Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes

OBJECTIVE

To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls.

SUMMARY BACKGROUND DATA

It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients.

METHODS

Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality.

RESULTS

We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001].

CONCLUSIONS

Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

Assessing the Ambulatory Surgery Center Volume-Outcome Association

Importance

In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US.

Objective

To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity.

Design, Setting, and Participants

This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019.

Main Outcomes and Measures

Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures).

Results

Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity.

Conclusions and Relevance

In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.

Pre-COVID-19 hospital quality and hospital response to COVID-19: examining associations between risk-adjusted mortality for patients hospitalised with COVID-19 and pre-COVID-19 hospital quality

OBJECTIVES

The extent to which care quality influenced outcomes for patients hospitalised with COVID-19 is unknown. Our objective was to determine if prepandemic hospital quality is associated with mortality among Medicare patients hospitalised with COVID-19.

DESIGN

This is a retrospective observational study. We calculated hospital-level risk-standardised in-hospital and 30-day mortality rates (risk-standardised mortality rates, RSMRs) for patients hospitalised with COVID-19, and correlation coefficients between RSMRs and pre-COVID-19 hospital quality, overall and stratified by hospital characteristics.

SETTING

Short-term acute care hospitals and critical access hospitals in the USA.

PARTICIPANTS

Hospitalised Medicare beneficiaries (Fee-For-Service and Medicare Advantage) age 65 and older hospitalised with COVID-19, discharged between 1 April 2020 and 30 September 2021.

INTERVENTION/EXPOSURE

Pre-COVID-19 hospital quality.

OUTCOMES

Risk-standardised COVID-19 in-hospital and 30-day mortality rates (RSMRs).

RESULTS

In-hospital (n=4256) RSMRs for Medicare patients hospitalised with COVID-19 (April 2020-September 2021) ranged from 4.5% to 59.9% (median 18.2%; IQR 14.7%-23.7%); 30-day RSMRs ranged from 12.9% to 56.2% (IQR 24.6%-30.6%). COVID-19 RSMRs were negatively correlated with star rating summary scores (in-hospital correlation coefficient -0.41, p<0.0001; 30 days -0.38, p<0.0001). Correlations with in-hospital RSMRs were strongest for patient experience (-0.39, p<0.0001) and timely and effective care (-0.30, p<0.0001) group scores; 30-day RSMRs were strongest for patient experience (-0.34, p<0.0001) and mortality (-0.33, p<0.0001) groups. Patients admitted to 1-star hospitals had higher odds of mortality (in-hospital OR 1.87, 95% CI 1.83 to 1.91; 30-day OR 1.46, 95% CI 1.43 to 1.48) compared with 5-star hospitals. If all hospitals performed like an average 5-star hospital, we estimate 38 000 fewer COVID-19-related deaths would have occurred between April 2020 and September 2021.

CONCLUSIONS

Hospitals with better prepandemic quality may have care structures and processes that allowed for better care delivery and outcomes during the COVID-19 pandemic. Understanding the relationship between pre-COVID-19 hospital quality and COVID-19 outcomes will allow policy-makers and hospitals better prepare for future public health emergencies.

Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates

BACKGROUND

We define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region.

OBJECTIVE

To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region.

DESIGN

A matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals.

MAIN MEASURES

30-day (primary) and 90-day (secondary) all-cause mortality.

KEY RESULTS

30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality.

LIMITATIONS

The study used claims-based data.

CONCLUSIONS

In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.

Initial Findings From an Acute Hospital Care at Home Waiver Initiative

This cohort study assesses outcomes of patients treated during the initial 16 months of the Centers for Medicare &amp;amp; Medicaid Services Acute Hospital Care at Home initiative.

The Anesthesiology Physician-Scientist Pipeline: Current Status and Recommendations for Future Growth-An Initiative of the Anesthesia Research Council

The limited number and diversity of resident physicians pursuing careers as physician-scientists in medicine has been a concern for many decades. The Anesthesia Research Council aimed to address the status of the anesthesiology physician-scientist pipeline, benchmarked against other medical specialties, and to develop strategic recommendations to sustain and expand the number and diversity of anesthesiology physician-scientists. The working group analyzed data from the Association of American Medical Colleges and the National Resident Matching Program to characterize the diversity and number of research-oriented residents from US and international allopathic medical schools entering 11 medical specialties from 2009 to 2019. Two surveys were developed to assess the research culture of anesthesiology departments. National Institutes of Health (NIH) funding information awarded to anesthesiology physician-scientists and departments was collected from NIH RePORTER and the Blue Ridge Medical Institute. Anesthesiology ranked eighth to tenth place of 11 medical specialties in the percent of "research-oriented" entering residents, defined as those with advanced degrees (Master's or PhDs) in addition to the MD degree or having published at least 3 research publications before residency. Anesthesiology ranked eighth of 11 specialties in the percent of entering residents who were women but ranked fourth of 11 specialties in the percent of entering residents who self-identified as belonging to an underrepresented group in medicine. There has been a 72% increase in both the total NIH funding awarded to anesthesiology departments and the number of NIH K-series mentored training grants (eg, K08 and K23) awarded to anesthesiology physician-scientists between 2015 and 2020. Recommendations for expanding the size and diversity of the anesthesiology physician-scientist pipeline included (1) developing strategies to increase the number of research intensive anesthesiology departments; (2) unifying the diverse programs among academic anesthesiology foundations and societies that seek to grow research in the specialty; (3) adjusting American Society of Anesthesiologists metrics of success to include the number of anesthesiology physician-scientists with extramural research support; (4) increasing the number of mentored awards from Foundation of Anesthesia Education and Research (FAER) and International Anesthesia Research Society (IARS); (5) supporting an organized and concerted effort to inform research-oriented medical students of the diverse research opportunities within anesthesiology should include the specialty being represented at the annual meetings of Medical Scientist Training Program (MSTP) students and the American Physician Scientist Association, as well as in institutional MSTP programs. The medical specialty of anesthesiology is defined by new discoveries and contributions to perioperative medicine which will only be sustained by a robust pipeline of anesthesiology physician-scientists.

Oral Health Among Medicare Beneficiaries in Nursing Homes

This cross-sectional study investigates rates of dental problems among Medicare beneficiaries in nursing homes and characteristics associated with these rates.

The Transitional Coverage for Emerging Technologies Pathway-Enhancing Innovation While Establishing Patient Safeguards

This Viewpoint discusses the Centers for Medicare &amp;amp; Medicaid Services’ Transitional Coverage for Emerging Technologies pathway, which aims to enhance coverage of emerging technologies with supporting evidence.

Changes in Patient Experiences of Hospital Care During the COVID-19 Pandemic

Importance

It is important to assess how the COVID-19 pandemic was adversely associated with patients' care experiences.

Objective

To describe differences in 2020 to 2021 patient experiences from what would have been expected from prepandemic (2018-2019) trends and assess correlates of changes across hospitals.

Design, Setting, and Participants

This cohort study compared 2020 to 2021 data with 2018 to 2019 data from 3 900 887 HCAHPS respondents discharged from 3381 HCAHPS-participating US hospitals. The data were analyzed from 2022 to 2023.

Main Outcomes and Measures

The primary outcome was an HCAHPS summary score (HCAHPS-SS), which averaged 10 HCAHPS measures. The primary analysis estimated whether HCAHPS scores from patients discharged from 2020 to 2021 differed from scores that would be expected based on quarterly and linear trends from 2018 to 2019 discharges. Secondary analyses stratified hospitals by prepandemic overall star ratings and staffing levels.

Results

Of the 3 900 887 HCAHPS 2020 to 2021 respondents, 59% were age 65 years or older, and 35% (11%) were in the surgical (maternity) service lines. Compared with trends expected based on prepandemic (2018-2019) data, HCAHPS-SS was 1.2 percentage points (pp) lower for quarter (Q) 2/2020 discharges and -1.9 to -2.0 pp for Q3/2020 to Q1/2021, which then declined to -3.6 pp by Q4/2021. The most affected measures (Q4/2021) were staff responsiveness (-5.6 pp) and cleanliness (-4.9 pp); the least affected were discharge information (-1.6 pp) and quietness (-1.8 pp). Overall rating and hospital recommendation measures initially exhibited smaller-than-average decreases, but then fell as much as the more specific experience measures by Q2/2021. Quietness did not decline until Q2/2021. The HCAHPS-SS fell most for hospitals with the lowest prepandemic staffing levels; hospitals with bottom-quartile staffing showed the largest decrements, whereas top-quartile hospitals showed smaller decrements in most quarters. Hospitals with better overall prepandemic quality showed consistently smaller HCAHPS-SS drops, with effects for 5-star hospitals about 25% smaller than for 1-star and 2-star hospitals.

Conclusions and Relevance

The results of this cohort study of HCAHPS-participating hospitals found that patient experience scores declined during 2020 to 2021. By Q4/2021, the HCAHPS-SS was 3.6 pp lower than would have been expected, a medium effect size. The most affected measures (staff responsiveness and cleanliness) showed large effect sizes, possibly reflecting high illness-associated hospital workforce absenteeism. Hospitals that were lower performing and less staffed prepandemic may have been less resilient to reduced staff availability and other pandemic-associated challenges. However, by Q4/2021, even prepandemic high-performing hospitals had similar declines.

Redefining Multimorbidity in Older Surgical Patients

BACKGROUND

Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations.

STUDY DESIGN

We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching.

RESULTS

Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795).

CONCLUSIONS

Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.

The Safety of Performing Surgery at Ambulatory Surgery Centers Versus Hospital Outpatient Departments in Older Patients With or Without Multimorbidity

BACKGROUND

Surgery for older Americans is increasingly being performed at ambulatory surgery centers (ASCs) rather than hospital outpatient departments (HOPDs), while rates of multimorbidity have increased.

OBJECTIVE

To determine whether there are differential outcomes in older patients undergoing surgical procedures at ASCs versus HOPDs.

RESEARCH DESIGN

Matched cohort study.

SUBJECTS

Of Medicare patients, 30,958 were treated in 2018 and 2019 at an ASC undergoing herniorrhaphy, cholecystectomy, or open breast procedures, matched to similar HOPD patients, and another 32,702 matched pairs undergoing higher-risk procedures.

MEASURES

Seven and 30-day revisit and complication rates.

RESULTS

For the same procedures, HOPD patients displayed a higher baseline predicted risk of 30-day revisits than ASC patients (13.09% vs 8.47%, P < 0.0001), suggesting the presence of considerable selection on the part of surgeons. In matched Medicare patients with or without multimorbidity, we observed worse outcomes in HOPD patients: 30-day revisit rates were 8.1% in HOPD patients versus 6.2% in ASC patients ( P < 0.0001), and complication rates were 41.3% versus 28.8%, P < 0.0001. Similar patterns were also found for 7-day outcomes and in higher-risk procedures examined in a secondary analysis. Similar patterns were also observed when analyzing patients with and without multimorbidity separately.

CONCLUSIONS

The rates of revisits and complications for ASC patients were far lower than for closely matched HOPD patients. The observed initial baseline risk in HOPD patients was much higher than the baseline risk for the same procedures performed at the ASC, suggesting that surgeons are appropriately selecting their riskier patients to be treated at the HOPD rather than the ASC.

Does Masked Interviewing Encourage Holistic Review in Residency Selection? A Mixed-Methods Study

Problem: Medical educators increasingly champion holistic review. However, in U.S. residency selection, holistic review has been difficult to implement, hindered by a reliance on standardized academic criteria such as board scores. Masking faculty interviewers to applicants' academic files is a potential means of promoting holistic residency selection by increasing the interview's ability to make a discrete contribution to evaluation. However, little research has directly analyzed the effects of masking on how residency selection committees evaluate applicants. This mixed-methods study examined how masking interviews altered residency selection in an anesthesiology program at a large U.S. academic medical center. Intervention: During the 2019-2020 residency selection season in the University of Pennsylvania's Department of Anesthesiology & Critical Care, we masked interviewers to the major academic components of candidates' application files (board scores, transcripts, letters) on approximately half of interview days. The intent of the masking intervention was to mitigate the tendency of interviewers to form predispositions about candidates based on standardized academic criteria and thereby allow the interview to make a more independent contribution to candidate evaluation. Context: Our examination of the masking intervention used a concurrent, partially mixed, equal-status mixed-methods design guided by a pragmatist approach. We audio-recorded selection committee meetings and qualitatively analyzed them to explore how masking affected the process of candidate evaluation. We also collected independent candidate ratings from interviewers and consensus committee ratings and statistically compared ratings of candidates interviewed on masked days to ratings from conventional days. Impact: In conventional committee meetings, interviewers focused on how to reconcile academic metrics and interviews, and their evaluations of interviews were framed according to predispositions about candidates formed through perusal of application files. In masked meetings, members instead spent considerable effort evaluating candidates' "fit" and whether they came off as tactful. Masked interviewers gave halting opinions of candidates and sometimes pushed for committee leaders to reveal academic information, leading to masking breaches. Higher USMLE Step 1 score and higher medical school ranking were statistically associated with more favorable consensus rating. We found no significant differences in rating outcomes between masked and conventional interview days. Lessons learned: Elimination of academic metrics during the residency interview phase does not straightforwardly promote holistic review. While critical reflection among medical educators about the fairness and utility of such metrics has been productive, research and intervention should focus on the more proximate topic of how programs apply academic and other criteria to evaluate applicants.

Assessing Hospital Quality Scores By Proportion Of Patients Dually Eligible For Medicare And Medicaid

The Centers for Medicare and Medicaid Services has been reporting hospital star ratings since 2016. Some stakeholders have criticized the star ratings methodology for not adjusting for social risk factors. We examined the relationship between 2021 star rating scores and hospitals' proportion of Medicare patients dually eligible for Medicaid. We found that, on average, hospitals caring for a greater proportion of dually eligible patients had lower star ratings, but there was significant overlap in performance among hospitals when we stratified them by quintile of dually eligible patients. Hospitals in the highest quintile (those with the greatest proportion of dually eligible patients) had the best mean mortality scores (0.28) but the worst readmission (-0.44) and patient experience (-0.78) scores. We assigned star ratings after stratifying the readmission measure group by proportion of dually eligible patients and found that a total of 142 hospitals gained a star and 161 hospitals lost a star, of which 126 (89 percent) and 1 (<1 percent) were in the highest quintile, respectively. Adjusting public reporting tools such as star ratings for social risk factors is ultimately a policy decision, and views on the appropriateness of accounting for factors such as proportion of dually eligible patients are mixed, depending on the organization and stakeholder.

A Vision of Medicare Coverage for New and Emerging Technologies-A Consistent Process to Foster Innovation and Promote Value

This Viewpoint details the commitment of the Centers for Medicare &amp;amp; Medicaid Services to ensure access for Medicare beneficiaries to new and emerging health care technologies.

Alzheimer's Dementia After Exposure to Anesthesia and Surgery in the Elderly: A Matched Natural Experiment Using Appendicitis

OBJECTIVE

The aim of this study was to determine whether surgery and anesthesia in the elderly may promote Alzheimer disease and related dementias (ADRD).

BACKGROUND

There is a substantial conflicting literature concerning the hypothesis that surgery and anesthesia promotes ADRD. Much of the literature is confounded by indications for surgery or has small sample size. This study examines elderly patients with appendicitis, a common condition that strikes mostly at random after controlling for some known associations.

METHODS

A matched natural experiment of patients undergoing appendectomy for appendicitis versus control patients without appendicitis using Medicare data from 2002 to 2017, examining 54,996 patients without previous diagnoses of ADRD, cognitive impairment, or neurological degeneration, who developed appendicitis between ages 68 through 77 years and underwent an appendectomy (the ''Appendectomy'' treated group), matching them 5:1 to 274,980 controls, examining the subsequent hazard for developing ADRD.

RESULTS

The hazard ratio (HR) for developing ADRD or death was lower in the Appendectomy group than controls: HR = 0.96 [95% confidence interval (CI) 0.94-0.98], P < 0.0001, (28.2% in Appendectomy vs 29.1% in controls, at 7.5 years). The HR for death was 0.97 (95% CI 0.95-0.99), P = 0.002, (22.7% vs 23.1% at 7.5 years). The HR for developing ADRD alone was 0.89 (95% CI 0.86-0.92), P < 0.0001, (7.6% in Appendectomy vs 8.6% in controls, at 7.5 years). No subgroup analyses found significantly elevated rates of ADRD in the Appendectomy group.

CONCLUSION

In this natural experiment involving 329,976 elderly patients, exposure to appendectomy surgery and anesthesia did not increase the subsequent rate of ADRD.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Telemedicine Across the Cancer Care Continuum: Evidence and Opportunities for Clinical Care, Research, and Policy

ABSTRACT

In this commentary, we provide an overview about the surge of telemedicine services during the COVID-19 pandemic, describe the cancer care continuum and existing evidence regarding the use of telemedicine across the continuum, and offer our perspective on existing opportunities to advance the use of telemedicine in clinical care, research, and policy. While research implications are relevant to an international audience, our focus pertains specifically to health care delivery and policy in the United States.

Improving Formative Feedback in the Operating Room Setting: Developing and Implementing an Initiative to Improve Feedback Quality and Culture

PROBLEM

Formative feedback, given in an ongoing fashion during the learning process, is fundamental to clinical education. However, dissatisfaction with formative feedback among residents is common. Difficulties with formative feedback are intensified in the operating room (OR) setting due to fast pace, space limitations, and frequent rotation of residents and attendings.

APPROACH

In the anesthesiology and critical care department at the University of Pennsylvania Perelman School of Medicine, the authors launched the Feedback Moment initiative from January 2018 to May 2018 in which 24 first-year residents and attendings were given a short series of prompts designed to facilitate regular, high-quality formative feedback. The authors conducted semistructured interviews with residents before and after the initiative to evaluate its impact.

OUTCOMES

In baseline interviews, 18 participating residents stressed the importance of formative feedback but described feeling unsure of their performance due to lack of ongoing constructive input from attendings. They felt hesitant to approach attendings for feedback due to a desire not to interrupt OR workflow or appear incompetent. In follow-up interviews, residents described the initiative as helping to normalize constructive formative feedback but difficult to execute regularly due to OR workflow issues and frequent rotation of attendings with varying approaches.

NEXT STEPS

Challenges faced by participants in this initiative highlight several considerations for effective OR-based formative feedback. Alternative timings for initiating feedback must be considered in light of the hectic nature of the OR workflow. Residents should be equipped with the skills necessary to adapt to varying practice patterns and frequent rotation between attendings, while attendings should be trained to provide a clear rationale for constructive feedback that allows residents to quickly adapt to practice variation. Finally, establishing clear goals among resident-attending pairs is critical to ensuring that formative feedback given in necessarily brief sessions is focused and productive.

Physicians' perspectives of prognosis and goals of care discussions after hip fracture

BACKGROUND

Hip fracture often represents a major transition in patients' health, with a 1-year mortality rate between 25% and 30% and a challenging recovery course. Caring for hip fracture patients presents opportunities for goals of care discussions that include prognostic information and guidance about functional dependence.

METHODS

We conducted qualitative, semi-structured interviews with 23 attending physicians involved with the care of hip fracture patients, including orthopedic surgeons, anesthesiologists, internists, and geriatricians, across 13 health systems in the United States and Canada. Questions addressed knowledge and interpretation of prognosis, discussing prognosis and goals of care, and timing and prioritization of surgery. Interviews were analyzed using a constructivist grounded theory approach to identify themes and develop a coding taxonomy.

RESULTS

Physicians agreed that hip fracture had a considerable 1-year mortality, felt that it was important to discuss prognostic outcomes and the recovery process, wanted to elucidate patients' priorities, and often promoted timely surgery. Physicians perceived challenges when discussing mortality data with new patients in an acute setting. They more easily discussed outcomes related to functional dependence and quality of life. Some physicians used iterative communication as a strategy to have in-depth conversations in a busy perioperative setting.

CONCLUSION

Providing timely, compassionate care for hip fracture patients is challenging. There are opportunities to study iterative communication to encourage dialogue at key points of patient care to better discuss prognosis and recovery and bolster coordinated multidisciplinary care that focuses on patients' goals and values.

Improving Serious Illness Care for Surgical Patients: Quality Indicators for Surgical Palliative Care

OBJECTIVE

Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients.

SUMMARY OF BACKGROUND DATA

PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery.

METHODS

We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion.

RESULTS

After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care.

CONCLUSIONS

This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode.

Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults

BACKGROUND

The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied.

METHODS

We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days.

RESULTS

A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30).

CONCLUSIONS

Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).

Relative contribution of vitamin D deficiency to subclinical atherosclerosis in Indian context: Preliminary findings

Asian Indians have a genetic predisposition to atherothrombotic risk. common carotid intima-media thickness (CCIMT) measured by ultrasound is a quantitative marker for atherosclerotic burden and a derived variable, that is, "CCIMT statistical Z-score (Z-score)" is useful for better quantification. The association between vitamin D deficiency and atherosclerosis is inconclusive. Since, vitamin D deficiency is highly prevalent in India, there is a need to study its relative contribution to subclinical atherosclerotic burden.This prospective cross-sectional study (n = 117) in apparently healthy individuals aged 20 to 60 years sought to identify the determinants of CCIMT Z score with CCIMT measured by "echo-tracking" method. A multivariable linear regression analysis was done with CCIMT Z score as dependent variable and the following as independent variables: age, body mass index, waist-to-height ratio, total cholesterol to HDL ratio (TC-HDL ratio), serum vitamin D3 levels (ng/mL), sex, diabetes mellitus, current cigarette smoking status. A diagnostic prediction model was also developed with a threshold value of 1.96 for CCIMT Z score.The mean (SD) for calendar age (y) was 40 (8). There were 26 (22.22%) individuals in sample with CCIMT Z score ≥1.96 (advanced stage) of whom 14 (23.33%) were <40 y (n = 60). The mean score was 1.28 (90th percentile) in the entire sample. Vitamin D3 deficiency with a mean (SD) blood level (ng/mL) of 14.3 (6.4) was noted and prevalence of deficiency was 81%. The final model wasCCIMT Z-score = 0.80 +  (0.841 × current smoking = 1) + (0.156 × TC-HDL ratio) - (0.0263 × vitamin D3 blood level in ng/mL).The decreasing order of association is smoking, TC-HDL ratio, and vitamin D3. With the model, likelihood ratio (95% CIs) was better for positive test 3.5 (1.23-9.94) than that for a negative test 0.83 (0.66-1.02).Internal validation with Bootstrap resampling revealed stability of baseline diagnostic variables.There is substantial subclinical atherosclerotic burden in Indian setting with independent contribution by vitamin D deficiency. The model is valuable in "ruling-in" of the underlying advanced atherosclerosis. The study is limited by convenient sampling and lack of external validation of the model.

The association of nursing home quality ratings and spread of COVID-19

Objectives

The coronavirus disease 2019 (COVID‐19) pandemic has severely affected nursing home residents. Given the continued high incidence of COVID‐19, and the likelihood that new variants and other infectious agents may cause future outbreaks, we sought to understand the relationship of nursing home quality ratings and measures of COVID‐19 outbreak severity and persistence.

Design

We analyzed nursing home facility‐level data on COVID‐19 cases and deaths, county‐level COVID‐19 rates, and nursing home data from the Centers for Medicare & Medicaid Services (CMS), including ratings from the CMS Nursing Home Five‐Star Quality Rating System. We used regression analysis to examine the association between star ratings and cumulative COVID‐19 incidence and mortality as well as persistent high resident incidence.

Setting

All nursing homes in the CMS COVID‐19 Nursing Home Dataset reporting data that passed quality assurance checks for at least 20 weeks and that were included in the January 2021 Nursing Home Care Compare update.

Participants

Residents of the included nursing homes.

Measurements

Cumulative resident COVID‐19 incidence and mortality through January 10, 2021; number of weeks with weekly resident incidence of COVID‐19 in the top decile nationally.

Results

As of January 10, 2021, nearly all nursing homes (93.6%) had reported at least one case of COVID‐19 among their residents, more than three‐quarters (76.9%) had reported at least one resident death, and most (83.5%) had experienced at least 1 week in the top decile of weekly incidence. In analyses adjusted for facility and county‐level characteristics, we found generally consistent relationships between higher nursing home quality ratings and lower COVID‐19 incidence and mortality, as well as with fewer high‐incidence weeks.

Conclusion

Nursing home quality ratings are associated with COVID‐19 incidence, mortality, and persistence. Nursing homes receiving five‐star ratings, for overall quality as well as for each domain, had lower COVID‐19 rates among their residents.

Recommendations for strengthening the role of embedded researchers to accelerate implementation in health systems: Findings from a state-of-the-art (SOTA) conference workgroup

BACKGROUND

Traditional research approaches do not promote timely implementation of evidence-based innovations (EBIs) to benefit patients. Embedding research within health systems can accelerate EBI implementation by blending rigorous methods with practical considerations in real-world settings. A state-of-the-art (SOTA) conference was convened in February 2019 with five workgroups that addressed five facets of embedded research and its potential to impact healthcare. This article reports on results from the workgroup focused on how embedded research programs can be implemented into heath systems for greatest impact.

METHODS

Based on a pre-conference survey, participants indicating interest in accelerating implementation were invited to participate in the SOTA workgroup. Workgroup participants (N = 26) developed recommendations using consensus-building methods. Ideas were grouped by thematic clusters and voted on to identify top recommendations. A summary was presented to the full SOTA membership. Following the conference, the workgroup facilitators (LJD, CDH, NR) summarized workgroup findings, member-checked with workgroup members, and were used to develop recommendations.

RESULTS

The workgroup developed 12 recommendations to optimize impact of embedded researchers within health systems. The group highlighted the tension between "ROI vs. R01" goals-where health systems focus on achieving return on their investments (ROI) while embedded researchers focus on obtaining research funding (R01). Recommendations are targeted to three key stakeholder groups: researchers, funders, and health systems. Consensus for an ideal foundation to support optimal embedded research is one that (1) maximizes learning; (2) aligns goals across all 3 stakeholders; and (3) implements EBIs in a consistent and timely fashion.

CONCLUSIONS

Four cases illustrate a variety of ways that embedded research can be structured and conducted within systems, by demonstrating key embedded research values to enable collaborations with academic affiliates to generate actionable knowledge and meaningfully accelerate implementation of EBIs to benefit patients.

IMPLICATIONS

Embedded research approaches have potential for transforming health systems and impacting patient health. Accelerating embedded research should be a focused priority for funding agencies to maximize a collective return on investment.