Background
Coronary atherosclerosis raises the risk of acute myocardial infarction (AMI), and is usually included in AMI risk‐adjustment models. Percutaneous coronary intervention (PCI) does not ...cause atherosclerosis, but may contribute to the notation of atherosclerosis in administrative claims. We investigated how adjustment for atherosclerosis affects rankings of hospitals that perform PCI.
Methods and Results
This was a retrospective cohort study of 414 715 Medicare beneficiaries hospitalized for AMI between 2009 and 2011. The outcome was 30‐day mortality. Regression models determined the association between patient characteristics and mortality. Rankings of the 100 largest PCI and non‐PCI hospitals were assessed with and without atherosclerosis adjustment. Patients admitted to PCI hospitals or receiving interventional cardiology more frequently had an atherosclerosis diagnosis. In adjustment models, atherosclerosis was associated, implausibly, with a 42% reduction in odds of mortality (odds ratio=0.58, P<0.0001). Without adjustment for atherosclerosis, the number of expected lives saved by PCI hospitals increased by 62% (P<0.001). Hospital rankings also changed: 72 of the 100 largest PCI hospitals had better ranks without atherosclerosis adjustment, while 77 of the largest non‐PCI hospitals had worse ranks (P<0.001).
Conclusions
Atherosclerosis is almost always noted in patients with AMI who undergo interventional cardiology but less often in medically managed patients, so adjustment for its notation likely removes part of the effect of interventional treatment. Therefore, hospitals performing more extensive imaging and more PCIs have higher atherosclerosis diagnosis rates, making their patients appear healthier and artificially reducing the expected mortality rate against which they are benchmarked. Thus, atherosclerosis adjustment is detrimental to hospitals providing more thorough AMI care.
More than a quarter of medical costs for Medicare beneficiaries are incurred in the last year of life; surgical intensity during this time is significant. This study was performed to determine types ...of operations patients undergo in their terminal year, and compare characteristics of decedents with those of survivors.
Population of 747 consecutive all-payer patients seen at the preoperative assessment center of a tertiary care hospital. Patient characteristics were obtained from the electronic medical record. Surgical indication (palliative, curative, diagnostic, elective) was assessed based on procedure performed and underlying diagnosis. Vital status was determined using the electronic medical record with confirmation via social security national death master file. Descriptive statistics were performed to compare patient characteristics and procedures performed on those who died within 1 yr of procedure with those of survivors.
Thirty-seven patients (5%) were confirmed dead at 1 yr. Ten (27%) of these had palliative procedures, 11 (30%) diagnostic, 14 (38%) curative, and 2 (5%) elective. Decedents were more likely to have undergone a palliative (27 vs. 3%) or diagnostic (30 vs. 14%) procedure and less likely to have undergone an elective procedure (5 vs. 42%) than survivors (P < 0.0001). Nearly half of decedents did not have an advanced directive by the date of surgical intervention.
Nearly 1 in 20 patients seen at the preoperative assessment clinic of a tertiary care hospital died within 1 yr of their procedure. Patient characteristics and procedure indication for decedents differed from those of survivors. Similar analyses based on institution and region may provide methodologies to compare variation in surgical intensity and assist preoperative care providers in evaluating appropriateness of resource allocation.
Abstract Background “War stories” are commonplace in surgical education, yet little is known about their purpose, construct, or use in the education of trainees. Methods Ten complex operations were ...videotaped and audiotaped. Narrative stories were analyzed using grounded theory to identify emergent themes in both the types of stories being told and the teaching objectives they illustrated. Results Twenty-four stories were identified in 9 of the 10 cases (mean, 2.4/case). They were brief (mean, 58 seconds), illustrative of multiple teaching points (mean, 1.5/story), and appeared throughout the operations. Anchored in personal experience, these stories taught both clinical (eg, operative technique, decision making, error identification) and programmatic (eg, resource management, professionalism) topics. Conclusions Narrative stories are used frequently and intuitively by physicians to emphasize a variety of intraoperative teaching points. They socialize trainees in the culture of surgery and may represent an underrecognized approach to teaching the core competencies. More understanding is needed to maximize their potential.
To develop and evaluate an intervention to reduce breakdowns in communication during inpatient surgical care.
Communication breakdowns are the second most common cause of avoidable surgical adverse ...events after technical errors.
In a pre- and postintervention study, a random selection of patients on the surgical services of 4 teaching hospitals were observed according to 3 measures: (1) resident-attending communication of critical patient events (eg, transfer into the intensive care unit, unplanned intubation, cardiac arrest); (2) resident-attending notification regarding routine weekend patient status; and (3) frequency of weekend patient visits by an attending. All departments then developed and adopted a set of policy and education initiatives designed to increase prompt and consistent resident-attending communication (especially in critical events) and to improve regular attending visits with surgical patients. Specific reinforcement of the policies included a pocket information card for residents, as well as periodic reminders. Repeat audits of the surgical services were then conducted.
We reviewed information for 211 critical events and 1360 patients for the nature of resident and attending communication practices. After the intervention, the proportion of critical events not conveyed to an attending decreased from 33% (26/80) to 2% (1/47), and gaps in the frequency of attending notification of patient status on weekends were virtually eliminated (P < 0.0001); the proportion of weekend patients not visited by an attending for greater than 24 hours decreased by half (from 61% to 33%; P = 0.0002). Contact resulted in attending-led changes in patient management in one-third of cases.
An intervention to improve surgical communication practices at 4 teaching hospitals led to significant reductions in potentially harmful communication breakdowns during inpatient care; significant alterations in patient management were noted in one-third of cases in which there was an adherence to recommended communication practices.
Traditionally, surgical educators have relied upon participant survey data for the evaluation of educational interventions. However, the ability of such subjective data to completely evaluate an ...intervention is limited. Our objective was to compare resident and attending surgeons’ self-assessments of coaching sessions from surveys with independent observations from analysis of intraoperative and postoperative coaching transcripts.
Senior residents were video-recorded operating. Each was then coached by the operative attending in a 1:1 video review session. Teaching points made in the operating room (OR) and in post-OR coaching sessions were coded by independent observers using dialogue analysis then compared using t-tests. Participants were surveyed regarding the degree of teaching dedicated to specific topics and perceived changes in teaching level, resident comfort, educational assessments, and feedback provision between the OR and the post-OR coaching sessions.
A single, large, urban, tertiary-care academic institution.
Ten PGY4 to 5 general surgery residents and 10 attending surgeons.
Although the reported experiences of teaching and coaching sessions by residents and faculty were similar (Pearson correlation coefficient = 0.88), these differed significantly from independent observations. Observers found that residents initiated a greater proportion of teaching points and had more educational needs assessments during coaching, compared to the OR. However, neither residents nor attendings reported a change between the 2 environments with regard to needs assessments nor comfort with asking questions or making suggestions. The only metric on which residents, attendings, and observers agreed was the provision of feedback.
Participants’ perspectives, although considered highly reliable by traditional metrics, rarely aligned with analysis of the associated transcripts from independent observers. Independent observation showed a distinct benefit of coaching in terms of frequency and type of learning points. These findings highlight the importance of seeking different perspectives, data sources, and methodologies when evaluating clinical education interventions. Surgical education can benefit from increased use of dialogue analyses performed by independent observers, which may represent a viewpoint distinct from that obtained by survey methodology.
To the Editor:
Arriaga and colleagues (Jan. 17 issue)
1
report a 75% reduction in omission errors with implementation of a surgical-crisis checklist during simulated operative events. They do not ...mention what education and training on use of the checklist the participants received before the simulated events. Clinicians who are not accustomed to using a checklist or other cognitive aids are unlikely to use such an aid during a critical event, simulated or otherwise, unless instruction and training in the use of the tools are provided. Although the reduction in missed steps is remarkable, the goal in critical events should be . . .
To evaluate whether adherence to evidence-based best practices in colorectal surgery predicts improved postoperative outcomes.
Over a quarter of a million colon and rectal resections are performed ...annually in the United States. The average postoperative complication rate for these procedures approaches 30%.
A panel of colorectal and general surgeons from 3 hospitals (1 academic medical center and 2 community hospitals) was assembled to ascertain a set of 37 evidence-based practices that they felt were the most pertinent to the evaluation and management of a patient undergoing a colorectal resection. Fifteen of these practices were classified as “key processes” for the prevention of complications. We then retrospectively reviewed medical records for 370 consecutive patients undergoing colorectal resection at these institutions. We evaluated the association of best-practice adherence to complications in the subset of patients with outcome data available through the American College of Surgeons National Surgical Quality Improvement Program.
Nonadherence rates exceeded 40% for 11 practices (including 2 key processes: avoidance of unnecessary blood transfusions and timely removal of central venous catheters). Among 198 patients with American College of Surgeons National Surgical Quality Improvement Program outcomes data, 38 (19%) experienced complications, of which 31 (82%) involved postoperative infection. Nonadherence to key-processes significantly predicted the occurrence of a complication (P = 0.002). Each additional process missed increased the odds of a postoperative complication by 60% (odds ratio: 1.6; 95% confidence interval: 1.2–2.2).
Failures of adherence with best practices in colorectal surgery is associated with an increased occurrence of complications. This study merits further research to confirm that improvement in compliance with perioperative best practices will reduce complication rates significantly.
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