Nasim Afsar-manesh

Analysis of 30-day readmissions among neurosurgical patients: surgical complication avoidance as key to quality improvement

UNLABELLED OBJECT.: In terms of measuring quality of care and hospital performance, an outcome of increasing interest is the 30-day readmission rate. Recent health care policy making has highlighted the necessity of understanding the factors that influence readmission. To elucidate the rate, reason, and predictors of readmissions at a tertiary/quaternary neurosurgical service, the authors studied 30-day readmissions for the Department of Neurosurgery at two University of California, Los Angeles (UCLA), hospitals. METHODS Over a 3-year period, the authors retrospectively identified adult and pediatric patients who had been discharged from the UCLA Medical Center after having undergone a major neurosurgical procedure and being readmitted within 30 days. Data were obtained on demographics, follow-up findings, diagnosis and reason for readmission, major operations performed, and length of stay during index admission and readmission. Reasons for readmission were broadly categorized into surgical, medical diagnosis/complication, problem associated with the original diagnosis, neurological decompensation, pain management, and miscellaneous. For further characterization, subgroup analysis and in-depth chart review were performed. RESULTS Over the study period, 365 (6.9%) of 5569 patients were readmitted within 30 days. The most common diagnosis at index admission was brain tumor (102 patients), followed by CSF shunt malfunction (63 patients). The most common reason for readmission was surgical complication (50.1%). Among those with surgical complications, the largest subgroup consisted of patients with CSF shunt-related problems (77 patients). The second and third largest subgroups were surgical site infection and CSF leakage (41 and 31 patients, respectively). Medical diagnosis/complication was the second most frequent (27.9%) reason for readmission. CONCLUSIONS Surgical complications seem to be a major reason for readmission at the neurosurgical practice studied. Results indicate that the outcomes that are amenable to and would have the greatest effect on quality improvement are CSF shunt-related complications, surgical site infections, and CSF leaks.

Improving patient satisfaction through physician education, feedback, and incentives.

BACKGROUND Patient satisfaction has been associated with improved outcomes and become a focus of reimbursement. OBJECTIVE Evaluate an intervention to improve patient satisfaction. DESIGN Nonrandomized, pre-post study that took place from 2011 to 2012. SETTING Large tertiary academic medical center. PARTICIPANTS Internal medicine (IM) resident physicians, non-IM resident physicians, and adult patients of the resident physicians. INTERVENTION IM resident physicians were provided with patient satisfaction education through a conference, real-time individualized patient satisfaction score feedback, monthly recognition, and incentives for high patient-satisfaction scores. MAIN MEASURES Patient satisfaction on physician-related and overall satisfaction questions on the HCAHPS survey. We conducted a difference-in-differences regression analysis comparing IM and non-IM patient responses, adjusting for differences in patient characteristics. KEY RESULTS In our regression analysis, the percentage of patients who responded positively to all 3 physician-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions increased by 8.1% in the IM and 1.5% in the control cohorts (absolute difference 6.6%, P = 0.04). The percentage of patients who would definitely recommend this hospital to friends and family increased by 7.1% in the IM and 1.5% in the control cohorts (absolute difference 5.6%, P = 0.02). The national average for the HCAHPS outcomes studied improved by no more than 3.1%. LIMITATIONS This study was nonrandomized and was conducted at a single site. CONCLUSION To our knowledge, this is the first intervention associated with a significant improvement in HCAHPS scores. This may serve as a model to increase patient satisfaction, hospital revenue, and train resident physicians.

A randomized, controlled trial of team-based competition to increase learner participation in quality-improvement education

OBJECTIVE Several barriers challenge resident engagement in learning quality improvement (QI). We investigated whether the incorporation of team-based game mechanics into an evidence-based online learning platform could increase resident participation in a QI curriculum. DESIGN Randomized, controlled trial. SETTING Tertiary-care medical center residency training programs. PARTICIPANTS Resident physicians (n = 422) from nine training programs (anesthesia, emergency medicine, family medicine, internal medicine, ophthalmology, orthopedics, pediatrics, psychiatry and general surgery) randomly allocated to a team competition environment (n = 200) or the control group (n = 222). INTERVENTION Specialty-based team assignment with leaderboards to foster competition, and alias assignment to de-identify individual participants. MAIN OUTCOME MEASURES Participation in online learning, as measured by percentage of questions attempted (primary outcome) and additional secondary measures of engagement (i.e. response time). Changes in participation measures over time between groups were assessed with a repeated measures ANOVA framework. RESULTS Residents in the intervention arm demonstrated greater participation than the control group. The percentage of questions attempted at least once was greater in the competition group (79% [SD ± 32] versus control, 68% [SD ± 37], P= 0.03). Median response time was faster in the competition group (P= 0.006). Differences in participation continued to increase over the duration of the intervention, as measured by average response time and cumulative percent of questions attempted (each P< 0.001). CONCLUSIONS Team competition increases resident participation in an online course delivering QI content. Medical educators should consider game mechanics to optimize participation when designing learning experiences.

Healthcare reform from the inside: A neurosurgical clinical quality program

During the past decade, the U.S. health care system has faced increasing challenges in delivering high quality of care, ensuring patient safety, providing access to care, and maintaining manageable costs. While reform progresses at a national level, health care providers have a responsibility and obligation to advance quality and safety. In 2009, the authors implemented a department-wide Clinical Quality Program. This Program comprised of an inter-disciplinary group of providers and staff working together to ensure the highest quality of patient care. The following methodology was followed to establish the Program: (1) Identifying the Departments quality improvement (QI) and patient safety priorities based on reviewing prior performance data; (2) Aligning the Departments priorities with institutional goals to select mutually significant initiatives; (3) Finalizing the goals for improvement based on departmental priorities, existing expertise and resources; (4) Launching the Program through an inter-disciplinary retreat that emphasizes open dialogue, innovative solutions, and fostering leadership in frontline providers; (5) Sustaining the QI initiatives through proactive performance review and management of barriers; and (6) Celebrating success to empower providers to remain engaged. Several challenges are inherent to the implementation of a clinical quality program, including lack of time and expertise, and the hierarchical nature of medicine, which can create a barrier to teamwork. This Program illustrates that improvement can lead to a sustainable clinical quality program and culture change.

Tracking and sustaining improvement initiatives: leveraging quality dashboards to lead change in a neurosurgical department.

Increasingly, hospitals and physicians are becoming acquainted with business intelligence strategies and tools to improve quality of care. In 2007, the University of California Los Angeles (UCLA) Department of Neurosurgery created a quality dashboard to help manage process measures and outcomes and ultimately to enhance clinical performance and patient care. At that time, the dashboard was in a platform that required data to be entered manually. It was then reviewed monthly to allow the department to make informed decisions. In 2009, the department leadership worked with the UCLA Medical Center to align mutual quality-improvement priorities. The content of the dashboard was redesigned to include 3 areas of priorities: quality and safety, patient satisfaction, and efficiency and use. Throughout time, the neurosurgery quality dashboard has been recognized for its clarity and its success in helping management direct improvement strategies and monitor impact. We describe the creation and design of the neurosurgery quality dashboard at UCLA, summarize the evolution of its assembly process, and illustrate how it can be used as a powerful tool of improvement and change. The potential challenges and future directions of this business intelligence tool are also discussed.

Hospital quality and patient safety competencies: Development, description, and recommendations for use

BACKGROUND Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally emphasized healthcare quality and patient safety in their curricula. METHODS Through a multistep process, the Society of Hospital Medicine (SHM) Quality Improvement Education (QIE) subcommittee developed the Hospital Quality and Patient Safety (HQPS) Competencies to provide a framework for developing and assessing curricula and other professional development experiences. This article describes the development, provides definitions, and makes recommendations on the use of the HQPS Competencies. RESULTS The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Reflecting differing levels of hospitalist involvement in healthcare quality, 3 levels of expertise within each area of competence have been established: basic, intermediate, and advanced. Standards for each competency area use carefully selected action verbs to reflect educational goals for hospitalists at each level. CONCLUSIONS Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.

An evidence-based approach to the efficient use of computed tomography imaging in the neurosurgical patient.

BACKGROUND Computed tomography (CT) is the current standard for rapidly diagnosing some of the more common structural pathologies that affect the neurosurgical patient perioperatively. With this convenience comes the potential for its overuse. OBJECTIVE To investigate the utility of head CT scans ordered for various clinical indications. METHODS All head CT studies ordered by the UCLA Neurosurgery Department from August 15, 2011 through December 15, 2011, were prospectively studied. Variables collected included demographic information, diagnosis, surgical procedures, indication for CT, CT findings, and whether the study led to a documentable change in management. RESULTS There were 801 head CT studies ordered for the 462 patients who were admitted to the neurosurgical service. The authors identified 14 indications for ordering a head CT with the following probabilities of a positive finding: examination change (17/56, 30.3%), follow-up (4-6 hours after intracerebral hemorrhage; 16/126, 12.7%), CT angiography (11/30, 36.7%), routine postoperative imaging (6/126, 4.7%), postventriculostomy placement (4/62, 6.5%), immediately before (4/31, 12.9%) or after removal of (2/42, 4.8%) a ventriculostomy, surveillance (>24 hours after intracerebral hemorrhage or external ventricular drain placement) (3/66, 4.5%), headaches (2/8, 25%), ground level fall (1/8, 12.5%), intracranial pressure spikes (2/6, 33.3%), and delayed (6-24 hours after intracerebral hemorrhage; 1/25, 4%). CONCLUSION The probability of discovering a clinically significant finding varies widely for each of the listed study indications. This prospective analysis of all CT scans ordered at a single institution suggests that imaging studies obtained without a change in neurological status were unlikely to produce a positive finding, and even when there was a positive finding, it was extremely unlikely to result in any intervention.

PRESsed for time

A 36-year-old woman was admitted after new-onset Hseizures. She had been diagnosed with breast cancer 5 years prior to admission. At that time, she underwent left radical mastectomy and lymph node dissection. Lymph nodes were positive for metastatic disease with negative HER-2-Neu and positive estrogen and progesterone receptors. She was treated with docetaxel and tamoxifen but subsequently developed metastatic left hip lesions and was treated with letrozole and anastrozole. Three years later, scans revealed further metastatic disease to the liver, lung, and vertebral column. She was subsequently treated with capecitabine, until further disease progression led to the use of carboplatin and paclitaxel. Seven months prior to admission, her cancer was progressing and she was switched to doxorubicin, gemcitabine, and bevacizumab. Six weeks prior to admission, both positron emission tomography (PET) and computed tomography (CT) scan of her whole body and magnetic resonance imaging (MRI) of the brain illustrated significant improvement. Her last dose of bevacizumab was given 3 weeks prior to her admission. Two weeks prior to admission, patient reported newonset daily headache. These were often localized in the occipital region. She reported some associated nausea and occasional emesis. Subsequently, she developed photophobia and phonophobia. On seeking outpatient treatment for her headache, it was noted that her systolic blood pressure had increased from a baseline of 100 mm Hg to 170 mm Hg. On the day prior to admission, she reported severe headache and several episodes of emesis and later that evening had a witnessed tonic-clonic seizure. The patient presented to an outside hospital and had an unremarkable noncontrast CT scan of her brain. An examination of her cerebrospinal fluid revealed negative gram stain, and a normal white blood cell count and protein level. She was treated with lorazepam, phenytoin, and decadron. On becoming more alert, she insisted on going home, where she later developed recurrent headache and presented to our emergency room. On admission to our service, she was noted to be confused and irritable, and unable to provide any history. Her exam revealed a blood pressure of 143/102 mmHg. No localizing neurologic signs were noted and her laboratory values were normal. After sedation, MRI of the brain was obtained (Figure 1). This revealed diffuse and patchy gyriform hyperintensity of the white matter, most consistent with posterior reversible encephalopathy syndrome (PRES). Upon reflection, the patient had new onset hypertension that coincided with the initiation and dosing of bevacizumab. Bevacizumab, an antineoplastic agent, is a recombinant humanized monoclonal antibody that binds to and neutralizes vascular endothelial growth factor, thereby preventing angiogenesis. It is known to cause grade 3 hypertension in a minority of patients. Therefore, it was postulated that the patient’s persistent blood pressure elevation resulted in vasogenic brain edema, precipitating her seizure. Subsequent to the diagnosis, her blood pressure was aggressively controlled with oral enalapril, metoprolol, triamterene/hydrochlorothiazide, and hydralazine. By hospital day 7, her headache had subsided and her altered mental status had resolved. She had no further episodes of seizures and bevacizumab was discontinued. FIGURE 1. T2-weighted MRI: multiple diffuse parenchymal brain lesions and generalized edema are noted.

Predictive value of the present-on-admission indicator for hospital-acquired venous thromboembolism

Background:Hospital-acquired venous thromboembolic (HA-VTE) events are an important, preventable cause of morbidity and death, but accurately identifying HA-VTE events requires labor-intensive chart review. Administrative diagnosis codes and their associated “present-on-admission” (POA) indicator might allow automated identification of HA-VTE events, but only if VTE codes are accurately flagged “not present-on-admission” (POA=N). New codes were introduced in 2009 to improve accuracy. Methods:We identified all medical patients with at least 1 VTE “other” discharge diagnosis code from 5 academic medical centers over a 24-month period. We then sampled, within each center, patients with VTE codes flagged POA=N or POA=U (insufficient documentation) and POA=Y or POA=W (timing clinically uncertain) and abstracted each chart to clarify VTE timing. All events that were not clearly POA were classified as HA-VTE. We then calculated predictive values of the POA=N/U flags for HA-VTE and the POA=Y/W flags for non-HA-VTE. Results:Among 2070 cases with at least 1 “other” VTE code, we found 339 codes flagged POA=N/U and 1941 flagged POA=Y/W. Among 275 POA=N/U abstracted codes, 75.6% (95% CI, 70.1%–80.6%) were HA-VTE; among 291 POA=Y/W abstracted events, 73.5% (95% CI, 68.0%–78.5%) were non-HA-VTE. Extrapolating from this sample, we estimated that 59% of actual HA-VTE codes were incorrectly flagged POA=Y/W. POA indicator predictive values did not improve after new codes were introduced in 2009. Conclusions:The predictive value of VTE events flagged POA=N/U for HA-VTE was 75%. However, sole reliance on this flag may substantially underestimate the incidence of HA-VTE.

Recent Advances in the Patient Safety and Quality Initiatives Movement Implications for Neurosurgery

The US health care system is fragmented in terms of quality care, costs, and patient satisfaction. With the passage of the Affordable Care Act, national attention has been placed on the health care system, but effective change has yet to be observed. Unnecessary costs, medical errors, and uncoordinated efforts contribute to patient morbidity, mortality, and decreased patient satisfaction. In addition to national efforts, local initiatives within individual departments must be implemented to improve overall satisfaction without the sacrifice of costs. In this article, the current issues with the health care system and potential initiatives for neurosurgery are reviewed.