Christina A. Minami

Association Between State Medical Malpractice Environment and Surgical Quality and Cost in the United States.

Context:The US medical malpractice system is designed to deter negligence and encourage quality of care through threat of liability. Objective:To examine whether state-level malpractice environment is associated with outcomes and costs of colorectal surgery. Design, Setting, and Patients:Observational study of 116,977 Medicare fee-for-service beneficiaries who underwent colorectal surgery using administrative claims data. State-level malpractice risk was measured using mean general surgery malpractice insurance premiums; paid claims per surgeon; state tort reforms; and a composite measure. Associations between malpractice environment and postoperative outcomes and price-standardized Medicare payments were estimated using hierarchical logistic regression and generalized linear models. Main Outcome Measures:thirty-day postoperative mortality; complications (pneumonia, myocardial infarction, venous thromboembolism, acute renal failure, surgical site infection, postoperative sepsis, any complication); readmission; total price-standardized Medicare payments for index hospitalization and 30-day postdischarge episode-of-care. Results:Few associations between measures of state malpractice risk environment and outcomes were identified. However, analyses using the composite measure showed that patients treated in states with greatest malpractice risk were more likely than those in lowest risk states to experience any complication (OR: 1.31; 95% CI: 1.22–1.41), pneumonia (OR: 1.36; 95%: CI, 1.16–1.60), myocardial infarction (OR: 1.44; 95% CI: 1.22–1.70), venous thromboembolism (OR:2.11; 95% CI: 1.70–2.61), acute renal failure (OR: 1.34; 95% CI; 1.22–1.47), and sepsis (OR: 1.38; 95% CI: 1.24–1.53; all P < 0.001). There were no consistent associations between malpractice environment and Medicare payments. Conclusions:There were no consistent associations between state-level malpractice risk and higher quality of care or Medicare payments for colorectal surgery.

Public reporting in surgery an emerging opportunity to improve care and inform patients

P ublic reporting is exploding, as federal, payer, state, and hospital organizations drive to increase the transparency of US health care. More than 4000 public reporting sites currently exist, with many more in development. There are significant benefits for hospitals and patients, including the opportunity for institutions to drive quality improvement and the ability of consumers to make informed health care choices. Several concerns do persist, however, including cherrypicking and the many ways information may be misconstrued and misused by the general public. We review the benefits and concerns surrounding public reporting and then suggest some possible solutions to these problems in a stride toward better implementation and utilization of public reporting to improve surgical outcomes.

Impact of Medical Malpractice Environment on Surgical Quality and Outcomes

Received July 23, 2013; Revised August 30, 2013; Accepted 2013. From the Surgical Outcomes andQuality Improvement Cen of Surgery, Feinberg School of Medicine, Northwes and Northwestern Memorial Hospital (Minami, Chung, H and the Center for Healthcare Studies, Feinberg Schoo Northwestern University, Chicago, IL. Correspondence address: Karl Y Bilimoria, MD, MS, Outcomes and Quality Improvement Center, Departm Feinberg School of Medicine, Northwestern University Memorial Hospital, 676 St Clair St, Arkes Pavilion Suite IL 60611. email: k-bilimoria@northwestern.edu

Process improvement in surgery

Process improvement in surgery Christina A. Minami, MD, Catherine R. Sheils, BA, Karl Y. Bilimoria, MD, MS, Julie K. Johnson, PhD, Elizabeth R. Berger, MD, Julia R. Berian, MD, Michael J. Englesbe, MD, Oscar D. Guillamondegui, MD, FACS, Leonard H. Hines, MD, FACS, Joseph B. Cofer, MD, FACS, David R. Flum, MD, MPH, Richard C. Thirlby, MD, Hadiza S. Kazaure, MD, Sherry M. Wren, MD, Kevin J. O’Leary, MD, Jessica L. Thurk, BA, Gregory D. Kennedy, MD, PhD, Sarah E. Tevis, MD, Anthony D. Yang, MD

Ethical Considerations in the Development of the Flexibility in Duty Hour Requirements for Surgical Trainees Trial

In February 2016, the results of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial were released1 amidst controversy. Participating general surgical residency programs were randomized to either a control arm, which adhered to current Accreditation Council for Graduate Medical Education (ACGME) duty hour requirements, or an intervention arm, which relaxed many duty hour restrictions while still adhering to the 80-hour work week. Critics of the trial questioned the ethics of its design and conduct. Public Citizen, a consumer watchdog group, and the American Medical Student Association, filed a complaint with the Department of Health and Human Services regarding the study’s unethical nature. They contended that the FIRST Trial was misclassified as nonhuman subjects research, involved unacceptable risk for the residents in the intervention arm, and failed to satisfy informed consent requirements.2 While these complaints represented an oversimplified view of the relevant issues, they highlighted the need to discuss the inherent ethical complexities of this trial. These issues, which are not unique to the FIRST Trial and could arise in future randomized studies testing institutional policy changes, include (1) institutional review board (IRB) determination, (2) assessment of equipoise, and (3) informed consent.

Development of a Composite Measure of State-Level Malpractice Environment

OBJECTIVE To develop a composite measure of state-level malpractice environment. DATA SOURCES Public use data from the National Practitioner Data Bank, Medical Liability Monitor, the National Conference of State Legislatures, and the American Bar Association. STUDY DESIGN Principal component analysis of state-level indicators (paid claims rate, malpractice premiums, lawyers per capita, average award size, and malpractice laws), with indirect validation of the composite using receiver-operating characteristic curves to determine how accurately the composite could identify states with high-tort activity and costs. PRINCIPAL FINDINGS A single composite accounted for over 73 percent of total variance in the seven indicators and demonstrated reasonable criterion validity. CONCLUSION An empirical composite measure of state-level malpractice risk may offer advantages over single indicators in measuring overall risk and may facilitate cross-state comparisons of malpractice environments.

Partnering Behavioral Modification With Bariatric Surgery

Problematic eating behaviors can be an influential component of weight gain. Initial management of obesity focuses on the modification of such behaviors, along with dietary changes and increasing physical activity. However, because such lifestyle changes are difficult to adopt and to sustain, the resultant weight loss using such a conservative, noninvasive approach can be variable and unsustainable.1 Similarly, despite the initial enthusiasm surrounding the successes of bariatric surgery, which has been considered to be a safe, effective way to achieve lasting, significant weight loss, studies have demonstrated substantial variability in and eventual attenuation of long-term postoperative weight loss.2,3 This variation has persisted despite the evolution of surgical procedures and techniques, thus reinforcing the need to conceptualize obesity as a disease modulated by anatomical, hormonal, genetic, and behavioral factors. The behavioral component of postoperative weight loss was the focus of the study by Mitchell and colleagues4 published in the April 2016 issue of JAMA Surgery. Using the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) multicenter observational cohort, Mitchell and colleagues analyzed preoperative and annual postoperative surveys of eating and weight control behaviors of JAMA SURGERY

The Science of Quality Improvement

In order to carry out meaningful PI in healthcare, it is important to understand the main methodologies and their origins. The philosophies used in PI in healthcare originated in the mechanized world of industry. In this chapter, an overview of the PDSA (Plan-Do-Study-Act) cycle, Six Sigma, Lean, Lean Six Sigma, and the DMAIC (Define-Measure-Analyze-Improve-Control) frameworks will be provided, along with examples of published surgical QI projects that have made use of these methodologies. Though differences exist between these approaches, they all provide a step-wise, iterative approach to finding solutions to a defined and measurable problem.

Relationship Between State Malpractice Environment and Quality of Health Care in the United States

BACKGROUND One major intent of the medical malpractice system in the United States is to deter negligent care and to create incentives for delivering high-quality health care. A study was conducted to assess whether state-level measures of malpractice risk were associated with hospital quality and patient safety. METHODS In an observational study of short-term, acute-care general hospitals in the United States that publicly reported in the Centers for Medicaid & Medicare Services Hospital Compare in 2011, hierarchical regression models were used to estimate associations between state-specific malpractice environment measures (rates of paid claims, average Medicare Malpractice Geographic Practice Cost Index [MGPCI], absence of tort reform laws, and a composite measure) and measures of hospital quality (processes of care, imaging utilization, 30-day mortality and readmission, Agency for Healthcare Research and Quality Patient Safety Indicators, and patient experience from the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]). RESULTS No consistent association between malpractice environment and hospital process-of-care measures was found. Hospitals in areas with a higher MGPCI were associated with lower adjusted odds of magnetic resonance imaging overutilization for lower back pain but greater adjusted odds of overutilization of cardiac stress testing and brain/sinus computed tomography (CT) scans. The MGPCI was negatively associated with 30-day mortality measures but positively associated with 30-day readmission measures. Measures of malpractice risk were also negatively associated with HCAHPS measures of patient experience. CONCLUSIONS Overall, little evidence was found that greater malpractice risk improves adherence to recommended clinical standards of care, but some evidence was found that malpractice risk may encourage defensive medicine.

Evaluation of an institutional project to improve venous thromboembolism prevention.

BACKGROUND Northwestern Memorial Hospital (NMH) was historically a poor performer on the venous thromboembolism (VTE) outcome measure. As this measure has been shown to be flawed by surveillance bias, NMH embraced process-of-care measures to ensure appropriate VTE prophylaxis to assess healthcare-associated VTE prevention efforts. OBJECTIVE To evaluate the impact of an institution-wide project aimed at improving hospital performance on VTE prophylaxis measures. DESIGN A retrospective observational study. SETTING NMH, an 885-bed academic medical center in Chicago, Illinois PATIENTS: Inpatients admitted to NMH from January 1, 2013 to May 1, 2013 and from October 1, 2014 to April 1, 2015 were eligible for evaluation. INTERVENTION Using the define-measure-analyze-improve-control (DMAIC) process-improvement methodology, a multidisciplinary team implemented and iteratively improved 15 data-driven interventions in 4 broad areas: (1) electronic medical record (EMR) alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes. MEASUREMENTS The Joint Commissions 6 core measures and the Surgical Care Improvement Project (SCIP) SCIP-VTE-2 measure. RESULTS Based on 3103 observations (1679 from January 1, 2013 to May 1, 2013, and 1424 from October 1, 2014 to April 1, 2015), performance on the core measures improved. Performance on measure 1 (chemoprophylaxis) improved from 82.5% to 90.2% on medicine services, and from 94.4% to 97.6% on surgical services. The largest improvements were seen in measure 4 (platelet monitoring), with a performance increase from 76.7% adherence to 100%, and measure 5 (warfarin discharge instructions), with a performance increase from 27.4% to 88.8%. CONCLUSION A systematic hospital-wide DMAIC project improved VTE prophylaxis measure performance. Sustained performance has been observed, and novel control mechanisms for continued performance surveillance have been embedded in the hospital system. Journal of Hospital Medicine 2016;11:S29-S37.