6090, P\u3c0.001), postacute care ($7315 versus$5947, P=0.031), and index hospitalization payments ($33 474 versus$30 800, P\u3c0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus$752, P\u3c0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, P\u3c0.001), but lower utilization of home health (66% versus 73%, P=0.016) and emergency department services (13% versus 17%, P=0.034). Conclusions To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services