Search

BACKGROUND: Local ablative therapies, a partial-gland treatment for localized prostate cancer (PCa), offers targeted cancer treatment while minimizing side-effects. We aim to describe national-level patterns in its use for localized PCa in the United States (U.S.).METHODS:We retrospectively interrogated the hospital-based National Cancer Database (NCDB) for men with clinically localized PCa from 2010-2017. The main outcome was receipt of local tumor ablation with either cryo or laser-ablation, and other focal therapy including high-intensity focused ultrasound (HIFU). Patient level, hospital level, and demographic variables were collected. A mixed effects logistic regression analysis was utilized to identify covariates and predictors on the patient- and hospital-level. RESULTS: Overall, 11 278 patients received ablative therapy. Cryotherapy was performed in 8 883 (78.8%), laser ablation in 1 755 (15.6%), and other focal therapy (HIFU) in 640 (5.7%) cases. On the patient-level, intermediate-risk PCa patients were more likely to be treated with ablative therapy (OR 1.05, 95% CI 1.00 – 1.11, p=0.05) than low-risk PCa patients, as were men with Charlson Comorbidity Index >1 (OR 1.36, 95%CI 1.29 -1.43, pnd quartile, OR 1.23, 95% CI 1.12-1.35, pCONCLUSIONS: In this study, we report trends from 2010-2017, in utilization of local ablative therapies using a large national database of U.S. cancer centers. The technique is more commonly used in older men with comorbidities. The financial aspects of ablative therapy need to be addressed to avoid inequity in access to care.

Objective To improve problem list documentation and care quality. Materials and methods We developed algorithms to infer clinical problems a patient has that are not recorded on the coded problem list using structured data in the electronic health record (EHR) for 12 clinically significant heart, lung, and blood diseases. We also developed a clinical decision support (CDS) intervention which suggests adding missing problems to the problem list. We evaluated the intervention at 4 diverse healthcare systems using 3 different EHRs in a randomized trial using 3 predetermined outcome measures: alert acceptance, problem addition, and National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (NCQA HEDIS) clinical quality measures. Results There were 288 832 opportunities to add a problem in the intervention arm and the problem was added 63 777 times (acceptance rate 22.1%). The intervention arm had 4.6 times as many problems added as the control arm. There were no significant differences in any of the clinical quality measures. Discussion The CDS intervention was highly effective at improving problem list completeness. However, the improvement in problem list utilization was not associated with improvement in the quality measures. The lack of effect on quality measures suggests that problem list documentation is not directly associated with improvements in quality measured by National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (NCQA HEDIS) quality measures. However, improved problem list accuracy has other benefits, including clinical care, patient comprehension of health conditions, accurate CDS and population health, and for research. Conclusion An EHR-embedded CDS intervention was effective at improving problem list completeness but was not associated with improvement in quality measures.

There is a lack of research on adverse event (AE) detection in oncology patients, despite the propensity for iatrogenic harm. Two common methods include voluntary safety reporting (VSR) and chart review tools, such as the Institute for Healthcare Improvement's Global Trigger Tool (GTT). Our objective was to compare frequency and type of AEs detected by a modified GTT compared with VSR for identifying AEs in oncology patients in a larger clinical trial.Patients across 6 oncology units (from July 1, 2013, through May 29, 2015) were randomly selected. Retrospective chart reviews were conducted by a team of nurses and physicians to identify AEs using the GTT. The VSR system was queried by the department of quality and safety of the hospital. Adverse event frequencies, type, and harm code for both methods were compared.The modified GTT detected 0.90 AEs per patient (79 AEs in 88 patients; 95% [0.71-1.12] AEs per patient) that were predominantly medication AEs (53/79); more than half of the AEs caused harm to the patients (41/79, 52%), but only one quarter were preventable (21/79; 27%). The VSR detected 0.24 AEs per patient (21 AEs in 88 patients; 95% [0.15-0.37] AEs per patient), a large plurality of which were medication/intravenous related (8/21); more than half did not cause harm (70%). Only 2% of the AEs (2/100) were detected by both methods.Neither the modified GTT nor the VSR system alone is sufficient for detecting AEs in oncology patient populations. Further studies exploring methods such as automated AE detection from electronic health records and leveraging patient-reported AEs are needed.

Objectives To test a structured electronic health record (EHR) case review process to identify diagnostic errors (DE) and diagnostic process failures (DPFs) in acute care. Methods We adapted validated tools (Safer Dx, Diagnostic Error Evaluation Research [DEER] Taxonomy) to assess the diagnostic process during the hospital encounter and categorized 13 postulated e-triggers. We created two test cohorts of all preventable cases (n=28) and an equal number of randomly sampled non-preventable cases (n=28) from 365 adult general medicine patients who expired and underwent our institution’s mortality case review process. After excluding patients with a length of stay of more than one month, each case was reviewed by two blinded clinicians trained in our process and by an expert panel. Inter-rater reliability was assessed. We compared the frequency of DE contributing to death in both cohorts, as well as mean DPFs and e-triggers for DE positive and negative cases within each cohort. Results Twenty-seven (96.4%) preventable and 24 (85.7%) non-preventable cases underwent our review process. Inter-rater reliability was moderate between individual reviewers (Cohen’s kappa 0.41) and substantial with the expert panel (Cohen’s kappa 0.74). The frequency of DE contributing to death was significantly higher for the preventable compared to the non-preventable cohort (56% vs. 17%, OR 6.25 [1.68, 23.27], p Conclusions We observed substantial agreement among final consensus and expert panel reviews using our structured EHR case review process. DEs contributing to death associated with DPFs were identified in institutionally designated preventable and non-preventable cases. While e-triggers may be useful for discriminating DE positive from DE negative cases, larger studies are required for validation. Our approach has potential to augment institutional mortality case review processes with respect to DE surveillance.

Objective: To assess a multi-pronged strategy using primarily digital methods to equitably recruit asthma patients into a clinical trial of a digital health intervention. Methods: We approached eligible patients using at least one of eight recruitment strategies. We recorded approach dates and the strategy that led to completion of a web-based eligibility questionnaire that was reported during the verbal consent phone call. Study team members conducted monthly sessions using a structured guide to identify recruitment barriers and facilitators. The proportion of participants who reported being recruited by a portal or non-portal strategy was measured as our outcomes. We used Fisher’s Exact test to compare outcomes by equity variable, and multivariable logistic regression to control for each covariate and adjust effect size estimates. Using grounded theory, we coded and extracted themes regarding recruitment barriers and facilitators. Results: The majority (84.4%) of patients who met study inclusion criteria were patient portal enrollees. Of 6366 eligible patients who were approached, 627 completed the eligibility questionnaire and were less frequently Hispanic, less frequently Spanish-speaking, and more frequently patient portal enrollees. Of 445 patients who consented to participate, 241 (54.2%) reported completing the eligibility questionnaire after being contacted by a patient portal message. In adjusted analysis, only race (OR 0.46 [(0.28, 0.77)], p=0.003) and college education (OR 0.60, 95% CI [0.39, 0.91], p = 0.016) remained significant. Key recruitment barriers included technology issues (e.g., lack of email access) and facilitators included bilingual study staff, Spanish-language recruitment materials, targeted phone calls, and clinician-initiated “1-click” referrals. Discussion/Conclusion: A primarily digital strategy to recruit patients into a digital health trial is unlikely to achieve equitable participation, even in a population overrepresented by patient portal enrollees. Non-digital recruitment methods that address racial and educational disparities and less active portal enrollees are necessary to ensure equity in clinical trial enrollment.

Objectives The coronavirus disease 2019 (COVID-19) is a resource-intensive global pandemic. It is important for healthcare systems to identify high-risk COVID-19-positive patients who need timely health care. This study was conducted to predict the hospitalization of older adults who have tested positive for COVID-19. Methods We screened all patients with COVID test records from 11 Mass General Brigham hospitals to identify the study population. A total of 1495 patients with age 65 and above from the outpatient setting were included in the final cohort, among which 459 patients were hospitalized. We conducted a clinician-guided, 3-stage feature selection, and phenotyping process using iterative combinations of literature review, clinician expert opinion, and electronic healthcare record data exploration. A list of 44 features, including temporal features, was generated from this process and used for model training. Four machine learning prediction models were developed, including regularized logistic regression, support vector machine, random forest, and neural network. Results All 4 models achieved area under the receiver operating characteristic curve (AUC) greater than 0.80. Random forest achieved the best predictive performance (AUC = 0.83). Albumin, an index for nutritional status, was found to have the strongest association with hospitalization among COVID positive older adults. Conclusions In this study, we developed 4 machine learning models for predicting general hospitalization among COVID positive older adults. We identified important clinical factors associated with hospitalization and observed temporal patterns in our study cohort. Our modeling pipeline and algorithm could potentially be used to facilitate more accurate and efficient decision support for triaging COVID positive patients.

BackgroundVentricular dyssynchrony and its relationship to clinical outcomes is not well characterized in patients following Fontan palliation.MethodsSingle-center retrospective analysis of cardiac magnetic resonance (CMR) imaging of patients with a Fontan circulation and age-matched healthy comparison cohort as controls. Feature tracking was performed on all slices of a ventricular short-axis cine stack. Circumferential and radial strain, strain rate, and displacement were measured; and multiple dyssynchrony metrics were calculated based on timing of these measurements (including standard deviation of time-to-peak, maximum opposing wall delay, and maximum base-to-apex delay). Primary endpoint was a composite measure including time to death or heart transplant listing (D/HTx); secondary outcomes were the presence of atrial or ventricular arrhythmias.ResultsA total of 503 cases (15y; IQR 10, 21) and 42 controls (16y; IQR 11, 20) were analyzed. Compared to controls, Fontan patients had increased dyssynchrony metrics, longer QRS duration, larger ventricular volumes, and worse systolic function. Dyssynchrony metrics were higher in patients with right ventricular (RV) or mixed morphology compared to those with LV morphology. At median follow-up of 4.3 years, 11% had D/HTx, 7% ventricular arrhythmia, and 38% atrial arrhythmia. Multiple risk factors for D/HTx were identified, including RV morphology, ventricular dilation, dysfunction, QRS prolongation, and dyssynchrony. Ventricular dilation and RV morphology were independently associated with D/HTx; ventricular dilation and global circumferential strain were independently associated with ventricular and atrial arrhythmias.ConclusionsMechanical dyssynchrony is highly prevalent in functional single ventricles palliated to the Fontan circulation and is more pronounced in hearts with RV or mixed ventricular morphology compared to those with LV morphology. Dyssynchrony is associated with death or need for heart transplantation and cardiac arrhythmias. These data add to the growing understanding regarding factors that can be used to risk-stratify patients with the Fontan circulation.

BackgroundThe United States Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening in 2012, which was modified in 2018 into shared decision making for men aged 55-70 years with a life expectancy over 10 years. We studied the trends in PSA screening in younger Black and White men with the implementation of the 2012 and 2018 guidelines.MethodsYounger Black and White men (aged 40-54 years) were identified using the Behavioral Risk Factor Surveillance System database biennially from 2012 to 2020. Our primary outcome was PSA screening within 2 years of the survey. An adjusted logistic regression model with 2-way interaction assessment between race and survey year was used to investigate the temporal trend of PSA screening in younger Black and White men.ResultsA total of 142 892 men were included. We saw steadily decreasing odds of PSA screening among both younger Black and White men in 2014, 2016, 2018, and 2020 compared with 2012 (for younger Black men: odds ratio [OR]2014 = 0.77, 95% confidence interval [CI] = 0.62 to 0.96, OR2016 = 0.51, 95% CI = 0.41 to 0.63, OR2018 = 0.33, 95%CI = 0.27 to 0.42, OR2020 = 0.25, 95% CI = 0.18 to 0.32; and for younger White men: OR2014 = 0.81, 95% CI = 0.76 to 0.87, OR2016 = 0.66, 95% CI = 0.61 to 0.71, OR2018 = 0.41, 95%CI = 0.37 to 0.44, OR2020 = 0.36, 95% CI = 0.33 to 0.39). Younger Black men showed a brisker decrease in PSA screening in 2016, 2018, and 2020 compared with younger White men (all P ConclusionsPSA screening among younger men steadily decreased over the past decade since the 2012 United States Preventive Services Task Force guidelines, demonstrating a narrowing racial gap. How such an observed trend translates to long-term clinical outcomes for younger Black men remains to be seen.

Purpose: We sought to establish whether nucleated red blood cells (NRBCs) are predictive of disposition, morbidity, and mortality for pediatric patients presenting to the emergency department (ED).Methods: A single center retrospective cohort study examining all ED encounters from patientsResults: The prevalence of NRBCs was 8.9% (4,195/46,991 patient encounters). Patient with NRBCs were younger (median age 4.58 vs 8.23 years; PConclusions: Presence of NRBCs is an independent predictor for mortality, including in-hospital mortality, ICU admission, CPR, and readmission within 30 days for children presenting to the ED.

As the United States faces the third wave of the ongoing opioid epidemic, development of measures which report on prolonged opioid prescribing (POP) rates, specifically following orthopedic surgeries, are needed to better understand and improve prescribing practices at the clinician group level. Brigham and Women’s Hospital (BWH) has been contracted by the Centers for Medicare and Medicaid Services (CMS) to create a novel electronic clinical quality measure (eCQM) to quantify the prolonged opioid prescribing rate of opioid episodes lasting > 42 days in patients aged 18+ years following elective primary total hip arthroplasties (THA) and/or total knee arthroplasties (TKA) for use in the Merit-Based Incentive Payment System (MIPS). When this measure was tested on two geographically distinct sites, it was found that the THA rate was 3.80% and 16.07% at sites 1 and 2, respectively, and that the TKA rate is 7.65% and 24.15% at sites 1 and 2, respectively. This manuscript reports on the testing of this eCQM between these two sites, highlighting differences in state and organizational level policies regarding opioid prescribing and documentation practices.

Objective Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control. Background There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions. Method We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups. Results Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography. Conclusion Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support Application Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.

The objective of this study was to assess the frequency, type, and severity of errors associated with intravenous medication administration before and after smart pump interoperability.We conducted an observational study at a community healthcare system before and after implementing smart pump interoperability. Point prevalence methodology was used to collect data on medication administration and errors in adult inpatient settings.Observations were completed for 350 infusions preintervention (178 patients) and 367 postintervention (200 patients). Total errors significantly decreased from 401 (114.6 per 100 infusions) to 354 (96.5 per 100 infusions, P = 0.02). Administration errors decreased from 144 (41.1 per 100 infusions) to 119 (32.4 per 100 infusions, P = 0.12). Expired medication errors significantly reduced from 11 (3.1 per 100 infusions) to 2 (0.5 per 100 infusions, P = 0.02). Errors involving high-risk medications significantly reduced from 45 (12.8 per 100 infusions) to 25 (6.8 per 100 infusions, P = 0.01). Errors involving continuous medications significantly reduced from 44 (12.6 per 100 infusions) to 22 (6.0 per 100 infusions, P = 0.005). When comparing programming type, manual programming resulted in 115 (77.2%) of administration and user documentation errors compared with 34 errors (22.8%) that occurred when autoprogramming was used. Of these, errors involving high-risk medications reduced from 21 (84.0%) to 4 (16.0%) after using autoprogramming.Smart pump interoperability resulted in a 16% reduction in medication administration errors. Despite using dose error reduction software and autoprogramming, some types of errors persisted. Further studies are needed to understand how technology use can be optimized.

Supported by the Centers for Medicare & Medicaid Services (CMS), Brigham and Women's Hospital (BWH) has retooled the existing claims-based measures NQF1550 and NQF3493 into an electronic clinical quality measure (eCQM) to assess the risk-standardized complication rate (RSCR) following elective primary total hip (THA) and knee arthroplasty (TKA) at the clinician group level. This novel eCQM includes risk-adjustment for social determinants of health, includes all adult patients from all payers, leverages electronic health records (EHRs) rather than claims-based data, and includes both inpatient and outpatient procedures and complications which offers benefits compared to existing metrics. Following testing in two geographically different healthcare systems, the overall risk-standardized complication rate within 90 days following THA and TKA at the two sites was 3.60% (Site 1) and 3.70% (Site 2). This measure is designed for use in the Merit-Based Incentive Payment System (MIPS).

Brigham and Women’s Hospital has received funding from the Centers for Medicare and Medicaid Services to develop a novel electronic clinical quality measure to assess the risk-standardized major bleeding and venous thromboembolism (VTE) rate following elective total hip and/or knee arthroplasty. There are currently no existing measures that evaluate both the bleeding and VTE events following joint arthroplasty (TJA). Our novel composite measure was tested within two academic health systems with 17 clinician groups meeting the inclusion criteria. Following risk adjustment, the overall adjusted bleeding rate was 3.87% and ranged between 1.99% – 5.66%. The unadjusted VTE rate was 0.39% and ranged between 0% – 2.65%. The overall VTE/Bleeding composite score was 2.15 and ranged between 1.15 – 3.19. This measure seeks to provide clinician groups with a tool to assess their patient bleeding and VTE rates and compare them to their peers, ultimately providing an evidence-based quality metric assessing orthopedic practices.

ObjectivesTo describe the feeding profile of low birthweight (LBW) infants in the first half of infancy; and to examine growth patterns and early risk factors of poor 6-month growth outcomes.DesignProspective observational cohort study.Setting and participantsStable, moderately LBW (1.50 to Variables of interestKey variables of interest included birth weight, LBW type (combination of preterm/term status and size-for-gestational age at birth), lactation practices and support, feeding profile, birthweight regain by 2 weeks of age and poor 6-month growth outcomes.ResultsBetween 13 September 2019 and 27 January 2021, 1114 infants were enrolled, comprising 4 LBW types. 363 (37.3%) infants initiated early breast feeding and 425 (43.8%) were exclusively breastfed to 6 months. 231 (22.3%) did not regain birthweight by 2 weeks; at 6 months, 280 (32.6%) were stunted, 222 (25.8%) underweight and 88 (10.2%) wasted. Preterm-small-for-gestational age (SGA) infants had 1.89 (95% CI 1.37 to 2.62) and 2.32 (95% CI 1.48 to 3.62) times greater risks of being stunted and underweight at 6 months compared with preterm-appropriate-for-gestational age (AGA) infants. Term-SGA infants had 2.33 (95% CI 1.77 to 3.08), 2.89 (95% CI 1.97 to 4.24) and 1.99 (95% CI 1.13 to 3.51) times higher risks of being stunted, underweight and wasted compared with preterm-AGA infants. Those not regaining their birthweight by 2 weeks had 1.51 (95% CI 1.23 to 1.85) and 1.55 (95% CI 1.21 to 1.99) times greater risks of being stunted and underweight compared with infants regaining.ConclusionLBW type, particularly SGA regardless of preterm or term status, and lack of birthweight regain by 2 weeks are important risk identification parameters. Early interventions are needed that include optimal feeding support, action-oriented growth monitoring and understanding of the needs and growth patterns of SGA infants to enable appropriate weight gain and proactive management of vulnerable infants.Trial registration numberNCT04002908.

ImportanceThere is insufficient research on the costs of patient falls in health care systems, a leading source of nonreimbursable adverse events.ObjectiveTo report the costs of inpatient falls and the cost savings associated with implementation of an evidence-based fall prevention program.Design, Setting, and ParticipantsIn this economic evaluation, a matched case-control study used the findings from an interrupted time series analysis that assessed changes in fall rates following implementation of an evidence-based fall prevention program to understand the cost of inpatient falls. An economic analysis was then performed to assess the cost benefits associated with program implementation across 2 US health care systems from June 1, 2013, to August 31, 2019, in New York, New York, and Boston, Massachusetts. All adults hospitalized in participating units were included in the analysis. Data analysis was performed from October 2021 to November 2022.InterventionsEvidence-based fall prevention program implemented in 33 medical and surgical units in 8 hospitals.Main Outcomes and MeasuresPrimary outcome was cost of inpatient falls. Secondary outcome was the costs and cost savings associated with the evidence-based fall prevention program.ResultsA total of 10 176 patients who had a fall event (injurious or noninjurious) with 29 161 matched controls (no fall event) were included in the case-control study and the economic analysis (51.9% were 65-74 years of age, 67.1% were White, and 53.6% were male). Before the intervention, there were 2503 falls and 900 injuries; after the intervention, there were 2078 falls and 758 injuries. Based on a 19% reduction in falls and 20% reduction in injurious falls from the beginning to the end of the postintervention period, the economic analysis demonstrated that noninjurious and injurious falls were associated with cost increases of $35 365 and $36 776, respectively. The implementation of the evidence-based fall prevention program was associated with $14 600 in net avoided costs per 1000 patient-days.Conclusions and RelevanceThis economic evaluation found that fall-related adverse events represented a clinical and financial burden to health care systems and that the current Medicare policy limits reimbursement. In this study, costs of falls only differed marginally by injury level. Policies that incentivize organizations to implement evidence-based strategies that reduce the incidence of all falls may be effective in reducing both harm and costs.

Existing surgical quality metrics have limited utility, are primarily used for high-mortality procedures, and often fail to account for differences in non-fatal outcomes. Our objective was to develop more comprehensive, novel surgical quality metrics, for patients undergoing abdominal aortic aneurysm (AAA) repair.Non-ruptured open and endovascular AAA repair (EVAR) from the Vascular Quality Initiative database were studied, 2016-2019. A win was defined as AAA repair without major complication (in-hospital) or mortality (in-hospital or within 30 days). Centers were divided into quality quartiles based on performance in two novel win-based metrics: (1) Wins Above Average (WAA) and (2) weighted Wins Above Average (wWAA). Patient-level and center-level analyses compared demographics and outcomes between "best" and "worst" quartiles, including wins, mortality, and failure to rescue (FTR) rates. Additional patient-level analyses were performed based on center stratification into volume quartiles. Correlation in surgical quality for open repair and EVAR was determined at centers performing both procedures.Overall, 3683 patients underwent open repair and 21,165 patients underwent EVAR. For open repair, crude rates of win, mortality, and FTR were 62.8%, 4.2%, and 10.3%, respectively. For EVAR, crude rates for win, mortality, and FTR were 94.4%, 1.1%, and 12.3%, respectively. When stratified by wWAA, patients undergoing open repair at "best" quartile centers had a higher win rate (72.0% vs 52.7%; risk ratio [RR], 1.37; 95% confidence interval [CI], 1.28-1.46) and lower mortality (3.1% vs 6.2%; RR, 0.50; 95% CI, 0.33-0.74) compared with "worst" quartile centers. Similarly, for EVAR, "best" quartile centers had a higher win rate (96.2% vs 92.1%; RR, 1.04; 95% CI, 1.03-1.05), lower mortality (0.4% vs 2.2%; RR, 0.19; 95% CI, 0.13-0.29), and a lower FTR rate (5.7% vs 17.9%; RR, 0.32; 95% CI, 0.18-0.56) compared with "worst" quartile centers. Stratification by volume showed that high-volume centers demonstrated improved wWAA for open repair (P = .04) but not for EVAR (P = .3) compared with low-volume centers. For centers that performed both open repair and EVAR, there was no correlation in quality as determined by wWAA (r = -0.056; P = .6).wWAA is a novel, risk-adjusted, complication-weighted surgical quality metric that also accounts for volume differences. wWAA successfully distinguishes high- and low-quality centers for both open AAA repair and EVAR. This methodology is potentially broadly applicable for measuring surgical quality.

ImportancePhysicians across the US spend substantial time working in the electronic health record (EHR), with primary care physicians (PCPs) spending the most time. The association between EHR time and ambulatory care quality outcomes is unclear.ObjectiveTo characterize measures of EHR use and ambulatory care quality performance among PCPs.Design, Setting, and ParticipantsA cross-sectional study of PCPs with longitudinal patient panels using a single EHR vendor was conducted at Brigham and Women’s Hospital and Massachusetts General Hospital during calendar year 2021.ExposuresIndependent variables included PCPs demographic and practice characteristics and EHR time measures (PCP-level mean of daily total EHR time, after-hours time, time from 5:30 pm to 7:00 am and time on weekends, and daily EHR time on notes, sending and receiving patient, staff, results, prescription, or system messages [in-basket], and clinical review).Main Outcomes and MeasuresOutcome variables were ambulatory quality measures (year-end, PCP panel–level achievement of targets for hemoglobin A1c level control, lipid management, hypertension control, diabetes screening, and breast cancer screening).ResultsThe sample included 291 physicians (174 [59.8%] women). Median panel size was 829 (IQR, 476-1157) patients and mean (SD) clinical full-time equivalent was 0.54 (0.27). The PCPs spent a mean (SD) of 145.9 (64.6) daily minutes on the EHR. There were significant associations between EHR time and panel-level achievement of hemoglobin A1c control, hypertension control, and breast cancer screening targets. In adjusted analyses, each additional 15 minutes of total daily EHR time was associated with 0.58 (95% CI, 0.32-0.84) percentage point greater panel-level hemoglobin A1c control, 0.52 (95% CI, 0.33-0.71) percentage point greater hypertension control, and 0.28 (95% CI, 0.05-0.52) higher breast cancer screening rates. Each daily additional 15 minutes of in-basket time was associated with 2.26 (95% CI, 1.05-3.48) greater panel-wide hemoglobin A1c control, 1.65 (95% CI, 0.83-2.47) percentage point greater hypertension control, and 1.26 (95% CI, 0.51-2.02) percentage point higher breast cancer screening rates. Associations were largely concentrated among PCPs with 0.5 clinical full-time equivalent or less. There were no associations between EHR use metrics and diabetes screening or lipid management in patients with cardiovascular disease.Conclusions and RelevanceThis cross-sectional study found an association between EHR time and some measures of ambulatory care quality. Although increased EHR time is associated with burnout, it may represent a level of thoroughness or communication that enhances certain outcomes. It may be useful for future studies to characterize payment models, workflows, and technologies that enable high-quality ambulatory care delivery while minimizing EHR burden.

Brigham and Women’s Hospital (BWH) has received funding from the Centers for Medicare and Medicaid Services (CMS) to design and implement an electronic clinical quality measure (eCQM) assessing the rate of prolonged opioid prescribing practices following Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA). Utilizing an existing guideline, ‘prolonged prescribing’ has been defined as opioid prescriptions that exceed 42 days (6 weeks) following surgery. This measure was tested on 12,803 Partners’ Healthcare (PHS) patients. Findings demonstrated that after 42 days, meeting the criteria for ‘prolonged prescribing’ as defined by the proposed measure, 3.7% of THA patients and 12.1% of TKA patients were still receiving opioids. With a better understanding of how specific clinician group post-operative prescribing practices compare with their peers and incorporating monetary incentives through the MIPS participation pathway of the Quality Payment Program (QPP), this measure will motivate orthopedic practices to improve their prescribing patterns, ultimately driving evidence-based quality improvement.

BACKGROUND: The WHO defines social determinants of health (SDoH) as “the conditions in which people are born, grow, live and age” which includes factors such as housing and food insecurity, employment, and social support and can account for 30-55% of health outcomes. Addressing unmet SDoH needs may reduce interruptions to cancer care caused by ED visits and hospitalizations (EDH). We aimed to determine feasibility of systematic patient-reported SDoH collection at a large academic cancer center and association of unmet SDoH needs with EDH.METHODS: We conducted a cross-sectional analysis of SDoH needs among new oncology patient (pt) consults from 5/15-9/21at Dana Farber Cancer Institute (DCFI). Pts completed an intake questionnaire including demographic, disease, as well as SDOH needs on a dichotomous or 5-point Likert scale, specifically health literacy (“how confident are you in filling out medical forms?”), health numeracy (“how confident are you in understanding medical statistics?”), financial distress (“how difficult is it for you, or your family, to meet monthly payments on your/your family’s bills?”) and social isolation (“do you currently live alone?”). We ran bivariate and multivariable models on the association between demographics, SDoH and EDH within 30 days of initial oncology visit using robust generalized estimating equations controlling for clustering by consult provider. RESULTS: 125,997new consults were seen from 05/15-09//21, of which 20,913 completed the intake questionnaire and were alive at 30 days of consult. Of those pts, most were female (60%), aged 40-64 (50%), White (90%), non-Hispanic (84%), primarily English-speaking (9%) and 7% had an EDH within 30 days of their 1st outpatient visit. The most reported SDOH need was limited health numeracy (26%). In bivariate analysis, factors associated with ED visits included: limited English proficiency lung or GU/GYN cancer, living > 25 mi.from DFCI, and limited health literacy and numeracy (all p 25 mi from DFCI (OR 2.50, p < 0.0001) were associated with increased likelihood of ED visit while EPL (OR 1.80, p *Compared to breast cancer Citation Format: Ashley Odai-Afotey, Ellana Haakenstad, Sunyi Zhang, Bridget A. Neville, Stuart Lipsitz, Nadine J. McCleary. Feasibility of systemic SDOH collection and associated resource utilization at a large academic cancer center [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5939.

IntroductionThe purpose of this study is to incorporate behavioural economic principles and user-centred design principles into a multicomponent intervention for the management of uncontrolled hypertension (HTN) in chronic kidney disease (CKD) in primary care.Methods and analysisThis is a multicentre, pragmatic, controlled trial cluster-randomised at the clinician level at The Brigham and Women’s Practice -Based Research Network of 15 practices. Of 220 total clinicians, 184 were eligible to be enrolled, and the remainder were excluded (residents and clinicians who see urgent care or walk-in patients); no clinicians opted out. The intervention consists of a clinical decision support system based in behavioural economic and user-centred design principles that will: (1) synthesise existing laboratory tests, medication orders and vital sign data; (2) increase recognition of CKD, (3) increase recognition of uncontrolled HTN in CKD patients and (4) deliver evidence-based CKD and HTN management recommendations. The primary endpoint is the change in mean systolic blood pressure between baseline and 6 months compared across arms. We will use the Reach Effectiveness Adoption Implementation Maintenance framework. At the conclusion of this study, we will have: (1) validated an intervention that combines laboratory tests, medication records and clinical information collected by electronic health records to recognise uncontrolled HTN in CKD patients and recommend a course of care, (2) tested the effectiveness of said intervention and (3) collected information about the implementation of the intervention that will aid in dissemination of the intervention to other practice settings.Ethics and disseminationThe Human Subjects Institutional Review Board at Brigham and Women’s Hospital provided an expedited review and approval for this study protocol, and a Data Safety Monitoring Board will ensure the ongoing safety of the trial.Trial registration numberNCT03679247.

The prevalence of facility-based childbirth in low-resource settings has increased dramatically during the past two decades, yet gaps in the quality of care persist and mortality remains high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes.We conducted a matched-pair, cluster-randomized, controlled trial in 60 pairs of facilities across 24 districts of Uttar Pradesh, India, testing the effect of the BetterBirth program, an 8-month coaching-based implementation of the Safe Childbirth Checklist, on a composite outcome of perinatal death, maternal death, or maternal severe complications within 7 days after delivery. Outcomes - assessed 8 to 42 days after delivery - were compared between the intervention group and the control group with adjustment for clustering and matching. We also compared birth attendants' adherence to 18 essential birth practices in 15 matched pairs of facilities at 2 and 12 months after the initiation of the intervention.Of 161,107 eligible women, we enrolled 157,689 (97.9%) and determined 7-day outcomes for 157,145 (99.7%) mother-newborn dyads. Among 4888 observed births, birth attendants' mean practice adherence was significantly higher in the intervention group than in the control group (72.8% vs. 41.7% at 2 months; 61.7% vs. 43.9% at 12 months; P0.001 for both comparisons). However, there was no significant difference between the trial groups either in the composite primary outcome (15.1% in the intervention group and 15.3% in the control group; relative risk, 0.99; 95% confidence interval, 0.83 to 1.18; P=0.90) or in secondary maternal or perinatal adverse outcomes.Birth attendants' adherence to essential birth practices was higher in facilities that used the coaching-based WHO Safe Childbirth Checklist program than in those that did not, but maternal and perinatal mortality and maternal morbidity did not differ significantly between the two groups. (Funded by the Bill and Melinda Gates Foundation; Clinical Trials number, NCT02148952 .).

BACKGROUND Patient-facing health information technology (HIT) tools, such as patient portals, are recognized as a potential mechanism to facilitate patient engagement and patient-centered care, yet the use of these tools remains limited in the hospital setting. Although research in this area is growing, it is unclear how the use of acute care patient portals might affect outcomes, such as patient activation. OBJECTIVE The aim of this study was to describe the use of an acute care patient portal and investigate its association with patient and care partner activation in the hospital setting. METHODS We implemented an acute care patient portal on 6 acute care units over an 18-month period. We investigated the characteristics of the users (patients and their care partners) of the patient portal, as well as their use of the portal. This included the number of visits to each page, the number of days used, the length of the user’s access period, and the average percent of days used during the access period. Patient and care partner activation was assessed using the short form of the patient activation measure (PAM-13) and the caregiver patient activation measure (CG-PAM). Comparisons of the activation scores were performed using propensity weighting and robust weighted linear regression. RESULTS Of the 2974 randomly sampled patients, 59.01% (1755/2974) agreed to use the acute care patient portal. Acute care patient portal enrollees were younger, less sick, less likely to have Medicare as their insurer, and more likely to use the Partners Healthcare enterprise ambulatory patient portal (Patient Gateway). The most used features of the acute care patient portal were the laboratory test results, care team information, and medication list. Most users accessed the portal between 1 to 4 days during their hospitalization, and the average number of days used (logged in at least once per day) was 1.8 days. On average, users accessed the portal 42.69% of the hospital days during which it was available. There was significant association with patient activation on the neurology service (P CONCLUSIONS Portal users most often accessed the portal to view their clinical information, though portal usage was limited to only the first few days of enrollment. We found an association between the use of the portal and HIT tools with improved levels of patient activation. These tools may help facilitate patient engagement and improve outcomes when fully utilized by patients and care partners. Future study should leverage usage metrics to describe portal use and assess the impact of HIT tools on specific outcome measures in the hospital setting.

Background In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow. Methods To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program. Results As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASSSM Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS. Conclusion Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.

BACKGROUND Repeated hospitalizations are frequent toward the end of life where each admission should be an opportunity to initiate advance care planning to high risk patients. OBJECTIVE To identify the risk factors for having a 30 day potentially avoidable readmission due to end of life care issues among all medical patients. DESIGN Nested case control study. SETTING/PATIENTS All 10275 consecutive discharges from any medical service of an academic tertiary medical center in Boston Massachusetts between July 1 2009 and June 30 2010. MEASUREMENTS A random sample of all the potentially avoidable 30 day readmissions was independently reviewed by 9 trained physicians to identify the ones due to end of life issues. RESULTS Among 534 30 day potentially avoidable readmission cases reviewed 80 (15) were due to an end of life care issue. In multivariable analysis the following risk factors were significantly associated with a 30 day potentially avoidable readmission due to end of life care issues: number of admissions in the previous 12 months (odds ratio [OR]: 1.10 per admission 95 confidence interval [CI]: 1.02 1.20) neoplasm (OR: 5.60 95 CI: 2.85 10.98) opiate medications at discharge (OR: 2.29 95 CI: 1.29 4.07) Elixhauser comorbidity index (OR: 1.16 per 5 point increase 95 CI: 1.10 1.22). The discrimination of the model (C statistic) was 0.85. CONCLUSIONS In a medical population we identified 4 main risk factors that were significantly associated with 30 day potentially avoidable readmission due to end of life care issues producing a model with very good to excellent discrimination. Patients with these risk factors might benefit from palliative care consultation prior to discharge in order to improve end of life care and possibly reduce unnecessary rehospitalizations. Journal of Hospital Medicine 2014;9:310 314. © 2014 Society of Hospital Medicine.

Accurately documenting mammography use is essential to assess quality of care for early breast cancer detection in underserved populations. Self-reports and medical record reports frequently result in different accounts of whether a mammogram was performed. We hypothesize that electronic medical records (EMRs) provide more accurate documentation of mammography use than paper records, as evidenced by the level of agreement between women's self-reported mammography use and mammography use documented in medical records.Black women aged 40-75 were surveyed in six primary care sites in Boston, Massachusetts (n = 411). Survey data assessed self-reported mammography prevalence within 2 years of study entry. Corresponding medical record data were collected at each site. Positive predictive value (PPV) of self-report and kappa statistics compared data agreement among sites with and without EMRs. Logistic regression estimated effects of site and patient characteristics on agreement between data sources.Medical records estimated a lower prevalence of mammography use (58%) than self-report (76%). However, self-report and medical record estimates were more similar in sites with EMRs. PPV of self-report was 88% in sites with continuous access to EMRs and 61% at sites without EMRs. Kappa statistics indicated greater data agreement at sites with EMRs (0.72, 95% CI 0.56-0.88) than without EMRs (0.46, 95% CI 0.29-0.64). Adjusted for covariates, odds of data agreement were greatest in sites where EMRs were available during the entire study period (OR 4.31, 95% CI 1.67-11.13).Primary care sites with EMRs better document mammography use than those with paper records. Patient self-report of mammography screening is more accurate at sites with EMRs. Broader access to EMRs should be implemented to improve quality of documenting mammography use. At a minimum, quality improvement efforts should confirm the accuracy of paper records with supplemental data.

Addressing patient expectations is necessary to achieve high satisfaction. However, few data are available on nurses' perceptions and performance with respect to patient expectations and satisfaction.This international multicenter study aimed to: (a) evaluate nurses' attitudes and performance with respect to patient satisfaction and expectations, and (b) identify predictors of nurses' inquiry of patients' satisfaction at the point of discharge.A questionnaire examining attitudes and performance toward patient satisfaction and expectations was developed and validated. Nurses at four academic hospitals in the United States, the United Kingdom, Israel, and Denmark were surveyed.A total of 536 nurses participated in the study (response rate 85.3%). Nurses expressed positive attitudes toward activities related to patient satisfaction and expectations, endorsing the importance of talking with patients about their satisfaction status (91.6%) and their expectations (93.2%). More than half of the responders (51.8%) claimed to have responded to the status of patient satisfaction or dissatisfaction (Israel: 25%; United States: 54.9%; United Kingdom: 61.7%; Denmark: 69.9%; p.001). However, only 12.1% stated that they routinely ask patients about their level of satisfaction, with nurses in the United States (18.3%) and Denmark (17.5%) more likely to ask compared to nurses in the United Kingdom (7.4%) and Israel (6.3%; p = .001). Adjusted logistic regression identified four significant predictors (p.05) of nurses' inquiry about patients' satisfaction: "Responding to patient's satisfaction status" (OR: 3.1; 95% CI: 1.7-5.8); "Documenting patient's satisfaction status" (OR: 2.8; 95% CI: 1.6-5.1); "Asking routinely about expectations" (OR: 5.4; 95% CI: 3-9.7); and "Responded to expectations during the past month" (OR: 4.3; 95% CI: 1.9-9.4).These findings warrant further investigation, potentially into the nurses' work environments or educational programs, to better understand why nurses' positive attitudes toward patient satisfaction and expectations do not result in actively asking patients about their satisfaction level and what should be done to improve nurses' performance. Healthcare organizations and policy makers should develop and support structured programs to address patient expectations and improve patient satisfaction during hospitalization.

This article proposes an estimate of the odds ratio in a (2 × 2) table obtained from studies in which the row totals are fixed by design, such as a phase II clinical trial. Our estimate, based on the median unbiased estimate of the probabilities of success in the (2× 2) table, will always be in the interval (0, ∞). Another estimate of the odds ratio which has such properties is obtained when adding .5 to each cell of the table. Using simulations, we compared our proposed estimate to that obtained by adding .5 to every cell, and found that our estimate had smaller finite sample bias, and larger mean square error. We also propose the use of the bootstrap to form a confidence interval for the odds ratio based on our proposed estimate. Instead of a Monte Carlo bootstrap, one can easily calculate the “exact” bootstrap distribution of our estimate of the odds ratio, and use this distribution to calculate confidence intervals.

While nursing activities represent a significant proportion of inpatient care, there are no reliable methods for determining nursing costs based on the actual services provided by the nursing staff. Capture of data to support accurate measurement and reporting on the cost of nursing services is fundamental to effective resource utilization. Adopting standard terminologies that support tracking both the quality and the cost of care could reduce the data entry burden on direct care providers. This pilot study evaluated the feasibility of using a standardized nursing terminology, the Clinical Care Classification System (CCC), for developing a reliable costing method for nursing services. Two different approaches are explored; the Relative Value Unit RVU and the simple cost-to-time methods. We found that the simple cost-to-time method was more accurate and more transparent in its derivation than the RVU method and may support a more consistent and reliable approach for costing nursing services.

To determine factors that influence radical prostatectomy (RP) operative times. Operative time assessment is inherent to defining surgeon learning curves and evaluating quality of care.Population-based observational cohort study using USA Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data of men diagnosed with prostate cancer during 2003-2007 who underwent robot-assisted radical prostatectomy (RARP, 3458 men) and retropubic RP (RRP, 6993) through to 2009. We obtained median operative time using anaesthesia administrative data for RP and used median regression to assess the contribution of patient, surgeon, and hospital factors to operative times.The median RARP operative time decreased from 315 to 247 min from 2003 to 2008-2009 (P0.001), while the median RRP operative time remained similar (195 vs 197 min, P = 0.90). In adjusted analysis, RARP vs RRP (parameter estimate [PE] 70.9; 95% confidence interval [CI] 58, 84; P0.001) and obesity (PE 15; 95% CI 7, 23; P0.001) were associated with longer operative times while higher surgeon volumes were associated with shorter operative times (P0.001). RPs performed by surgeons employed by group (parameter estimate [PE] -22.76; 95% CI -38, -7.49; P = 0.004) and non-government (PE -35.59; 95% CI -68.15, -3.03; P = 0.032) vs government facilities and non-profit vs government hospital ownership (PE -21.85; 95% CI -32.28, -11.42; P0.001) were associated with shorter operative times.During our study period, RARP operative times decreased by 68 min while RRP operative times remained stagnant. Higher surgeon volume was associated with shorter operative times, and selective referral or improved efficiency to the level of high-volume surgeons would net almost $15 million (USA dollars) in annual savings.