Steven E. Lerman

Fatigue risk management in the workplace

Safety and productivity in the workplace are intimately related to worker health. A workplace may have chemical, physical, biological, and/or psychosocial hazards that have the potential to impact physical and psychological well-being. How these hazards are managed in the workplace is key. A workplace in which these hazards are wellcontrolled, with an active culture of health and a supportive work environment, can enhance worker health and well-being, both on and off the job. Healthier employees result in fewer health claims, better safety records, and greater productivity. Well-rested, alert employees are critical to safe and productive operations. Virtually everyone experiences some level of fatigue from time to time. However, excessive fatigue while working is an important condition in which the interrelationship of health, safety, and productivity can create a vicious or a virtuous cycle. Specific medical and lifestyle interventions have been shown to promote a well-rested and alert workforce. In addition, specific factors in the organization of work have been shown to promote either alertness or fatigue. Because of the potential impact of fatigue on health, safety, and productivity, any organization in which individuals work extended hours or hours during which people typically sleep can benefit from addressing fatigue in the workplace. This is particularly important for safety-sensitive oper-

Sleep and alertness in a 12-hour rotating shift work environment.

Industrial workers on rotating shifts were evaluated for the effects of rotating shift work. Twenty-five (86%) of 29 workers in the study area who work 12-hour shifts in a scheduled 16-day rotation participated. The mean number of hours of sleep at home after working day shifts (5.6 hours) was less than after the first three night shifts (6.0, 6.4, and 6.6 hours, respectively). At work, the mean number of hours at reported peak alertness was greater during the night shift (6.1 hours) than the day shift (4.9 hours), but the perceived alertness levels were relatively lower on the night shift. Increased perceived difficulty working and decreased perceived productivity and safety were reported on the first night of the night shift. We demonstrate that workers on rotating shift work exhibit low alertness-related outcomes on both shifts. These workers have early shift work starting times that appear to disrupt sleep patterns on both day and night shifts. At this work site, a number of interventions to lessen the effects of rotating shift work are being evaluated.

Measurement of bladder compliance can be standardized by a dimensionless number: clinical perspective

To devise a new, practical and more accurate method for measuring bladder compliance, and to show that traditional estimates of compliance are impractical.

Outcomes of bladder neck closure for intractable urinary incontinence in patients with neurogenic bladders

OBJECTIVE Recent reports of outcomes of bladder neck closure for neurogenic urinary incontinence reveal poor initial continence and high vesicourethral fistula rates. We evaluated a large series of patients who underwent complete transection and closure of the bladder neck with modified abdominal stoma creation. MATERIALS AND METHODS The medical records of 52 consecutive patients (23 males and 29 females) undergoing bladder neck closure by a single surgeon between July 1996 and January 2003 were reviewed. Mean follow up was 20 months (range 2-68 months) and mean age was 13.9 years (range 1.5-58 years). Forty-two patients (81%) underwent concomitant bladder augmentation. Catheterizable stomas included 46 appendicovesicostomies (88%) and six Monti tubes (12%). Of the 52 patients, 22 were confined to wheelchairs (42%), and the majority of patients had spinal cord pathology (40/52, 77%). Mean preoperative vesical leak point pressure was 25 cm/H(2)O (range 4-69 cm/H(2)O). RESULTS Complete postoperative urinary continence was achieved in 44 patients (88%) after one procedure. Of the six patients who were incontinent (12%), one had a vesicourethral fistula (2%) and five had incontinence at the urinary diversion stoma (10%). Twelve of 50 patients had urinary stomal stenosis (24%), with six requiring urgent evaluation (12%) and six requiring surgical revision (12%). Postoperative urinary continence was unknown in two patients due to inadequate follow-up data. CONCLUSIONS Our findings suggest that bladder neck closure is a safe and effective method of achieving urinary continence in children with neurogenic voiding dysfunction. While there are risks of stomal stenosis and fistula formation, modifications in surgical technique may reduce them to acceptable levels.

Building a medical neighborhood in the safety net: an innovative technology improves hematuria workups.

OBJECTIVE To analyze whether ereferral is associated with decreased time to completion of hematuria workup. METHODS We included 100 individuals referred to Olive View-UCLA Medical Center for urologic consultation for hematuria. Half were referred before implementation of ereferral, and half were referred after the system was implemented. We performed bivariate analysis to assess correlations of baseline subject sociodemographic and clinical characteristics with ereferral status. We also created a multivariate linear regression model for log days to completion of hematuria workup, with ereferral as the main predictor and subject sociodemographic and clinical characteristics as covariates. RESULTS Excluding cases with an infectious cause, the mean number of days from urinalysis documenting hematuria to completed hematuria workup was 404 days before ereferral and 192 days after implementation of ereferral (median 239 vs 170; 2-sample median P = .0013). Upper tract imaging was obtained at a median of 76 days after initial positive urinalysis in the absence of infection, 122 days before ereferral, and 41 days after implementation of ereferral (2-sample median P = .1114). In all cases, lower tract evaluation was completed after upper tract imaging. Our multivariable model evaluating factors associated with time to hematuria workup demonstrated that ereferral use was independently associated with shorter time to hematuria workup (P = .006). CONCLUSION Electronic consultations can significantly shorten the time to work-up of hematuria in the safety net.

Selective Use of Voiding Cystourethrography in Children Undergoing Renal Transplant Evaluation

PURPOSE Voiding cystourethrography is a routine component in evaluating children awaiting renal transplantation. We examined whether this assessment is necessary in children with renal failure due to dysplasia/aplasia/hypoplasia syndrome and unknown etiology, which account for up to 25% of those with renal failure requiring renal replacement therapies. MATERIALS AND METHODS We performed an institutional review board approved, retrospective review of 191 children undergoing transplantation between 2002 and 2007. We reviewed clinical factors associated with positive findings on voiding cystourethrogram. We also reviewed cystography results in children with chronic kidney disease due to renal dysplasia and unknown etiology. RESULTS We identified 113 boys and 78 girls who underwent renal transplantation during the study period. Pre-transplant voiding cystourethrography was documented in 108 children (57%). Predictors of positive pre-transplant results included history of hydronephrosis, urinary tract infections and renal failure due to urological causes. No pre-transplant cystogram was positive in children with renal failure due to dysplasia or unknown etiology. CONCLUSIONS We recommend selective use of voiding cystourethrography to evaluate children awaiting renal transplantation. We continue to support performing this test in children with renal failure due to urological causes and those with a history of urinary tract infection, hydronephrosis or voiding dysfunction. In the absence of these findings children with renal failure due to renal dysplasia/aplasia/hypoplasia syndrome or unknown etiology need not undergo pre-transplant voiding cystourethrography.

Prototype system for enhancing cystometric analysis with special emphasis on the pediatric population.

BACKGROUND AND PURPOSE A urodynamic test system of improved accuracy and reliability was developed and implemented for enhancing cystometry. This system integrates known medical information, including the specialized problems of pediatric urodynamics, with the cystometric and imaging data. METHODS After the requirements for the ideal cystometrogram test unit were established, a system was constructed, calibrated, and implemented in clinical practice. The patients age, size, and sex are used to produce a patient-specific pressure-volume template for the cystometrogram test. RESULTS This template showed the minimal and normal bladder capacities and the physiologically safe, equivocal, and dangerous pressure fields coded with symbolic colors. Different time averages of the pressure data were used to show bladder factors such as compliance and instability. The templates with data were presented automatically (therefore objectively) without operator intervention on monitors during testing and as printed copies on completion. CONCLUSIONS The presentation of data in an easily understood format facilitates effective communication between the urologist, referring physician, and patient. Some of the physiological and statistical problems in pediatric urodynamic testing are efficiently and accurately resolved by this system, resulting in better analysis and diagnostic capabilities.

Variations in payment patterns for surgical care in the centers for Medicare and Medicaid Services

BACKGROUND We investigated provider and regional variation in payments made to surgeons by the Centers for Medicare & Medicaid Services (CMS) by indexing payments to unique beneficiaries treated and examined the proportion of charges that resulted in payments. Understanding variation in care within CMS may prove actionable by identifying modifiable, and potentially unwarranted, variations. METHODS We analyzed the Medicare Part B Provider Utilization and Payment Data released by CMS for 2012. We included Medicare B participants in the fee‐for‐service program. We calculated for each provider the ratio of number of services provided to individual beneficiaries, and the ratio of total submitted charges to total Medicare payments. We also categorized each provider into deciles of total Medicare payments, and calculated the means per decile of total Medicare payment for surgeons and urologists. To determine any associations with ratio of services to beneficiaries, we conducted multivariate linear regressions. RESULTS The 20th, 40th, 60th, and 80th percentiles for the services‐per‐beneficiary ratios are 1.6, 2.2, 3.1, and 5.0, respectively (n = 83,376). Greater‐earning surgeons offered more services per beneficiary, with a precipitous increase from the lowest decile to the highest. Charges were consistently greater than payments by a factor of 3. In our multivariate analysis of services per beneficiary ratio, female providers had lower ratios (P < .01), and we noted significant regional variation in the ratio of services per unique beneficiary (P < .001 for each of the 10 Standard Federal Regions). CONCLUSION We found significant variation in patterns of payments for surgical care in CMS.

Engaging Physician Learners Through a Web-Based Platform Individualized End-of-Life Education

Background: Web-based modules provide a convenient and low-cost education platform, yet should be carefully designed to ensure that learners are actively engaged. In order to improve attitudes and knowledge in end-of-life (EOL) care, we developed a web-based educational module that employed hyperlinks to allow users access to auxiliary resources: clinical guidelines and seminal research papers. Methods: Participants took pre-test evaluations of attitudes and knowledge regarding EOL care prior to accessing the educational module, and a post-test evaluation following the module intervention. We recorded the type of hyperlinks (guideline or paper) accessed by learners, and stratified participants into groups based on link type accessed (none, either, or both). We used demographic and educational data to develop a multivariate mixed-effects regression analysis to develop adjusted predictions of attitudes and knowledge. Results: 114 individuals participated. The majority had some professional exposure to EOL care (prior instruction 62%; EOL referral 53%; EOL discussion 56%), though most had no family (68%) or personal experience (51%). On bivariate analysis, non-partnered (p = .04), medical student training level (p = .03), prior palliative care referral (p = .02), having a family member (p = .02) and personal experience of EOL care (p < .01) were all associated with linking to auxiliary resources via hyperlinks. When adjusting for confounders, β coefficient estimates and least squares estimation demonstrated that participants clicking on both hyperlink types were more likely to score higher on all knowledge and attitude items, and demonstrate increased score improvements. Conclusion: Auxiliary resources accessible by hyperlink are an effective adjunct to web-based learning in end-of-life care.