Tim Xu

The Potential Hazards of Hospital Consolidation: Implications for Quality, Access, and Price.

Hospital consolidation has increased substantially over the last 5 years, with 95 hospital mergers occurring in 2014, the highest number since 2000.1 Moreover, it is predicted that as many as 20% of all US hospitals will seek a merger in the next 5 years.2 A recent analysis of competition in 306 geographic health care markets in the United States, known as hospital referral regions, found that none of the markets are considered “highly competitive,” and nearly half are “highly concentrated.”3 What are the implications of these new hospital conglomerates, especially in regions where one health system dominates the medical care of a population? This Viewpoint considers the implications of the growing trend of hospital consolidation with respect to quality, access, and price. Consolidation has some benefits. One argument in favor of large hospital mergers is that large hospital conglomerates result in increased quality control throughout the system. However, although this may be a potential benefit, most of the leading quality and safety successes in medicine (eg, implementation of the World Health Organization Surgical Safety Checklist

Why are patients being readmitted after surgery for esophageal cancer

OBJECTIVE Readmission after surgery is an unwanted adverse event that is costly to the healthcare system. We sought to evaluate factors associated with increased risk of readmission and to characterize the nature of these readmissions in patients who have esophageal cancer. METHODS A retrospective cohort study was performed in 306 patients with esophageal carcinoma who underwent neoadjuvant chemoradiation followed by esophagectomy at Johns Hopkins Hospital between 1993 and 2011. Logistic regression was used to identify factors associated with 30-day readmission. Readmissions were defined as inpatient admissions to our institution within 30 days of discharge. RESULTS The median age at surgery was 61 years; the median postoperative length of stay was 9 days; and 48% of patients had ≥1 postoperative complication (POC). The 30-day readmission rate was 13.7% (42 of 306). In univariate analysis, length of stay and having ≥1 POC were significantly associated with readmission. In multivariate analysis, having ≥1 POC was significantly associated with a >2-fold increase in risk for 30-day readmission (odds ratio 2.35, with 95% confidence interval [1.08-5.09], P = .031) when controlling for age at diagnosis and length of stay. Of the 42 patients who were readmitted, 67% experienced POCs after surgery; 50% of patients who experienced POCs were readmitted for reasons related to their postoperative complication. The most common reasons for readmission were pulmonary issues (29%), anastomotic complications (20%), gastrointestinal concerns (17%), and venous thromboembolism (14%). CONCLUSIONS Complications not adequately managed before discharge may lead to readmission. Quality improvement efforts surrounding venous thromboembolism prophylaxis, and discharging patients nothing-by-mouth, may be warranted.

Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications

BACKGROUND: Hysterectomy is among the most common major surgical procedures performed in women. Approximately 450,000 hysterectomy procedures are performed each year in the United States for benign indications. However, little is known regarding contemporary US hysterectomy trends for women with benign disease with respect to operative technique and perioperative complications, and the association between these 2 factors with patient, surgeon, and hospital characteristics. OBJECTIVE: We sought to describe contemporary hysterectomy trends and explore associations between patient, surgeon, and hospital characteristics with surgical approach and perioperative complications. STUDY DESIGN: Hysterectomies performed for benign indications by general gynecologists from July 2012 through September 2014 were analyzed in the all‐payer Maryland Health Services Cost Review Commission database. We excluded hysterectomies performed by gynecologic oncologists, reproductive endocrinologists, and female pelvic medicine and reconstructive surgeons. We included both open hysterectomies and those performed by minimally invasive surgery, which included vaginal hysterectomies. Perioperative complications were defined using the Agency for Healthcare Research and Quality patient safety indicators. Surgeon hysterectomy volume during the 2‐year study period was analyzed (0‐5 cases annually = very low, 6‐10 = low, 11‐20 = medium, and ≥21 = high). We utilized logistic regression and negative binomial regression to identify patient, surgeon, and hospital characteristics associated with minimally invasive surgery utilization and perioperative complications, respectively. RESULTS: A total of 5660 hospitalizations were identified during the study period. Most patients (61.5%) had an open hysterectomy; 38.5% underwent a minimally invasive surgery procedure (25.1% robotic, 46.6% laparoscopic, 28.3% vaginal). Most surgeons (68.2%) were very low– or low‐volume surgeons. Factors associated with a lower likelihood of undergoing minimally invasive surgery included older patient age (reference 45‐64 years; 20‐44 years: adjusted odds ratio, 1.16; 95% confidence interval, 1.05–1.28), black race (reference white; adjusted odds ratio, 0.70; 95% confidence interval, 0.63–0.78), Hispanic ethnicity (adjusted odds ratio, 0.62; 95% confidence interval, 0.48–0.80), smaller hospital (reference large; small: adjusted odds ratio, 0.26; 95% confidence interval, 0.15–0.45; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.79–0.96), medium hospital hysterectomy volume (reference ≥200 hysterectomies; 100‐200: adjusted odds ratio, 0.78; 95% confidence interval, 0.71–0.87), and medium vs high surgeon volume (reference high; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.78–0.97). Complications occurred in 25.8% of open and 8.2% of minimally invasive hysterectomies (P < .0001). Minimally invasive hysterectomy (adjusted odds ratio, 0.22; 95% confidence interval, 0.17–0.27) and large hysterectomy volume hospitals (reference ≥200 hysterectomies; 1‐100: adjusted odds ratio, 2.26; 95% confidence interval, 1.60–3.20; 101‐200: adjusted odds ratio, 1.63; 95% confidence interval, 1.23–2.16) were associated with fewer complications, while patient payer, including Medicare (reference private; adjusted odds ratio, 1.86; 95% confidence interval, 1.33–2.61), Medicaid (adjusted odds ratio, 1.63; 95% confidence interval, 1.30–2.04), and self‐pay status (adjusted odds ratio, 2.41; 95% confidence interval, 1.40–4.12), and very‐low and low surgeon hysterectomy volume (reference ≥21 cases; 1‐5 cases: adjusted odds ratio, 1.73; 95% confidence interval, 1.22–2.47; 6‐10 cases: adjusted odds ratio, 1.60; 95% confidence interval, 1.11–2.23) were associated with perioperative complications. CONCLUSION: Use of minimally invasive hysterectomy for benign indications remains variable, with most patients undergoing open, more morbid procedures. Older and black patients and smaller hospitals are associated with open hysterectomy. Patient race and payer status, hysterectomy approach, and surgeon volume were associated with perioperative complications. Hysterectomies performed for benign indications by high‐volume surgeons or by minimally invasive techniques may represent an opportunity to reduce preventable harm.

Effect of Surgeon and Hospital Volume on Emergency General Surgery Outcomes

BACKGROUND Emergency general surgery (EGS) contributes to half of all surgical mortality nationwide, is associated with a 50% complication rate, and has a 15% readmission rate within 30 days. We assessed associations between surgeon and hospital EGS volume with these outcomes. STUDY DESIGN Using Marylands Health Services Cost Review Commission database, we identified nontrauma EGS procedures performed by general surgeons among patients 20 years or older, who were admitted urgently or emergently, from July 2012 to September 2014. We created surgeon and hospital volume categories, stratified EGS procedures into simple (mortality ≤ 0.5%) and complex (>0.5%) procedures, and assessed postoperative mortality, complications, and 30-day readmissions. Multivariable logistic regressions both adjusted for clinical factors and accounted for clustering by individual surgeons. RESULTS We identified 14,753 procedures (61.5% simple EGS, 38.5% complex EGS) by 252 (73.3%) low-volume surgeons (≤25 total EGS procedures/year), 63 (18.3%) medium-volume surgeons (26 to 50/year), and 29 (8.4%) high-volume surgeons (>50/year). Low-volume surgeons operated on one-third (33.1%) of all patients. For simple procedures, the very low rate of death (0.2%) prevented a meaningful regression with mortality; however, there were no associations between low-volume surgeons and complications (adjusted odds ratio [aOR] 1.07; 95% CI 0.81 to 1.41) or 30-day readmissions (aOR 0.80; 95% CI 0.64 to 1.01) relative to high-volume surgeons. Among complex procedures, low-volume surgeons were associated with greater mortality (aOR 1.64; 95% CI 1.12 to 2.41) relative to high-volume surgeons, but not complications (aOR 1.06; 95% CI 0.85 to 1.32) or 30-day readmission (aOR 0.99; 95% CI 0.80 to 1.22). Low-volume hospitals (≤125 total EGS procedures/year) relative to high-volume hospitals (>250/year) were not associated with mortality, complications, or 30-day readmissions for simple or complex procedures. CONCLUSIONS We found evidence that surgeon EGS volume was associated with outcomes. Developing EGS-specific services, mentorship opportunities, and clinical pathways for less-experienced surgeons may improve outcomes.

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.

The Student Curriculum Review Team: How we catalyze curricular changes through a student-centered approach.

Abstract Student feedback is a valuable asset in curriculum evaluation and improvement, but many institutions have faced challenges implementing it in a meaningful way. In this article, we report the rationale, process and impact of the Student Curriculum Review Team (SCRT), a student-led and faculty-supported organization at the Johns Hopkins University School of Medicine. SCRT’s evaluation of each pre-clinical course is composed of a comprehensive three-step process: a review of course evaluation data, a Town Hall Meeting and online survey to generate and assess potential solutions, and a thoughtful discussion with course directors. Over the past two years, SCRT has demonstrated the strength of its approach by playing a substantial role in improving medical education, as reported by students and faculty. Furthermore, SCRT’s uniquely student-centered, collaborative model has strengthened relationships between students and faculty and is one that could be readily adapted to other medical schools or academic institutions.

Outlier Practice Patterns in Mohs Micrographic Surgery: Defining the Problem and a Proposed Solution

Importance Outlier physician practices in health care can represent a significant burden to patients and the health system. Objective To study outlier physician practices in Mohs micrographic surgery (MMS) and the associated factors. Design, Setting, and Participants This retrospective analysis of publicly available Medicare Part B claims data from January 2012 to December 2014 includes all physicians who received Medicare payments for MMS from any practice performing MMS on the head and neck, genitalia, hands, and feet region of Medicare Part B patients. Main Outcomes and Measures Characteristics of outlier physicians, defined as those whose mean number of stages for MMS was 2 standard deviations greater than the mean number for all physicians billing MMS. Logistic regression was used to study the physician characteristics associated with outlier status. Results Our analysis included 2305 individual billing physicians performing MMS. The mean number of stages per MMS case for all physicians practicing from January 2012 to December 2014 was 1.74, the median was 1.69, and the range was 1.09 to 4.11. Overall, 137 physicians who perform Mohs surgery were greater than 2 standard deviations above the mean (2 standard deviations above the mean = 2.41 stages per case) in at least 1 of the 3 examined years, and 49 physicians (35.8%) were persistent high outliers in all 3 years. Persistent high outlier status was associated with performing Mohs surgery in a solo practice (odds ratio, 2.35; 95% CI, 1.25-4.35). Volume of cases per year, practice experience, and geographic location were not associated with persistent high outlier status. Conclusions and Relevance Marked variation exists in the number of stages per case for MMS for head and neck, genitalia, hands, and feet skin cancers, which may represent an additional financial burden and unnecessary surgery on individual patients. Providing feedback to physicians may reduce unwarranted variation on this metric of quality.

The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments

Study objective: A proposed benefit of expanding Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for primary care needs. Pre‐ACA studies found that new Medicaid enrollees increased their ED utilization rates, but the effect on system‐level ED visits was less clear. Our objective was to estimate the effect of Medicaid expansion on aggregate and individual‐based ED utilization patterns within Maryland. Methods: We performed a retrospective cross‐sectional study of ED utilization patterns across Maryland, using data from Maryland’s Health Services Cost Review Commission. We also analyzed utilization differences between pre‐ACA (July 2012 to December 2013) uninsured patients who returned post‐ACA (July 2014 to December 2015). Results: The total number of ED visits in Maryland decreased by 36,531 (–1.2%) between the 6 quarters pre‐ACA and the 6 quarters post‐ACA. Medicaid‐covered ED visits increased from 23.3% to 28.9% (159,004 additional visits), whereas uninsured patient visits decreased from 16.3% to 10.4% (181,607 fewer visits). Coverage by other insurance types remained largely stable between periods. We found no significant relationship between Medicaid expansion and changes in ED volume by hospital. For patients uninsured pre‐ACA who returned post‐ACA, the adjusted visits per person during 6 quarters was 2.38 (95% confidence interval 2.35 to 2.40) for those newly enrolled in Medicaid post‐ACA compared with 1.66 (95% confidence interval 1.64 to 1.68) for those remaining uninsured. Conclusion: There was a substantial increase in patients covered by Medicaid in the post‐ACA period, but this did not significantly affect total ED volume. Returning patients newly enrolled in Medicaid visited the ED more than their uninsured counterparts; however, this cohort accounted for only a small percentage of total ED visits in Maryland.

Rodent models of obsessive compulsive disorder: Evaluating validity to interpret emerging neurobiology.

Obsessive Compulsive Disorder (OCD) is a common neuropsychiatric disorder with unknown molecular underpinnings. Identification of genetic and non-genetic risk factors has largely been elusive, primarily because of a lack of power. In contrast, neuroimaging has consistently implicated the cortico-striatal-thalamo-cortical circuits in OCD. Pharmacological treatment studies also show specificity, with consistent response of OCD symptoms to chronic treatment with serotonin reuptake inhibitors; although most patients are left with residual impairment. In theory, animal models could provide a bridge from the neuroimaging and pharmacology data to an understanding of pathophysiology at the cellular and molecular level. Several mouse models have been proposed using genetic, immunological, pharmacological, and optogenetic tools. These experimental model systems allow testing of hypotheses about the origins of compulsive behavior. Several models have generated behavior that appears compulsive-like, particularly excessive grooming, and some have demonstrated response to chronic serotonin reuptake inhibitors, establishing both face validity and predictive validity. Construct validity is more difficult to establish in the context of a limited understanding of OCD risk factors. Our current models may help us to dissect the circuits and molecular pathways that can elicit OCD-relevant behavior in rodents. We can hope that this growing understanding, coupled with developing technology, will prepare us when robust OCD risk factors are better understood.

Video transparency: a powerful tool for patient safety and quality improvement.

Transparency can be a powerful driver of better healthcare quality.1 In 2013, it was proposed that recording video data in healthcare begin with the several medical procedures that are already video based (cardiac stent placement, arthroscopic surgery, colonoscopy, etc).1 Different from the past era when recording required new hardware, most of the procedures performed in medicine today are now mediated by video, enabling a new opportunity for learning health systems.2 ,3 Some hospitals, like Johns Hopkins, have even built operating rooms (ORs) equipped with cameras—some of these are used to monitor room turnover times for scheduling efficiency, while others have been installed in anticipation of a future of increased transparency. Ever since our group first described a surgery checklist,4 compliance with the tool has been a challenge. Overdyk et al 5 demonstrate the potential of using video-derived data to improve compliance rates. The authors, based at Hofstra North Shore-LIJ School of Medicine, performed a prospective study in which surgeons and other OR staff were randomised to video monitoring with real-time feedback on key patient safety activities, including compliance with the safety checklist during sign-in, time-out and sign-out procedures. They found that the feedback increased compliance dramatically and reduced OR turnaround times for scheduled cases by 14%. Moreover, these improvements were sustained throughout the feedback period. As Overdyk et al shows, video transparency is one of very few interventions in healthcare to result in immediate behaviour change around safe practices. This is a landmark study in the rapidly expanding field of using technology to take patient safety to the next level and can be generalised to improve compliance with other established safe practices in healthcare. For years, healthcare has suffered from endemic problems associated with unwarranted variation in practice patterns, behaviours and compliance. Transparency works because …