Daniel E. Lage

Diversity based on race, ethnicity, and sex between academic orthopaedic surgery and other specialties: a comparative study.

BACKGROUND Previous studies have demonstrated a lack of diversity in orthopaedics; however, it is unclear whether this observation is unique to orthopaedics or similar to other surgical fields. The present study compares diversity in the field of orthopaedics with diversity in other surgical and nonsurgical fields. To our knowledge, no previous study has placed this issue in a comparative perspective between specialties at both the residency and faculty levels. METHODS Public registries from 2006 and 2007 were used to determine the composition (according to race, ethnicity, and sex) of the orthopaedic workforce in the United States, including medical students, orthopaedic residents, orthopaedic faculty, and full professors. The diversity of orthopaedic residents and faculty was then compared with that in five other specialties. In addition, the applicant pools to orthopaedic and general surgery residencies were compared. RESULTS Within the 2006 orthopaedic workforce, there was a significant decrease in the representation of African-Americans, Hispanics/Latinos, Asian-Americans, and women from medical schools to orthopaedic residencies (p < 0.001). African-Americans, Hispanics/Latinos, and Asian-Americans were underrepresented among orthopaedic faculty compared with their representation in orthopaedic residency programs (p < 0.05). Furthermore, women and Asian-Americans were disproportionately underrepresented as full professors compared with their presence on the faculty at academic orthopaedic institutions (p < 0.05). When compared with other surgical specialties, African-Americans and Hispanics/Latinos made up a significantly smaller proportion of orthopaedic residents than general surgery residents and neurological surgery. Orthopaedic surgery had the lowest representation of female residents and faculty (p < 0.05 for all comparisons). In examining the applicant pool, orthopaedic surgery was less diverse than general surgery (p < 0.001). Furthermore, African-American and Hispanic/Latino orthopaedic applicants also submitted a lower average number of applications than Whites or Asian-Americans. CONCLUSIONS Our findings suggest that on a comparative basis, orthopaedic surgery lags behind general surgery and other surgical and nonsurgical fields in terms of the representation of minorities and women. Thus, given similar capabilities and qualifications of applicants, a concerted effort could be made to recruit more diverse residents and faculty.

Creating a network of high-quality skilled nursing facilities: preliminary data on the postacute care quality improvement experiences of an accountable care organization.

Postacute care (PAC) is an important source of cost growth and variation in the Medicare program and is critical to accountable care organization (ACO) and bundled payment efforts to improve quality and value in the Medicare program, but ACOs must often look outside their walls to identify high‐value external PAC partners, including skilled nursing facilities (SNFs). As a solution to this problem, the integrated health system, Partners HealthCare System (PHS) and its Pioneer ACO launched the PHS SNF Collaborative Network in October 2013 to identify and partner with high‐quality SNFs. This study details the method by which PHS selected SNFs using minimum criteria based on public scores and secondary criteria based on self‐reported measures, describes the characteristics of selected and nonselected SNFs, and reports SNF satisfaction with the collaborative. The selected SNFs (n = 47) had significantly higher CMS Five‐Star scores than the nonselected SNFs (n = 93) (4.6 vs 3.2, P < .001) and were more likely than nonselected SNFs that met the minimum criteria (n = 35) to have more than 5 days of clinical coverage (17.0% vs 2.9%, P = .02) and to have a physician see admitted individuals within 24 (38.3% vs 17.1%, P = .02) and 48 hours (93.6% vs 80.0%, P = .03). A survey sent to collaborative SNFs found high satisfaction with the process (average satisfaction, 4.6/5, with 1 = very dissatisfied and 5 = very satisfied, n = 19). Although the challenges of improving care in SNFs remain daunting, this approach can serve as a first step toward greater clinical collaboration between acute and postacute settings that will lead to better outcomes for frail older adults.

Use of Antidepressant Medications Moderates the Relationship Between Depressive Symptoms and Hospital Length of Stay in Patients with Advanced Cancer

Patients with cancer often experience depression, which can influence treatment outcomes and quality of life. This article evaluates associations among depressive symptoms, use of antidepressants, and hospital length of stay in patients with advanced cancer.

The Care Continuum for Hospitalized Medicare Beneficiaries Near Death

Background: Rising use of postacute care (PAC) facilities over the past 2 decades has contributed to increased transitions of care in the last year of life (1, 2). Medicare PAC facility benefits cover rehabilitation from acute illness in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals. Amid pressure to reduce length of stay, hospitals often use PAC facilities as a stopgap and send elderly patients near the end of life to facilities designed more for rehabilitation than palliative care. The role of PAC facilities as a discharge destination for patients in the last days or weeks of life has been underappreciated, particularly because the alternative choice of hospice care may improve their quality of life (3). Objective: To assess the use of PAC facilities, overall and by hospice use, as well as hospital readmissions from these facilities in patients near death. Methods and Findings: We studied Medicare fee-for-service beneficiaries who died between 2006 and 2011 using the beneficiary summary files, data from the Medicare Provider Analysis and Review, and hospice base claims. We described use of PAC facilities and acute hospitals overall and by hospice status, dichotomized as any versus no hospice claims in the last year of life. Among 8216193 Medicare beneficiaries who died, 23.3% received care in a PAC facility in the last 90 days of life. Further, 16.1% received care in a PAC facility in the last 14 days of life and 9.9% received care in in a PAC facility on the day of or day before death. Among patients using a PAC facility within the last 30 and 90 days of life, 50.1% and 60.4%, respectively, returned to an acute hospital before death; most of these readmissions were transferred directly from PAC facilities (Table 1). Table 1. Readmissions in the Last 30 and 90 Days of Life Among Medicare Beneficiaries With> =1 PAC Facility Stay* Among all Medicare beneficiaries who died during the study period, 39.0% used hospice services in the last year of life. Those who did not had higher use of acute care hospitals and PAC facilities in the days and weeks before death (Table 2). Table 2. Medicare Fee-for-Service Beneficiaries Who Used Acute Care Hospitals or PAC Facilities Before Death, by Hospice Status* Discussion: Patients who used PAC facilities in the last month of life were frequently readmitted to an acute care hospital before death, and patients who did not use hospice services had higher use of acute care hospitals and PAC facilities before death. Given the lack of palliative care expertise in PAC facilities and the key contribution of such facilities to Medicare spending growth (4), these transitions may lead to lower-quality end-of-life care for patients and increased cost to the health system. Many potential explanations exist for high use of PAC facilities and hospital readmissions near the end of life. Although some patients may have unrealistic hopes for rehabilitation, many frail elderly patients hospitalized for serious illness may be unable to return home because of functional decline, lack of caregiver support, or difficulty controlling such symptoms as pain or dyspnea. Postacute care facilities can meet some of these needs; however, such patients are often rehospitalized when their clinical status changes, leading to potentially burdensome transitions. Other patients interested in hospice may be unable to receive home-based hospice care because of functional decline or lack of a caregiver. Hospice facility fees for room and board for such patients can cost hundreds of dollars per day (5), because fully funded general inpatient hospice care is limited to those who require intravenous pain medication and intensive symptom management. That many of these patients may be discharged to Medicare-funded PAC facilities is thus not surprising. These findings suggest future interventions and research questions and could inform conversations with patients near the end of life about their setting and goals of care. Policies that require documentation of advanced care planning before transfer to a PAC facility, including discussion of do-not-hospitalize orders, could help facilitate these conversations. Further, financial incentives for PAC facilities to reduce hospital readmissions could help fund interventions, such as having palliative care clinicians on call to answer questions about managing acute symptoms or training the staff of PAC facilities in palliative care. This study was limited by its retrospective, claims-based approach and lack of patient-reported data. Future studies should explore why patients use PAC facilities near the end of life and prospectively assess how doing so affects the quality of end-of-life care.