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Background Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. Methods A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. Results In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. Conclusion After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

Objectives To examine the role of microsystem characteristics in the translation of an evidence-based intervention (the Diabetes Prevention Initiative (DPI)) into practice in a community-health centre (CHC). Design Case study. Analysis Constant comparative method of qualitative analysis. Setting Community-health centre in a mid-sized city in the USA. Participants 27 administrators, clinicians and staff of a community-health centre implementing a DPI. Main outcome measures Perceptions of microsystem characteristics that influence the implementation of this initiative. Results Five characteristics of high-performing microsystems were reflected, but not maximised, in the implementation of the DPI. First, there was no universally shared definition of the desired purpose of the DPI. Second, investment in quality improvement (QI) was strong, yet sustainability remained a concern, since efforts were dependent upon external grant support. Third, lack of cohesiveness between the initiative planning team and the rest of the organisation served to both facilitate and constrain implementation. Fourth, administrators showed both support for new initiatives and a lack of strategic vision for QI. Fifth, this initiative substantially strained already-stretched role definitions. Conclusions Translation of the DPI in this CHC was constrained by the lack of a cohesive QI infrastructure and incomplete alignment with characteristics of high-performing microsystems. The findings suggest an important role for microsystem characteristics in the process of implementing evidence-based interventions. Enhancing the level of microsystem performance of CHCs is essential to informing efforts to improve quality of care in this critical safety-net system.

Objectives: Primary care networks within integrated health systems can experience significant variation in diabetes care. We studied an established, 20-site network to determine the impact of a quality improvement intervention to add certified diabetes educators (CDEs). We sought to measure whether sites with CDEs had higher quality and whether care improved over time more in sites with CDEs, beyond the existing differences among sites. Methods: Diabetes quality outcomes were (1) HbA1c ≤8%, (2) low-density lipoprotein (LDL) ≤100 mg/dL, (3) microalbumin checked, (4) blood pressure (BP) ≤130/80 mm Hg (tight control), and (5) BP ≤140/90 mm Hg (lenient control). Baseline differences brought us to divide sites into 3 site types by predominant payer and teaching status (commercial/nonteaching, mixed [mostly government-sponsored]/teaching and mixed/nonteaching). We measured the association between CDEs and each outcome using a 2-level mixed effects logistic regression with site type as a random effect. Results: Our analysis included 13 001 patients with visits and labs pre- and post-CDE implementation. Sites with CDEs improved significantly in 2 of 5 outcomes compared with sites without CDEs. Improvements occurred in microalbumin checks (odds ratio = 2.21, P < .001) and BP

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEs/ARBs) have proven benefit for patients with myocardial infarction and heart failure; their use is a core measure of hospital quality for the Centers for Medicare and Medicaid Services. The authors' urban medical center has lower-than-average performance on this measure. The authors used published best practices to design and implement a comprehensive strategy to improve ACE/ARB performance with existing decision support and human resources. Chart reminders were targeted to providers of patients eligible for ACEs/ARBs but not receiving them. ACE/ARB performance increased 8.5% in postintervention patients compared with historical controls. The increase was 20.7% among patients not on ACEs/ARBs on admission (P =.03). Chronic kidney disease (CKD) was inversely associated with the effectiveness of the intervention. A comprehensive strategy can be effective in narrowing the performance gap even for populations with a high prevalence of CKD. However, future work is needed to improve performance among patients whose ACEs/ARBs are withheld during hospitalization.

Although interdisciplinary hospital quality improvement (QI) teams are both prevalent and associated with success of (QI) efforts, little is known about the behaviors of successful interdisciplinary QI teams.We examined the specific behaviors of interdisciplinary QI teams in hospitals that successfully redesigned care for patients with ST-elevation myocardial infarction (STEMI) and reduced door-to-balloon times.Qualitative study.Researchers interviewed 122 administrators, providers, and staff in 11 hospitals with substantial improvements in door-to-balloon times.Using data from the in-depth qualitative interviews, the authors identified themes that described the behaviors of interdisciplinary QI teams in successful hospitals.Teams focused on 5 behaviors: (1) motivating involved hospital staff toward a shared goal, (2) creating opportunities for learning and problem-solving, (3) addressing the impact of changes to care processes on staff, (4) protecting the integrity of the new care processes, and (5) representing each involved clinical discipline effectively.The behaviors observed may enhance a QI team's ability to motivate the various disciplines involved, understand the care process they must change, be responsive to front-line concerns while maintaining control over the improvement process, and share information across all levels of the hospital hierarchy. Teams in successful hospitals did not avoid interdisciplinary conflict, but rather allowed each discipline to contribute to the team from its own perspective. Successful QI teams addressed the concerns of each involved discipline, modified protocols guided by clinical outcomes, and became conduits of information on changes to care processes to both executive managers and front-line staff.

Comanagement of vascular patients improves surgical outcomes David L Feldman, MD, MBA, FACS, Patricia Kischak, RN, MBA, Michael Brodman, MD, Ronald N Kaleya, MD, FACS, I Michael Leitman, MD, FACS, Meg A Rosenblatt, MD, Calie Santana, MD, Peter Shamamian, MD, FACS, Donna Somerville Mount Sinai Health System, New York, NY; Montefiore Medical Center, Bronx, NY; Maimonides Medical Center, Brooklyn, NY

Health care quality in the US territories is poorly characterized. We used process measures to compare the performance of hospitals in the US territories and in the US states.Our sample included nonfederal hospitals located in the United States and its territories discharging Medicare fee-for-service (FFS) patients with a principal discharge diagnosis of acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PNE) (July 2005-June 2008). We compared risk-standardized 30-day mortality and readmission rates between territorial and stateside hospitals, adjusting for performance on core process measures and hospital characteristics.In 57 territorial hospitals and 4799 stateside hospitals, hospital mean 30-day risk-standardized mortality rates were significantly higher in the US territories (P.001) for AMI (18.8% vs 16.0%), HF (12.3% vs 10.8%), and PNE (14.9% vs 11.4%). Hospital mean 30-day risk-standardized readmission rates (RSRRs) were also significantly higher in the US territories for AMI (20.6% vs 19.8%; P=.04), and PNE (19.4% vs 18.4%; P=.01) but was not significant for HF (25.5% vs 24.5%; P=.07). The higher risk-standardized mortality rates in the US territories remained statistically significant after adjusting for hospital characteristics and core process measure performance. Hospitals in the US territories had lower performance on all core process measures (P.05).Compared with hospitals in the US states, hospitals in the US territories have significantly higher 30-day mortality rates and lower performance on every core process measure for patients discharged after AMI, HF, and PNE. Eliminating the substantial quality gap in the US territories should be a national priority.