Non-patient Factors Research Articles

Understanding delays to parathyroidectomy: A mixed-methods approach

BackgroundPatients from ethnic and racial minority groups with primary hyperparathyroidism may have greater time delays to curative parathyroidectomy. Contributing factors are unclear. MethodsThis was a sequential mixed-methods study. The quantitative phase was a retrospective chart review of adults with primary hyperparathyroidism who underwent parathyroidectomy between 2015 and 2020, collecting demographic and clinical data. Social vulnerability of the patients' residential area, measured with the Social Vulnerability Index, and relevant clinical time intervals were calculated. A multivariable analysis of factors associated with greater time intervals was performed. The qualitative phase involved semistructured interviews with endocrinologists, analyzed inductively for themes. ResultsOn chart review of 1,083 patients, the median age was determined to be 61 years and 856 (79%) were female. Six hundred twenty-eight (57.9%) were non-Hispanic White and 456 (42.1%) were Hispanic ethnicity or Asian, Pacific Islander, Black, Native American, Other or Unknown race. Patients of Hispanic ethnicity, or Asian or Pacific Islander, Black, Native American, Other or Unknown race were more likely than non-Hispanic White patients to live in the most socially vulnerable areas (19.3% vs 5.9%, P < .01) and had greater time intervals than non-Hispanic White patients between index hypercalcemia and first parathyroid hormone level, surgical referral, or parathyroidectomy (all P < .05). On multivariable analysis, age (coefficient 7.9, 95% CI 2.8–13.0) and living in the most socially vulnerable areas (coefficient 297.9, 95% CI 87–508.7) were associated with greater days between index hypercalcemia and parathyroidectomy. In the study's qualitative phase, identified themes for reasons for care delays included socioeconomic, nonsocioeconomic patient, and nonsocioeconomic nonpatient factors. ConclusionCare delays are driven by a combination of socioeconomic and nonsocioeconomic factors.

MULTIPLE BIOSIMILAR INFLIXIMAB SWITCHING IS NOT ASSOCIATED WITH DISEASE FLARE IN INFLAMMATORY BOWEL DISEASE: A REAL-WORLD EFFECTIVENESS ANALYSES IN A NATIONAL U.S. COHORT

Abstract BACKGROUND Infliximab (IFX) biosimilars are available for inflammatory bowel disease (IBD). Many options of IFX biosimilars exist, however there is a paucity of data on the safety and efficacy of switching between multiple IFX biosimilars. The goal of this study is to evaluate the safety and outcomes in patients who received multiple IFX biosimilars in a National U.S. Cohort of patients with IBD. METHODS We conducted a retrospective cohort study of IBD patients who received maintenance IFX originator from 2017- 2019 in the national Veterans Affairs (VA) healthcare system. Crohn’s disease (CD) and ulcerative colitis (UC) patients were identified using a previously validated algorithm. All cases, exposures and outcomes were confirmed by chart review. Patents on IFX originator were identified by dispensed medication from the VA Corporate Data Warehouse. Patients were classified as no-switch (NS)- receiving originator but no biosimilar during study period, Single Switch (SS)- switch from IFX originator to one biosimilar, or Double Switch (DS)- switch from IFX originator to two different biosimilars. Primary outcome was IBD flare, defined as escalation of steroid, IBD-related Emergency department visit or hospitalization within 12 months. Secondary outcomes were immunogenicity, serious infection, and infusion reaction. Event rates of the DS group were compared to NS and SS groups using univariate and multivariate logistic regression models adjusting for patient and non-patient factors. RESULTS A total of 789 patients (487 CD, 298 UC, 4 IBDU) on maintenance IFX originator were identified during the study period. Of these, 410 patients were categorized as NS, 249 as SS, and 130 as DS. Overall, the rate of flare within 12 months was 19.9% (22.2% NS, 15.3% SS, 21.5% DS, p= 0.08), rate of infection was 11.2% (11.5% NS, 8% SS, 16.2% DS, p= 0.056). No statistically significant differences in rates of immunogenicity or infusion reaction were identified between the DS and NS or SS groups. In multivariate (MV) logistic regression including age, race, gender, concomitant medication, comorbidity, and VA priority status, no significant differences in flares at 12 months was observed between the DS (ref) and NS (aOR 1.12, 95% CI 0.68-1.84), or SS groups (aOR 0.64, 95% CI 0.36-1.12). In MV analyses, SS was associated with lower rate of infection compared to DS (aOR 0.41, 95% CI 0.21-0.82). CONCLUSION In a national U.S. cohort of patients with IBD, multiple IFX biosimilar switching was not associated with flare at 12 months compared to patients continued on IFX originator or with a single IFX biosimilar switch. However, double switch was associated with increased odds of infection compared to single switch. These findings provide reassurance that multiple IFX biosimilar switching for IBD is effective but further study on infection risks may be warranted.

P708 Multiple Biosimilar Infliximab Switching is Not Associated with Adverse Outcomes in Inflammatory Bowel Disease: A Real-World Effectiveness Analysis in a National U.S. Cohort

Abstract Background Infliximab (IFX) biosimilars are available for inflammatory bowel disease (IBD). Many options of IFX biosimilars exist, however there is a paucity of data on the safety and efficacy of switching between multiple IFX biosimilars. The goal of this study is to evaluate the safety and outcomes in patients who received multiple IFX biosimilars in a National U.S. Cohort of patients with IBD. Methods We conducted a retrospective cohort study of IBD patients on maintenance IFX originator from 2017- 2019 in the national Veterans Affairs (VA) healthcare system. Crohn’s disease (CD) and ulcerative colitis (UC) patients were identified using a previously validated algorithm. Cases, exposures and outcomes were confirmed by chart review. Patents on IFX originator were identified by dispensed medication from the VA Corporate Data Warehouse. Patients were classified as no-switch (NS)- receiving originator but no biosimilar during study period, Single Switch (SS)- switch from originator to one biosimilar, or Double Switch (DS)-switch from IFX originator to two different biosimilars. Primary outcome was IBD flare, defined as escalation of steroid, IBD-related Emergency department visit or hospitalization within 12 months. Secondary outcomes were immunogenicity, serious infection, and infusion reaction. Event rates of the DS group were compared to NS and SS groups using univariate and multivariate (MV) logistic regression models adjusting for patient and non-patient factors. Results 789 patients (487 CD, 298 UC) on maintenance IFX originator were identified. Of these, 410 patients were categorized as NS, 249 as SS, and 130 as DS. Overall, the rate of flare within 12 months was 19.9% (22.2% NS, 15.3% SS, 21.5% DS, p= 0.08), rate of infection was 11.2% (11.5% NS, 8% SS, 16.2% DS, p= 0.056). No statistically significant differences in rates of immunogenicity or infusion reaction were identified between the DS and NS or SS groups. In MV logistic regression including age, race, gender, medication, comorbidity and VA priority status, no significant differences in flares at 12 months was observed between DS (ref) and NS (aOR 1.12, 95% CI 0.68-1.84), or SS groups (aOR 0.64, 95% CI 0.36-1.12). In MV analyses, SS was associated with lower rate of infection compared to DS (aOR 0.41, 95% CI 0.21-0.82). Conclusion In a national U.S. cohort of patients with IBD, multiple IFX biosimilar switching was not associated with flare at 12 months compared to patients continued on IFX originator or with a single IFX biosimilar switch. However, DS was associated with increased odds of infection compared to single switch. These findings provide reassurance that multiple IFX biosimilar switching for IBD is effective but further study on infection risks may be warranted.

Stress experiences of healthcare assistants in family practice at the onset of the COVID-19 pandemic: a mixed methods study.

At the beginning of the pandemic in 2020, healthcare assistants in general practices were confronted with numerous new challenges. The aim of the study was to investigate the stress factors of healthcare assistants in March/April 2020 as well as in the further course of the pandemic in 2020. From August to December 2020, 6,300 randomly selected healthcare assistants in four German states were invited to participate in the study. We performed a mixed methods design using semi-structured telephone interviews and a cross-sectional survey with quantitative and open questions. The feeling of psychological burden was assessed on a 6-point likert-scale. We defined stress factors and categorized them in patient, non-patient and organizational stress factors. The results of the three data sets were compared within a triangulation protocol. One thousand two hundred seventy-four surveys were analyzed and 28 interviews with 34 healthcare assistants were conducted. Of the participants, 29.5% reported experiences of a very high or high feeling of psychological burden in March/April 2020. Worries about the patients' health and an uncertainty around the new disease were among the patient-related stress factors. Non-patient-related stress factors were problems with the compatibility of work and family, and the fear of infecting relatives with COVID-19. Organizational efforts and dissatisfaction with governmental pandemic management were reported as organizational stress factors. Support from the employer and team cohesion were considered as important resources. It is necessary to reduce stress among healthcare assistants by improving their working conditions and to strengthen their resilience to ensure primary healthcare delivery in future health crises.

Predictors of referral for long-term EEG monitoring for Medicare beneficiaries with drug-resistant epilepsy.

For people with drug-resistant epilepsy, the use of epilepsy surgery is low despite favorable odds of seizure freedom. To better understand surgery utilization, we explored factors associated with inpatient long-term EEG monitoring (LTM), the first step of the presurgical pathway. Using 2001-2018 Medicare files, we identified patients with incident drug-resistant epilepsy using validated criteria of ≥2 distinct antiseizure medication (ASM) prescriptions and ≥1 drug-resistant epilepsy encounter among patients with ≥2 years pre- and ≥1 year post-diagnosis Medicare enrollment. We used multilevel logistic regression to evaluate associations between LTM and patient, provider, and geographic factors. We then analyzed neurologist-diagnosed patients to further evaluate provider/environmental characteristics. Of 12 044 patients with incident drug-resistant epilepsy diagnosis identified, 2% underwent surgery. Most (68%) were diagnosed by a neurologist. In total, 19% underwent LTM near/after drug-resistant epilepsy diagnosis; another 4% only underwent LTM much prior to diagnosis. Patient factors most strongly predicting LTM were age <65 (adjusted odds ratio 1.5 [95% confidence interval 1.3-1.8]), focal epilepsy (1.6 [1.4-1.9]), psychogenic non-epileptic spells diagnosis (1.6 [1.1-2.5]) prior hospitalization (1.7, [1.5-2]), and epilepsy center proximity (1.6 [1.3-1.9]). Additional predictors included female gender, Medicare/Medicaid non-dual eligibility, certain comorbidities, physician specialties, regional neurologist density, and prior LTM. Among neurologist-diagnosed patients, neurologist <10 years from graduation, near an epilepsy center, or epilepsy-specialized increased LTM likelihood (1.5 [1.3-1.9], 2.1 [1.8-2.5], 2.6 [2.1-3.1], respectively). In this model, 37% of variation in LTM completion near/after diagnosis was explained by individual neurologist practice and/or environment rather than measurable patient factors (intraclass correlation coefficient 0.37). A small proportion of Medicare beneficiaries with drug-resistant epilepsy completed LTM, a proxy for epilepsy surgery referral. While some patient factors and access measures predicted LTM, non-patient factors explained a sizable proportion of variance in LTM completion. To increase surgery utilization, these data suggest initiatives targeting better support of neurologist referral.

Factors affecting timeliness in management of head and neck cancer.

Timeliness in the management of patients with head and neck cancer (HNC) can be affected by both patient and non-patient related factors. This study aims to investigate the factors associated with the timeliness of managing HNC. A retrospective review was conducted on Western Health medical records including all new patients presenting to the Western Health HNC surgical outpatient clinic in the five-year period from first January 2017 to 31st December 2021 with the diagnosis of a HNC. Both patient and non-patient related factors were compared with the duration between a patient's referral to a HNC service and the commencement of their treatment. Two hundred and twenty-eight patients were included in this study. The median duration from referral to the commencement of treatment was 48 days. Lack of radiological or pathological investigations prior to referral to a HNC service as well as early staging were found to significantly impact timeliness in management. Socioeconomic factors such as non-English speaking backgrounds, distance from the hospital and lack of social supports were not found to negatively impact timeliness of management. The management of patients with HNC require careful consideration of all patient and non-patient related factors which may affect timeliness in management, particularly investigations performed prior to their referral to a HNC service.

P750 Biosimilar Infliximab Switching is Not Associated with Adverse Outcomes: A Real-World Effectiveness Analyses in a National U.S. Cohort of U.S. Military Veterans with Inflammatory Bowel Disease

Abstract Background Infliximab (IFX) biosimilars are widely available for Crohn’s disease (CD) and ulcerative colitis (UC). However, implementation of biosimilar switching has been highly variable in the U.S. Barriers to switching include patient and provider concerns of lower efficacy, immunogenicity, and safety. Biosimilar switching in Veterans Affairs (VA) was based on local facility policy rather than patient/provider selection and thus less prone to selection bias. The goal of this study is to evaluate the safety and effectiveness of biosimilar switching in a National U.S. Cohort of Veterans with CD and UC. Methods We conducted a retrospective cohort study of CD and UC patients who received maintenance originator IFX from 2017-2019 in the VA. CD and UC patients were identified using a previously validated algorithm and confirmed by chart review. Patents on maintenance IFX originator were identified by dispensed medication from Corporate Data Warehouse (CDW). Patients switched to IFX biosimilar after 2017 were identified in CDW by dispensed medication and confirmed by chart review. Adverse outcomes were defined as infusion reaction, serious infection (intravenous antibiotic, delay of IFX), immunogenicity (anti-IFX antibody or IFX escalation) or disease flare (escalation of steroid, IBD related Emergency department visit, hospitalization) confirmed by chart review. Adverse event rates at 12 months for patients continued on originator IFX were compared to patients switched to IFX biosimilar using univariate and multivariate logistic regression models adjusting for patient and non-patient factors. Results A total of 790 patients (492 CD, 298 UC) on originator IFX were identified during the study period. Of these, 380 patients were identified to have switched to IFX biosimilar and 410 patients continued on IFX originator during the study period. Overall adverse outcomes occurred in 35.6% of patients at 12 months (35.6% switch, 35.3% non-switch, p=0.87). No statistically significant difference in rates of infusion reaction, serious reaction, immunogenicity, or IBD flare were identified between switch and non-switch groups. In multivariate logistic regression including age, race, gender, concomitant medication, and VA priority status, no significant differences in adverse outcomes at 12 months were observed between switch and non-switch groups (aOR 1.09, 95% CI 0.76-1.42). Conclusion In a real-world national U.S. cohort of patients with CD and UC, we observed IFX biosimilar switching was not associated with adverse events compared to continuation on IFX originator. While this study may be underpowered to detect such a small difference, these findings provide further reassurance that IFX biosimilar switching for CD and UC is safe and effective.

Practising prioritisation: exploring variation in applying a clinical pharmacy risk stratification tool

ObjectivesTo evaluate the use of a risk stratification tool and explore the contributing factors to variation in practice by clinical pharmacists.MethodsThe quantitative phase was a prospective evaluation of adherence to...

Association Between Critical Events in the PICU and Outcomes in Neighboring Patients.

OBJECTIVE:PICU patients who experience critical illness events, such as intubation, are at high risk for morbidity and mortality. Little is known about the impact of these events, which require significant resources, on outcomes in other patients. Therefore, we aimed to assess the association between critical events in PICU patients and the risk of similar events in neighboring patients over the next 6 hours.DESIGN:Retrospective observational cohort study.SETTING:Quaternary care PICU at the University of Chicago.PATIENTS:All children admitted to the PICU between 2012 and 2019.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:The primary outcome was a critical event defined as the initiation of invasive ventilation, initiating vasoactive medications, cardiac arrest, or death. The exposure was the occurrence of a critical event among other patients in the PICU within the preceding 6 hours. Discrete-time survival analysis using fixed 6-hour blocks beginning at the time of PICU admission was used to model the risk of experiencing a critical event in the PICU when an event occurred in the prior 6 hours. There were 13,628 admissions, of which 1,886 (14%) had a critical event. The initiation of mechanical ventilation was the most frequent event (n = 1585; 59%). In the fully adjusted analysis, there was a decreased risk of critical events (odds ratio, 0.82; 95% CI, 0.70–0.96) in the 6 hours following exposure to a critical event. This association was not present when considering longer intervals and was more pronounced in patients younger than 6 years old when compared with patients 7 years and older.CONCLUSION:Critical events in PICU patients are associated with decreased risk of similar events in neighboring patients. Further studies targeted toward exploring the mechanism behind this effect as well as identification of other nonpatient factors that adversely affect outcomes in children are warranted.

Physician-Specific Utilization of an Electronic Best Practice Alert for Pediatric Sepsis in the Emergency Department.

Early recognition of sepsis remains a critical goal in the pediatric emergency department (ED). Although this has led to the development of best practice alerts (BPAs) to facilitate screening and bundled care, research on how individual physicians interact with sepsis alerts and protocols is limited. This study aims to identify common reasons for acceptance and rejection of a sepsis BPA by pediatric emergency medicine (PEM) physicians and understand how the BPA affects physician management of patients with suspected sepsis. This is a qualitative study of PEM physicians in a quaternary-care children's hospital. Data were collected through semistructured interviews and analyzed through an iterative coding process until thematic saturation was achieved. Member checking was completed to ensure trustworthiness. Thematic analysis of PEM physicians' rejection reasons in the electronic health record was used to categorize their responses and calculate each theme's frequency. Twenty-two physicians participated in this study. Seven physicians (32%) relied solely on patient characteristics when deciding to accept the BPA, whereas the remaining physicians considered nonpatient factors specific to the ED environment, individualized practice patterns, and BPA design. Eleven principal reasons for BPA rejection were derived from 1406 electronic health record responses, with clinical appearance not consistent with shock being the most common. Physicians identified the BPA's configuration and incomplete understanding of the BPA as the biggest barriers to utilization and provided strategies to improve the BPA screening process and streamline sepsis care. Physicians emphasized the need for further BPA education for physicians and triage staff and improved transparency of the alert. Physicians consider patient and nonpatient factors when responding to the BPA. Improved BPA functionality combined with measures to enhance screening, optimize sepsis management, and educate ED providers on the BPA may increase satisfaction with the alert and promote more effective utilization when it fires.

Trends, Outcomes, and Impact of Early Discharge Following Bariatric Surgery: a Retrospective MBSAQIP Analysis of 748,955 Patients.

Decreasing the length of stay following bariatric surgery can reduce pressure on hospitals and surgical costs and increase patient satisfaction. We examine trends in length of hospital stay following bariatric surgery and in post-operative complications. The 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was used to compile patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy. Patients were categorized into either early discharge (within one day of surgery) or late discharge, and patient and non-patient factors were compared between the two groups. A multivariable logistic regression was carried out to determine predictive factors for early discharge. We evaluated 748,955 patients, with 399,918 (53%) being discharged early. Patients discharged early were younger and had fewer associated medical problems. The rate of early discharge increased between 2015 and 2019 (42.1% in 2015 vs 62.0% in 2019), while complication rates decreased or were unchanged. Multivariable analysis revealed lower ASA classification (OR 1.07; CI 1.06-1.09; p < 0.0001) and operative year (2019 vs. 2015 OR 2.26; CI 2.22-2.29; p < 0.0001) to be independently associated with early discharge.Several factors including undergoing RYGB (OR 0.44 CI 0.44-0.45; p < 0.0001), and dialysis dependence (OR 0.50; CI 0.45-0.55; p < 0.0001) among others, were associated with reduced early discharge likelihood. There is a trend in bariatric surgery towards the practice of early discharge, which is safe for patients. Further work is needed to develop a set of criteria to determine which patients are best suited for this practice.

Conceptual Model of Emergency Department Utilization among Deaf and Hard-of-Hearing Patients: A Critical Review.

Deaf and hard-of-hearing (DHH) populations are understudied in health services research and underserved in healthcare systems. Existing data indicate that adult DHH patients are more likely to use the emergency department (ED) for less emergent conditions than non-DHH patients. However, the lack of research focused on this population’s ED utilization impedes the development of health promotion and quality improvement interventions to improve patient health and quality outcomes. The purpose of this study was to develop a conceptual model describing patient and non-patient (e.g., community, health system, provider) factors influencing ED utilization and ED care processes among DHH people. We conducted a critical review and used Andersen’s Behavioral Model of Health Services Use and the PRECEDE-PROCEED Model to classify factors based on their theoretical and/or empirically described role. The resulting Conceptual Model of Emergency Department Utilization Among Deaf and Hard-of-Hearing Patients provides predisposing, enabling, and reinforcing factors influencing DHH patient ED care seeking and ED care processes. The model highlights the abundance of DHH patient and non-DHH patient enabling factors. This model may be used in quality improvement interventions, health services research, or in organizational planning and policymaking to improve health outcomes for DHH patients.

Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States

Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients. All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size. 75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF. Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

Non-patient factors associated with infections in LVAD recipients: A scoping review

Infections are the most common complication in recipients of durable left ventricular assist devices (LVAD) and are associated with increased morbidity, mortality, and expenditures. The existing literature examining factors associated with infection in LVAD recipients is limited and principally comprises single-center studies. This scoping review synthesizes all available evidence related to identifying modifiable, non-patient factors associated with infections among LVAD recipients. Published studies were identified through searching 5 bibliographic databases: PubMed, Scopus, EMBASE, CINAHL, and Web of Science Core Collection. Inclusion criteria required examination of factors associated with infections among recipients of contemporary, implantable, continuous flow LVADs. Key study characteristics were extracted by 4 independent reviewers and current literature described narratively. The Systems Engineering Initiative for Patient Safety (SEIPS) model was used to develop a taxonomy for non-patient related factors (e.g., tasks, tools, technologies, organization, and environment) associated with infections following LVAD implantation. All analyses took place between February 2019 and May 2021. A total of 43 studies met inclusion criteria. The majority of included studies were observational (n=37), single-center (n=29), from the U.S. (n=38), and focused on driveline infections (n=40). Among the 22 evaluated sub-domains of non-patient related factors, only two: increasing center experience and establishing a silicone-skin interface at the driveline exit site, were identified as consistently being associated with a lower risk of infection. This review identified 43 studies that described non-patient related factors associated with infection in LVAD recipients. Only two factors were consistently associated with lower infection risk in LVAD recipients: increasing experience and establishing a silicone-skin interface at driveline exit site. The large variability in reporting across multiple studied interventions limited the ability to discern their effectiveness.

Systematic review of factors influencing decisions to limit treatment in the emergency department

BackgroundEmergency physicians are frequently faced with making decisions regarding how aggressive to be in caring for critically ill patients. We aimed to identify factors that influence decisions to limit treatment...

Variation in neurosurgical intervention for severe traumatic brain injury: The challenge of measuring quality in trauma center verification.

Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution. We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval). We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement. Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification. Epidemiological, level III; Care management/Therapeutic level III.

Machine-Learning Accurately Predicts Adverse Outcomes Following Clostridioides difficile Infection in Colorectal Surgery

Background:Clostridioides difficile infection (CDI) following colorectal surgery can lead to significant adverse outcomes. Although previous studies have identified risk factors for CDI, their relative importance for predicting complications remains unclear. Objective: We sought to use machine-learning algorithms to accurately determine which perioperative risk factors are most predictive of adverse outcomes after CDI. Methods: The National Surgical Quality Improvement Project (NSQIP) database was used to identify all patients who developed CDI after a colorectal operation in 2016 (N = 14,392). We excluded patients without CDI and patients &lt;18 years of age. Any missing data were replaced with multivariate singular value decomposition imputation. We collected data on patient demographics, comorbidities, preoperative laboratory values, operative details, and outcomes, including infectious, cardiovascular, hematologic, renal, and pulmonary complications, unplanned returns to the operating room (RTOR), non–home discharge, readmission, and mortality. Data were univariably assessed for significant association with outcomes. If an input variable significantly correlated with ≥5 outcomes, it was included in our machine-learning models. We utilized bootstrap aggregation with random forests to improve prediction accuracy. We then calculated each input variable’s importance to the model outcome (VIP). The VIPs of each variable were averaged to yield an overall impact. Each model’s accuracy was determined by the area under the receiver operator curve (AUROC). Results: There were 841 patients in our cohort (median age 66 years (IQR, 55–75.8), 482 (57%) were women, and the mean American Society of Anesthesiologists [ASA] class score was 2.9 (SD, ±0.7). Of all colorectal surgeries, 172 (20.5%) were emergent. Overall mortality was 3.8% (n=32), and 371 patients (44.1%) experienced at least 1 postoperative complication, of which infectious complications (eg, septic shock, sepsis, wound infection, urinary tract infection) were most common (n=255, 30.3%). The RTOR rate was 10.3% (n = 87), the non–home discharge rate was 23.8% (n = 200), and the readmission rate was 30.9% (n = 260). The input variables most predictive of any adverse outcome were hematocrit (VIP, 24.9%), ASA class (VIP, 24.4%), creatinine (VIP, 17.4%), and prealbumin (VIP, 11.6%). The probability of any adverse outcome was 90.6% in the setting of hematocrit ≤27%, ASA class ≥3, creatinine ≥1.6 mg/dL, and prealbumin ≤3.1 mg/dL. All machine-learning models had an AUROC ≥0.99. Conclusions: Although nonpatient factors can contribute to unfavorable outcomes in patients with CDI following colorectal surgery, we identified 4 patient-specific variables that account for almost 80% of any adverse outcomes. Although further prospective study is needed, individuals with these preoperative risk factors could consider delaying their elective colorectal operations until they are medically optimized.Funding: NoneDisclosures: None

Patient- and Physician-Level Factors Associated With Adherence to C-CHANGE Recommendations in Primary Care Settings in Ontario

BackgroundWe previously found large variation among family physicians in adherence to the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE). We assessed the role of patient- and physician-level factors in the variation in adherence to recommendations for managing cardiovascular disease risk factors. MethodsWe conducted a retrospective study using multilevel logistic regression analyses with the Electronic Medical Record Administrative data Linked Database (EMRALD) housed at ICES in Ontario. Five quality indicators based on C-CHANGE guidelines were modelled. Effects of clustering and between-group variation, patient-level (sociodemographics, comorbidities) and physician-level characteristics (demographic and practice information) were assessed to determine odds ratios of receiving C-CHANGE recommended care. ResultsIn all, 324 Ontario physicians practicing in 41 clinics who provided care to 227,999 adult patients were studied. We found significant variation in quality indicators, with 15% to 39% of the total variation attributable to nonpatient factors. The largest variation was in performing 2-hour plasma glucose testing in prediabetic patients. Patient-level factors most frequently associated with recommendation adherence included sex, age, and multi-comorbidities. Women were more likely than men to have their body mass index measured, and their blood pressure controlled, but less likely to receive antiplatelet medications and liver-enzyme testing if overweight or obese. ConclusionsThe majority of variations in adherence were attributable to patient attributes, but a substantial proportion of unexplained variation was due to differences among physicians and clinics. This finding may signal suboptimal processes or structures and warrant further investigation to improve the quality of primary care management of cardiovascular disease in Ontario.

A new approach to airway assessment-"Line of Sight" and more. Recommendations of the Task Force of Airway Management Foundation (AMF).

Assessment of airway is recommended by every airway guideline to ensure safe airway management. Numerous unifactorial and multifactorial tests have been used for airway assessment over the years. However, there is none that can identify all the difficult airways. The reasons for the inadequacy of these methods of airway assessment might be their dependence on difficult to remember and apply mnemonics and scores, inability to identify all the variations from the “normal”, and their lack of stress on evaluating the non-patient factors. Airway Management Foundation (AMF) experts and members have been using a different approach, the AMF Approach, to overcome these problems inherent to most available models of airway assessment. This approach suggests a three-step model of airway assessment. The airway manager first makes the assessment of the patient through focused history, focused general examination, and focused airway assessment using the AMF “line of sight” method. The AMF “line of sight” method is a non-mnemonic, non-score-based method of airway assessment wherein the airway manager examines the airway along the line of sight as it moves over the airway and notes down all the variations from the normal. Assessment of non-patient factors follows next and finally there is assimilation of all the information to help identify the available, difficult, and impossible areas of the airway management. The AMF approach is not merely intubation centric but also focuses on all other methods of securing airway and maintaining oxygenation. Airway assessment in the presence of contagion like COVID-19 is also discussed.

Mechanisms of decision-making in preoperative assessment for older adult prostate cancer patients-A qualitative study.

Little research exists which investigates the contextual factors and hidden influences that inform surgeons and surgical teams decision-making in preoperative assessment when deciding whether to or not to operate on older adult prostate cancer patients living with aging-associated functional declines and illnesses. The aim of this study is to identify and examine the underlying mechanisms that uniquely shape preoperative surgical decision-making strategies concerning older adult prostate cancer patients. Qualitative methodologies were used that paired ethnographic field observations with semistructured interviews for data collection. An inductive thematic analysis approach was used to identify, analyze, and describe patterns in the data. Factors underlining surgical decision-making originated from the context of two categories: (1) clinical and surgery-specific factors; and (2) non-patient factors. Thematic subcategories included personal experiences, methods of assessment during medical encounters, anticipation of outcomes, perceptions of preoperative assessment instruments for frailty and multimorbidity, routines and workflow patterns, microcultures, and indirect observation and second-hand knowledge. Surgeon's personal experiences has a significant impact on the decision-making processes during preoperative assessments. However, non-patient factors such as institutional microcultures passively and actively influence decision-making process during preoperative assessment.