John A. Harris

Prophylactic Antibiotic Choice and Risk of Surgical Site Infection After Hysterectomy.

OBJECTIVE: To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy. METHODS: A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving &bgr;-lactam antibiotics and those receiving alternatives to &bgr;-lactam antibiotics. Patients receiving nonrecommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving nonstandard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results. RESULTS: The study included 21,358 hysterectomies. The overall rate of any surgical site infection was 2.06% (n=441). Unadjusted rates of “any surgical site infection” were 1.8%, 3.1%, and 3.7% for &bgr;-lactam, &bgr;-lactam alternatives, and nonstandard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared with the &bgr;-lactam antibiotics (reference group), the risk of “any surgical site infection” was higher for the group receiving &bgr;-lactam alternatives (odds ratio [OR] 1.7, confidence interval [CI] 1.27–2.07) or the nonstandard antibiotics (OR 2.0, CI 1.31–3.1). CONCLUSION: Compared with women receiving &bgr;-lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended &bgr;-lactam alternative or nonstandard regimen.

Racial and Ethnic Differences in End‐of‐Life Medicare Expenditures

To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End‐of‐Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life.

Milestones for the Final Mile: Interspecialty Distinctions in Primary Palliative Care Skills Training

CONTEXT Primary palliative care (PPC) skills are useful in a wide variety of medical and surgical specialties, and the expectations of PPC skill training are unknown across graduate medical education. OBJECTIVES We characterized the variation and quality of PPC skills in residency outcomes-based Accreditation Council for Graduate Medical Education (ACGME) milestones. METHODS We performed a content analysis with structured implicit review of 2015 ACGME milestone documents from 14 medical and surgical specialties chosen for their exposure to clinical situations requiring PPC. For each specialty milestone document, we characterized the variation and quality of PPC skills in residency outcomes-based ACGME milestones. RESULTS We identified 959 occurrences of 29 palliative search terms within 14 specialty milestone documents. Within these milestone documents, implicit review characterized 104 milestones with direct saliency to PPC skills and 196 milestones with indirect saliency. Initial interrater agreement of the saliency rating among the primary reviewers was 89%. Specialty milestone documents varied widely in their incorporation of PPC skills within milestone documents. PPC milestones were most commonly found in milestone documents for Anesthesiology, Pediatrics, Urology, and Physical Medicine and Rehabilitation. PPC-relevant milestones were most commonly found in the Interpersonal and Communication Skills core competency with 108 (36%) relevant milestones classified under this core competency. CONCLUSIONS Future revisions of specialty-specific ACGME milestone documents should focus on currently underrepresented, but important PPC skills.

Variations by state in physician disciplinary actions by US medical licensure boards.

Objective To investigate the variation in the rate of state medical board physician disciplinary actions between US states. Methods Longitudinal study of state medical board physician disciplinary action rates using the US National Practitioner Data Bank and American Medical Association estimates of physician demographics across all 50 states and the District of Columbia from 2010 to 2014. Results were reliability adjusted using a multilevel logistic model controlling for year of disciplinary action, physicians per capita in each state and the rate of malpractice claims per physician in each state. Results From 2010 to 2014, there were a total of 5046 506 physician licensure years present. Medical boards reported a total of 21 647 disciplinary actions, of which 5137 (23.7%) were major disciplinary actions involving revocation, suspension or surrender of licence. The mean, reliability-adjusted rate of all disciplinary actions was 3.76 (95% CI 3.21 to 4.42) with a significant variation between states. State rates ranged from 2.13 (95% CI 1.86 to 2.45) to 7.93 (95% CI 6.33 to 9.93) actions per 1000 physicians. The mean rate of major disciplinary actions was 2.71 (95% CI 1.93 to 3.82), ranging from 0.64 (95% CI 0.53 to 0.76) to 2.71 (95% CI 1.93 to 3.82) actions per 1000 physicians. The correlation between the rate of major disciplinary action and minor disciplinary actions was 0.34. Conclusions There is a significant, fourfold variation in the annual rate of medical board physician disciplinary action by state in the USA. When indicated, state medical boards should consider policies aimed at improving standardisation and coordination to provide consistent supervision to physicians and ensure public safety.

Are perioperative bundles associated with reduced postoperative morbidity in women undergoing benign hysterectomy? Retrospective cohort analysis of 16,286 cases in Michigan

BACKGROUND: Healthcare teams that frequently follow a bundle of evidence‐based processes provide care with lower rates of morbidity. Few process bundles to improve surgical outcomes in hysterectomy have been identified. OBJECTIVE: The purpose of this study was to investigate whether a bundle of 4 perioperative care processes is associated with fewer postoperative complications and readmissions for hysterectomies in the Michigan Surgical Quality Collaborative. STUDY DESIGN: A bundle of perioperative care process goals was developed retrospectively with 30‐day peri‐ and postoperative outcome data from the Hysterectomy Initiative in Michigan Surgical Quality Collaborative. All benign hysterectomies that had been performed between January 2013 and January 2015 were included. Based on evidence of lower complication rates after benign hysterectomy, the following processes were considered to be the “bundle”: use of guideline‐appropriate preoperative antibiotics, a minimally invasive surgical approach, operative duration <120 minutes, and avoidance of intraoperative hemostatic agent use. Each process was considered present or absent, and the number of processes was summed for a bundle score that ranged from 0–4. Cases with a score of zero were excluded. Outcomes measured were rates of complications (any and major) and hospital readmissions, all within 30 days of surgery. Postoperative events that were considered a “major complication” included acute renal failure, cardiac arrest that required cardiopulmonary resuscitation, central line infection, cerebral vascular accident, death, deep vein thrombosis, intestinal obstruction, myocardial infarction, pelvic abscess, pulmonary embolism, rectovaginal fistula, sepsis, surgical site infection (deep and organ‐space), unplanned intubation, ureteral obstruction, and ureterovaginal and vesicovaginal fistula. The outcome “any complication” included all those events already described in addition to blood transfusion within 72 hours of surgery, urinary tract infection, and superficial surgical site infection. Outcomes were adjusted for patient demographics, surgical factors, and hospital‐level clustering effects. RESULTS: There were 16,286 benign hysterectomies available for analysis. Among all hysterectomies that were reviewed, 33.6% met criteria for all bundle processes; however, there was wide variation in the rate among the 56 hospitals in the study sample with 9.1% of cases at the lowest quartile and 60.4% at the highest quartile of hospitals that met criteria for all bundle processes. Overall, the rate of any complication was 6.8% and of any major complication was 2.3%. The rate of hospital readmissions was 3.6%. After adjustment for confounders, in cases in which all bundle criterion were met compared with cases in which all bundle criterion were not met, the rate of any complications increased from 4.3–7.8% (P<.001); major complications increased from 1.7–2.6% (P<.001), and readmissions increased from 2.6–4.1% (P<.001). After adjustment for confounders, hospitals with greater rates of meeting all 4 criteria were associated significantly with lower hospital‐level rates of postoperative complications (P<.001) and readmissions (P<.001). CONCLUSIONS: This multiinstitutional evaluation reveals that reduced morbidity and readmission are associated with rates of bundle compliance. The proposed bundle is a surgical goal, which is not possible in every case, and there is significant variation in the proportion of cases meeting all 4 bundle processes in Michigan hospitals. Implementation of evidence‐based process bundles at a healthcare system level are worthy of prospective study to determine whether improvements in patient outcomes are possible.

Characteristics of Decedents in Medicare Advantage and Traditional Medicare

Methods | Waiver for this study was obtained through Alberta Health Services for collection of aggregate data. Based on these various sources of recommendations, a guideline was formed (Box) and was approved by Alberta Health Services. This guideline led to a separate form being developed and issued by laboratory services. Physicians now had to identify the indication for testing vitamin D levels. Indications other than those identified in the guideline did not allow for testing of vitamin D levels. This new requisition was implemented on April 1, 2015. Before this date, for several years, the number of annual 25-hydroxy vitamin Dassayswasapproximately310 000peryear(ie,1in14Albertans). We measured the monthly number of vitamin D order requests before and after introducing a new procedure for ordering tests.

A retrospective cohort study of hemostatic agent use during hysterectomy and risk of post‐operative complications

To determine if the use of intraoperative hemostatic agents was a risk factor for post‐operative adverse events within 30 days of patients undergoing hysterectomy.

Timing of and Reasons for Unplanned 30-Day Readmission After Hysterectomy for Benign Disease.

OBJECTIVE: To characterize timing and reasons associated with unplanned 30-day readmissions after hysterectomy for benign indications. METHODS: We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project database files from 2012 to 2013. We identified patterns of 30-day readmission after benign hysterectomy for all surgical approaches (abdominal, laparoscopic, vaginal). Readmission timing was determined from discharge date and readmission diagnoses were tabulated. Statistical analyses included &khgr;2 tests and multivariable logistic regression. RESULTS: The 30-day readmission rate was 2.8% (1,118/40,580 hysterectomies). Readmissions complicated 3.7% (361/9,869) of abdominal, 2.6% (576/22,266) of laparoscopic, and 2.1% (181/8,445) of vaginal hysterectomies. Readmissions were more likely when hysterectomy was performed abdominally (adjusted odds ratio [OR] 1.45, 95% confidence interval [CI] 1.2–1.76) but not laparoscopically (adjusted OR 1.1, 95% CI 0.9–1.4) compared with a vaginal approach. Eighty-two percent of readmissions occurred within 15 days of discharge. The shortest median time to readmission was associated with pain (3 days), and the longest was associated with noninfectious wound complications (10 days). Surgical site infection was the most common diagnosis (abdominal 36.6%, laparoscopic 28.3%, vaginal 32.6%). Surgical site infections, surgical injuries, and wound complications combined accounted for 51.5% of abdominal, 51.9% of laparoscopic, and 50.8% of vaginal hysterectomy readmissions. Medical complications such as cardiovascular events and venous thromboembolism were responsible for 5.8% of abdominal, 6.9% of laparoscopic, and 8.8% of vaginal hysterectomy readmissions. Surgical injuries were responsible for more readmissions after laparoscopic (unadjusted OR 2.3, 95% CI 1.48–3.65) and vaginal hysterectomies (unadjusted OR 2.3, 95% CI 1.29–3.97) than abdominal cases. CONCLUSION: Readmissions after hysterectomy tend to occur shortly after discharge. Most readmissions are related to surgical issues, most commonly surgical site infection. Medical complications, including venous thromboembolism, account for less than 10% of readmissions. Readmission reduction efforts should focus on early postdischarge follow-up, preventing infectious complications, and determining preventability of surgical-related reasons for readmission.