Non-patient Factors Research Articles

A qualitative exploration of escalation of care in the acute ward setting.

Background“Failure to Rescue” includes failing to prevent avoidable patient deterioration and death. Despite its use, delays in care escalation still affect patient outcomes.Aims and ObjectiveThe aim of this qualitative service evaluation was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable.DesignA total of 55 hours of qualitative observations were completed to capture care escalation events. These were conducted at two hospital sites in one National Health Service trust.MethodsObservations were iterative, with research team meetings being used to discuss the data and future methods. Field notes were analysed thematically by two researchers, extracting data on barriers and facilitators to escalation of care.ResultsClinical nursing staff challenged the sensitivity and specificity of Early Warning Scores, describing tool failings in certain clinical scenarios. Staff did not escalate based on the alerting Early Warning Scores alone but used other clinical factors, such as bleeding, which are not necessarily captured in the scoring systems. Staff frequently did not re‐escalate low‐level scores. Patient and non‐patient factors identified as posing barriers to escalation were complex care needs, patient outlier status, and involvement of multiple care teams. Factors negatively affecting the chain of communication during escalation were team tension, staffing levels, and inadequate handover.ConclusionThis service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re‐escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams.Relevance to clinical practiceThis service evaluation demonstrates continuing health care communication barriers. Patient groups (complex patients and outliers) risk process failures during escalation. This can be applied in clinical practice by staff anticipating problems in these patients, documenting clear escalation pathways.

Abstract 133: Early Impact of Systematizing the Evaluation of Patients with Heart Failure Presenting to the Emergency Department

Introduction: It can be difficult in patients with heart failure (HF) who present to the emergency department (ED) with shortness of breath to decide who warrants admission and who can be safely sent home. At our institution, there was great variability across ED physicians’ admission rates (66%-100%). To address this, we developed an evidence-based protocol to support more consistent HF evaluation in the ED and implemented the program with the help of a multi-disciplinary team. Methods: HF patients presenting to the ED with shortness of breath were eligible for the CODE HF protocol, which was hinged on the use of the prospectively-validated Emergency Heart Failure Mortality Risk Grade (EHMRG) score. Patients with a <1% 7-day mortality were eligible for discharge, if their symptoms improved and the patient and ED physician were comfortable with discharge. The protocol also included HF education in the ED and follow-up. Outcomes included a comparison of patients on and off the CODE HF pathway (1/18-10/18) for ED length of stay, ED discharge, time to outpatient visits among those discharged from the ED and short-stay (potentially unnecessary) hospitalizations. Pearson Chi-square and one-way ANOVA tests were used for comparison. Given our experience that non-patient factors were responsible for not using the protocol, patient-level adjustment was not done. Results: A total of 112 patients out of 933 HF patients seen in the ED between 1/18 and 10/18 were managed through the CODE HF protocol. The EHMRG was calculated in 82 (73%) patients (45 high risk, 37 low risk). When used, the CODE HF protocol was associated with 46% greater rates of ED discharges (14.1% vs 25.9%), a 7-day faster cardiology follow-up visit (25 vs 16 days) and 36% fewer hospital short-stays of <48 hours (12.6% vs 8%) among admitted patients (p<0.05 for all). Importantly, the protocol reduced time in the ED by 42 minutes (288 vs 246 minutes). Conclusions: In this quality improvement pilot study, early implementation of the CODE HF protocol showed more effective care being delivered. A more robust study with wider implementation and evaluation of its impact on return visits is underway.

20 Comparison of Admission Rates Among Patients Treated by Male and Female Emergency Physicians

The volume of emergency department (ED) visits has been steadily increasing over the past decade. Also, in parallel, the number of board certified emergency medicine (EM) physicians has been growing. One of the most important decisions made in a patient’s course in the ED is the development of a disposition plan by the physician provider. Many factors influence the development of an appropriate plan of care, such as, patient medical and social needs. Literature from other specialties such as internal medicine and general surgery have shows us that practice patterns and outcomes differ at times by non-patient factors, more specifically, by physician sex bias. Studies in EM have shown non-patient variables that potentially have an influence such as ED crowding and years of physician experience. No paper to date has looked at sex of EM providers in the United States as a function of adult admission rates. The current study seeks to investigate admission rates of adult patients who are treated by male versus female emergency physicians, in order to identify whether or not a practice pattern bias exists. This was a multi-center retrospective cross-sectional study of one health care system in the Midwest. All patient encounters by EM-trained physicians in the emergency department of 4 hospitals over the academic year, July 1, 2016 to June 30, 2017 were analyzed. The primary outcome was admission rate of each physician with admission rate defined as the percentage of encounters that resulted in admission to the hospital as a portion of all encounters. Admission defined by patients who were admitted to observation, inpatient or emergent surgery from the ED. Any physician with less than 100 patient encounters was excluded. Secondary analysis assessed physician metrics and benchmarks with potential confounding effects: patient acuity, average length of stay, return visits, patient age and years of practice by physician, using independent samples t-tests. 110,230 patient encounters were analyzed, treated by 80 emergency physicians; 49 male, 31 female. The average admission rates were male 28%, female 29%, t = .504 with equal variances assumed. Acuity of patients seen by providers: male .741, female .763, t = -2.862. Average length of stay in minutes: male 264, female 292, t = -2.158. Average returns visits per 1,000: male 8.24, female 8.37, t = -.222. Patient age: male 49.74, female 51.12, t = -1.439. Years of practice: male 20.24, female 15.77, t = 2.097. In this analytic retrospective observational study, we found that the difference of admission rates of male and female EM providers was not statistically significant. We did find significance between the average length of stay, patient acuity seen and years of practice. The etiology of these significances can be postulated to be interrelated. Further studies are needed with a greater sample size of physicians to potentially find sex bias practice patterns and differences.Table 1Descriptive statistics with independent samples t-testsAdmission RatePatient Acuity (0-1)Average LOS (minutes)Returns per 1,000Patient AgeYears of PracticeMale28%0.7412648.2449.7420.24Female29%0.7632928.3751.1215.77T value0.504-2.862-2.158-0.222-1.4392.097 Open table in a new tab

A qualitative exploration of the discharge process and factors predisposing to readmissions to the intensive care unit

BackgroundQuantitative studies have demonstrated several factors predictive of readmissions to intensive care. Clinical decision tools, derived from these factors have failed to reduce readmission rates. The purpose of this study was to qualitatively explore the experiences and perceptions of physicians and nurses to gain more insight into intensive care readmissions.MethodsSemi-structured interviews of intensive care unit (ICU) and general medicine care providers explored work routines, understanding and perceptions of the discharge process, and readmissions to intensive care. Participants included ten providers from the ICU setting, including nurses (n = 5), consultant intensivists (n = 2), critical care fellows (n = 3) and 9 providers from the general medical setting, nurses (n = 4), consulting physicians (n = 2) and senior resident physicians (n = 3). Principles of grounded theory were used to analyze the interview transcripts.ResultsNine factors within four broad themes were identified: (1) patient factors – severity-of-illness and undefined goals of care; (2) process factors – communication, transitions of care; (3) provider factors – discharge decision-making, provider experience and comfort level; (4) organizational factors – resource constraints, institutional policies.ConclusionsSevere illness predisposes ICU patients to readmission, especially when goals of care were not adequately addressed. Communication, premature discharge, and other factors, mostly unrelated to the patient were also perceived by physicians and nurses to be associated with readmissions to intensive care. Quality improvement efforts that focus on modifying or improving aspects of non-patient factors may improve outcomes for patients at risk of ICU readmission.

Factors associated with appropriate psychotropic drug prescription in nursing home patients with severe dementia.

In a cross-sectional study, the appropriateness of prescriptions was explored using the Appropriate Psychotropic drug use In Dementia (APID) index sum score. This index assesses information from medical records on indication, evaluation, dosage, drug-drug interactions, drug-disease interactions, duplications, and therapy duration. Various measurements were carried out to identify the possible patient and non-patient factors. Linear multilevel regression analysis was used to identify factors that are associated with APID index sum scores. Analyses were performed for groups of PDs separately, i.e. antipsychotics, antidepressants, anxiolytics, and hypnotics. The sample consisted of 338 patients with a PD prescription that used 147 antipsychotics, 167 antidepressants, 85 anxiolytics, and 76 hypnotics. It was found that older patients and more severe aggression, agitation, apathy, and depression were associated with more appropriate prescriptions. Additionally, less appropriate prescriptions were found to be associated with more severe anxiety, dementia diagnoses other than Alzheimer dementia, more physician time available per patient, more patients per physician, more years of experience of the physician, and higher nurse's workload. The association of more pronounced NPS with more appropriate PD prescriptions implies that physicians should pay more attention to the appropriateness of PD prescriptions when NPS are less manifest. Non-patient-related factors are also associated with the appropriateness of PD prescriptions. However, especially considering that some of these findings are counter-intuitive, more research on the topic is recommended.

Erratum to: The Validity of a New Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS) for Evaluating Symptoms in the Clinical Setting.

The clinical assessments of patients with gastrointestinal symptoms can be time-consuming, and the symptoms captured during the consultation may be influenced by a variety of patient and non-patient factors. To facilitate standardized symptom assessment in the routine clinical setting, we developed the Structured Assessment of Gastrointestinal Symptom (SAGIS) instrument to precisely characterize symptoms in a routine clinical setting. We aimed to validate SAGIS including its reliability, construct and discriminant validity, and utility in the clinical setting. Development of the SAGIS consisted of initial interviews with patients referred for the diagnostic work-up of digestive symptoms and relevant complaints identified. The final instrument consisted of 22 items as well as questions on extra intestinal symptoms and was given to 1120 consecutive patients attending a gastroenterology clinic randomly split into derivation (n = 596) and validation datasets (n = 551). Discriminant validity along with test–retest reliability was assessed. The time taken to perform a clinical assessment with and without the SAGIS was recorded along with doctor satisfaction with this tool. Exploratory factor analysis conducted on the derivation sample suggested five symptom constructs labeled as abdominal pain/discomfort (seven items), gastroesophageal reflux disease/regurgitation symptoms (four items), nausea/vomiting (three items), diarrhea/incontinence (five items), and difficult defecation and constipation (2 items). Confirmatory factor analysis conducted on the validation sample supported the initially developed five-factor measurement model ( $$\chi_{193}^{2} = 892.2$$ , p < 0.0001, χ 2/df = 4.6, CFI = 0.90, TLI = 0.88, RMSEA = 0.08). All symptom groups demonstrated differentiation between disease groups. The SAGIS was shown to be reliable over time and resulted in a 38% reduction of the time required for clinical assessment. The SAGIS instrument has excellent psychometric properties and supports the clinical assessment of and symptom-based categorization of patients with a wide spectrum of gastrointestinal symptoms.

The Validity of a New Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS) for Evaluating Symptoms in the Clinical Setting.

The clinical assessments of patients with gastrointestinal symptoms can be time-consuming, and the symptoms captured during the consultation may be influenced by a variety of patient and non-patient factors. To facilitate standardized symptom assessment in the routine clinical setting, we developed the Structured Assessment of Gastrointestinal Symptom (SAGIS) instrument to precisely characterize symptoms in a routine clinical setting. We aimed to validate SAGIS including its reliability, construct and discriminant validity, and utility in the clinical setting. Development of the SAGIS consisted of initial interviews with patients referred for the diagnostic work-up of digestive symptoms and relevant complaints identified. The final instrument consisted of 22 items as well as questions on extra intestinal symptoms and was given to 1120 consecutive patients attending a gastroenterology clinic randomly split into derivation (n=596) and validation datasets (n=551). Discriminant validity along with test-retest reliability was assessed. The time taken to perform a clinical assessment with and without the SAGIS was recorded along with doctor satisfaction with this tool. Exploratory factor analysis conducted on the derivation sample suggested five symptom constructs labeled as abdominal pain/discomfort (seven items), gastroesophageal reflux disease/regurgitation symptoms(four items), nausea/vomiting (three items), diarrhea/incontinence (five items), and difficult defecation and constipation (2 items). Confirmatoryfactor analysis conducted on the validation samplesupported the initially developed five-factormeasurement model ([Formula: see text], p<0.0001, χ 2/df=4.6, CFI=0.90, TLI=0.88, RMSEA=0.08). All symptom groups demonstrated differentiation between disease groups. The SAGIS was shown to be reliable over time and resulted in a 38% reduction of the time required for clinical assessment. The SAGIS instrument has excellent psychometric properties and supports the clinical assessment of and symptom-based categorization of patients with a wide spectrum of gastrointestinal symptoms.

Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors.

At least 45% of patients with type 2 diabetes (T2D) fail to achieve adequate glycemic control (HbA1c <7%). One of the major contributing factors is poor medication adherence. Poor medication adherence in T2D is well documented to be very common and is associated with inadequate glycemic control; increased morbidity and mortality; and increased costs of outpatient care, emergency room visits, hospitalization, and managing complications of diabetes. Poor medication adherence is linked to key nonpatient factors (eg, lack of integrated care in many health care systems and clinical inertia among health care professionals), patient demographic factors (eg, young age, low education level, and low income level), critical patient beliefs about their medications (eg, perceived treatment inefficacy), and perceived patient burden regarding obtaining and taking their medications (eg, treatment complexity, out-of-pocket costs, and hypoglycemia). Specific barriers to medication adherence in T2D, especially those that are potentially modifiable, need to be more clearly identified; strategies that target poor adherence should focus on reducing medication burden and addressing negative medication beliefs of patients. Solutions to these problems would require behavioral innovations as well as new methods and modes of drug delivery.

Evaluación de la calidad de un servicio de voluntariado en oncología: un Análisis Importancia-Valoración (IPA)

Objective: Using an Importance-Performance Analysis (IPA), this paper examined a Radiotherapy and Oncological Patient and Non-patient perceived importance and performance of ten Humanization Volunteer Program selection factors in the General Hospital in Spain. Methods: The authors identified a list of seven items from the Health-marketing literature reviews, and each item was rated using a 5-point Likert scale. Responses were obtained of 148 usable interviews. Results: The importance-performance patient grid was corrected with literature recommendations and, in the patient sample, shows three items fall in the “Keep up the good work” quadrant, four items fall into the “Low priority” quadrant, zero items fall into the “Possible overkill” quadrant, and no items fall in the “Concentrate here” quadrant. Non-patient (n=80) factors means shows statistical differences with patient (n=68) means in catering (t=-2.38; df.=146; p<0.05), and information (t=2.16; df146; p<0,05). Conclusions: The results are useful in identifying areas for strategic focus to help Health Services managers develop humanization programs with volunteer workers and different program users. Implication to volunteer programs managers and researchers were discussed.

Surgical ligation of patent ductus arteriosus in premature infants: trends and practice variation.

We sought to analyse the variation in the incidence of patent ductus arteriosus over three recent time points and characterise ductal ligation practices in preterm infants in the United States, adjusting for demographic and morbidity factors. Using the Kids' Inpatient Database from 2003, 2006, and 2009, we identified infants born at ⩽32 weeks of gestation with International Classification of Diseases, Ninth Revision diagnosis of patent ductus arteriosus and ligation code. We examined patient and hospital characteristics and identified patient and hospital variables associated with ligation. Of 182,610 preterm births, 30,714 discharges included a patent ductus arteriosus diagnosis. The rate of patent ductus arteriosus diagnosis increased from 14% in 2003 to 21% in 2009 (p<0.001). A total of 4181 ligations were performed, with an overall ligation rate of 14%. Ligation rate in infants born at ⩽28 weeks of gestation was 20% overall, increasing from 18% in 2003 to 21% in 2009 (p<0.001). The ligation rate varied by state (4-28%), and ligation was associated with earlier gestational age, associated diagnoses, hospital type, teaching hospital status, and region (p<0.001). The rates of patent ductus arteriosus diagnosis and ligation have increased in the recent years. Variation exists in the practice of patent ductus arteriosus ligation and is influenced by patient and non-patient factors.

Who is less likely to die in association with improved National Emergency Access Target (NEAT) compliance for emergency admissions in a tertiary referral hospital?

Objective The aim of the present study was to identify patient and non-patient factors associated with reduced mortality among patients admitted from the emergency department (ED) to in-patient wards in a major tertiary hospital that had previously reported a near halving in mortality in association with a doubling in National Emergency Access Target (NEAT) compliance over a 2-year period from 2012 to 2014. Methods We retrospectively analysed routinely collected data from the Emergency Department Information System (EDIS) and hospital discharge abstracts on all emergency admissions during calendar years 2011 (pre-NEAT interventions) and 2013 (post-NEAT interventions). Patients admitted to short-stay wards and then discharged home, as well as patients dying in the ED, were excluded. Patients included in the study were categorised according to age, time and day of arrival to the ED, mode of transport to the ED, emergency triage category, type of clinical presentation and major diagnostic codes. Results The in-patient mortality rate for emergency admissions decreased from 1.9% (320/17022) in 2011 to 1.2% (202/17162) in 2013 (P<0.001). There was no change from 2011 to 2013 in the percentage of deaths in the ED (0.19% vs 0.17%) or those coded as in-patient palliative care (17.9% vs 22.2%). Although deaths were not associated with age by itself, the mortality rate of older patients admitted to medical wards decreased significantly from 3.5% to 1.7% (P=0.011). A higher mortality rate was seen among patients presenting to ED triage between midnight and 12 noon than at other times in 2011 (2.5% vs 1.5%; P<0.001), but this difference disappeared by 2013 (1.3% vs 1.1%; P=0.150). A similar pattern was seen among patients presenting on weekends versus weekdays: 2.2% versus 1.7% (P=0.038) in 2011 and 1.3% versus 1.1% (P=0.150) in 2013. Fewer deaths were noted among patients with acute cardiovascular or respiratory disease in 2013 than in 2011 (1.7% vs 3.6% and 1.5% vs 3.4%, respectively; P<0.001 for both comparisons). Mode of transport to the ED or triage category was not associated with changes in mortality. These analyses took account of any possible confounding resulting from differences over time in emergency admission rates. Conclusions Improved NEAT compliance as a result of clinical redesign is associated with improved in-patient mortality among particular subgroups of emergency admissions, namely older patients with complex medical conditions, those presenting after hours and on weekends and those presenting with time-sensitive acute cardiorespiratory conditions. What is known about the topic? Clinical redesign aimed at improving compliance with NEAT and reducing time spent within the ED of acutely admitted patients has been associated with reduced mortality. To date, no study has attempted to identify subgroups of patients who potentially derive the greatest benefit from improved NEAT compliance in terms of reduced risk of in-patient death. It also remains unclear as to what extent non-patient factors (e.g. admission practices and differences in coding of palliative care patients) affect or confound this reduced risk. What does this paper add? The present study is the first to reveal that enhanced NEAT compliance is associated with lower mortality among particular subgroups of emergency patients admitted to in-patient wards. These include older patients with complex medical conditions, those presenting after hours or on weekends or those with time-sensitive acute cardiorespiratory conditions. These results took account of any possible confounding resulting from differences over time in emergency admission rates, deaths in the ED, numbers of short-stay ward admissions and coding of palliative care deaths. What are the implications for practitioners? Efforts aimed at improving NEAT compliance and efficiencies at the ED-in-patient interface appear to be worthwhile in reducing in-patient mortality among particular subgroups of emergency admissions at high risk. More research is urgently needed in identifying patient- and system-level factors that predispose to higher mortality rates in such populations, but are potentially amenable to focused interventions aimed at optimising transitions of care at the ED-in-patient interface and increasing NEAT compliance for patients admitted to in-patient wards from the ED.

“It's easier to stick a tube in”: a qualitative study to understand clinicians’ individual decisions to place urinary catheters in acute medical care

BackgroundIndwelling urinary catheters (IUCs) placed in acute care are a leading cause of healthcare-associated urinary tract infection. Despite initiatives to minimise the placement of IUCs, levels of inappropriate use are...

Nurses' Experiences of Nonpatient Factors That Affect Nursing Workload: A Study of the PAONCIL Instrument's Nonpatient Factors.

In the RAFAELA patient classification system, the professional assessment of optimal nursing care intensity level (PAONCIL) instrument is used to assess the optimal nursing intensity level per unit. The PAONCIL instrument contains an overall assessment of the actual nursing intensity level and an additional list of central nonpatient factors that may increase or decrease the total nursing workload (NWL). The aim of this cross-sectional study was to assess and determine which nonpatient factors affect nurses' experiences of their total NWL in both outpatient settings and hospitals, as captured through the PAONCIL instrument. The data material consisted of PAONCIL questionnaires from 38 units and 37 outpatient clinics at 11 strategically selected hospitals in Finland, and included nurses' answers (n = 1307) to the question of which factors, other than nursing intensity, affect total NWL. The methods for data analyses were qualitative content analyses. The nonpatient factors that affected nurses' experiences of total NWL are “organization of work,” “working conditions,” “self-control,” and “cooperation.” The actual list of nonpatient factors in the PAONCIL instrument is to a reasonable extent relevant, but the list should be improved to include nurses' actual working conditions and self-control.

Factors associated with delayed treatment onset for acute myocardial infarction in Victorian emergency departments: A regression tree analysis

Minimising time to treatment onset for acute myocardial infarction (AMI) in the emergency department (ED) is essential, yet little is understood about the interactions between variables affecting it. The aim of this study was to develop a regression tree model explicating the influence of patient and non-patient factors on the time taken to commence treatment for patients with AMI in Victorian EDs. A regression tree model for variables impacting time to treatment was developed on retrospective data for patients aged 18-85 years with AMI treated in Victorian EDs from 2005 to 2010 (n=21,080). Data were partitioned into three subsets, with a complexity parameter set at 0.0005. Four variables emerged in the final regression tree model: triage score; mode of arrival; area of residence; and patient sex. The variable most influencing time to treatment onset for AMI was triage category. For undertriaged patients, treatment time patterns were affected by arrival mode, residential location and their sex, significantly extending delays to treatment onset. Interactions between specific variables influenced whether patients with AMI were treated with equity in Victorian EDs, resulting in previously unidentified evidence-practice gaps and an improved understanding of which patient groups were vulnerable to delayed treatment for AMI.

Inpatient Stroke Rehabilitation Lengths of Stay in Canada Derived From the National Rehabilitation Reporting System, 2008 and 2009

ObjectiveTo determine rehabilitation length of stay (LOS) for patients with stroke in Canada, and to evaluate which factors contribute to variations in LOS. DesignA retrospective cohort study of Canadians rehabilitating from stroke using medical, functional, and sociodemographic variables extracted from the Canadian Institute for Health Information's National Rehabilitation Reporting System. SettingCanadian rehabilitation hospitals providing stroke rehabilitation services. ParticipantsPatients with stroke (N=11,983) admitted to rehabilitation hospitals from January 2008 through December 2009. InterventionsNone. Main Outcome MeasuresRehabilitation LOSs were calculated nationally and regionally. Regression models incorporating sociodemographic and clinical measures were constructed to test their effect on LOS. ResultsThe median stroke rehabilitation LOSs was 35 days (quartiles: 20d, 54d). LOSs varied regionally within Canada. A multivariable regression model including age, FIM motor function scores at admission, and geographic region explained 20% of the variation in LOSs. Modeling these data using a Function-Related Groups case-mix model explained 16% of the variation in LOSs. ConclusionsFIM motor function scores at admission along with age and geographic region best predicted rehabilitation LOS. These variables explained 20% of the variation in LOSs. Despite regional differences in LOSs, patient characteristics were similar between regions. Other nonpatient factors not captured in these data may contribute to a greater extent in determining stroke rehabilitation LOS.

Clamshell Incision vs. Sternal-Sparing Incision in Lung Transplantation

Purpose Transverse thoracosternotomy, or ‘clamshell’ incision, has been regarded as the incision of choice for bilateral lung transplantation (LTx) for the past decade. However, the clamshell incision can result in significant morbidity including sternal wound dehiscence, sternal instability, wound infection and pain. Bilateral anterior thoracotomy, which avoids transection of the sternum, has been proposed as an alternative. We assessed the safety and efficacy of bilateral anterior thoracotomy compared with the clamshell incision. Methods and Materials Single center retrospective review of 130 bilateral LTx patients operated January 2009-May 2012. 79/130 (61%) underwent clamshell incisions (Group A) (Median follow up time: 866 days) and 51/130 (39%) underwent sternal-sparing incisions (Group B) (Median follow up time: 699 days). Operative approach was allocated according to surgeon preference based on patient factors (diagnosis, body mass index, past surgery) and non-patient factors (donor ischaemic time, donor lung to recipient lung size match). Results 14/79 (18%) Group A patients developed sternal wound infection while 8/79 (10%) had sternal healing complications (10%). There was only one wound infection in Group B (chi-square, p=0.006). Median, (interquartile range) postoperative inpatient stay was comparable between groups (Group A vs Group B = 17 days, (13 – 30) vs. 15 days (11-25), as was ICU stay: 5.5 days (3-12) vs. 4 days (2-11 days ). No significant difference was found between groups in median (interquartile range) transplant duration:7 hours (5-8) vs. 7 hours (6–8), perfusion time: 209 hours ( 168 – 255) vs. 220 (191–247), or lung function at 1 year viz: VC% (mean±SD)= 87±19 vs. 92±23, median (interquartile range) FEV%= 81 (73–98) vs. 94 (66–105), FEV1/FVC = 0.79 (0.72–0.87) vs. 0.83 (0.71–0.91 ). Conclusions Sternal-sparing incisions performed for bilateral LTx are associated with a lower rate of wound infection and healing complications than clamshell incisions. Surgery times, ICU bed days and functional outcomes were comparable.

Referral and receipt of treatment for hepatocellular carcinoma in United States veterans: Effect of patient and nonpatient factors

The delivery of treatment for hepatocellular carcinoma (HCC) could be influenced by the place of HCC diagnosis (hospitalization versus outpatient), subspecialty referral following diagnosis, as well as physician and facility factors. We conducted a study to examine the effect of patient and nonpatient factors on the place of HCC diagnosis, referral, and treatment in Veterans Administration (VA) hospitals in the United States. Using the VA Hepatitis C Clinical Case Registry, we identified hepatitis C virus (HCV)-infected patients who developed HCC during 1998-2006. All cases were verified and staged according to Barcelona Clinic Liver Cancer (BCLC) criteria. The main outcomes were place of HCC diagnosis, being seen by a surgeon or oncologist, and treatment. We examined factors related to these outcomes using hierarchical logistic regression. These factors included HCC stage, HCC surveillance, physician specialty, and facility factors, in addition to risk factors, comorbidity, and liver disease indicators. Approximately 37.2% of the 1,296 patients with HCC were diagnosed during hospitalization, 31.0% were seen by a surgeon or oncologist, and 34.3% received treatment. Being seen by a surgeon or oncologist was associated with surveillance (adjusted odds ratio [aOR] = 1.47; 95% CI: 1.20-1.80) and varied by geography (1.74;1.09-2.77). Seeing a surgeon or oncologist was predictive of treatment (aOR = 1.43; 95% CI: 1.24-1.66). There was a significant increase in treatment among patients who received surveillance (aOR = 1.37; 95% CI: 1.02-1.71), were seen by gastroenterology (1.65;1.21-2.24), or were diagnosed at a transplant facility (1.48;1.15-1.90). Approximately 40% of patients were diagnosed during hospitalization. Most patients were not seen by a surgeon or oncologist for treatment evaluation and only 34% received treatment. Only receipt of HCC surveillance was associated with increased likelihood of outpatient diagnosis, being seen by a surgeon or oncologist, and treatment.

Pulmonary artery catheters: Evolving rates and reasons for use*

Randomized trials have demonstrated risks and failed to establish a clear benefit for the use of the pulmonary artery catheter. We assessed rates of pulmonary artery catheter use in multiple centers over 5 yrs, variables associated with their use, and how these variables changed over time (2002-2006). A multicenter longitudinal study using the Hamilton Regional Critical Care Database. A two-level multiple logistic regression analysis was used to determine significant variables associated with pulmonary artery catheter use and whether these varied over time. Academic intensive care units in Hamilton, Canada. We identified patients from five intensive care units who received a pulmonary artery catheter within the first 2 days of intensive care unit admission. Pulmonary artery catheter use over a 5-yr period. Among 15,006 patients, 1,921 (12.8%) had a pulmonary artery catheter. Adjusted rates of pulmonary artery catheter use decreased from 16.4% to 6.5% over 5 yrs. Determinants of pulmonary artery catheter use included Acute Physiology and Chronic Health Evaluation II score (odds ratio [OR], 1.05; confidence interval [CI], 1.04-1.06; p < .0001), elective surgical status (OR, 2.82; CI, 2.29-3.48; p < .0001), postabdominal aortic aneurysm repair (OR, 10.91; CI, 8.24-14.45; p < .0001), cardiogenic shock (OR, 5.31; CI, 3.35-8.42; p < .0001), sepsis (OR, 2.83; CI, 1.94-4.13; p < .0001), vasoactive infusion use (OR, 4.04; CI, 3.47-4.71; p < .0001), and mechanical ventilation (OR, 2.21; CI, 1.86-2.63; p < .0001). Physician's base specialty and local intensive care unit were also associated with pulmonary artery catheter use (p < .0001). The determinants of pulmonary artery catheter use did not change over time. We observed a >50% reduction in the rate of pulmonary artery catheter use over 5 yrs. Patient factors predicting pulmonary artery catheter use were illness severity, specific diagnoses, and the need for advanced life support. Nonpatient factors predicting pulmonary artery catheter use were intensive care unit and the attending physician's base specialty.

Provider Factors Associated with Intramedullary Nail Use for Intertrochanteric Hip Fractures

Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures. Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported. There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors. The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital's burden of their choices for higher cost devices under the Medicare payment system.

Predictors of treatment in patients with chronic hepatitis C infection—Role of patient versus nonpatient factors

Treatment with interferon and ribavirin is effective in patients with chronic infection with hepatitis C virus (HCV). Previous data indicate that treatment rates are suboptimal. We sought to identify patient and provider-level predictors of treatment receipt in HCV by conducting a retrospective cohort study of 5701 HCV patients in a large regional Veteran's Administration (VA) healthcare network. We also determined the degree of variation in treatment rates attributable to patient, provider, and facility factors. Three thousand seven hundred forty-three patients (65%) were seen by a specialist and 894 (15.7%) received treatment. Treatment rates varied from 6% to 29% across the 5 facilities included in the analysis. Patients were less likely to receive treatment if they were older [RR, 0.55; 95% CI, 0.45, 0.67), single (RR, 0.77; 95%CI, 0.67, 0.88), had hepatic dysfunction (RR, 0.73; 95%CI, 0.66, 0.89), had normal alanine aminotransferase (ALT) (RR, 0.73; 95%CI, 0.59, 0.89), had HCV genotype 1 (RR, 0.78; 95%CI, 0.71, 0.86), were African American with genotype 1 (RR, 0.78; 95% CI, 0.71, 0.86), or were anemic (RR, 0.70; CI, 0.60, 0.89). In addition, patients evaluated by less experienced providers were 77% less likely to receive treatment than those evaluated by more experienced providers. The patient, provider, and facility factors explained 23%, 25%, and 7% of variation in treatment rates, respectively. These data suggest that although patient characteristics are important predictors of treatment in HCV, a significant proportion of variation in treatment rates is explained by provider factors. These potentially modifiable provider-level factors may serve as high-yield targets for future quality improvement initiatives in HCV.