Kandace A. Lackore

How best to measure surgical quality? comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution

BACKGROUND Evaluating surgical outcomes is an important tool to compare providers and institutions and to drive process improvements. Differing methodologies, however, may provide conflicting measurements of similar clinical outcomes making comparisons difficult. ACS-NSQIP is a validated, risk-adjusted, clinically derived data methodology to compare observed to expected outcomes after a wide variety of operations. The AHRQ-PSI are a set of computer algorithms to identify potential adverse in-patient events using secondary ICD-9-CM diagnosis and procedure codes from hospital discharge abstracts. METHODS We compared the ACS-NSQIP and AHRQ-PSI methods for hospital general surgical (n = 6565) or vascular surgical inpatients procedures (n = 1041) at a tertiary-care academic institution from April 2006 to June 2009 on 7 adverse event types. RESULTS ACS-NSQIP inpatient adverse events were identified in 564 (7.4%) patients. AHRQ-PSIs were identified in 268 (3.5%) patients. Only 159 (2.1%) patients had inpatient events identified by both methods. Using ACS-NSQIP as the clinically based standard the sensitivity of the specific AHRQ-PSI ranged from 0.030 for infections to 0.535 for PE/DVT. Positive predictive values of AHRQ-PSI ranged from 18% for hemorrhage/hematoma to 89% for renal failure. Greater agreement at greater ASA class and wound classification was observed. CONCLUSION AHRQ-PSI algorithms identified less than a third of the ACS-NSQIP clinically important adverse events. Furthermore, the AHRQ-PSI identified a large number of events with no corresponding clinically important adverse outcomes. The sensitivity of the AHRQ-PSI for detecting clinically relevant adverse events identified by the ACS-NSQIP varied widely. The AHRQ-PSI as applied to postoperative patients is a poor measure of quality performance.

Predicting patients' expectations of hospital chaplains: a multisite survey.

OBJECTIVE To identify patient expectations regarding chaplain visitation, characteristics of patients who want to be visited by a chaplain, and what patients deem important when a chaplain visits. PARTICIPANTS AND METHODS Three weeks after discharge, 4500 eligible medical and surgical patients from hospitals in Minnesota, Arizona, and Florida were surveyed by mail to collect demographic information and expectations regarding chaplain visitation. The survey was conducted during the following time periods: Minnesota participants, April 6 until April 25, 2006; Arizona participants, October 16, 2008, until January 13, 2009; Florida participants, October 16, 2008, until January 20, 2009. Categorical variables were summarized with frequencies or percentages. Associations between responses and site were examined using χ(2) tests. Multivariate logistic regression was used to assess the likelihood of wanting chaplain visitation on the basis of patient demographics and perceived importance of reasons for chaplain visitation. RESULTS About one-third of those surveyed responded from each site. Most were male, married, aged 56 years or older, and Protestant or Catholic. Of the respondents, nearly 70% reported wanting chaplain visitation, 43% were visited, and 81% indicated that visitation was important. The strongest predictor of wanting chaplain visitation was denomination vs no indicated religious affiliation (Catholic: odds ratio [OR], 8.11; 95% confidence interval [CI], 4.49-14.64; P<.001; evangelical Protestant: OR, 4.95; 95% CI, 2.74-8.91; P<.001; mainline Protestant: OR, 4.34; 95% CI, 2.58-7.29; P<.001). Being female was a weak predictor (OR, 1.48; 95% CI, 1.05-2.09; P=.03), as was site. Among the reasons given by respondents for wanting chaplain visitation, the most important were that chaplains served as reminders of Gods care and presence (OR, 4.37; 95% CI, 2.58-7.40; P<.001) and that they provided prayer or scripture reading (OR, 2.54; 95% CI, 1.53-4.20; P<.001). CONCLUSION The results of this study suggest the importance medical and surgical patients place on being visited by a chaplain while they are hospitalized. Those who valued chaplains because they reminded them of Gods care and presence and/or because they prayed or read scripture with them were more likely to desire a visit. Our results also suggest that being religiously affiliated is a very strong predictor of wanting chaplain visitation.

Shortening a survey and using alternative forms of prenotification: Impact on response rate and quality

BackgroundEvidence suggests that survey response rates are decreasing and that the level of survey response can be influenced by questionnaire length and the use of pre-notification. The goal of the present investigation was determine the effect of questionnaire length and pre-notification type (letter vs. postcard) on measures of survey quality, including response rates, response times (days to return the survey), and item nonresponse.MethodsIn July 2008, the authors randomized 900 residents of Olmsted County, Minnesota aged 25-65 years to one of two versions of the Talley Bowel Disease Questionnaire, a survey designed to assess the prevalence of functional gastrointestinal disorders (FGID). One version was two pages long and the other 4 pages. Using a 2 × 2 factorial design, respondents were randomized to survey length and one of two pre-notification types, letter or postcard; 780 residents ultimately received a survey, after excluding those who had moved outside the county or passed away.ResultsOverall, the response rates (RR) did not vary by length of survey (RR = 44.6% for the 2-page survey and 48.4% for the 4-page) or pre-notification type (RR = 46.3% for the letter and 46.8% for the postcard). Differences in response rates by questionnaire length were seen among younger adults who were more likely to respond to the 4-page than the 2-page questionnaire (RR = 39.0% compared to 21.8% for individuals in their 20s and RR = 49.0% compared to 32.3% for those in their 30s). There were no differences across conditions with respect to item non-response or time (days after mailing) to survey response.ConclusionThis study suggests that the shortest survey does not necessarily provide the best option for increased response rates and survey quality. Pre-notification type (letter or postcard) did not impact response rate suggesting that postcards may be more beneficial due to the lower associated costs of this method of contact.

Use of Complementary Therapies in Cardiovascular Disease

The aim of the present study was to assess the use of complementary and alternative medicine (CAM) treatments in outpatients with cardiovascular disease and their interest in future use. The increasing popularity of CAM therapies highlights the need to explore their use among patients with cardiovascular disease. Data were collected with a prospective, point-of-care, anonymous, 17-question survey about basic medical information and previous use and interest in the future use of dietary supplements and other CAM interventions among patients undergoing outpatient cardiology evaluation at a Midwestern tertiary care center. The survey was completed by 1,055 patients (655 men, 351 women; mean age 63.5 years) of whom 98.1% were white. Of these, 36.8% had cardiac symptoms for >10 years, 48.2% had coronary artery disease, and 82.5% reported use of CAM therapies. Of these patients, 75.4% reported using dietary supplements, 31.5% chiropractic therapy, 23.9% mind-body therapies, and 19.2% massage. Only 14.4% had discussed the use of CAM treatments with their physicians. The top 4 treatments used for cardiac symptoms were relaxation techniques, stress management, meditation, and guided imagery. Also, 48.6% were interested in participating in a future clinical trial of an alternative treatment. The great majority of patients seen in current practice use CAM therapies, and a large proportion expressed an interest in participating in research with CAM therapies. In conclusion, research directed with an integrative approach to cardiovascular care might prove beneficial when designing future studies.

Potential Bias in the Bank: What Distinguishes Refusers, Nonresponders and Participants in a Clinic-Based Biobank?

Background: Biobanks are an important resource for genetic and epidemiologic research, but bias may be introduced if those who accept the recruitment invitation differ systematically from those who do not in terms of attributes important to health-related investigations. To understand potential bias in a clinic-based biobank of biological samples, including genetic data linked to electronic health record information, we compared patient characteristics and self-reported information among participants, nonresponders and refusers. We also compared reasons for nonparticipation between refusers and nonresponders to elucidate potential pathways to reduce nonparticipation and any uncovered bias. Methods: We mailed recruitment packets to 1,600 adult patients with upcoming appointments at Mayo Clinic (Rochester, Minn., USA) and recorded their participation status. Administrative data were used to compare characteristics across groups. We used phone interviews with 26 nonresponders and 26 refusers to collect self-reported information, including reasons for nonparticipation. Participants were asked to complete a mailed questionnaire. Results: We achieved 26.2% participation (n = 419) with 12.1% refusing (n = 193) and 61.8% nonresponse (n = 988). In multivariate analyses, sex, age, region of residence, and race/ethnicity were significantly associated with participation. The groups differed in information-seeking behaviors and research experience. Refusers more often cited privacy concerns, while nonresponders more often identified time constraints as the reason for nonparticipation. Conclusion: For genomic medicine to advance, large, representative biobanks are required. Significant associations between patient characteristics and nonresponse, as well as systematic differences between refusers and nonresponders, could introduce bias. Oversampling or recruitment changes, including heightened attention to privacy protection and participation burden, may be necessary to increase participation among less-represented groups.

Is Usage of a Wellness Center Associated With Improved Quality of Life

Purpose. There is limited documentation regarding the potential quality of life (QOL) benefits associated with use of a worksite wellness center. Therefore, the aim of this study was to examine the relationship between potential QOL change and use of a worksite wellness center during a 12-month period. Design. Analysis of an annual QOL wellness center member survey and wellness center use during a 12-month time period. Setting. A worksite wellness center. Participants. A total of 1151 employee wellness center members, average age of 39.5 years, 69.7% female, and 43.5% reported being overweight. Intervention. Members of the worksite wellness center have access to a range of fitness options, including exercise classes, water aerobics, an indoor track, strength training, and aerobic conditioning equipment. Additionally, nutritional classes are offered, and there is a wellness café. For resiliency, members can participate in wellness coaching or a stress-reduction group program. Method. Participants completed a baseline QOL survey and a second QOL survey 1 year later. An electronic entry system tracked use of the wellness center. Results. Participants were divided into four wellness center use quartiles: low users (less than once every 2 weeks), below-average users, above-average users, and high users (two to three visits per week). High users reported experiencing improvements in their physical QOL (p < .0001) compared with the low users. Additionally, low users experienced a greater decline in their mental QOL (p = .05) compared with high users. Conclusion. In a large sample of employees, use of a wellness center during a 12-month period was associated with benefits for physical QOL. QOL is an important domain of wellness; therefore, in addition to measuring physiologic changes, examining potential QOL changes may be another important outcome measure for wellness centers.

Dermatopathologists' concerns and challenges with clinical information in the skin biopsy requisition form: a mixed-methods study.

Communication failures between clinicians and dermatopathologists are prevalent. Our primary objective was to characterize the concerns and challenges of dermatopathologists posed by incomplete or inaccurate clinical information in the skin biopsy requisition form.

Motivational improvements for health behavior change from wellness coaching.

OBJECTIVES To identify client priorities prior to wellness coaching, and examine motivational improvements for health behaviors on follow-up. METHODS Clients completed a wellness questionnaire at baseline (before coaching) and at a 3-month follow-up. Overall, 177 participants (92% female, average age 42.9 (SD 11.2) years) were included in the analysis. Clients indicated priorities for coaching, and levels of importance, confidence, and readiness to change within each domain were compared between baseline and follow-up. RESULTS Participants identified weight management as their top priority and successfully reduced their BMI. Participants also demonstrated significant improvements in motivation and confidence in most health behavior domains. CONCLUSIONS These results provide further support for the effectiveness of wellness coaching for weight management and for improving motivational readiness for behavior change.

Breast Cancer Survivors' Self-Reported Needs and Preferences of Survivorship Care

To the Editor: There are increasing numbers of breast cancer survivors in the US, and it is paramount to deliver patient-centered survivorship care. However, what patients deem important in their care is not fully recognized. We surveyed women treated at our institution to better understand the burden of medical and psychosocial conditions and to examine the needs and preferences regarding survivorship care. We identified a random sample of female breast cancer survivors (aged 18–99 years) from the institutional databases at Mayo Clinic in Rochester, MN. Patients were eligible if they had been diagnosed with stages 0–3 breast cancer, were within 1–5 years of the diagnosis, and resided within the surrounding tri-state area (MN, WI, IA). Approval was granted by the Mayo Clinic Institutional Review Board, and all participants provided informed consent. In September 2010, prospective participants were mailed a questionnaire. Nonrespondents were sent a letter and later telephoned to confirm receipt of the survey. Measures included demographics, health status, utilization of health services, and importance of particular aspects of cancer survivorship care (scale of 0–10 with 10 = “extremely important”). The “importance” items were dichotomized as “very important” (7+) versus “not very important” (<7). Psychological distress was measured with the Distress Thermometer, a single-item measure that asks patients to rank their distress in the past week on a 0 (“no distress”) to 10 (“extreme distress”) scale (1). We used a cutpoint ≥4 to identify distressed individuals (2,3). Categorical and continuous survey responses were summarized. Responses were compared between groups using the chi-squared test for categorical items and the Kruskal–Wallis test for continuous items. Paired analyses between categorical items were compared with the Bowker’s test. Associations with “interest in a survivor clinic” were analyzed using univariate and multivariate logistic regression models (adjusting for age, years since diagnosis, treatment, distress, cancer stage, number of sequelae, and feelings of unmet need). Missing data varied (generally <3% item nonresponse), and no imputation was used. All analyses were conducted using SAS version 9 (Cary, NC). p < 0.05 was considered significant. Of the 600 breast cancer survivors identified, seven were deceased, and therefore 593 surveys were mailed. Of these, 98 declined, 143 did not respond, and 17 had exclusions, resulting in 329 completed surveys (55% response rate). Demographic characteristics of participants are listed in Table 1. Self-reported, treatmentrelated sequelae are listed in Table 2. Only 73% “strongly agreed” that their medical needs were met, whereas only 49% “strongly agreed” that their psychological and spiritual needs were met (p < 0.01). In terms of distress, 120 respondents (37%) reported significant distress in the past week, and higher levels of distress were associated with younger age (p = 0.01). When queried about post-treatment care, the following aspects were considered important (% of patients ranking ≥7 on a 0–10 scale; 0 = not important, 10 = very important): breast/chest wall exam (89%); screening for osteoporosis (71%), colorectal cancer (71%), and heart disease (68%); educational materials (64%); mammography (64%); physical therapy (61%); diet (60%) and exercise (59%) counseling; and complementary/alternative medicine (CAM) information (53%). Younger patients rated the importance of many aspects higher than older patients, including physical therapy/rehabilitation, gynecology, CAM, infertility, psychology, support groups, social work, diet and exercise counseling, chaplaincy, and educational resources (p < 0.05). However, older patients ranked mammography as more important (p = 0.002). Most participants (60%; n = 194) expressed interest in attending a survivorship clinic. Those who were most interested were younger (mean age 57 versus Address correspondence and reprint requests to: Carrie A. Thompson, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA, or e-mail: thompson.carrie@mayo.edu

Preventing cardiovascular disease: Participant perspectives of the FAITH! Program

Striking cardiovascular health disparities exist among African-Americans in Minnesota compared to Whites; however, community-based interventions to address cardiovascular disease risk are lacking. This study explored participant perceptions of a culturally tailored, cardiovascular disease prevention program developed using a community-based participatory research process. Research participation perceptions, program benefits, and program satisfaction/acceptability were analyzed using a mixed-methods approach. Overall, acceptability was high. Findings highlight the favorable inclusion of African-Americans (research perception), knowledge gained about healthy lifestyle practices (benefits), and quality of the curriculum/speakers (satisfaction). Community-based participatory research may be useful in fostering the acceptability of behavior change interventions among marginalized African-American communities.