Heather Lyu

Patient Satisfaction as a Possible Indicator of Quality Surgical Care

IMPORTANCE In 2010, national payers announced they would begin using patient satisfaction scores to adjust reimbursements for surgical care. OBJECTIVE To determine whether patient satisfaction is independent from surgical process measures and hospital safety. DESIGN We compared the performance of hospitals that participated in the Patient Satisfaction Survey, the Centers for Medicare & Medicaid Services Surgical Care Improvement Program, and the employee Safety Attitudes Questionnaire. SETTING Thirty-one US hospitals. PARTICIPANTS Patients and hospital employees. INTERVENTIONS There were no interventions for this study. MAIN OUTCOMES AND MEASURES Hospital patient satisfaction scores were compared with hospital Surgical Care Improvement Program compliance and hospital employee safety attitudes (safety culture) scores during a 2-year period (2009-2010). Secondary outcomes were individual domains of the safety culture survey. RESULTS Patient satisfaction was not associated with performance on process measures (antibiotic prophylaxis, R = -0.216 [P = .24]; appropriate hair removal, R = -0.012 [P = .95]; Foley catheter removal, R = -0.089 [P = .63]; deep vein thrombosis prophylaxis, R = 0.101 [P = .59]). In addition, patient satisfaction was not associated with a hospitals overall safety culture score (R = 0.295 [P = .11]). We found no association between patient satisfaction and the individual culture domains of job satisfaction (R = 0.327 [P = .07]), working conditions (R = 0.191 [P = .30]), or perceptions of management (R = 0.223 [P = .23]); however, patient satisfaction was associated with the individual culture domains of employee teamwork climate (R = 0.439 [P = .01]), safety climate (R = 0.395 [P = .03]), and stress recognition (R = -0.462 [P = .008]). CONCLUSIONS AND RELEVANCE Patient satisfaction was independent of hospital compliance with surgical processes of quality care and with overall hospital employee safety culture, although a few individual domains of culture were associated. Patient satisfaction may provide information about a hospitals ability to provide good service as a part of the patient experience; however, further study is needed before it is applied widely to surgeons as a quality indicator.

Underreporting of robotic surgery complications

Background:Since its Food and Drug Administration (FDA) approval, robot‐assisted laparoscopic surgery has grown with expanding indications. One factor used to expand indications is device‐related complications. We designed a study to evaluate device‐related robotic surgery complications reported to FDA. Methods:We searched the FDA device‐related complication database, LexisNexis, and PACER (Public Access to Court Electronic Records) to identify robotic surgery‐related complications over a 12‐year period (January 1, 2000 to August 1, 2012). Cases from LexisNexis and PACER were cross‐referenced with the FDA database to determine cases where an FDA report was inaccurate, filed late or not filed. Results:A total of 245 events were reported to the FDA during the study period, including 71 deaths and 174 nonfatal injuries. Median time to report an event to the FDA was 30 days (range = 0–930 days). Eight cases were identified from the LexisNexis and PACER searches where FDA reports were improperly filed. In five of these, no report was filed with a mean follow‐up of 4.1 years (range = 2.3–5.8 years). In the three cases where a report was filed, the mean time between the event and the FDA report was 20.4 months (611 days, range = 292–930 days). Conclusions:It is important that the true incidence of complications with robotic‐assisted laparoscopic surgery be known to ensure continued safe innovation.

Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review

Objective To determine casemix adjusted hospital level utilization of minimally invasive surgery for four common surgical procedures (appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy) in the United States. Design Retrospective review. Setting United States. Participants Nationwide inpatient sample database, United States 2010. Methods For each procedure, a propensity score model was used to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, hospitals were categorized into thirds (low, medium, and high) based on their actual to predicted proportion of utilization of minimally invasive surgery. Main outcome measures The primary outcome measures were the actual and predicted proportion of procedures performed with minimally invasive surgery. Secondary outcome measures included surgical complications and hospital characteristics. Results Mean hospital utilization of minimally invasive surgery was 71.0% (423/596) for appendectomy (range 40.9-93.1% (244-555)), 28.4% (154/541) for colectomy (6.7-49.8% (36/541-269/541)), 13.0% (65/499) for hysterectomy (0.0-33.6% (0/499-168/499)), and 32.0% (67/208) for lung lobectomy (3.6-65.7% (7.5/208-137/208)). Utilization of minimally invasive surgery was highly variable for each procedure type. There was noticeable discordance between actual and predicted utilization of the surgery (range of actual to predicted ratio for appendectomy 0-1.49; colectomy 0-3.88; hysterectomy 0-6.68; lung lobectomy 0-2.51). Surgical complications were less common with minimally invasive surgery compared with open surgery, respectively: overall rate for appendectomy 3.94% (1439/36 513) v 7.90% (958/12 123), P<0.001; for colectomy: 13.8% (1689/12 242) v 35.8% (8837/24 687), P<0.001; for hysterectomy: 4.69% (270/5757) v 6.64% (1988/29 940), P<0.001; and for lung lobectomy: 17.1% (367/2145) v 25.4% (971/3824), P<0.05. High utilization of minimally invasive surgery was associated with urban location (appendectomy: odds ratio 4.66, 95% confidence interval 1.17 to 18.5; colectomy: 4.59, 1.04 to 20.3; hysterectomy: 15.0, 2.98 to 75.0), large hospital size (hysterectomy: 8.70, 1.62 to 46.8), teaching hospital (hysterectomy: 5.41, 1.27 to 23.1), Midwest region (appendectomy: 7.85, 1.26 to 49.1), south region (appendectomy: 21.0, 3.79 to 117; colectomy: 10.0, 1.83 to 54.7), and west region (appendectomy: 9.33, 1.48 to 58.8). Conclusion Hospital utilization of minimally invasive surgery for appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy varies widely in the United States, representing a disparity in the surgical care delivered nationwide.

Rates and predictors of readmission after minor lower extremity amputations

OBJECTIVE One goal of the Patient Protection and Affordable Care Act is to reduce hospital readmissions, with financial penalties applied for excessive rates of unplanned readmissions within 30 days among Medicare beneficiaries. Recent data indicate that as many as 24% of Medicare patients require readmission after vascular surgery, although the rate of readmission after limited digital amputations has not been specifically examined. The present study was therefore undertaken to define the rate of unplanned readmission among patients after digital amputations and to identify the factors associated with these readmissions to allow the clinician to implement strategies to reduce readmission rates in the future. METHODS The electronic medical and billing records of all patients undergoing minor amputations (defined as toe or transmetatarsal amputations using International Classification of Diseases, Ninth Revision, codes) from January 2000 through July 2012 were retrospectively reviewed. Data were collected for procedure- and hospital-related variables, level of amputation, length of stay, time to readmission, and level of reamputation. Patient demographics included hypertension, diabetes, hyperlipidemia, smoking history, and history of myocardial infarction, congestive heart failure, peripheral arterial disease, chronic obstructive pulmonary disease, and cerebrovascular accident. RESULTS Minor amputations were performed in 717 patients (62.2% male), including toe amputations in 565 (72.8%) and transmetatarsal amputations in 152 (19.5%). Readmission occurred in 100 patients (13.9%), including 28 (3.9%) within 30 days, 28 (3.9%) between 30 and 60 days, and 44 (6.1%) >60 days after the index amputation. Multivariable analysis revealed that elective admission (P < .001), peripheral arterial disease (P < .001), and chronic renal insufficiency (P = .001) were associated with readmission. The reasons for readmission were infection (49%), ischemia (29%), nonhealing wound (19%), and indeterminate (4%). Reamputation occurred in 95 (95%) of the readmitted patients, including limb amputation in 64 (64%) of the patients (below knee in 58, through knee in 2, and above knee in 4). CONCLUSIONS Readmission after minor amputation was associated with limb amputation in the majority of cases. This study identified a number of nonmodifiable patient factors that are associated with an increased risk of readmission. Whereas efforts to reduce unplanned hospital readmissions are laudable, payers and regulators should consider these observations in defining unacceptable rates of readmission. Further, although beyond the scope of this study, it is not unreasonable to assume that pressure to reduce readmission rates in the population of patients with extensive comorbidity may induce practitioners to undertake amputation at a higher level initially to minimize the risk of readmission for reamputation and associated financial penalties and thus deprive the patient the chance for limb salvage.

Epithelioid sarcoma: one institution’s experience with a rare sarcoma

BACKGROUND Epithelioid sarcomas (ES) are extremely rare soft tissue sarcomas. As such, their clinical behavior and response to treatment are poorly described in the literature. METHODS We queried the centralized cancer registry and pathology archives at the Johns Hopkins Medical Institution and identified 22 patients with a diagnosis of ES. We excluded two patients because of inadequate data. A pathologist reviewed patient charts and reexamined available histological slides. This study was performed with institutional review board approval. RESULTS The median age at diagnosis was 27.8 y; most patients (75%) were male. Regional lymph node metastases were present in 10% of patients at presentation. The majority of tumors (57.9%) recurred and 35% recurred more than once, although the number of recurrences did not affect survival (P = 0.48). Patients did not experience a decrease in time to recurrence with increasing number of resections. The median time between resection and recurrence was 1.23 y and the maximum was 18.8 y. Median overall survival was 56.2 mo and 5-y survival was 92%. CONCLUSIONS Our study reveals that ES is an extremely rare tumor with a protracted and recurrent course, but overall survival may be more favorable than in the past. Patients benefit from aggressive and repeated resection. Epithelioid sarcoma is unique because it metastasizes to regional nodal basins. Extended surveillance is indicated, because recurrences can appear after decades of quiescence.

Synergistic effects of A1896, T1653 and T1762/A1764 mutations in genotype c2 hepatitis B virus on development of hepatocellular carcinoma.

The effects of genomic changes in hepatitis B virus (HBV) on the occurrence of hepatocellular carcinoma (HCC) are still unclear, especially in relation to the genotype of HBV. In this study, we examined the effects of genomic changes in HBV of genotype C2 on the development of HCC. A total of 318 patients with HBV‐associated HCC and 234 patients with chronic hepatitis B (CHB) were studied. All of HCC cases were diagnosed histologically and treated with surgical resection. The whole of the X, S, basal core promoter (BCP) and precore regions of the viral genome from sera or liver tissues were sequenced. All subjects had HBV of genotype C2. The prevalence of the T1653 mutation in the X region and the A1896 mutation in the precore region of HBV was significantly higher in the HCC group than in the control CHB group (22% vs 11%, P = 0.003; 50% vs 23%, P < 0.001, respectively). Moreover, the T1762/A1764 mutations in the BCP region in combination with either T1653 or A1896 were more common in the HCC compared with the CHB group (BCP+X1653: 18% vs 11%, P = 0.05; BCP+PC, 40% vs 15%, P < 0.001, respectively). In multivariate analysis, T1653 and A1896 were revealed to be independent risk factors for HCC development. G1896A in the precore region and C1653T mutation in the X region of genotype C2 HBV are important risk factors for HCC development. Also, the A1762T/G1764A double mutation may act in synergy with C1653T to increase the risk of HCC in patients chronically infected with HBV genotype C2.

Overtreatment in the United States

Background Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment. Methods 2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment. Findings The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs. Conclusion From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.

Prevalence and Data Transparency of National Clinical Registries in the United States

Objective: To determine the prevalence and characteristics of national clinical registries. Methods: Review of clinical registries through the following: (1) PubMed search using MeSH term “registries,” (2) clinical trials database search using the term “registry,” (3) review of the American Medical Association (AMA) recognized specialty societies for registry affiliation, and (4) consultation with a panel representing the American Board of Medical Specialties (ABMS). Main Outcome Measures: Outcomes that characterize registries (type, participants, specialty affiliation, funding), reflect data quality (risk adjustment, auditing practices), and indicate transparency (public reporting). Results: We identified 153 clinical registries of which 47.7% (73) were health services registries, 43.1% (66) were disease registries, and 9.2% (14) were combination registries. The mean number of hospitals per registry was 1,693 (interquartile range [IQR] = 45–230), and the mean number of patients per registry was 1,160,492 (IQR = 2,150–10,045). Among the 117 AMA specialty societies, 16.2% (19) were affiliated with a registry. Government funding was associated with 26.1% (40/153) of registries. Of the 153 registries, 23.5% (36) risk adjusted outcomes and 18.3% (23) audited data. Mandatory public reporting of hospital outcomes for all participating hospitals was associated with 2.0% (3/153) of registries. Conclusion: There is substantial opportunity to develop more specialty-specific clinical registries with publicly available data.

Genomic change in hepatitis B virus associated with development of hepatocellular carcinoma

AIM To determine the genomic changes in hepatitis B virus (HBV) and evaluate their role in the development of hepatocellular carcinoma (HCC) in patients chronically infected with genotype C HBV. METHODS Two hundred and forty chronic hepatitis B (CHB) patients were subjected and followed for a median of 105 mo. HCC was diagnosed in accordance with AASLD guidelines. The whole X, S, basal core promoter (BCP), and precore regions of HBV were sequenced using the direct sequencing method. RESULTS All of the subjects were infected with genotype C HBV. Out of 240 CHB patients, 25 (10%) had C1653T and 33 (14%) had T1753V mutation in X region; 157 (65%) had A1762T/G1764A mutations in BCP region, 50 (21%) had G1896A mutation in precore region and 67 (28%) had pre-S deletions. HCC occurred in 6 patients (3%). The prevalence of T1753V mutation was significantly higher in patients who developed HCC than in those without HCC. The cumulative occurrence rates of HCC were 5% and 19% at 10 and 15 years, respectively, in patients with T1753V mutant, which were significantly higher than 1% and 1% in those with wild type HBV (P < 0.001). CONCLUSION The presence of T1753V mutation in HBV X-gene significantly increases the risk of HCC development in patients chronically infected with genotype C HBV.

Medical Harm: Patient Perceptions and Follow-up Actions

Objectives Much research has been conducted to describe medical mistakes resulting in patient harm using databases that capture these events for medical organizations. The objective of this study was to describe patients’ perceptions regarding disclosure and their actions after harm. Methods We analyzed a patient harm survey database composed of responses from a voluntary online survey administered to patients by ProPublica, an independent nonprofit news organization, during a 1-year period (May 2012 to May 2013). We collected data on patient demographics and characteristics related to the acknowledgment of patient harms, the reporting of patient harm to an oversight agency, whether the patient or the family obtained the harm-associated medical records, as well as the presence of a malpractice claim. Results There were 236 respondents reporting a patient harm (mean age, 49.1 y). In 11.4% (27/236) of harms, an apology by the medical organization or the clinician was made. In 42.8% (101/236) of harms, a complaint was filed with an oversight agency. In 66.5% (157/236) of harms, the patient or the family member obtained a copy of the pertinent medical records. A malpractice claim was reported in 19.9% (47/236) of events. Conclusions In this sample of self-reported patient harms, we found a perception of inadequate apology. Nearly half of patient harm events are reported to an oversight agency, and roughly one-fifth result in a malpractice claim.