Clinical Performance Measures Research Articles

Alignment Between Objective and Subjective Assessments of Health System Performance: Findings From a Mixed-Methods Study.

The article examines whether subjective performance assessments from health system executives match objective performance assessments and qualitatively explores ways to achieve high performance. We interviewed 138 C-suite executives of 24 health systems in California, Minnesota, Washington, and Wisconsin between 2017 and 2019. We used maximum variation sampling to select health systems to achieve diversity in performance on objective measures of clinical performance. Our interviews focused on executives' perceptions of their own health system's performance and factors they thought generally contributed to high performance. In our analysis, we grouped health systems based on objective performance levels (high, medium, and low) used in sampling, compared objective performance ratings with executives' subjective performance assessments, and used thematic analysis to identify reasons for subjective assessment of health system performance and levers of high performance in general. There was poor agreement between objective and subjective performance assessments (kappa = 0.082). Subjective assessments were higher than objective assessments and captured more factors than are typically considered in performance accountability and value-based payment initiatives. Executives whose views were inconsistent with objective performance assessments did not cite clinical care quality per se as the basis for their assessment, focusing instead on market competition, financial performance, and high customer satisfaction and loyalty. Executives who cited clinical quality metrics as the basis of their assessment offered subjective ratings consistent with objective ratings. Executives identified organizational culture, organizational governance, and staff engagement as levers for achieving high performance. Future research should explore the benefits and drawbacks of considering subjective performance assessments in value-based payment initiatives.

Hospital Accreditation: A Review of Evidence, Regulatory Compliance, and Healthcare Outcome Measures

Background: Hospitals are increasingly under pressure to provide safe and high-quality care at an affordable cost. In response to this challenge, many have adopted accreditation as an internationally recognized tool to facilitate improvements in healthcare quality and patient safety. The objectives of the study were to (a) evaluate the impact of international hospital accreditation in Dubai and (b) inform policy decision-making. Methods: We adopted a literature review, analysis of violation data, and clinical performance measures. Results: The literature review suggests insufficient evidence to link accreditation to healthcare outcomes. We report a gradual increase in hospital violations and an improvement of clinical outcomes over three years, however the improvement in clinical outcome measures were not statistically significant. Conclusions: There is limited evidence to determine the impact of international hospital accreditation. Performance measures for accreditation are needed to validate the contribution accreditation may have on reducing non-compliance and improving clinical performance measures. Further research is needed to explore how well accreditation models fit within the Donabedian framework for healthcare quality.

Stakeholder Perceptions of Key Aspects of High-Quality Cancer Care to Assess with Patient Reported Outcome Measures: A Systematic Review.

Simple SummaryWe conducted a review to identify important symptoms reported by patients on questionnaires (e.g., pain) that can be used to compare cancer centers on how well they provide care. For example, cancer centers could be compared on the percentage of patients with controlled pain after adjusting for demographic and clinical characteristics. Standard review methods were used to identify studies through August 2020. Searches generated 1813 articles and 1779 were coded as not relevant. The remaining 34 studies showed that patients, caregivers, clinicians, and healthcare administrators identify psychosocial care (e.g., distress) and symptom management as critical parts of high-quality care. Patients and caregivers also perceive that maintaining physical function and daily activities are important. Clinicians and healthcare administrators perceive control of specific symptoms to be important (e.g., pain, poor sleep, diarrhea). Results were used to inform testing of symptom questionnaires to compare the quality of care provided by six cancer centers.Performance measurement is the process of collecting, analyzing, and reporting standardized measures of clinical performance that can be compared across practices to evaluate how well care was provided. We conducted a systematic review to identify stakeholder perceptions of key symptoms and health domains to test as patient-reported performance measures in oncology. Stakeholders included cancer patients, caregivers, clinicians, and healthcare administrators. Standard review methodology was used, consistent with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). MEDLINE/PubMed, EMBASE, and the Cochrane Library were searched to identify relevant studies through August 2020. Four coders independently reviewed entries and conflicts were resolved by a fifth coder. Efficacy and effectiveness studies, and studies focused exclusively on patient experiences of care (e.g., communication skills of providers) were excluded. Searches generated 1813 articles and 1779 were coded as not relevant, leaving 34 international articles for extraction. Patients, caregivers, clinicians, and healthcare administrators prioritize psychosocial care (e.g., distress) and symptom management for patient-reported performance measures. Patients and caregivers also perceive that maintaining physical function and daily activities are critical. Clinicians and administrators perceive control of specific symptoms to be critical (gastrointestinal symptoms, pain, poor sleep). Results were used to inform testing at six US cancer centers.

Outpatient Prescription Practices in Patients with Atrial Fibrillation (From the NCDR PINNACLE Registry)

This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present.

The use of EPA assessments in decision-making: Do supervision ratings correlate with other measures of clinical performance?

Background Entrustable professional activities (EPAs) have been introduced as a framework for teaching and assessment in competency-based educational programs. With growing use, has come a call to examine the validity of EPA assessments. We sought to explore the correlation of EPA assessments with other clinical performance measures to support use of supervision ratings in decisions about medical students’ curricular progression. Methods Spearman rank coefficients were used to determine correlation of supervision ratings from EPA assessments with scores on clerkship evaluations and performance on an end-of-clerkship-year Objective Structured Clinical Examination (CPX). Results Both overall clinical evaluation items score (rho 0.40; n = 166) and CPX patient encounter domain score (rho 0.31; n = 149) showed significant correlation with students’ overall mean EPA supervision rating during the clerkship year. There was significant correlation between mean supervision rating for EPA assessments of history, exam, note, and oral presentation skills with scores for these skills on clerkship evaluations; less so on the CPX. Conclusions Correlation of EPA supervision ratings with commonly used clinical performance measures offers support for their use in undergraduate medical education. Data supporting the validity of EPA assessments promotes stakeholders’ acceptance of their use in summative decisions about students’ readiness for increased patient care responsibility.

CMS ESRD quality incentive program has not improved patient dialysis vascular access.

Over 468,000 patients in the United States use hemodialysis to manage End Stage Renal Disease (ESRD). The purpose of this study was to determine whether the dialysis access Clinical Performance Measures (CPMs) of Centers for Medicare & Medicaid Services (CMS) ESRD Quality Incentive Program (QIP) have increased arteriovenous fistula (AVF) rates and decreased long-term tunneled hemodialysis catheter (TDC) rates among hemodialysis patients in United States. Retrospective observational study: evaluated reported AVF and long-term TDC rates of 4804 dialysis facilities which reported dialysis access data as part of the ESRD QIP from Payment Year (PY) 2014-2020. Facilities were also sorted by specific additional criteria to examine disparities in dialysis access. Mean AVF rates of included facilities increased from 63.7% in PY 2014 to 67.2% in PY 2016 (p < 0.05), did not change in PY 2017 (p > 0.05), and declined significantly in PY 2018-2020 to 64.1% in PY 2020, near AVF rates at the inception of program. Long-term TDC rates decreased from 10.4% in PY 2014 to 9.88% in PY 2015 (p < 0.05), then increased in PY 2015-PY 2020 to rates higher than at the inception of program, at 11.8% in PY 2020 (p < 0.05). Facilities serving majority Black ZIP Code Tabulation Areas (ZCTAs) or ZCTAs with median income <$45,000 achieved significantly lower AVF rates (p < 0.05) with no significant difference in long-term TDC rates (p > 0.05). AVF rates correlated positively and long-term TDC rates correlated negatively with star rating of facilities (p < 0.05). As one of the first financial QIPs in healthcare, the ESRD QIP has not achieved the stated goals of the CMS to increase AVF access rates above 68% and reduce long-term TDC clinical rates below 10%. Systemic disparities in race, geographic region, economic status, healthcare access, and education of providers and patients prevent successful attainment of goal metrics.

CORRELATIONS BETWEEN FUNCTIONAL TESTING AND THE PEDI-CHAMP© AGILITY TEST IN YOUTH ATHLETES

Background:The Pediatric Comprehensive High-Level Activity Mobility Predictor (Pedi-CHAMP©) is a 4-part agility test which assesses balance, lateral agility, directional changes, and acceleration/deceleration. Designed to assess children with orthopedic conditions or sports medicine injuries, it is unclear if the agility assessed with the Pedi-CHAMP© correlates to other clinical performance measures in uninjured healthy youth athletes.Hypothesis/Purpose:To determine if the Pedi-CHAMP component (Single-Limb-Stance [SLS], modified Edgren Side Step [mESS], L-Test, Illinois Agility Test [IAT]) and composite scores are correlated to the Lower Quarter Y-Balance Test (LQ-YBT) and sprint speed.Methods:Uninjured youth athletes were recruited to undergo a battery of tests as part of the Specialized Athlete Functional Evaluation (SAFE) Program. Completion times for each component of Pedi-CHAMP© were converted to points using age-sex matched scoring algorithms. Each participant completed the LQ-YBT and a single repetition of 10m and 20m sprints. Spearman correlations assessed relationships between the Pedi-CHAMP© component and composite scores and the LQ-YBT components, LQ-YBT composite score, and sprint times.Results:Forty-two, right-leg dominant youth athletes (30F, age:13.9±2.6yrs; BMI:20.±3.1) completed functional testing. 62% of participants specialized in a single sport and 83% participated in high-impact sports. There were no significant correlations between the SLS component score and functional tests (Table 1). While the posteromedial and posterolateral components of the LQ-YBT showed significant, fair correlations to the mESS (PM:r=0.338, PL:r=0.379), L-Test (PL only:r=0.374), IAT (PM:r=0.307, PL:r=0.407) and Pedi-CHAMP© composite scores (PM:r=0.370, PL:r=0.361), the anterior component and LQ-YBT composite scores were not significantly correlated to the Pedi-CHAMP©.There were strong correlations between the 10m and 20m sprints and the mESS (10m:r=-0.660, 20m:r=-0.693), L-Test (10m:r=-0.663, 20m:r=-0.736), IAT (10m:r=-0.704, 20m:r=-0.693) and Pedi-CHAMP© composite score (10m:r=-0.617, 20m:r=-0.678, all p<0.001).Conclusion:Performance on the mESS, L-Test, and IAT components of the Pedi-CHAMP© correlated to sprint times and posterior components of the LQ-YBT. The SLS component of the Pedi-CHAMP© may not be challenging enough for the older youth athlete, as this simple 30sec single limb balance test was designed for children with injuries or underlying orthopedic conditions. Replacing the SLS with one or more LQ-YBT components may be more appropriate for uninjured youth, particularly elite athletes. It is not surprising that forward sprint speeds were highly correlated with the agility portions of the Pedi-CHAMP© in this cohort of relatively high-level youth athletes. Future work should focus on evaluating the ability of the Pedi-CHAMP© to detect differences based on sport.Tables/Figures:

Deep learning-based automated detection of pulmonary embolism on CT pulmonary angiograms: No significant effects on report communication times and patient turnaround in the emergency department nine months after technical implementation

ObjectivesRapid communication of CT exams positive for pulmonary embolism (PE) is crucial for timely initiation of anticoagulation and patient outcome. It is unknown if deep learning automated detection of PE on CT Pulmonary Angiograms (CTPA) in combination with worklist prioritization and an electronic notification system (ENS) can improve communication times and patient turnaround in the Emergency Department (ED). MethodsIn 01/2019, an ENS allowing direct communication between radiology and ED was installed. Starting in 10/2019, CTPAs were processed by a deep learning (DL)-powered algorithm for detection of PE. CTPAs acquired between 04/2018 and 06/2020 (n = 1808) were analysed. To assess the impact of the ENS and the DL-algorithm, radiology report reading times (RRT), radiology report communication time (RCT), time to anticoagulation (TTA), and patient turnaround times (TAT) in the ED were compared for three consecutive time periods. Performance measures of the algorithm were calculated on a per exam level (sensitivity, specificity, PPV, NPV, F1-score), with written reports and exam review as ground truth. ResultsSensitivity of the algorithm was 79.6 % (95 %CI:70.8−87.2%), specificity 95.0 % (95 %CI:92.0−97.1%), PPV 82.2 % (95 %CI:73.9−88.3), and NPV 94.1 % (95 %CI:91.4–96 %). There was no statistically significant reduction of any of the observed times (RRT, RCT, TTA, TAT). ConclusionDL-assisted detection of PE in CTPAs and ENS-assisted communication of results to referring physicians technically work. However, the mere clinical introduction of these tools, even if they exhibit a good performance, is not sufficient to achieve significant effects on clinical performance measures.

The Impact of Shortened Clinical Clerkships on Medical Student Performance and Clerkship Assessment.

IntroMedical schools sometimes need to adjust the length of third-year clinical clerkships. The literature surrounding the effects of shortened clerkships on student experience and performance is mixed.MethodsOur medical school shortened the third year by an average of 20% per clerkship to accommodate a curricular re-design in 2018-2019. We examined test scores and measures of clinical performance as well as student experience in order to understand the impact of this change.ResultsTwo hundred and eight students were included in the analysis, 104 in each cohort. No statistically significant differences were noted between cohorts on NBME subject examination results. There were no significant differences on Step 2 CK scores between the traditional curriculum cohort (M = 249.4, SD = 13.7) and shortened curriculum cohort (M = 248.7, SD = 15.8). Student performance on OSCE cases was similar. Similar percentages of students rated each clerkship either “good” or “excellent” in the traditional (77%) and shortened (78%) curriculum.ConclusionThere was no significant impact on student test scores after shortening the curriculum. Measures of student satisfaction and experience also remained stable, likely related to emphasis on retaining patient care experiences and streamlining of didactics. Curricular shortening during the third year of medical school was feasible and safe from the student perspective in our experience.

FC 094THREE VERSUS TWICE-WEEKLY HEMODIALYSIS SESSIONS: A COMMUNITY EXPERIENCE

Abstract Background and Aims We investigated the feasibilty of converting stable end stage renal disease (ESRD) patients from three to twice weekly hemodialysis (HD) sessions based on published criteria. Method ESRD patients on three times weekly (3xwkly) HD sessions for at least 3 months duration were screened for eligibility for conversion to twice weekly (2xwkly) maintenace HD schedule in a university-affiliated community dialysis program. Eligibility criteria were: residual renal function &amp;gt; 3ml/min; urine output &amp;gt;500mL/day; intradialytic weight gain &amp;lt;2.5kg; hemoglobin &amp;gt;8gm/dL; manageable phosphorus and potasium levels. Clinical parameters on 3xwkly vs. 2xwkly HD sessions were then performed in the eligible patients. Results 7/71 (9.8%) of the patients met criteria for conversion to 2xwkly HD sessions. Baseline patient characteristics are shown in Table 1. Major indication for HD initiation was symptomatic progression of disease. Less than 50% of patients had a functioning arteriovenous fistula at initiation of HD. In the current cohort, residual renal function &amp;gt; 3mL/min was maintainedfor &amp;gt;200 days after initiation of HD. There were no significant changes in electrolytes, hemoglobin, nutrition staus or adequacy of dialysis. PTH levels were not significantly different: 3xwkly, 625.7 + 546.2pg/mL vs. 2xwkly, 399 + 344.2pg/mL; p=0.374). Karnofsky Performance Status Scale improved post conversion but did not achieve statistical significance (3xwkly, 57.1 vs. 2xwkly, 70; p=0.316). There were no hospital admissions since conversion to 2xwkly schedule during the study period. Conclusion In a community-based dialysis program, 10% of total HD patients qualified for conversion from 3xwkly to 2xwkly maintenance HD without significant changes to their laboratory or clinical performance measures. These observations stimulate discussion regarding increased application of incremental dialysis initiation strategies to preserve residual renal function, increase dialysis-free days and alleviate transportation and care provider-related burden to patients and families.

Evaluation of medical quality and treatment trends of nonvalvular atrial fibrillation in Beijing inpatients.

The quality of care presented to AF cases in tertiary and non-tertiary hospitals in China remains obscure and needs further investigation. Therefore, we examined the compliance with quality measures (QMs) and clinical performance measures (PMs) that were proposed by the ACC/AHA in 2016 in a Chinese adult population with nonvalvular atrial fibrillation (AF). We also investigated the changes in patients' characteristics, treatment plans, and quality of provided care at different time-points [2011-2016]. We used the datasets from two registry-based studies in Beijing, including the Chinese Atrial Fibrillation Registry (CHINA-AF) investigation. From August 2011 to July 2016, an overall number of 13,439 nonvalvular AF cases were included. Our primary outcome was to determine the compliance rate with two PMs [oral anticoagulant (OAC) use and prothrombin time international normalized ratio (INR)] and six QMs (beta-blocker, ACEI-ARB, and the inappropriate prescription of antiarrhythmic drugs, Sotalol, antiplatelet and OAC, and non-dihydropyridine calcium channel antagonist) over a period of 5 years [2011-2016]. Also, the difference in compliance between tertiary and non-tertiary hospitals was investigated. The compliance with PMs and QMs was variable between tertiary and non-tertiary hospitals. In tertiary hospitals, the total number of inpatient beds was >500, and each bed was equipped with >1.03 health technical personnel and >0.4 nurses. In non-tertiary hospitals, the available beds capacity was <500, and each bed corresponded with 0.7-0.88 health technical personnel and >0.4 nurses. The compliance rates with OAC use steadily increased from 2011-2015 in tertiary hospitals (35%, 35.9%, 37.9%, 45%, and 49%, P<0.001). In non-tertiary hospitals, INR follow-up of warfarin use increased significantly over the years, with rates of 36.2%, 60.5%, 71.6%, 64.3%, and 81.5% (P=0.04), respectively. In terms of QMs, the compliance with the six measure sets was quite similar among tertiary and non-tertiary hospitals avoiding any significant difference over the years (P>0.05). We noted an improvement in medical quality regarding the use of OAC, especially in tertiary hospitals. Meanwhile, the compliance rates of INR follow-up improved in non-tertiary hospitals. However, the compliance rates of other performance and QMs are still low, which are in need of improvement.

Mitral Surgery After Transcatheter Edge-to-Edge Repair: Society of Thoracic Surgeons Database Analysis

BackgroundTranscatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined. ObjectivesThis study evaluated national outcomes of mitral surgery after TEER. MethodsThe Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality. ResultsIn the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease. ConclusionsThis study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.

Assessment of Variation in Electronic Health Record Capabilities and Reported Clinical Quality Performance in Ambulatory Care Clinics, 2014-2017

Electronic health records (EHRs) are widely promoted to improve the quality of health care, but information about the association of multifunctional EHRs with broad measures of quality in ambulatory settings is scarce. To assess the association between EHRs with different degrees of capabilities and publicly reported ambulatory quality measures in at least 3 clinical domains of care. This cross-sectional and longitudinal study was conducted using survey responses from 1141 ambulatory clinics in Minnesota, Washington, and Wisconsin affiliated with a health system that responded to the Healthcare Information and Management Systems Society Annual Survey and reported performance measures in 2014 to 2017. Statistical analysis was performed from July 10, 2019, through February 26, 2021. A composite measure of EHR capability that considered 50 EHR capabilities in 7 functional domains, grouped into the following ordered categories: no functional EHR, EHR underuser, EHR, neither underuser or superuser, EHR superuser; as well as a standardized composite of ambulatory clinical performance measures that included 3 to 25 individual measures (median, 13 individual measures). In 2014, 381 of 746 clinics (51%) were EHR superusers; this proportion increased in each subsequent year (457 of 846 clinics [54%] in 2015, 510 of 881 clinics [58%] in 2016, and 566 of 932 clinics [61%] in 2017). In each cross-sectional analysis year, EHR superusers had better clinical quality performance than other clinics (adjusted difference in score: 0.39 [95% CI, 0.12-0.65] in 2014; 0.29 [95% CI, -0.01 to 0.59] in 2015; 0.26 [95% CI, -0.05 to 0.56] in 2016; and 0.20 [95% CI, -0.04 to 0.45] in 2017). This difference in scores translates into an approximately 9% difference in a clinic's rank order in clinical quality. In longitudinal analyses, clinics that progressed to EHR superuser status had only slightly better gains in clinical quality between 2014 and 2017 compared with the gains in clinical quality of clinics that were static in terms of their EHR status (0.10 [95% CI, -0.13 to 0.32]). In an exploratory analysis, different types of EHR capability progressions had different degrees of associated improvements in ambulatory clinical quality (eg, progression from no functional EHR to a status short of superuser, 0.06 [95% CI, -0.40 to 0.52]; progression from EHR underuser to EHR superuser, 0.18 [95% CI, -0.14 to 0.50]). Between 2014 and 2017, ambulatory clinics in Minnesota, Washington, and Wisconsin with EHRs having greater capabilities had better composite measures of clinical quality than other clinics, but clinics that gained EHR capabilities during this time had smaller increases in clinical quality that were not statistically significant.

Prevalence of Effective Audit-and-Feedback Practices in Primary Care Settings: A Qualitative Examination Within Veterans Health Administration.

The purpose of this study is to uncover and catalog the various practices for delivering and disseminating clinical performance in various Veterans Affairs (VA) locations and to evaluate their quality against evidence-based models of effective feedback as reported in the literature. Feedback can enhance clinical performance in subsequent performance episodes. However, evidence is clear that the way in which feedback is delivered determines whether performance is harmed or improved. We purposively sampled 16 geographically dispersed VA hospitals based on high, low, consistently moderate, and moderately average highly variable performance on a set of 17 outpatient clinical performance measures. We excluded four sites due to insufficient interview data. We interviewed four key personnel from each location (n = 48) to uncover effective and ineffective audit and feedback strategies. Interviews were transcribed and analyzed qualitatively using a framework-based content analysis approach to identify emergent themes. We identified 102 unique strategies used to deliver feedback. Of these strategies, 64 (62.74%) have been found to be ineffective according to the audit-and-feedback research literature. Comparing features common to effective (e.g., individually tailored, computerized feedback reports) versus ineffective (e.g., large staff meetings) strategies, most ineffective strategies delivered feedback in meetings, whereas strategies receiving the highest effectiveness scores delivered feedback via visually understood reports that did not occur in a group setting. Findings show that current practices are leveraging largely ineffective feedback strategies. Future research should seek to identify the longitudinal impact of current feedback and audit practices on clinical performance. Feedback in primary care has little standardization and does not follow available evidence for effective feedback design. Future research in this area is warranted.

The Importance of Competency-Based Programmatic Assessment in Graduate Medical Education.

The Importance of Competency-Based Programmatic Assessment in Graduate Medical Education.

Effect of COVID-19 Pandemic on Performance Measures in Acute Myocardial Infarction.

Objective To assess performance measures of attention of STEMI in Coronary Intensive Care Unit in General Hospital Camilo Cienfuegos.Methods Admitted patients with STEMI, from February-April 2020, were compared with patients from similar period from 2015-2019, and patients from January 2019 to January 2020. Primary endpoint were performance measures according to the 2017 AHA / ACC Clinical Performance and Quality Measures for Adults with STEMI document, and secondary endpoint were all-cause in-hospital mortality and major acute coronary events.Results Only 35 patients were admitted from February-April 2020. When comparing with similar periods from recent years, in-hospital death (8.3 % vs. 20 %; p=0.03), major complications (38.7 % vs. 57.1 %; p=0.03), and cardiogenic shock (6.9 % vs. 17.4 %; p=0.04) were significantly higher. When comparing with 2019 and January 2020, in-hospital death (9.6 %; p=0.04), and major complications (35.8 % p=0.03) were significantly higher in February-April 2020; however, there was no difference in prevalence of cardiogenic shock (8 %; p=0.12).Conclusion COVID-19 pandemic had decreased prevalence of STEMI, as well as some performance measures of attention in this center.

Can Biomechanical Testing After Anterior Cruciate Ligament Reconstruction Identify Athletes at Risk for Subsequent ACL Injury to the Contralateral Uninjured Limb?

Background: Athletes are twice as likely to rupture the anterior cruciate ligament (ACL) on their healthy contralateral knee than the reconstructed graft after ACL reconstruction (ACLR). Although physical testing is commonly used after ACLR to assess injury risk to the operated knee, strength, jump, and change-of-direction performance and biomechanical measures have not been examined in those who go on to experience a contralateral ACL injury, to identify factors that may be associated with injury risk. Purpose: To prospectively examine differences in biomechanical and clinical performance measures in male athletes 9 months after ACLR between those who ruptured their previously uninjured contralateral ACL and those who did not at 2-year follow-up and to examine the ability of these differences to predict contralateral ACL injury. Study Design: Case-control study; Level of evidence, 3. Methods: A cohort of male athletes returning to level 1 sports after ACLR (N = 1045) underwent isokinetic strength testing and 3-dimensional biomechanical analysis of jump and change-of-direction tests 9 months after surgery. Participants were followed up at 2 years regarding return to play or at second ACL injury. Between-group differences were analyzed in patient-reported outcomes, performance measures, and 3-dimensional biomechanics for the contralateral limb and asymmetry. Logistic regression was applied to determine the ability of identified differences to predict contralateral ACL injury. Results: Of the cohort, 993 had follow-up at 2 years (95%), with 67 experiencing a contralateral ACL injury and 38 an ipsilateral injury. Male athletes who had a contralateral ACL injury had lower quadriceps strength and biomechanical differences on the contralateral limb during double- and single-leg drop jump tests as compared with those who did not experience an injury. Differences were related primarily to deficits in sagittal plane mechanics and plyometric ability on the contralateral side. These variables could explain group membership with fair to good ability (area under the curve, 0.74-0.80). Patient-reported outcomes, limb symmetry of clinical performance measures, and biomechanical measures in change-of-direction tasks did not differentiate those at risk for contralateral injury. Conclusion: This study highlights the importance of sagittal plane control during drop jump tasks and the limited utility of limb symmetry in performance and biomechanical measures when assessing future contralateral ACL injury risk in male athletes. Targeting the identified differences in quadriceps strength and plyometric ability during late-stage rehabilitation and testing may reduce ACL injury risk in healthy limbs in male athletes playing level 1 sports. Clinical Relevance: This study highlights the importance of assessing the contralateral limb after ACLR and identifies biomechanical differences, particularly in the sagittal plane in drop jump tasks, that may be associated with injury to this limb. These factors could be targeted during assessment and rehabilitation with additional quadriceps strengthening and plyometric exercises after ACLR to potentially reduce the high risk of injury to the previously healthy knee. Registration: NCT02771548 (ClinicalTrials.gov identifier).

The COVID-19 pandemic as a catalyst for differentiated care models to end the HIV epidemic in the United States: applying lessons from high-burden settings.

The COVID-19 pandemic as a catalyst for differentiated care models to end the HIV epidemic in the United States: applying lessons from high-burden settings.

Blindfolding Improves Communication in Inexperienced Residents Undergoing ACLS Training.

Closed-loop communication (CLC) is associated with decreased medical errors and improved time-to-task completion during resuscitations. Depriving team leaders of sight during training may accelerate the acquisition of favorable communication skills; however, its effect on the frequency of CLC is unclear, especially with trainees. We assessed the effect of depriving interns of sight during advanced cardiovascular life support (ACLS) on verbal communication patterns and resuscitation confidence. All interns undergoing ACLS training in June 2019 at a single center were eligible. Interns were randomized to blindfolded training (BT) or standard training (ST). BT team leaders were blindfolded during practice sessions and permitted to use sight during testing. Testing scenarios were video- and audio-recorded. Recordings were assessed for teams' performance and communication patterns. Participants were surveyed for confidence with resuscitation skills before and after ACLS training. All 87 eligible interns participated in the study (100% participation). Eighty-five of 87 (98%) interns were included for analysis; 46 were randomized to BT and 39 to ST. Interns in the BT group were significantly more likely to exhibit CLC (mean: BT 20.3, ST 16.6; P = .003), directed communication (mean: BT 4.3, ST 1.5; P < .001), and follower-initiated communication (mean: BT 12.8, ST 10.2; P = .028). There was no significant difference in clinical performance measures or self-reported confidence with resuscitation between BT and ST groups. Blindfolding trainees results in greater instances of CLC, directed communication, and follower-initiated communication during ACLS training.

Self-Reflection and its Relationship to Occupational Competence and Clinical Performance in Level II Fieldwork

Purpose: Reflective practitioners embody the ability to critique their own clinical thinking about the dilemmas that frequently arise in professional practice and everyday life. Conflicting evidence exists on whether or not self-reflective practices are effective in promoting academic, clinical, and personal success. This quantitative study investigated self-reflection as a predictor of increased occupational competence and clinical performance in Level II Fieldwork for entry-level Master's degree occupational therapy students. Method: The study used convenience sampling to recruit participants and data were collected via a demographic survey and self-assessment questionnaires. Multiple linear regression analyses were conducted to determine the extent to which self-reflection predicts occupational competence and clinical performance. R2 values were examined to determine the importance of each dependent variable (occupational competence and clinical performance). Results: Findings revealed a statistically significant relationship between self-reflection and occupational competence (p = 0.0053) but not between self-reflection and clinical performance (p = 0.08). Self-reflection accounted for 14% of the variance in clinical performance (R2 = 0.14), and more than one third (R2 = 0.38) of the variance in occupational competence. Results suggest that students who self-reflect regularly during fieldwork may have a greater ability to maintain everyday life routines during the demands of Level II Fieldwork. Conclusions: Self-reflection strongly predicts occupational competence of occupational therapy students during Level II Fieldwork, but does not significantly predict students’ clinical performance. Recommendations: Occupational therapy educators should consider incorporating guided self-reflection activities into the academic program in order to support student occupational competence. Intentional coaching in self-reflection may better prepare students for a clinical setting by supporting healthy daily routines, which may help them to manage stress during Level II Fieldwork. Future research should explore the impact of self-reflection training during clinical rotations (provided by clinical educators) on student clinical performance. Revision of the measurement of clinical performance is warranted to include questions pertaining to soft skills such as self-reflection and awareness.