Decision support tool for hospital resource allocation during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic has placed unprecedented demands on entire health systems and driven them to their capacity, so that health care professionals have been confronted with the difficult problem of ensuring appropriate staffing and resources to a high number of critically ill patients. In light of such high-demand circumstances, we describe an open web-accessible simulation-based decision support tool for a better use of finite hospital resources. The aim is to explore risk and reward under differing assumptions with a model that diverges from most existing models which focus on epidemic curves and related demand of ward and intensive care beds in general. While maintaining intuitive use, our tool allows randomized "what-if" scenarios which are key for real-time experimentation and analysis of current decisions' down-stream effects on required but finite resources over self-selected time horizons. While the implementation is for COVID-19, the approach generalizes to other diseases and high-demand circumstances.

Public unawareness of physician reimbursement

Objectives

To assess subjects' perception of healthcare costs and physician reimbursement.

Background

The lack of transparency in healthcare reimbursement leaves patients and physicians unaware of the distribution of health care dollars.

Methods

Anonymous survey‐based study by means of convenience sampling. Participants were asked to estimate the total hospital cost and physician fee for one of the six medical procedures (n = 250).

Results

On the average for all 6 procedures, patients estimated the total cost was $36,177, ∼1,540% more than the actual Medicare rate of $7,333. Similarly, patients estimated the physician fee was $7,694, 1,474% more the actual Medicare rate of $589.

Conclusion

Patients' perception of the total cost and physician fee are significantly higher than Medicare rates for all 6 procedures. This lack of insight may have widespread negative implications on the patient–physician relationship, on political trends to reduce physician reimbursement, and on a physician's desire to continue practicing medicine.

Systems approach to assessing and improving local human research Institutional Review Board performance

OBJECTIVE

To quantifying the interdependency within the regulatory environment governing human subject research, including Institutional Review Boards (IRBs), federally mandated Medicare coverage analysis and contract negotiations.

METHODS

Over 8000 IRB, coverage analysis and contract applications initiated between 2013 and 2016 were analyzed using traditional and machine learning analytics for a quality improvement effort to improve the time required to authorize the start of human research studies.

RESULTS

Staffing ratios, study characteristics such as the number of arms, source of funding and number and type of ancillary reviews significantly influenced the timelines. Using key variables, a predictive algorithm identified outliers for a workflow distinct from the standard process. Improved communication between regulatory units, integration of common functions, and education outreach improved the regulatory approval process.

CONCLUSIONS

Understanding and improving the interdependencies between IRB, coverage analysis and contract negotiation offices requires a systems approach and might benefit from predictive analytics.

Competency based clinical shoulder examination training improves physical exam, confidence, and knowledge in common shoulder conditions

BACKGROUND

Deficiencies in musculoskeletal knowledge are reported at every stage of learning. Medical programs are looking for effective ways to incorporate competency-based training into musculoskeletal education.

AIM

To evaluate the impact of bedside feedback on learner's shoulder examination skills, confidence, and knowledge of common shoulder conditions.

SETTING

Four-week musculoskeletal clinic rotation.

PARTICIPANTS

UCSD third year medical students and internal medicine residents.

PROGRAM DESCRIPTION

Learners completed three baseline evaluations: videotaped shoulder examination, attitude survey, and knowledge test. During the 4-week intervention learners received bedside observation and feedback from musculoskeletal experts while evaluating patients with shoulder conditions. Post-intervention learners repeated the three assessments.

PROGRAM EVALUATION

Eighty-nine learners participated. In the primary outcome measure evaluating the pre/post videotaped shoulder examination, significant improvement was seen in 21 of 23 shoulder examination maneuvers. Secondary outcomes include changes in learner confidence and knowledge. Greatest gains in learner confidence were seen in performing the shoulder examination (61.5% improvement) and performing injections (97.1% improvement). Knowledge improved significantly in all categories including anatomy/examination interpretation, diagnosis, and procedures.

DISCUSSION

Direct observation and feedback during clinical evaluation of patients with shoulder pain improves shoulder examination competency, provider confidence, and knowledge of common shoulder conditions.

Life expectancy and health expenditure evolution in Eastern Europe-DiD and DEA analysis

BACKGROUND

Exploration of long-term health expenditure and longevity trends across three major sub-regions of Eastern Europe since 1989.

METHODS

24 countries were classified as EU 2004, CIS, or SEE. European Health for All Database (HFA-DB) 1989-2012 data were processed using difference-in-difference (DiD) and data envelopment analysis (DEA).

RESULTS

The strongest expenditure growth was recorded in EU 2004 followed by SEE and the CIS. A surprisingly similar longevity increase was present in SEE and EU 2004. In 1989, countries that joined EU in 2004 were relatively inefficient in the number of life-years gained yet had a lower life expectancy than the SEE region and was only slightly higher than the CIS region (DEA). By 2012 the revenue spent was roughly linear to additional life-year expectancies.

CONCLUSION

EU 2004 members were the best performers in terms of balanced longevity increase followed by health expenditure growth. The SEE economies' longevity gains were lagging slightly behind at a far lower cost. An extrapolated CIS expenditure to longevity increase ratio has the fastest-growing long-term promise.

Magnetic resonance imaging and liver histology as biomarkers of hepatic steatosis in children with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. In order to advance the field of NAFLD, noninvasive imaging methods for measuring liver fat are needed. Advanced magnetic resonance imaging (MRI) has shown great promise for the quantitative assessment of hepatic steatosis but has not been validated in children. Therefore, this study was designed to evaluate the correlation and diagnostic accuracy of MRI-estimated liver proton density fat fraction (PDFF), a biomarker for hepatic steatosis, compared to histologic steatosis grade in children. The study included 174 children with a mean age of 14.0 years. Liver PDFF estimated by MRI was significantly (P < 0.01) correlated (0.725) with steatosis grade. The correlation of MRI-estimated liver PDFF and steatosis grade was influenced by both sex and fibrosis stage. The correlation was significantly (P < 0.01) stronger in girls (0.86) than in boys (0.70). The correlation was significantly (P < 0.01) weaker in children with stage 2-4 fibrosis (0.61) than children with no fibrosis (0.76) or stage 1 fibrosis (0.78). The diagnostic accuracy of commonly used threshold values to distinguish between no steatosis and mild steatosis ranged from 0.69 to 0.82. The overall accuracy of predicting the histologic steatosis grade from MRI-estimated liver PDFF was 56%. No single threshold had sufficient sensitivity and specificity to be considered diagnostic for an individual child.

CONCLUSIONS

Advanced magnitude-based MRI can be used to estimate liver PDFF in children, and those PDFF values correlate well with steatosis grade by liver histology. Thus, magnitude-based MRI has the potential for clinical utility in the evaluation of NAFLD, but at this time no single threshold value has sufficient accuracy to be considered diagnostic for an individual child.

A case study of quality improvement methods for complex adaptive systems applied to an academic hepatology program

Although demands for greater access to hepatology services that are less costly and achieve better outcomes have led to numerous quality improvement initiatives, traditional quality management methods may be inappropriate for hepatology. We empirically tested a model for conducting quality improvement in an academic hepatology program using methods developed to analyze and improve complex adaptive systems. We achieved a 25% increase in volume using 15% more clinical sessions with no change in staff or faculty FTEs, generating a positive margin of 50%. Wait times for next available appointments were reduced from five months to two weeks; unscheduled appointment slots dropped from 7% to less than 1%; "no-show" rates dropped to less than 10%; Press-Ganey scores increased to the 100th percentile. We conclude that framing hepatology as a complex adaptive system may improve our understanding of the complex, interdependent actions required to improve quality of care, patient satisfaction, and cost-effectiveness.

Paediatric gastroenterology evaluation of overweight and obese children referred from primary care for suspected non-alcoholic fatty liver disease

BACKGROUND

Screening overweight and obese children for non-alcoholic fatty liver disease (NAFLD) is recommended by paediatric and endocrinology societies. However, gastroenterology societies have called for more data before making a formal recommendation.

AIM

To determine whether the detection of suspected NAFLD in overweight and obese children through screening in primary care and referral to paediatric gastroenterology resulted in a correct diagnosis of NAFLD.

METHODS

Information generated in the clinical evaluation of 347 children identified with suspected NAFLD through screening in primary care and referral to paediatric gastroenterology was captured prospectively. Diagnostic outcomes were reported. The diagnostic performance of two times the upper limit of normal (ULN) for alanine aminotransferase (ALT) was assessed.

RESULTS

Non-alcoholic fatty liver disease was diagnosed in 55% of children identified by screening and referral. Liver disease other than NAFLD was present in 18% of those referred. Autoimmune hepatitis was the most common alternative diagnosis. Children with NAFLD had significantly (P < 0.05) higher screening ALT (98 ± 95) than children with liver disease other than NAFLD (86 ± 74). Advanced fibrosis was present in 11% of children. For the diagnosis of NAFLD, screening ALT two times the clinical ULN had a sensitivity of 57% and a specificity of 71%.

CONCLUSIONS

Screening of overweight and obese children in primary care for NAFLD with referral to paediatric gastroenterology has the potential to identify clinically relevant liver pathology. Consensus is needed on how to value the risk and rewards of screening and referral, to identify children with liver disease in the most appropriate manner.

Decoding laboratory test names: a major challenge to appropriate patient care

Clinical laboratory tests have no value if clinicians cannot quickly order and obtain the results they need. We found that efforts to obtain even the most commonly ordered tests are often derailed by excessively complex nomenclature. Ordering the right laboratory tests is critical to diagnosis and treatment, but existing mechanisms for entering lab orders actively interfere with physicians' efforts to provide good clinical care. Rather than simplifying lab orders, the advent of computerized physician order entry (CPOE) systems-generally programmed by non-clinicians-has introduced new and vexing practical problems. Medical laboratories have filled their test menus, whether paper or electronic, with bewildering nomenclature and abbreviations, and have failed to appreciate the dangers of assigning perilously similar names to different tests. The efficient and efficacious patient care demanded by the quality care initiative requires progress beyond traditional solutions, such as convening naming conventions, to the development of innovative software with intelligent, real-time, clinically driven search functions that will allow these programs to help rather than hinder physicians.

Effectiveness of automated notification and customer service call centers for timely and accurate reporting of critical values: a laboratory medicine best practices systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review of the evidence available in support of automated notification methods and call centers and to acknowledge other considerations in making evidence-based recommendations for best practices in improving the timeliness and accuracy of critical value reporting.

DESIGN AND METHODS

This review followed the Laboratory Medicine Best Practices (LMBP) review methods (Christenson, et al. 2011). A broad literature search and call for unpublished submissions returned 196 bibliographic records which were screened for eligibility. 41 studies were retrieved. Of these, 4 contained credible evidence for the timeliness and accuracy of automatic notification systems and 5 provided credible evidence for call centers for communicating critical value information in in-patient care settings.

RESULTS

Studies reporting improvement from implementing automated notification findings report mean differences and were standardized using the standard difference in means (d=0.42; 95% CI=0.2-0.62) while studies reporting improvement from implementing call centers generally reported criterion referenced findings and were standardized using odds ratios (OR=22.1; 95% CI=17.1-28.6).

CONCLUSIONS

The evidence, although suggestive, is not sufficient to make an LMBP recommendation for or against using automated notification systems as a best practice to improve the timeliness of critical value reporting in an in-patient care setting. Call centers, however, are effective in improving the timeliness of critical value reporting in an in-patient care setting, and meet LMBP criteria to be recommended as an "evidence-based best practice."

Data envelopment analysis: dynamic possibilities in an academic medical center application

In a fairly short period of time, data envelopment analysis (DEA) has grown into a powerful quantitative, analytical tool for measuring the relative performance of similar organizations. DEA has been successfully applied to traditional service industries such as universities and hospitals as well as to trades as diverse as banking and manufacturing. To the best of our knowledge, however, DEA has not been applied in the academic medicine healthcare setting. This paper discusses fundamental DEA models and some of their extensions, the arena into which we introduced DEA, and an example from our own institution exploring how DEA can advance the value proposition within an academic healthcare organization.

Introduction of the Balanced Scorecard into an academic department of medicine: creating a road map to success

In this paper, we describe: 1) the environmental forces driving performance measurement and management in the University of California San Diego Department of Medicine; 2) the systematic process used by the department to implement a Balanced Scorecard; 3) the initial direct and indirect outcomes of this effort; 4) the opportunities and challenges to the Balanced Scorecard as a management directive; and 5) future directions.

Opportunities for the use of decision aids in primary care

BACKGROUND AND OBJECTIVES

Shared decision making (SDM) is part of a larger movement for patient-centered approaches to care. SDM can be facilitated through the use of decision aids (DA), which are evidence-based tools designed to transmit information on topics suitable for SDM. They are intended to facilitate the process of patients arriving at an informed, values-based choice in partnership with physicians. Research indicates that SDM and the use of DA are underutilized. This study evaluated SDM and DA in primary care.

METHODS

Adult patients presenting for chronic disease follow-up to one of four participating primary care health centers were recruited over 16 months. Visit discussions were audiorecorded, transcribed, and coded using Davis coding. Discussion comments were coded for type of SDM (with and without DA) and topics matched against two DA registries.

RESULTS

Forty-four unique patient visits were recorded. Shared decision activities on 15 topics were found in 34 discussions, across 27 (61%) of the visits. DA use did not occur in any visit. Fifteen (34%) visits included topics with peer-validated, freely available DA.

CONCLUSIONS

Even when shared decision making occurs, DAs are rarely used. Research is needed to identify and reduce barriers to using DAs in primary care.

Translating operational research to the medical community: using "guiding measurements" to improve the quality of healthcare delivery

Despite the ubiquity problems with pay-for-performance and other quality improvement initiatives, there is little in the way of objective evidence that these efforts have improved the quality of care. In part, it may be because the measurements selected are used to "grade" instead of guide improvement efforts. We propose using operational research methods that include how to develop "guiding measurements" to improve care. We show that use of this type of guiding measurements can lead to improved patient understanding, throughput, and satisfaction in a pediatric nephrology ambulatory care clinic, and may have wider applications across the continuum of care.

Cognitive and adaptive outcome in extracerebellar low-grade brain tumors in children: a report from the Children's Oncology Group

PURPOSE

To determine whether pediatric patients treated with surgery only for low-grade tumors in the cerebral hemispheres, supratentorial midline, and exophytic brainstem evidence neurocognitive, academic, adaptive, or emotional/behavioral sequelae.

PATIENTS AND METHODS

Ninety-three patients from a natural history study of low-grade astrocytomas were tested an average of 111 days after surgery. Rates of below average (< or = 25th percentile) scores in this sample were compared with test norms, and performances were compared across anatomic sites. Finally, the relationships of pre-, peri-, and postsurgical complications to outcome were investigated.

RESULTS

For the entire sample, there was a significantly elevated rate of below average scores across intelligence quotient, achievement, and adaptive behavior, but not behavioral/emotional adjustment measures. Patients with hemispheric, midline, and brainstem tumors did not differ significantly. Patients with left hemisphere tumors generally performed worse than those with right hemisphere tumors. Finally, neurobehavioral outcome was unrelated to pre-, peri-, or postsurgery complications.

CONCLUSION

After surgery for low-grade brain tumors, a significant number of patients was found to function below average, by as much as 55% compared with 25% in the normative population. Moreover, these results suggest greater risk for patients with lesions situated in the left cerebral hemisphere. Routine neuropsychological follow-up of children after treatment for low-grade tumors is recommended.

Improving physician involvement in care management programs

Care management delivered by interdisciplinary teams has been demonstrated to be a successful method for treating diseases such as asthma, hypertension, diabetes, and heart failure. Two models have emerged: (1) office-based programs, in which most services are delivered directly from the practice; and (2) insurer-run or purchased (external) programs delivered by third parties. Physician involvement and coordination of patient care with both programs is felt to be advantageous, yet physician involvement has been found to be sporadic. The issues surrounding physician noninvolvement have not been delineated, as the few studies conducted have tended to be descriptive, and they have not provided a model that could inform policy makers how to improve collaborative relationships. The purpose of this study was to construct such a model.

How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents?

OBJECTIVES

Our goal was to evaluate the capacity of various health care settings to supplement the activities of the traditional medical home by delivering vaccines to adolescents.

METHODS

A group of experts in the fields of adolescent-immunization delivery and the provision of preventive care in various health care settings summarized the available literature, considered setting-specific factors, and assessed the ability of various health care settings beyond the traditional medical home to conform to the immunization quality standards set by the National Vaccine Advisory Committee, report vaccination information for the quantitative assessment of vaccine-coverage rates, be likely to offer vaccines to adolescents, and be viewed by adolescents as acceptable sites for receiving vaccinations.

RESULTS

Seven candidate settings were evaluated: pharmacies, obstetrics-gynecology practices, sexually transmitted disease clinics, hospital emergency departments, family planning clinics, teen clinics, and local public health department immunization clinics. The panel concluded that all could safely provide vaccinations to adolescents but that vaccination efforts at some of the settings could potentially have a markedly greater impact on overall adolescent-immunization rates than could those at other settings. In addition, for adolescent-vaccination services to be practical, candidate settings need to have a clear interest in providing them. Conditional on that, several issues need to be addressed: (1) funding; (2) orienting facilities to provide preventive care services; (3) enhancing access to immunization registries; and (4) clarifying issues related to immunization consent.

CONCLUSIONS

With supporting health policy, health education, and communication, health care settings beyond the traditional medical home have the potential to effectively augment the vaccination efforts of more traditional settings to deliver vaccines to adolescents. These health care settings may be particularly well suited to reach adolescents who lack access to traditional sources of preventive medical care or receive fragmented medical care.

Should we measure the individual or the system? Operational factors affecting compliance with treatment

Chronic kidney disease requires a complex array of treatment interventions, including dietary and fluid restriction, medications, and self-monitoring of blood pressure. Patient well-being is directly linked to adhering to physician recommendations and treatment schedules. While considerable efforts have been directed to understanding the contribution of patient characteristics, burden of treatment, and patient-provider relations, little study has been conducted on the "system" requirements that support good patient-provider communication. This study examines how operational characteristics occurring at the time of an encounter affect the likelihood a patient will "hear" provider recommendations.

Mass vaccination clinics versus appointments

Influenza vaccine is a safe, effective, and cost-effective intervention that can prevent serious disease in adults. Opinions differ as to the most effective method for delivering the vaccine to the greatest number of high-risk adults. The objective of this article is to compare immunization delivery of influenza vaccine to high-risk adults during two types of clinic visits: routine scheduled appointments versus mass clinics. Data was collected at 15 ambulatory care settings on 599 patients 50 years and over from October 23, 2001, to January 31, 2002. Immunizations given at either routine scheduled visits or at mass influenza immunization clinics were compared for costs and resource requirements (productivity), and completeness of delivery of quality visit components (efficiency). The two visit types presented significantly different strengths on key clinical functions. Routine scheduled appointments promoted more review of patient health history and more of the contact information necessary for reminder/recall and audit functions. In mass immunization clinics, patients were more likely to be vaccinated, with far less time spent in either direct services or in waiting, and it was more likely that the required vaccination information statements (VIS) would be provided. Mass vaccination clinics and routine scheduled appointments are both viable service strategies for delivering influenza vaccines. This study suggests the greatest advantage occurs when both strategies are used in a coordinated manner.

Status of Quality Improvement Activities to Improve Immunization Practices and Delivery

The Centers for Disease Control and Prevention convened a symposium on 22-23 October 2003 to bring together investigators and stakeholders working to apply the quality improvement (QI) approaches to immunization delivery in individual medical practices. The goal was to identify effective program components and further development of model programs. A call for projects was widely disseminated; of 61 submissions received, eight projects were selected. Three of the eight programs used the "train the trainer" approach, three used site-specific training, one used a "practice collaborative" approach, and one employed the use of tracking and outreach workers to effect change. At the symposium, invited experts reviewed each program. Common program features that appeared effective included involvement of a variety of staff within the office environment, collection and review of site-specific performance measurements to identify gaps in delivery, periodic monitoring of performance measurement to revise interventions and maintain the improvements, and provision of formal continuing education credits. While research is needed on ways to promote and integrate QI into practices, it is likely that a variety of QI strategies will be shown to be effective, depending on the clinical settings. The field will benefit from standardized outcome measures, cost analysis, and evaluation, so comparisons can be made among different programs.

Cognitive and adaptive outcome in low-grade pediatric cerebellar astrocytomas: evidence of diminished cognitive and adaptive functioning in National Collaborative Research Studies (CCG 9891/POG 9130)

PURPOSE

Clinicians often assume that children with posterior fossa tumors are at minimal risk for cognitive or adaptive deficits if they do not undergo cranial irradiation. However, small case series have called that assumption into question, and have also suggested that nonirradiated cerebellar tumors can cause location-specific cognitive and adaptive impairment. This study (1) assessed whether resected but not irradiated pediatric cerebellar tumors are associated with cognitive and adaptive functioning deficits, and (2) examined the effect of tumor location and medical complications on cognitive and adaptive functioning.

PATIENTS AND METHODS

The sample was composed of 103 children aged 3 to 18 years with low-grade cerebellar astrocytomas, who underwent only surgical treatment as part of Children's Cancer Group protocol 9891 or Pediatric Oncology Group protocol 9130. The sample was divided into three groups based on primary tumor location: vermis, left hemisphere, or right hemisphere. Data were collected prospectively on intelligence, academic achievement, adaptive skills, behavioral functioning, and pre-, peri-, and postsurgical medical complications.

RESULTS

The sample as a whole displayed an elevated risk for cognitive and adaptive impairment that was not associated consistently with medical complications. Within this group of children with cerebellar tumors, tumor location had little effect on cognitive, adaptive, or medical outcome.

CONCLUSION

We did not replicate previous findings of location-specific effects on cognitive or adaptive outcome. However, the elevated risk of deficits in this population runs contrary to clinical lore, and suggests that clinicians should attend to the functional outcomes of children who undergo only surgical treatment for cerebellar tumors.

Why do not patients receive influenza vaccine in December and January?

BACKGROUND

Influenza vaccination levels in older patients have changed little since the mid-1990s. Despite frequent health care visits by a majority of older persons, many missed opportunities continue to occur.

METHODS

Patients were eligible for the study if they were age 50 and older, had not received influenza vaccine during the current season and were making a scheduled visit to one of the 13 study sites in California, New York, or New Mexico for purposes other than vaccination. Through direct observation, we determined if office staff inquired about vaccination status, discussed vaccination, or both. We defined missed opportunities as failure to administer influenza vaccine to patients for whom it was indicated.

RESULTS

Missed opportunities increased steadily from October to January (P < 0.0001), and were more common when there was no inquiry or discussion (P < 0.00001), among patients aged 50-64 (P < 0.0001) and in California and New Mexico (P = 0.001). A classification tree analysis revealed that lack of inquiry and week of visit contributed most to missed opportunities.

DISCUSSION

Early in the vaccination season, missed opportunities were uncommon and specific inquiries into or discussion of vaccination did not appear necessary. In December and January, patients tended to be vaccinated only when vaccination was addressed during the visit. Efforts to remind patients about vaccination later in the vaccination season may be essential to achieving higher coverage in the U.S.

Estimating medical practice expenses from administering adult influenza vaccinations

Potential business losses incurred vaccinating adults against influenza have not been defined because of a lack of estimates for medical practice costs incurred delivering vaccines. We collected data on vaccination labor time and other associated expenses. We modeled estimates of per-vaccination medical practice business costs associated with delivering adult influenza vaccine in different sized practices. Per-shot costs ranged from USD 13.87 to USD 46.27 (2001 dollars). When compared with average Medicare payments of USD 11.71, per-shot losses ranged from US$ 2.16 to USD 34.56. More research is needed to determine less expensive delivery settings and/or whether third-party payers need to make higher payments for adult vaccinations.

The (mis)application of management science in medicine: a flawed concept

The business of medicine once again finds itself in the throes of rapidly escalating costs, concerns about quality of care, and demands for efficiency while simultaneously enhancing quality. Considerable effort has already been spent in trying to improve costs, quality, and patient satisfaction. The apparent failure to do so may be the result of a fundamental misunderstanding of the salient features of clinical practice and the misapplication of quality improvement techniques. This article explores some of the significant issues and offers potential new directions.

Operational conditions affecting the vaccination of older adults

BACKGROUND

The content and context of the process of vaccinating older adults against influenza in outpatient settings has not been adequately described. Failure to appreciate the causal antecedents or precursors to the act of provider recommendation may explain why so many efficacious interventions identified by the U.S. Task Force on Community Preventive Services fail to be routinely implemented and why influenza immunization rates have remained static over the past decade.

METHODS

This study used critical path analysis from data collected during standardized workflow observations of patients more than 50 years of age from a convenience sample of 16 ambulatory care settings in San Diego, California; Rochester, New York; and Albuquerque, New Mexico. Observations were made from October 23, 2001 to January 31, 2002.

RESULTS

In this study, 62% (151/243) of patients observed during scheduled extended visits received influenza vaccinations. When operational, temporal, and clinical factors are examined altogether through critical path analysis, a model of seven critical organizational support, temporal, and clinical activities emerges that is able to predict 93% of the immunizations. Variation from the model predicts 73% of the missed opportunities.

CONCLUSIONS

Vaccination of adults should not be seen as simply an incremental activity added to the general health encounter. Assuring a high rate of vaccination requires adequate time and operational support. Provider-patient discussion is more productively viewed as the culmination of the immunization process, not the beginning. Finally, this study indicates the potential need to identify and compare processes of care associated with other specific preventive services.

The price of prevention. cost of recommended activities to improve immunizations

PURPOSE

To calculate the cost structure of a suite of immunization improvement interventions recommended by the Centers for Disease Control and Prevention (CDC).

METHODS

A determination was made of the cost to clinics and agencies that implement a suite of CDC-recommended practice improvement interventions to fully immunize a child for diphtheria-tetanus-attenuated pertussis (DTaP), inactivated poliovirus (IPV), and measles-mumps-rubella (MMR) vaccines. Patient data were collected through chart analysis of 16-month-old children in clinics participating in this study's interventions between May 1997 and August 2000. The study began on October 1, 1996, and was funded for 5 years (until September 30, 2002).

RESULTS

Study calculations suggest that an additional $0.013/per patient per month would be needed to cover these activities.

CONCLUSIONS

Identifiable cost structures are associated with the practice improvement strategies recommended by the CDC. The method of implementation may be as important as the interventions themselves. Present compensation for immunization may not actually cover the cost of service provision, and it is unlikely to cover the costs of practice improvement, as described in this paper.

Loss of p16 expression is of prognostic significance in locally advanced prostate cancer: an analysis from the Radiation Therapy Oncology Group protocol 86-10

PURPOSE

The retinoblastoma (RB) cell cycle regulatory pathway is known to be deregulated in virtually all known human tumors. The protein product of the RB gene, pRB, and its upstream regulator, p16, are among the most commonly affected members of this pathway. We investigated the prognostic significance of both pRB and p16 expression in locally advanced prostate cancers, from patients treated on the Radiation Therapy Oncology Group (RTOG) protocol 86-10.

MATERIALS AND METHODS

Sixty-seven cases from RTOG 86-10 had immunohistochemically stained slides, judged interpretable for both p16 and pRB, available for analysis. Median follow-up was 8.9 years (range, 6.0 to 11.8 years) for surviving patients. Staining for each marker was then correlated with overall survival, local progression, distant metastasis, and disease-specific survival.

RESULTS

Loss of p16 expression, as defined by expression was significantly associated with reduced overall survival (P =.039), disease-specific survival (P =.006), and higher risk of local progression (P =.0007) and distant metastasis (P =.026) in the univariate analysis. In the multivariate analysis, loss of p16 was significantly associated with reduced disease-specific survival (P =.0078) and increased risk of local failure (P =.0035) and distant metastasis (P =.026). A borderline association with reduced overall survival (P =.07) was also evident. Loss of pRB was associated with improved disease-specific survival on univariate (P =.028) and multivariate analysis (P =.043), but carried no other significant outcome associations.

CONCLUSION

Loss of p16 is significantly associated with adverse clinical outcome in cases of locally advanced prostate cancer.

Can the doctor still see me? What happens when patients arrive late?

Demands to optimize productivity and quality require a patient scheduling system that can balance patient demand and clinic resources. The consequences of unscheduled and late patient arrivals on operational efficiencies have been documented. Less understood is the impact of unscheduled and late arrivals on the quality of service each receives. This article examines the impact of unscheduled and late patient arrivals on operational, clinical and administrative outcomes that affect quality of care of children potentially eligible for immunizations. An unexpected finding was the generally better and faster levels of service for late arrivals.

Non-punctual patients: planning for variability in appointment arrival times

Tighter competition and rationed resources place a premium on health clinic management of patient arrival times to maximize smooth workflow dynamics and consistency in patient processes. Early efforts to analyze patient arrival characteristics relied on assumptions that may have been too simplistic. For instance, it was assumed that a scheduled patient's arrival was likely to fit a bell-shaped curve in terms of being early, late, or on time and that any one patient's likelihood of being "on time" was purely a random event. However, our analysis of patient arrival times, obtained from detailed workflow observations in nine community clinics, indicates that the likelihood of a patient arriving early, late, or on time is neither entirely random nor does the pattern of arrivals fit a bell-shaped curve. Rather, patients tend to arrive in "clumps," possibly due to factors such as traffic patterns and parking availability. These findings are important with respect to 1) clinic practice management, 2) scheduling optimization strategies, and 3) computer simulation and analysis of clinic processes.

The forms that bind: multiple data forms result in internal disaggregation of immunization information

To examine how forms encountered during routine clinical activities impact a provider's immunization activity, workflow analysis was performed in nine community clinics and small private practices. Data gathered included the number, source, and nature of forms. A total of 200 forms were used by the nine clinics just for children under 35 months of age. These represent a real labor cost as well as an opportunity cost. Use of a single summary sheet, yearly review of the forms, and coordination of agency documentation efforts are recommended.

Implant volume as a prognostic variable in brachytherapy decision-making for malignant gliomas stratified by the RTOG recursive partitioning analysis

PURPOSE

When an initial retrospective review of malignant glioma patients (MG) undergoing brachytherapy was carried out using the Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis (RPA) criteria, it revealed that glioblastoma multiforme (GBM) cases benefit the most from implant. In the present study, we focused exclusively on these GBM patients stratified by RPA survival class and looked at the relationship between survival and implanted target volume, to distinguish the prognostic value of volume in general and for a given GBM class.

METHODS AND MATERIALS

Between 1991 and 1998, 75 MG patients were treated with surgery, external beam radiation, and stereotactic iodine-125 (I-125) implant. Of these, 53 patients (70.7%) had GBMs, with 52 (98%) having target volume (TV) data for analysis. Stratification by RPA criteria showed 12, 26, 13, and 1 patients in classes III to VI, respectively. For analysis purposes, classes V and VI were merged. There were 27 (51.9%) male and 25 (48.1%) female patients. Mean age was 57.5 years (range 14-79). Median Karnofsky performance status (KPS) was 90 (range 50-100). Median follow-up time was 11 months (range 2-79).

RESULTS

At analysis, 18 GBM patients (34.6%) were alive and 34 (65.4%) were dead. Two-year and 5-year survivals were 42% and 17.5%, respectively, with a median survival time (MST) of 16 months. Two-year survivals and MSTs for the implanted GBM patients compared to the RTOG database were as follows: 74% vs. 35% and 28 months vs. 17.9 months for class III; 32% vs. 15% and 16 months vs. 11.1 months for class IV; 29% vs. 6% and 11 months vs. 8.9 months for class V/VI. Mean implanted TV was 15.5 cc (range 0.8-78), which corresponds to a spherical implant diameter of 3.1 cm. Plotting survival as a function of 5-cc TV increments suggested a trend toward poorer survival as the implanted volume increases. The impact of incremental changes in TV on survival within a given RPA class of GBMs was compared to the RTOG database. Looking at absolute differences in MSTs: for classes III and IV, there was little effect of different TVs on survival; for class V/VI, a survival benefit to implantation was still seen at the target volume cutoff (TV > 25 cc). Within a given RPA class, no significant differences were found within class III; for class IV, the most significant difference was at 10 cc (p = 0.05); and for class V/VI, at 20 cc (p = 0.06).

CONCLUSION

For all GBM patients, an inverse relationship between implanted TV size and median survival is suggested by this study. However, when GBM patients are stratified using the RTOG's RPA criteria, the prognostic effect of implant volume disappears within each RPA survival class. At the critical volume of 25 cc, which approximates an implant of 5-cm diameter (upper implantation limit of many CNS brachytherapy protocols), the "poorest" prognosis GBM patients stratified by RPA still demonstrate a survival benefit with implant. We suggest that any GBM patient meeting brachytherapy recognized size criteria be considered for I-125 implant.

The cost to immunize during well-child visits

The objective of this study was to determine the incremental labor costs or opportunity costs associated with the provision of immunizations in ambulatory care settings. A time and motion analysis of primary care health visits by pediatric patients was performed in 10 community clinics and 5 private primary care practices. These clinics and practices were located in areas designated as Health Professional Shortage Areas, with traditionally low immunization coverage rates and other unmet primary care needs. The outcome measure for this study was the comparative duration of the visit, contrasting well-child visits during which immunization was given with well-child visits during which no immunization was given. The results suggested that immunizations present an opportunity cost during well-child visits. The average time of patient-provider contact found in this study supports other findings showing that this time is now significantly longer than that reported in the past. In order for providers to comply with increased recommendations and requirements for preventive health care services, the allotted visit time, capitation rates, and overall clinic system effectiveness need to be reexamined.

Hepatoblastoma with spinal metastases

Spinal cord compression secondary to metastases is an infrequent complication of childhood cancer. We describe an infant with hepatoblastoma in whom cord compression developed because of extensive epidural metastases during treatment. This is a hitherto undescribed metastatic site for hepatoblastoma.

Applying workflow analysis tools to assess immunization delivery in outpatient primary care settings

BACKGROUND

As health care organizations face increasing pressure to institute quality assurance activities, the already-underfunded community clinics that treat the poor and underserved are challenged to perform these activities within tight constraints of human and financial resources. With pediatric immunizations as a marker, a workflow observation tool was used to identify causal processes affecting immunization delivery.

METHODS

Ten clinics and five private practices, located in areas designated as health professional shortage areas, participated in the study, gaining access to a tool that would have been unaffordable to them from the private sector. Trained observers followed families through the clinic, using a 127-item workflow observation form--the Observational Checklist of Patient Encounters (OCPE)--assessing discrete activities that families encountered during the checkin/pre-exam, exam, discharge, and billing processes. A convenience sampling of the targeted population--children younger than three years of age--included observations of scheduled acute, scheduled well-child, follow-up, and walk-in visits. In the feedback session, a summary of each clinic's immunization delivery patterns was presented, with an emphasis on the individual health center's operational issues.

RESULTS

The workflow observation tool was used to identify operational errors affecting both clinical and fiscal processes in each of the clinics that had not been previously apparent to either clinic management or the quality improvement (QI) teams.

DISCUSSION

Feedback addressed and encouraged process-oriented improvements in response to the workflow observations, which were incorporated into the clinics' QI procedures. Twelve of the 15 clinics have formed process action teams to address QI issues on an ongoing basis.

Use of the RTOG recursive partitioning analysis to validate the benefit of iodine-125 implants in the primary treatment of malignant gliomas

PURPOSE

To date, numerous retrospective studies have suggested that the addition of brachytherapy to the conventional treatment of malignant gliomas (MG) (surgical resection followed by radiotherapy +/- chemotherapy) leads to improvements in survival. Two randomized trials have suggested either a positive or no survival benefit with implants. Critics of retrospective reports have suggested that the improvement in patient survival is due to selection bias. A recursive analysis by the RTOG of MG trials has stratified MG patients into 6 prognostically significant classes. We used the RTOG criteria to analyze the implant data at Wayne State University to determine the impact of selection bias.

METHODS AND MATERIALS

Between July 1991 and January 1998, 75 patients were treated with a combination of surgery, radiotherapy, and stereotactic I-125 implant as primary MG management. Forty-one (54.7%) were male; 34 (45.3%) female. Median age was 52 years (range 4-79). Twenty-two (29.3%) had anaplastic astrocytoma (AA); 53 (70.7%), glioblastoma multiforme (GBM). Seventy-two patients had data making them eligible for stratification into the 6 RTOG prognostic classes (I-VI). Median Karnofsky performance status (KPS) was 90 (range 50-100). There were 14, 0, 14, 31, 12, and 1 patients in Classes I to VI, respectively. Median follow-up time for AA, GBM, and any surviving patient was 29, 12.5, and 35 months, respectively.

RESULTS

At analysis, 29 (40.3%) patients were alive; 43 (59.7%), dead. For AA and GBM patients, 2-year and median survivals were: 58% and 40%; 38 and 17 months, respectively. For analysis purposes, Classes I and II, V and VI were merged. By class, the 2-year survival for implanted patients compared to the RTOG data base was: III--68% vs. I--76%; III--74% vs. 35%; IV--34% vs. 15%; V/VI--29% vs. V--6%. For implant patients, median survival by class was (in months): I/II--37; III--31; IV--16; V/VI--11.

CONCLUSION

When applied to MG patients receiving permanent I-125 implant, the criteria of the RTOG recursive partitioning analysis are a valid tool to define prognostically distinct survival groups. As reflected in the RTOG study, a downward survival trend for the implant patients is seen from "best to worse" class patients. Compared to the RTOG database, median survival achieved by the addition of implant is improved most demonstrably for the poorer prognostic classes. This would suggest that selection bias alone does not account for the survival benefit seen with I-125 implant and would contradict the notion that the patients most eligible for implant are those gaining the most benefit from the treatment. In light of the contradictory results from two randomized studies and given the present results, further randomized studies with effective stratification are required since the evidence for a survival benefit with brachytherapy (as seen in retrospective studies) is substantial.

Permanent 125iodine implants for recurrent malignant gliomas

PURPOSE

To determine the efficacy and toxicity of permanent 125iodine implants for recurrent malignant gliomas.

METHODS AND MATERIALS

Between January 1989 and January:, 59 patients with histologically confirmed recurrent malignant gliomas (22 nonglioblastoma malignant gliomas, 37 glioblastoma multiforme at the time of implant) received a permanent 125iodine implant. Patients ranged in age from 13-74 years. The median ages for the overall group, nonglioblastoma (nonGBM), and glioblastoma (GBM) groups was 47 years, 39 years, and 53 years, respectively.

RESULTS

With a median follow-up of 40 months, the median survival for the 59 total patients is 1.34 years; nonGBM 2.04 years, GBM 0.9 years. Factors predictive for poor prognosis were GBM histology, age 60 years or more, target volume 17 cc or more, and/or tumor location within the corpus callosum or thalamus. Reoperations have been performed in 24 (40%) patients; 15 (25%) for tumor progression; 3 (5%) for radiation necrosis; 2 (3%) for skull necrosis/infection, and 4 (7%) for other reasons (Ommaya reservoir insertion, catheter removal, hematoma evacuation).

CONCLUSION

Permanent 125iodine implants in selected patients with recurrent malignant gliomas are associated with reasonable long-term survival and a low risk of complications. Given the low incidence of radiation necrosis, future plans are to increase dose rate and/or total dose delivered with the permanent implant.