Exploring the atypia of undetermined significance: Malignant ratio, ThyroSeq v3 positive call rate, molecular-derived risk of malignancy, and risk of malignancy as possible quality metric tools in thyroid cytology

BACKGROUND

The atypia of undetermined significance (AUS) category is heterogeneous, leading to variations in its use. To prevent excessive usage, the AUS rate should be ≤10%. Although this recommendation aims to maintain diagnostic quality, it lacks supporting data. The AUS:Malignant (AUS:M) ratio has been proposed as a metric tool to evaluate AUS use. Furthermore, integrating ThyroSeq v3 (TSV3) positive call rate (PCR) and the molecular-derived risk of malignancy (MDROM) have been put forward as performance improvement tools. The authors reviewed their AUS:M ratios, TSV3 PCR, MDROM, and ROM.

METHODS

Thyroid aspirates evaluated in the laboratory (from August 2022 to September 2023) by seven cytopathologists (CPs) were identified. AUS:M ratio, MDROM, ROM, and TSV3 PCR results for the laboratory and each CP were recorded and analyzed.

RESULTS

A total of 2248 aspirates were identified (462 AUS and 80 malignant). The AUS:M ratio for the laboratory was 5.8 (CPs range, 2.8 to 7.3). The TSV3 PCR for the laboratory was 23% (CPs range, 11% to 41%). The MDROM for the laboratory was 19% (CPs range, 9% to 31%), whereas the ROM was 36% (CPs range, 29% to 50%). Linear regression analysis of AUS:M ratio versus TSV3 PCR and MDROM demonstrated a moderate positive correlation but a weak negative correlation to the ROM. Deviations from established targets were attributed to multiple factors.

CONCLUSION

The findings of this study underscore the importance of using a combination of metrics to evaluate diagnostic practices. By dissecting the practice patterns of each CP, the authors can measure different aspects of their performance and provide individualized feedback.

Programmatic quality measures: a new model to promote surgical quality

Health care performance metrics are offered predominantly in terms of outcomes, processes, or structural components of health care delivery. However, measurement is limited by variability in data sources, definitions, and workarounds. The American College of Surgeons has recently developed a new type of performance metric known as a "programmatic measure". These metrics align structures, processes, and outcomes to better coordinate quality measurement with support of frontline care teams. In this multifaceted way, these measures differ from current "single" measures such as targeting surgical site infection. The thematic focus of these measures and alignment of structure-resource components to support processes and outcomes also sets these measures apart from contemporary composite measures. Importantly, structural elements of these measures reflect minimum resources required for patient care, addressing staffing and resource barriers felt by local institutions in addressing numerous existing quality metrics. These metrics will streamline quality reporting to improve care navigation for patients. Clinicians will find more appropriately aligned goals and responsibilities, resulting in increased teamwork and communication. These measures are designed to address the current burdens of overabundant metrics, priority misalignment, and low resources in a patient-centric fashion to better align health care quality and measurement.

Hospital-onset bacteremia: clinical and regulatory ramifications

Tweetable abstract Read the commentary by @Kalvin_Yu_MD and Anuprita Patkar, PhD on the higher risk mortality, LOS and cost of hospital-onset bacteremia (HOB), and the implications of a regulatory HOB quality metric for patient care, clinical workflows and hospital administration #PatientSafety #QualityMetric.

Assessing the Differential Methylation Analysis Quality for Microarray and NGS Platforms

Differential methylation (DM) is actively recruited in different types of fundamental and translational studies. Currently, microarray- and NGS-based approaches for methylation analysis are the most widely used with multiple statistical models designed to extract differential methylation signatures. The benchmarking of DM models is challenging due to the absence of gold standard data. In this study, we analyze an extensive number of publicly available NGS and microarray datasets with divergent and widely utilized statistical models and apply the recently suggested and validated rank-statistic-based approach Hobotnica to evaluate the quality of their results. Overall, microarray-based methods demonstrate more robust and convergent results, while NGS-based models are highly dissimilar. Tests on the simulated NGS data tend to overestimate the quality of the DM methods and therefore are recommended for use with caution. Evaluation of the top 10 DMC and top 100 DMC in addition to the not-subset signature also shows more stable results for microarray data. Summing up, given the observed heterogeneity in NGS methylation data, the evaluation of newly generated methylation signatures is a crucial step in DM analysis. The Hobotnica metric is coordinated with previously developed quality metrics and provides a robust, sensitive, and informative estimation of methods' performance and DM signatures' quality in the absence of gold standard data solving a long-existing problem in DM analysis.

Team-Based Hospice Referrals: A Potential Quality Metric for Lung Cancer in the Immunotherapy Era

BACKGROUND

Immune checkpoint inhibitors (ICIs) can lead to durable responses in patients with lung cancer but may delay transitions to hospice at the end of life (EOL). We aimed to test the association of continuity of care with EOL outcomes in the ICI era.

METHODS

We collected retrospective data on all patients with lung cancer who started ICI treatment at a single comprehensive cancer center in the United States (1/1/14-5/1/18) and subsequently died. We defined a hospice referral as having continuity of care if placed by a provider from the patient's multidisciplinary cancer team (e.g., a medical oncologist, palliative care specialist, intensivist, and hospitalist).

RESULTS

In this cohort of 143 patients, 58% had a team-based hospice referral which was associated with a lower risk of death in the hospital. The most common reason patients declined hospice at EOL was an unwillingness to discontinue cancer-directed therapy. As compared to a similar historical cohort of patients treated with chemotherapy alone (2008-2010), there was a similar rate of hospice referral (68% vs 74%) but higher rates of new systemic therapy initiated within 30 days of death (17% vs 6%, p .001) and last dose within 14 days of death (13% vs 5%, p .005).

CONCLUSIONS

Future studies should test the continuity of care at EOL as a new quality metric for advanced NSCLC.

Delivery of drinking, eating and mobilising (DrEaMing) and its association with length of hospital stay after major noncardiac surgery: observational cohort study

Background

Enhanced recovery pathways are associated with improved postoperative outcomes. However, as enhanced recovery pathways have become more complex and varied, compliance has reduced. The ‘DrEaMing’ bundle re-prioritises early postoperative delivery of drinking, eating, and mobilising. We investigated relationships between DrEaMing compliance, postoperative hospital length of stay (LOS), and complications in a prospective multicentre major surgical cohort.

Methods

We interrogated the UK Perioperative Quality Improvement Programme dataset. Analyses were conducted in four stages. In an exploratory cohort, we identified independent predictors of DrEaMing. We quantified the association between delivery of DrEaMing (and its component variables) and prolonged LOS in a homogenous colorectal subgroup and assessed generalisability in multispecialty patients. Finally, LOS and complications were compared across hospitals, stratified by DrEaMing compliance.

Results

The exploratory cohort comprised 22 218 records, the colorectal subgroup 7230, and the multispecialty subgroup 5713. DrEaMing compliance was 59% (13 112 patients), 60% (4341 patients), and 60% (3421), respectively, but varied substantially between hospitals. Delivery of DrEaMing predicted reduced odds of prolonged LOS in colorectal (odds ratio 0.51 [0.43–0.59], P<0.001) and multispecialty cohorts (odds ratio 0.47 [0.41–0.53], P<0.001). At the hospital level, complications were not the primary determinant of LOS after colorectal surgery, but consistent delivery of DrEaMing was associated with significantly shorter LOS.

Conclusions

Delivery of bundled and unbundled DrEaMing was associated with substantial reductions in postoperative LOS, independent of the effects of confounder variables. Consistency of process delivery, and not complications, predicted shorter hospital-level length of stay. DrEaMing may be adopted by perioperative health systems as a quality metric to support improved patient outcomes and reduced hospital length of stay.

A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes

BACKGROUND

Cesarean delivery rates have been used as obstetrical quality indicators. However, these approaches do not consider the accompanying maternal and neonatal morbidities. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses preexisting high-risk maternal factors and associated maternal and neonatal morbidities and is universally acceptable to all stakeholders, including patients, healthcare providers, payers, and governmental agencies.

OBJECTIVE

This study aimed to (1) establish a new single metric for obstetrical quality improvement among nulliparous patients with term singleton vertex-presenting fetus, integrating cesarean delivery rates adjusted for preexisting high-risk maternal factors with associated maternal and neonatal morbidities, and (2) determine whether obstetrician quality ranking by this new metric is different compared with the rating based on individual crude and/or risk-adjusted cesarean delivery rates. The single metric has been termed obstetrical safety and quality index.

STUDY DESIGN

This was a cross-sectional study of all nulliparous patients with term singleton vertex-presenting fetuses delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed, including a review of maternal high-risk factors and maternal and neonatal outcomes. Maternal and neonatal medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean delivery rates and rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the obstetrical safety and quality index for each obstetrician. The final ranking based on the obstetrical safety and quality index was compared with the initial ranking by crude cesarean delivery rates. Maternal and neonatal morbidities were analyzed as ≥1 and ≥2 maternal and/or neonatal complications.

RESULTS

These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05; 95% confidence interval, -0.54 to 0.60) to the final ranking based on the obstetrical safety and quality index. Of note, 8 of 12 obstetricians shifted their rank quartiles after adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 maternal and/or neonatal complication and ranking based on ≥2 maternal and/or neonatal complications (rho=0.63; 95% confidence interval, 0.08-0.88).

CONCLUSION

Ranking based on crude cesarean delivery rates varied significantly after considering high-risk maternal conditions and associated maternal and neonatal outcomes. Therefore, the obstetrical safety and quality index, a single metric, was developed to identify ways to improve clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared toward patient safety, balancing cesarean delivery rates with optimal maternal and neonatal outcomes. This metric could be used to compare obstetrical quality not only among individual obstetricians but also among hospitals that practice obstetrics.

Stereo Video Quality Metric Based on Multi-Dimensional Analysis

Stereo video has been widely applied in various video systems in recent years. Therefore, objective stereo video quality metric (SVQM) is highly necessary for improving the watching experience. However, due to the high dimensional data in stereo video, existing metrics have some defects in accuracy and robustness. Based on the characteristics of stereo video, this paper considers the coexistence and interaction of multi-dimensional information in stereo video and proposes an SVQM based on multi-dimensional analysis (MDA-SVQM). Specifically, a temporal-view joint decomposition (TVJD) model is established by analyzing and comparing correlation in different dimensions and adaptively decomposes stereo group of frames (sGoF) into different subbands. Then, according to the generation mechanism and physical meaning of each subband, histogram-based and LOID-based features are extracted for high and low frequency subband, respectively, and sGoF quality is obtained by regression. Finally, the weight of each sGoF is calculated by spatial-temporal energy weighting (STEW) model, and final stereo video quality is obtained by weighted summation of all sGoF qualities. Experiments on two stereo video databases demonstrate that TVJD and STEW adopted in MDA-SVQM are convincible, and the overall performance of MDA-SVQM is better than several existing SVQMs.

Quantitative assessment of ensemble coherency in contrast-free ultrasound microvasculature imaging

Purpose

Contrast‐free visualization of microvascular blood flow (MBF) using ultrasound can play a valuable role in diagnosis and detection of diseases. In this study, we demonstrate the importance of quantifying ensemble coherence for robust MBF imaging. We propose a novel approach to quantify ensemble coherence by estimating the local spatiotemporal correlation (LSTC) image, and evaluate its efficacy through simulation and in vivo studies.

Methods

The in vivo patient studies included three volunteers with a suspicious breast tumor, 15 volunteers with a suspicious thyroid tumor, and two healthy volunteers for renal MBF imaging. The breast data displayed negligible prior motion and were used for simulation analysis involving synthetically induced motion, to assess its impact on ensemble coherency and motion artifacts in MBF images. The in vivo thyroid data involved complex physiological motion due to its proximity to the pulsating carotid artery, which was used to assess the in vivo efficacy of the proposed technique. Further, in vivo renal MBF images demonstrated the feasibility of using the proposed ensemble coherence metric for curved array‐based MBF imaging involving phase conversion. All ultrasound data were acquired at high imaging frame rates and the tissue signal was suppressed using spatiotemporal clutter filtering. Thyroid tissue motion was estimated using two‐dimensional normalized cross correlation‐based speckle tracking, which was subsequently used for ensemble motion correction. The coherence of the MBF image was quantified based on Casorati correlation of the Doppler ensemble.

Results

The simulation results demonstrated that an increase in ensemble motion corresponded with a decrease in ensemble coherency, which reciprocally degraded the MBF images. Further the data acquired from breast tumors demonstrated higher ensemble coherency than that from thyroid tumors. Motion correction improved the coherence of the thyroid MBF images, which substantially improved its visualization. The proposed coherence metrics were also useful in assessing the ensemble coherence for renal MBF imaging. The results also demonstrated that the proposed coherence metric can be reliably estimated from downsampled ensembles (by up to 90%), thus allowing improved computational efficiency for potential applications in real‐time MBF imaging.

Conclusions

This pilot study demonstrates the importance of assessing ensemble coherency in contrast‐free MBF imaging. The proposed LSTC image quantified coherence of the Doppler ensemble for robust MBF imaging. The results obtained from this pilot study are promising, and warrant further development and in vivo validation.

Quality metrics for head and neck cancer treated with definitive radiotherapy and/or chemotherapy

BACKGROUND

The standardization of quality measures has been key in advancing the aims of the National Quality Forum established to improve health outcomes.

METHODS

The National Cancer Database was used to identify eligible patients. Two quality metrics were evaluated including time to treatment initiation (TTI) and chemotherapy in locoregionally head and neck squamous cell carcinoma (HNSCC).

RESULTS

TTI was significantly associated with mortality reflected by a hazard ratio (HR) of 1.13 for 60-90 days of TTI (95% CI 1.08-1.17), 1.19 for >90 days of TTI (95% CI 1.13-1.26). Patients with locoregionally advanced HNSCC had an 87% adherence to chemotherapy, which correlated with reduced mortality (HR 0.57; 95% CI 0.55-0.59). Patients treated at high quality centers had a 9% increase in survival (HR 0.91; 95% CI 0.88-0.93).

CONCLUSION

We identified that both TTI and chemotherapy for locoregionally advanced HNSCC meet criteria for valid quality metrics potentially suitable for national adoption.

Analysis of Subtelomeric REXTAL Assemblies Using QUAST

Genomic regions of high segmental duplication content and/or structural variation have led to gaps and misassemblies in the human reference sequence, and are refractory to assembly from whole-genome short-read datasets. Human subtelomere regions are highly enriched in both segmental duplication content and structural variations, and as a consequence are both impossible to assemble accurately and highly variable from individual to individual. Recently, we developed a pipeline for improved region-specific assembly called Regional Extension of Assemblies Using Linked-Reads (REXTAL). In this study, we evaluate REXTAL and genome-wide assembly (Supernova) approaches on 10X Genomics linked-reads data sets partitioned and barcoded using the Gel Bead in Emulsion (GEM) microfluidic method. Our results describe the accuracy and relative performance of these two approaches using the reference-based assessment module of QUAST. We show that REXTAL dramatically outperforms the Supernova whole genome assembler in subtelomeric segmental duplication regions, and results in highly accurate assemblies. Nearly all of the REXTAL "misassemblies" identified using default QUAST parameters simply pinpoint locations of tandem repeat arrays in the reference sequence where the repeat array length differs from that in the cognate REXTAL assembly by 1000 bp.

Special statement: Proposed quality metrics to assess accuracy of prenatal detection of congenital heart defects

Congenital heart defects are a leading cause of neonatal morbidity and mortality. Accurate prenatal diagnosis of congenital heart defects can reduce morbidity and mortality by improving prenatal care, facilitating predelivery pediatric cardiology consultation, and directing delivery to facilities with resources to manage the complex medical and surgical needs of newborns with congenital heart defects. Unfortunately, less than one half of congenital heart defect cases are detected prenatally, resulting in lost opportunities for counseling, shared decision-making, and delivery at an appropriate facility. Quality improvement initiatives to improve prenatal congenital heart defects detection depend on the ability to measure the rate of detection at the level of providers, facilities, or populations, but no standard metric exists for measuring the detection of congenital heart defects at any level. The need for such a metric was recognized at a Cooperative Workshop held at the 2016 Annual Meeting of the Society for Maternal-Fetal Medicine, which recommended the development of a quality metric to assess the rate of prenatal detection of clinically significant congenital heart defects. In this paper, we propose potential quality metrics to measure prenatal detection of critical congenital heart defects, defined as defects with a high rate of morbidity or mortality or that require surgery or tertiary follow-up. One metric is based on a retrospective approach, assessing whether postnatally diagnosed congenital heart defects had been identified prenatally. Other metrics are based on a prospective approach, assessing the sensitivity and specificity of prenatal diagnosis of congenital heart defects by comparing prenatal ultrasound findings with newborn findings. Potential applications, limitations, challenges, barriers, and value for both approaches are discussed. We conclude that future development of these metrics will depend on an expansion of the International Classification of Diseases system to include specific codes that distinguish fetal congenital heart defects from newborn congenital heart defects and on the development of record systems that facilitate the linkage of fetal records (in the maternal chart) with newborn records.

An analysis of unplanned readmissions after head and neck microvascular reconstructive surgery

The 30-day readmission rate is a highly scrutinized metric of quality surgical care, because readmission is costly and perceived to be avoidable with planning and patient education. Head and neck surgery patients generally have multiple risk factors for readmission, as readmitted patients are generally older, with more co-morbidities, lower socio-economic status, and a history of multiple emergency department visits and readmissions. A retrospective cohort study was implemented to determine the incidence and etiology of 30-day readmission after microvascular head and neck reconstructive surgery, focusing on social risk factors. Data were analyzed by χ² test, analysis of variance, t-test, and logistic regression, with statistical significance set at P<0.05. Of 209 patients included in this study, 35 (16.7%) had a 30-day readmission. Increased needs at discharge were associated with increased readmission, while other social risk factors were less significant for a readmission in this study.

Missing the Mark: High Rates of Absent and Untimely Access to Specialty Palliative Care in Patients with Peri-Hospital Mortality

Background: Despite mounting evidence that specialty palliative care (PC) improves patients' symptoms, quality of life, and goal concordant care, these services are likely underutilized. Objective: To determine the rate of missed and delayed opportunities for specialty PC in patients with peri-hospital death. Design: A retrospective, cross-sectional analysis, using electronic medical records of a state-wide healthcare system in Colorado, was performed. Included were adults who died during admission or within seven days of discharge from January 2015 to October 2018 at an academic medical center and had prior encounters within the affiliated state-wide healthcare system in the last year of life. Excluded were patients with sudden or obstetrics-related deaths. Referral orders from the electronic medical record identified specialty PC consultation. Data from the Colorado Department of Public Health and Environment linked with the medical record determined time from first PC consultation to death. Results: The sample included 2088 decedent patients, with most deaths (81%) occurring in the hospital. Only 33% of patients had PC consultation, which was higher for patients with cancer (42%) than for those without cancer (26%). Of patients with specialty PC consultation, the median time from first referral to death was eight days (interquartile range: 3.25-25 days). Conclusions: Patients with peri-hospital death have low rates of specialty PC consultation, which, when present, often occurs close to death. This suggests there is a high rate of missed opportunities for specialty PC in this population.

Access to extracorporeal life support as a quality metric: Lessons from trauma

BACKGROUND

Access to centers with extracorporeal membrane oxygenation (ECMO) capabilities varies by region and may affect overall outcomes. We assessed the outcomes of trauma patients requiring ECMO support and compared the overall survival of all patients with trauma at facilities with and without ECMO capabilities.

METHODS

A retrospective review of the National Trauma Data Bank was performed to identify all trauma patients receiving care at ECMO and non-ECMO centers. Baseline patient characteristics and outcomes were analyzed. Adjusted odds ratio (OR) was used to compare survival at ECMO and non-ECMO facilities.

RESULTS

Between 2007 and 2015, a total of 5 781 123 patients with trauma were identified with 1 983 986 (34%) admitted to an ECMO facility and 3 797 137 (66%) admitted to a non-ECMO facility. A total of 522 (0.03%) patients required ECMO. Both the number of patients with trauma requiring ECMO support and the number of trauma facilities utilizing ECMO increased over the 9-year-study period (4.9 to 13.8 patients per 100 000 admissions, and 18 to 77 centers, respectively). The mortality for ECMO patients was 40.5%. Patients with trauma admitted to ECMO facilities had more severe injuries (injury severity score: 9.0 vs 8.0; P < .001). The overall mortality was 3.3%. The adjusted OR for mortality associated with admission to an ECMO facility vs a non-ECMO facility was 0.96 (95% confidence interval: 0.95-0.97; adjusted P < .001).

CONCLUSIONS

The use of ECMO for patients with trauma is expanding. Our study demonstrates a survival benefit associated with admission to a facility with ECMO capabilities. Thus, access to ECMO is a potential quality metric for trauma centers.

Assessment of hospital-level adjusted breast cancer sentinel lymph node positivity rates

BACKGROUND/OBJECTIVES

Proficiency of performing sentinel lymph node biopsy (SLNB) for breast cancer varies among hospitals and may be reflected in the hospital's SLNB positivity rate. Our objectives were to examine whether hospital characteristics are associated with variation in SLNB positivity rates and whether hospitals with lower-than-expected SLNB positivity rates have worse patient survival.

METHODS

Using the National Cancer Data Base, stage I to III breast cancer patients were identified (2004-2012). Hospital-level SLNB positivity rates were adjusted for tumor and patient factors. Hospitals were divided into terciles of SLNB positivity rates (lower-, higher-, as-expected). Hospital characteristics and survival were examined across terciles.

RESULTS

Of 438 610 SLNB patients (from 1357 hospitals), 78 104 had one or more positive SLN (21.3%). Hospitals in the low and high terciles were more likely to be low volume (low: RRR, 4.40; 95% CI, 2.89-6.57; P < 0.001; and high: RRR, 1.79; 95% CI, 1.21-2.64; P < 0.001) compared to hospitals with as-expected (middle tercile) SLNB positivity rates. Stage I patients at low- and high-tercile hospitals had statistically worse survival.

CONCLUSIONS

There is a wide variation in hospital SLNB positivity rates. Hospitals with lower- or higher-than-expected SLNB positivity rates were associated with survival differences. Hospital SLNB positivity rates may be a novel 'process measure' to report to hospitals for internal quality assessment.

Efficiently train and validate a RapidPlan model through APQM scoring

PURPOSE

The aim of this study was to propose and validate an intuitive method for training and to validate knowledge-based planning (KBP) systems based on a patient-specific plan quality scoring.

METHODS

A sample of 80 clinical plans of prostate cancer patients were ranked on the basis of the Adjusted Plan Quality Metric (APQM%). This quality metric was computed normalizing the Plan Quality Metric (PQM%) score to the best possible OAR sparing estimated by the Feasibility DVH (FDVH) algorithm. Two different plan libraries were created, purging all the plans below the first quartile or below the median the APQM% distribution. These libraries were used to populate and train two RapidPlan models: respectively, the APMQ_25% and the APMQ_50% models. No further refinements or actions were undertaken on these two models. Their performances were benchmarked against another two RapidPlan models. An Uncleaned model, which was populated and trained with the initial sample of 80 plans, and a Cleaned model, obtained through the standard iterative cleaning and refinement process suggested by the vendor and in literature. The outcomes of a planning test based on 20 patients within the training library (closed loop) and 20 patients outside of the training library (open-loop) were compared through various DVH metrics and the PQM% score.

RESULTS

The selection through APQM% thresholding roughly preserves the geometric variety of the Cleaned model; only the APMQ_50% model showed a modest broadness reduction. The models generated through APQM% thresholding showed target coverage and OARs sparing equal or superior to the Uncleaned and Cleaned models both for the closed- and the open-loop tests. No significant differences were found between the four models. PQM% analysis ranked the overall plan quality as: 86.5 ± 6.5% APQM_50% , 83.1 ± 5.9% APQM_25% , 80.39 ± 10.6% Cleaned and 79.4 ± 8.5% Uncleaned in the closed-loop test; 84.9 ± 7.6% APQM_50% , 82.6 ± 7.9% APQM_25% , 80.39 ± 10.6% Cleaned and 79.4 ± 8.5% Uncleaned in the open-loop test.

CONCLUSIONS

Forward feeding a RapidPlan model through a thresholding selection based on APQM% is proven to produce equal or better results than a model based on a manually and iteratively refined population. A tighter APQM% threshold turns approximately into a higher average quality of plans generated with RapidPlan. A trade-off must be found between the mean quality of the KBP library and its numerosity. The proposed KBP feeding method helps the KBP user, because it makes the model refinement more intuitive and less time consuming.

A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough?

BACKGROUND/PURPOSE

Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions.

METHODS

A before-and-after study from 2011-2014 at eleven children's hospitals was conducted. The SWC recorded in the hospital's intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohen's weighted kappa and chi square.

RESULTS

Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution.

CONCLUSIONS

Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.

Antenatal corticosteroid administration: understanding its use as an obstetric quality metric

OBJECTIVE

In 1994, the National Institutes of Health recommended a full course of antenatal corticosteroids (ACS) to women who were at risk of delivery at 24-32 weeks of gestation. In 2010, the Joint Commission on Accreditation of Healthcare Organization incorporated ACS administration rates as a perinatal core quality measure. The objective of this study is (1) to assess ACS administration rates among eligible patients at a tertiary care center and (2) to identify modifiable factors to optimize administration rates.

STUDY DESIGN

A retrospective chart review of preterm deliveries at <37 weeks of gestation from July 2009 to July 2011 was performed. Hospital level data, delivery information, obstetric history, and neonatal outcomes were abstracted. Categoric variables were compared with the use of the χ(2) test. Continuous variables were compared with the use of a 2-sample t-test, Wilcoxon rank-sum, or Kruskal Wallis tests.

RESULTS

Nine hundred four women had preterm delivery; 38% of them delivered from 24-34 weeks of gestation. Of the eligible patients, 81.3% received at least 1 dose of ACS, and 69.6% received both doses before delivery. The median time from evaluation to ACS administration was 2.6 hours (interquartile range, 1.6-4.8 hours). Thirty-three percent of the patients who did not receive ACS had had a previous triage visit within 2 weeks of delivery (66.6% of them were evaluated for symptoms of preterm labor) vs 2.8% for those women who received ACS.

CONCLUSION

Of the eligible patients, 81.3% received at least 1 dose of ACS. Tangible opportunities that were identified for systems-based improvement in ACS administration rates included decreasing the time interval from patient evaluation to ACS administration and standardizing outpatient follow-up evaluation for patients who were discharged with symptoms of preterm labor.