Eugene C. Nelson

Developing a pathway for high-value, patient-centered total joint arthroplasty.

BackgroundTotal joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed.Questions/purposesThe purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA.MethodsWe used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9).ResultsThe care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level.ConclusionsWe developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation.Level of EvidenceLevel V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Automated detection of harm in healthcare with information technology: a systematic review

Context To improve patient safety, healthcare facilities are focussing on reducing patient harm. Automated harm-detection methods using information technology show promise for efficiently measuring harm. However, there have been few systematic reviews of their effectiveness. Objective To perform a systematic literature review to identify, describe and evaluate effectiveness of automated inpatient harm-detection methods. Methods Data sources included MEDLINE and CINAHL databases indexed through August 2008, extended by bibliographic review and search of citing articles. The authors included articles reporting effectiveness of automated inpatient harm-detection methods, as compared with other detection methods. Two independent reviewers used a standardised abstraction sheet to extract data about automated and comparison harm-detection methods, patient samples and events identified. Differences were resolved by discussion. Results From 176 articles, 43 articles met inclusion criteria: 39 describing field-defined methods, two using natural language processing and two using both methods. Twenty-one studies used automated methods to detect adverse drug events, 10 detected general adverse events, eight detected nosocomial infections, and four detected other specific adverse events. Compared with gold standard chart review, sensitivity and specificity of automated harm-detection methods ranged from 0.10 to 0.94 and 0.23 to 0.98, respectively. Studies used heterogeneous methods that often were flawed. Conclusion Automated methods of harm detection are feasible and some can potentially detect patient harm efficiently. However, effectiveness varied widely, and most studies had methodological weaknesses. More work is needed to develop and assess these tools before they can yield accurate estimates of harm that can be reliably interpreted and compared.

Accelerating implementation of biomedical research advances: critical elements of a successful 10 year Cystic Fibrosis Foundation healthcare delivery improvement initiative

Context: Scientific and therapeutic advances Remarkable biomedical research advances have led to innovative and increasingly effective therapies. We highlight several scientific milestones in elucidating the pathophysiology of cystic fibrosis (CF) and review the therapies that have become available over the past 20 years. Impact of the quality improvement initiative In 2002, the CF Foundation launched a multifaceted quality improvement initiative to accelerate improvement in CF care. We present evidence of substantial improvement in process measures, such as more consistent outpatient follow-up, and key medical outcomes, including survival, pulmonary function and nutritional status. Critical success factors We offer our perspective on factors critical to the success of the quality improvement initiative, including a compelling strategic plan and the commitment of the CF Foundation to its implementation; the investment in building improvement capacity at CF care centres; the engagement of people with CF and their families as partners; and the integration of quality improvement into the existing CF care framework. Directions for the next decade In addition to a continued investment in building and sustaining improvement capacity at CF care centres, and deeper patient engagement, we will address the oppressive treatment burden. We will also complement the measurement of clinical outcomes with patient reported outcomes and healthcare costs for a balanced assessment of the quality and value of care. Conclusions Major advances in basic science and therapeutic development coupled with improvements in healthcare delivery have resulted in striking gains in medical outcomes for people with CF.

Creating a culture of health: Evolving healthcare systems & patient engagement.

Creating a culture of health: evolving healthcare systems and patient engagement S. Lindblad, S. Ernestam, A.D. Van Citters, C. Lind, T.S. Morgan and E.C. Nelson From the Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Medical Management Centre, Stockholm, Sweden, QRC Stockholm Quality Register Centre, Stockholm, Sweden and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, USA

Measuring Adverse Events in Hospitalized Patients: An Administrative Method for Measuring Harm.

Context Current methods for tracking harm either require costly full manual chart review (FMCR) or rely on proxy methods that have questionable accuracy. We propose an administrative measure of harm detection that uses electronically captured data. Objective Determine the level of agreement on harm event occurrence when harm is detected based on an administrative harm measurement tool (AHMT) compared with FMCR. Design A retrospective chart review was used to measure the level of agreement in harm detection between an AHMT that uses electronically captured data and a FMCR. Setting The inpatient hospital setting was used. Patients Approximately 771 medical records from 5 hospitals were reviewed. Main Outcome Measures Measures of positive predictive value, negative predictive value, weighted sensitivity, weighted specificity, and concordance were used to evaluate agreement between the 2 methods. Results Although there was agreement at the harm-event level, the results were not all as high as desired: adjusted sensitivity 65%, adjusted specificity 85%, positive predictive value (PPV) 59%, negative predictive value (NPV) 88%, and concordance 75%. The patient-level results show greater agreement: adjusted sensitivity 95%, adjusted specificity 86%, PPV 61%, NPV 99%, and concordance 81%. Conclusion The AHMT is sufficiently accurate for use as a within hospital tool to reliably detect and track harm. Nevertheless, it is not recommended as a tool to make comparisons across institutions, which has policy and payment implications. Further research using administrative harm detection, including the use of a broader set of measures and electronic health records, is needed.

Validation of a new predictive risk model: measuring the impact of the major modifiable risks of death for patients and populations.

BackgroundModifiable risks account for a large fraction of disease and death, but clinicians and patients lack tools to identify high risk populations or compare the possible benefit of different interventions.MethodsWe used data on the distribution of exposure to 12 major behavioral and biometric risk factors inthe US population, mortality rates by cause, and estimates of the proportional hazards of risk factor exposure from published systematic reviews to develop a risk prediction model that estimates an adult’s 10 year mortality risk compared to a population with optimum risk factors. We compared predicted risk to observed mortality in 8,241 respondents in NHANES 1988-1994 and NHANES 1999-2004 with linked mortality data up to the end of 2006.ResultsPredicted risk showed good discrimination with an area under the receiver operating characteristic (ROC) curve of 0.84 (standard error 0.01) for women and 0.84 (SE 0.01) for men. Across deciles of predicted risk, mortality was accurately predicted in men ((Χ2 statistic = 12.3 for men, p=0.196) but slightly overpredicted in the highest decile among women (Χ2 statistic = 22.8, p=0.002). Mortality risk was highly concentrated; for example, among those age 30-44 years, 5.1 % (95 % CI 4.1 % - 6.0 %) of the male and 5.9 % (95 % CI 4.8 % - 6.9 %) of the female population accounted for 25 % of the risk of death.ConclusionThe risk model accurately predicted mortality in a representative sample of the US population and could be used to help inform patient and provider decision-making, identify high risk groups, and monitor the impact of efforts to improve population health.

Local emergency medical response after a terrorist attack in Norway: a qualitative study

Introduction On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare. Methods We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS’ success. Two independent teams of professional experts classified and validated the identified determinants. Results Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation. Conclusion The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.