Clinical perspective: creating an effective practice peer review process-a primer

Pathophysiologic Origins of Brachial Plexus Injury

OBJECTIVE

To analyze the origins and consequences of cases of brachial plexus injuries and their relationship to shoulder dystocia.

METHODS

We conducted a retrospective cohort study and identified all neonates with brachial plexus injury delivered at our institution between March 2012 and July 2019. A review was performed of the maternal and neonatal records of each neonate to identify obstetric antecedents, including the occurrence of shoulder dystocia and persistence of the injury. Experience of the delivering clinician was also examined. Statistical analysis was performed with the Fisher exact test, χ test for trends, and two-tailed t tests.

RESULTS

Thirty-three cases of brachial plexus injury were identified in 41,525 deliveries (0.08%). Fourteen (42%) of these cases were not associated with shoulder dystocia; three (9%) followed cesarean delivery. Brachial plexus injury without shoulder dystocia was related to the absence of maternal diabetes, lower birth weights, and a longer second stage of labor. Persistent brachial plexus injury at the time of discharge was seen with equal frequency among neonates with (17/19, 89%, 95% CI 0.52-100%) and without shoulder dystocia (10/14, 71%, 95% CI 34-100%), P=.36). Whether brachial plexus injury was transient or persistent after shoulder dystocia was unrelated to the years of experience of the delivering clinician. Despite ongoing training and simulation, the already low incidence of brachial plexus injury did not decrease over time at our institution.

CONCLUSION

Brachial plexus injury and shoulder dystocia represent two complications of uterine forces driving a fetus through the maternal pelvis in the presence of disproportion between the passage and the shoulder girdle of the passenger. Either or both of these complications may occur, but often are not causally related.

The advantages of peer review over arbitration for resolving authorship disputes

A recent commentary argued for arbitration to resolve authorship disputes within academic research settings explaining that current mechanisms to resolve conflicts result in unclear outcomes and institutional power vested in senior investigators could compromise fairness. We argue here that arbitration is not a suitable means to resolve disputes among researchers in academia because it remains unclear who will assume the costs of arbitration, the rules of evidence do not apply to arbitration, and decisions are binding and very difficult to appeal. Instead of arbitration, we advocate for peer-based approaches involving a peer review committee and research ethics consultation to help resolve authorship disagreements. We describe the composition of an institutional peer review committee to address authorship disputes. Both of these mechanisms are found, or can be formed, within academic institutions and offer several advantages to researchers who are likely to shy away from legalistic processes and gravitate towards those handled by their peers. Peer-based approaches are cheaper than arbitration and the experts involved have knowledge about academic publishing and the culture of research in the specific field. Decisions by knowledgeable and neutral experts could reduce bias, have greater authority, and could be appealed. Not only can peer-based approaches be leveraged to resolve authorship disagreements, but they may also enhance collegiality and promote a healthy team environment.

A case for revisiting peer review: Implications for professional self-regulation and quality improvement

Background

Quality improvement in healthcare has often been promoted as different from and more valuable than peer review and other professional self-regulation processes. In spite of attempts to harmonize these two approaches, the perception of dichotomous opposition has persisted. A sequence of events in the troubled California prison system fortuitously isolated workforce interventions from more typical quality improvement interventions. Our objectives were to (1) evaluate the relative contributions of professional accountability and quality improvement interventions to an observed decrease in population mortality and (2) explore the organizational dynamics that potentiated positive outcomes.

Methods

Our retrospective mixed-methods case study correlated time-series analysis of mortality with the timing of reform interventions. Quantitative and qualitative evidence was drawn from court documents, public use files, internal databases, and other archival documents.

Results

Change point analysis reveals with 98% confidence that a significant improvement in age-adjusted natural mortality occurred in 2007, decreasing from 138.7 per 100,000 in the 1998–2006 period to 106.4 in the 2007–2009 period. The improvement in mortality occurred after implementation of accountability processes, prior to implementation of quality improvement interventions. Archival evidence supports the positive impact of physician competency assessments, robust peer review, and replacement of problem physicians.

Conclusions

Our analysis suggests that workforce accountability provides a critical quality safeguard, and its neglect in scholarship and practice is unjustified. As with quality improvement, effective professional self-regulation requires systemic implementation of enabling policies, processes, and staff resources. The study adds to evidence that the distribution of physician performance contains a heterogeneous left skew of dyscompetence that is associated with significant harm and suggests that professional self-regulation processes such as peer review can reduce that harm. Beyond their responsibility for direct harm, dyscompetent professionals can have negative impacts on group performance. The optimal integration of professional accountability and quality improvement systems merits further investigation.