Duncan Neuhauser

Prophylactic Cholecystectomy or Expectant Management for Silent Gallstones: A Decision Analysis to Assess Survival

Decision analysis was done to compare the consequences of prophylactic cholecystectomy with expectant management for silent gallstone disease. Probability values were derived from a study of the natural history of silent gallstone disease, published cholecystectomy mortality rates, and life tables. The two strategies were compared by calculating cumulative numbers of person-years lost for hypothetical cohorts of men and women. Prophylactic cholecystectomy slightly decreases survival. A 30-year-old man choosing prophylactic cholecystectomy instead of expectant management would lose, on average, 4 days of life; a 50-year-old man would lose 18 days. Consideration of monetary costs and discounting further disfavors prophylactic cholecystectomy. Sensitivity analysis shows that differences between the two strategies remain small over a broad range of probability values, both for men and women.

Does cost information availability reduce physician test usage? A randomized clinical trial with unexpected findings.

Four similar teams of physicians associated with similar inpatient units and randomly assigned patients were used to study the effect of providing physicians with cost information about their use of lab tests and x-rays. Two teams received information about lab test costs, and two teams received x-ray test costs. Test usage fell during the experimental conditions and continued to fall after the experimental period ended in teams in which there was an interested leader.

Quality Health Care

Despite a long history in industry, the principles and methods of continuous improvement are new to medicine. Continuous improvement led to a 73% drop in the number of inadequate cervical smears in a large urban health center.

Ernest Amory Codman: the End Result of a Life in Medicine.

An editorial in the New York Times of 28 December 1999 praises the US Veterans Administration (VA) hospital system for publicly reporting their medical errors. The VA reported 3000 medical mistakes resulting in 700 patient deaths during the 18 months up to the start of 1999. There will be strong pressure for all US hospitals to follow this painful path of public admission of error in spite of the threat of litigation. This expectation will not stop at the borders of the USA. Ernest Amory Codman, MD (1869–1940) has already “been there and done that”. He created his own “End Result Hospital” in Boston, Massachusetts, 1911–1917 where errors in diagnosis and treatment were recorded for every patient, all patients were followed years after discharge to evaluate the end results of care, and all this was publicly reported in the hospitals annual report. For example: “Patient #18, Feb. 11, 1912. Female 38. Intermittent right-sided abdominal pain and …

Patient and Hospital Characteristics Associated with Patient Assessments of Hospital Obstetrical Care

OBJECTIVES The goals of this study were to examine the relationship of patient assessments of hospital care with patient and hospital characteristics. In addition, the authors sought to assess relationships between patient assessments and other patient-derived measures of care (eg, how much they were helped by the hospitalization and amount of pain experienced). METHODS The authors surveyed 16,051 women (response rate, 58%) discharged after labor and delivery from 18 hospitals during the study period of 1992 to 1994. Patient assessments were obtained using a previously validated survey instrument, Patient Judgment of Hospital Quality, that includes eight scales assessing different aspects of the process of care (eg, physician care, discharge procedures) and other single item assessments (eg, overall quality). For this study, we utilized five of the scales (physician care, nursing care, information, discharge preparation, global assessments [willingness to brag, recommend or return to the hospital]). For analysis, items were rated on a five-point ordinal scale from poor to excellent. For scoring purposes, responses were transformed to linear ratings, ranging from 0 to 100 (eg, 0 = poor care, 100 = excellent care). RESULTS In multivariable analyses, the authors found that patients who were older, white, not married, uninsured or had commercial insurance, and in better health status were significantly more likely to give higher assessments (P < 0.01), although very little of the variance in assessment scores was explained by these characteristics (2%-3%). In bivariate analyses, patient assessments were higher in nonteaching hospitals and those with fewer beds, fewer deliveries, lower cesarean-section (C-section) rates, fewer patients with Medicaid, and higher rates of vaginal births after C-section deliveries. When these variables were utilized as independent predictors in multivariable analyses using adjusted nested linear regression (to account for clustering of patients), few of the hospital characteristics reached a level of statistical significance. Finally, correlations between the five scales and other patient assessments of quality, such as how much they were helped by the hospitalization, were statistically significant (P < 0.01) and high in magnitude, ranging from 0.47 to 0.61. CONCLUSIONS Although hospital scores differed according to several patient and hospital characteristics, the magnitude of the associations was relatively small. The findings suggest that, with respect to obstetric care, patient assessments may represent a robust measure that can be applied to diverse hospitals and patient casemix.

Ernest Amory Codman, M.D., and End Results of Medical Care

Ernest Amory Codman, M.D., was one of the most important figures in the history of outcomes research in medicine. While his contemporaries scorned his efforts to create systematic procedures to evaluate the end results of medical care, his work foreshadowed many of todays most pressing issues in technology assessment. This article traces Codmans career as an innovator and political gadfly at the Massachusetts General Hospital during the first three decades of this century, and examines the development and demise of his end-result system.

Collaborating for improvement in health professions education.

Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations.

Preoperative anemia and perioperative outcomes in patients who undergo elective spine surgery.

Study Design. Analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database. Objective. To assess whether preoperative anemia predicted adverse, early, perioperative outcomes in patients undergoing elective spine surgery. Summary of Background Data. Prior studies have assessed the association of anemia with outcomes in various noncardiac surgical procedures. The association between preoperative anemia and 30-day outcomes for spine surgery is unknown. Methods. A total of 24,473 adults, classified as having severe (N = 88), moderate (N = 314), mild (N = 5477), and no anemia. Using propensity scores, patients with severe, mild, and moderate anemia were matched with patients with no anemia. Logistic regression was used to predict adverse postoperative outcomes. Sensitivity analyses were conducted limiting the study sample to patients who did not receive intra- or postoperative transfusion and to patients with and without preoperative cardiovascular comorbidities. Results. Patients with all levels of anemia had significantly higher risk of nearly all adverse outcomes than nonanemic patients in unadjusted and propensity-matched models. Patients with moderate and mild anemia were more likely to have prolonged length of hospitalization, experience 1 or more complications, and expire within 30 days of surgery compared with nonanemic patients. The association between anemia and adverse outcomes was found independently of intra- and postoperative transfusions, and was not more pronounced in patients with preoperative cardiovascular comorbidities. Conclusion. All levels of anemia were significantly associated with prolonged length of hospitalization and poorer operative or 30-day outcomes in patients undergoing elective spine surgery. Our findings, using a large multi-institutional sample of prospectively collected data, suggests that anemia should be regarded as an independent risk factor for perioperative and postoperative complications that deserves attention prior to elective spine surgery. Level of Evidence: 3

Impact of increased body mass index on outcomes of elective spinal surgery.

Study Design. Observational retrospective cohort study of prospectively collected database. Objective. To determine whether overweight body mass index (BMI) influences 30-day outcomes of elective spine surgery. Summary of Background Data. Obesity is prevalent in the United States, but its impact on the outcome of elective spine surgery remains controversial. Methods. We used National Surgical Quality Improvement Program, a prospective clinical database with proven validity and reproducibility consisting of 256 perioperative standardized variables from surgical patients at nearly 400 academic and nonacademic hospitals nationwide. We identified 49,314 patients who underwent elective fusion, laminectomy or both between 2006 and 2012. We divided patients according to BMI (kg/m2) as normal (18.5–24.9), preobese (25.0–29.9), obese I (30.0–34.9), obese II (35.0–39.9), and obese III (≥40). Relationship between increased BMI and outcome of surgery measured as prolonged hospitalization, complications, return to the operating room, discharged with continued care requirement, readmission, and death was determined using logistic regression before and after propensity score matching. Results. All overweight patients (BMI ≥25 kg/m2) showed increased odds of an adverse outcome compared with normal patients in unmatched analyses, with maximal effect seen in obese III group. In the propensity-matched sample, obese III patients continued to show increased odds for complications (odds ratio, 1.6; 95% confidence interval, 1.1–2.3), readmission (odds ratio, 2.3; 95% confidence interval, 1.1–4.9), and return to the operating room (odds ratio, 1.8; 95% confidence interval, 1.1–3.1). Conclusion. Impact of obesity on elective spine surgery outcome is mediated, at least in part, by comorbidities in patients with BMI between 25.0 and 39.9 kg/m2. However, BMI itself is an independent risk factor for adverse outcomes in morbidly obese patients. Level of Evidence: 3

Continuous self-improvement: systems thinking in a personal context.

BACKGROUND Continuous quality improvement (CQI) thinking and tools have broad applicability to improving peoples lives--in continuous self-improvement (CSI). Examples include weight loss, weight gain, increasing exercise time, and improving relationship with spouse. In addition, change agents, who support and facilitate organizational efforts, can use CSI to help employees understand steps in CQI. A STEP-BY-STEP APPROACH: Team members should be involved in both the definition of the problem and the search for the solution. How do everyday processes and routines affect the habit that needs to change? What are the precursors of the event? Clients list possible solutions, prioritize them, and pilot test the items selected. One needs to change the daily routines until the desired behavior is accomplished habitually and with little external decision. DISCUSSION CSI is successful because of its emphasis on habits embedded in personal processes. CSI organizes support from process owners, buddies, and coaches, and encourages regular measurement, multiple small improvement cycles, and public reporting.