The Changing Geography of Outpatient Procedures

Since the early 80s, many surgical procedures have moved from the inpatient to outpatient setting. Outpatient surgical visits now account for about two-thirds of all surgical visits in the U.S. Over the same period, freestanding ambulatory surgery centers (ASCs) have arisen as alternatives to traditional hospital-based outpatient surgical departments. The number of ASCs grew from 240 in 1983 to 5,174 in 2008. The growth of ASCs raises safety concerns about the risk of complications and adequate access to emergency care. This Issue Brief summarizes evidence from one state about the changing geography of outpatient procedures and the possible risks associated with these changes

Physician Division of Labor and Patient Selection for Outpatient Procedures

Little is known about the ability of incentives to influence decisions by physicians regarding choices of settings for care delivery. In the context of outpatient procedural care, the emergence of freestanding ambulatory surgery centers (ASCs) as alternatives to hospital-based outpatient departments (HOPDs) creates a unique opportunity to study this question. We advance a model where physicians’ division of labor between ASCs and HOPDs affects the medical complexity of patients treated in low-acuity settings (i.e. ASCs). Analyses of outpatient surgical procedure data show that physicians working exclusively in low-acuity settings (i.e. ASCs) treat patients of significantly higher medical complexity in these settings than do physicians who also practice in higher-acuity settings (i.e. HOPDs). This discrepancy shrinks with increasing procedural risk and with increasing distance between ASCs and acute care hospitals

Purification and electron cryomicroscopy of coronavirus particles.

Intact, enveloped coronavirus particles vary widely in size and contour, and are thus refractory to study by traditional structural means such as X-ray crystallography. Electron microscopy (EM) overcomes some problems associated with particle variability and has been an important tool for investigating coronavirus ultrastructure. However, EM sample preparation requires that the specimen be dried onto a carbon support film before imaging, collapsing internal particle structure in the case of coronaviruses. Moreover, conventional EM achieves image contrast by immersing the specimen briefly in heavy-metal-containing stain, which reveals some features while obscuring others. Electron cryomicroscopy (cryo-EM) instead employs a porous support film, to which the specimen is adsorbed and flash-frozen. Specimens preserved in vitreous ice over holes in the support film can then be imaged without additional staining. Cryo-EM, coupled with single-particle image analysis techniques, makes it possible to examine the size, structure and arrangement of coronavirus structural components in fully hydrated, native virions. Two virus purification procedures are described

Affording to Wait: Medicare Initiation and the Use of Health Care

Delays in receipt of necessary diagnostic and therapeutic medical procedures related to the timing of Medicare initiation at age 65 years have potentially broad welfare implications. We use 2005–2007 data from Florida and North Carolina to estimate the effect of initiation of Medicare benefits on healthcare utilization across procedures that differ in urgency and coverage. In particular, we study trends in the use of elective procedures covered by Medicare to treat conditions that vary in symptoms; these are compared with elective surgical procedures not eligible for Medicare reimbursement, and to a set of urgent and emergent procedures. We find large discontinuities in health services utilization at age 65 years concentrated among low urgency, Medicare‐reimbursable procedures, most pronounced among screening interventions and treatments for minimally symptomatic disease

Comparative safety of anesthetic type for hip fracture surgery in adults: retrospective cohort study

Objective: To evaluate the effect of anesthesia type on the risk of in-hospital mortality among adults undergoing hip fracture surgery in the United States. Design: Retrospective cohort study. Setting: Premier research database, United States. Participants: 73 284 adults undergoing hip fracture surgery on hospital day 2 or greater between 2007 and 2011. Of those, 61 554 (84.0%) received general anesthesia, 6939 (9.5%) regional anesthesia, and 4791 (6.5%) combined general and regional anesthesia. Main outcome measure In-hospital all cause mortality. Results: In-hospital deaths occurred in 1362 (2.2%) patients receiving general anesthesia, 144 (2.1%) receiving regional anesthesia, and 115 (2.4%) receiving combined anesthesia. In the multivariable adjusted analysis, when compared with general anesthesia the mortality risk did not differ significantly between regional anesthesia (risk ratio 0.93, 95% confidence interval 0.78 to 1.11) or combined anesthesia (1.00, 0.82 to 1.22). A mixed effects analysis accounting for differences between hospitals produced similar results: compared with general anesthesia the risk from regional anesthesia was 0.91 (0.75 to 1.10) and from combined anesthesia was 0.98 (0.79 to 1.21). Findings were also consistent in subgroup analyses. Conclusions: In this large nationwide sample of hospital admissions, mortality risk did not differ significantly by anesthesia type among patients undergoing hip fracture surgery. Our results suggest that if the previously posited beneficial effect of regional anesthesia on short term mortality exists, it is likely to be more modest than previously reported

Evaluating A State Opioid Prescribing Limit and Electronic Medical Record Alert

Because long-term opioid use has been linked to the length and strength of an initial prescription, 33 states, Medicare, and some private insurers have set limits on the duration of new opioid prescriptions. In May 2017, New Jersey implemented a statewide 5-day limit on new opioid prescriptions and Penn Medicine implemented an Electronic Medical Record (EMR) alert to notify prescribers when a prescription exceeded the limit and provide compliant prescription orders. This study compared outcomes in Penn Medicine outpatient practices in New Jersey with its practices in Pennsylvania not subject to the law. Outcomes included total opioid dose and number of tablets per prescription as well as rates of prescription refills, health care visits, and telephone calls within 30 days to account for potential unintended consequences

Survival and Functional Outcomes After Hip Fracture Among Nursing Home Residents

Importance Little is known regarding outcomes after hip fracture among long-term nursing home residents. Objective To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture. Design, Setting, and Participants Retrospective cohort study of 60 111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009. Main Outcomes and Measures Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture. Results Of 60 111 patients, 21 766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ≤75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P \u3c .001]), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 [P \u3c .001]), and advanced comorbidity (Charlson score of ≥5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 [P \u3c .001]). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk [RR], 1.66; 95% CI, 1.56-1.77 [P \u3c .001]), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 [P \u3c .001]), and patients older than 90 years (vs ≤75 years: RR, 1.42; 95% CI, 1.37-1.46 [P \u3c .001]). Conclusions and Relevance Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population

Combined Estimation of Hydrogeologic Conceptual Model, Parameter, and Scenario Uncertainty with Application to Uranium Transport at the Hanford Site 300 Area

This report to the Nuclear Regulatory Commission (NRC) describes the development and application of a methodology to systematically and quantitatively assess predictive uncertainty in groundwater flow and transport modeling that considers the combined impact of hydrogeologic uncertainties associated with the conceptual-mathematical basis of a model, model parameters, and the scenario to which the model is applied. The methodology is based on a n extension of a Maximum Likelihood implementation of Bayesian Model Averaging. Model uncertainty is represented by postulating a discrete set of alternative conceptual models for a site with associated prior model probabilities that reflect a belief about the relative plausibility of each model based on its apparent consistency with available knowledge and data. Posterior model probabilities are computed and parameter uncertainty is estimated by calibrating each model to observed system behavior; prior parameter estimates are optionally included. Scenario uncertainty is represented as a discrete set of alternative future conditions affecting boundary conditions, source/sink terms, or other aspects of the models, with associated prior scenario probabilities. A joint assessment of uncertainty results from combining model predictions computed under each scenario using as weight the posterior model and prior scenario probabilities. The uncertainty methodology was applied to modeling of groundwater flow and uranium transport at the Hanford Site 300 Area. Eight alternative models representing uncertainty in the hydrogeologic and geochemical properties as well as the temporal variability were considered. Two scenarios represent alternative future behavior of the Columbia River adjacent to the site were considered. The scenario alternatives were implemented in the models through the boundary conditions. Results demonstrate the feasibility of applying a comprehensive uncertainty assessment to large-scale, detailed groundwater flow and transport modeling and illustrate the benefits of the methodology I providing better estimates of predictive uncertiay8, quantitative results for use in assessing risk, and an improved understanding of the system behavior and the limitations of the models