Opportunities For Improving Care Research Articles

Abstract 14459: Ten Year Evolving Profile of Black Americans With Myocardial Infarctions

Background: Racial disparities in the management and outcomes of myocardial infarction have been widely reported. Overall, the rate of cardiovascular (CV) death has risen since 2010 while hospitalization rates remain flat. Here, we provide a comprehensive analysis, using a large database, of the evolving profile of Black Americans (BA) who suffered myocardial infarctions (MI) over the past 10 years and compared BA to the non-Black (non-BA) population. We also describe the change in their characteristics between 2 continuous 5-year periods (2010-14, 2015- 19) with the goal of identifying opportunities for care improvement. Methods: We used the OptumLabs Data Warehouse EHR data. Acute MI cases were based on discharge diagnosis codes for adults > 35 years of age between 1/1/2010 and 12/31/2019. A single individual could have had multiple MI’s. Data were analyzed descriptively. Results: A total of 36M annual observations were analyzed which included 129,146 MI’s with complete EHR data. MI’s among BA patients comprised 8.7% of the total in the 1 st period and went up to 10.4% in the 2 nd period.The main characteristics between BA and non-BA cases and between periods are shown in the table. In general, BA MI patients were younger than non-BA (57% vs 40% were <65). Conclusion: Compared to non-Blacks, Black patients with myocardial infarctions over the past 10 years exhibit a profile characterized by: MI’s at a younger age, almost half female, more DM, higher cholesterol and blood pressure levels, higher rate of smoking, more are Medicaid and ¾ live in the South.When comparing only Black patients between 2010-14 and 2015-2019 there was a marked increase in total MI’s, mostly in the 55-75 age range, increased diabetes, smoking and rising SBP levels.The description of an evolving profile among Blacks with MI’s could, at least partly, explain the rising trend of CV mortality, identify potential gaps in care and the need to design new forms to detect subclinical atherosclerosis.

CARE AND CHARACTERISTICS OF PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION (PAH) IN US CLINICAL PRACTICE

CARE AND CHARACTERISTICS OF PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION (PAH) IN US CLINICAL PRACTICE

Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough?

Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough?

Severe obesity in a specialist type 2 diabetes outpatient clinic: an Australian retrospective cohort study

BackgroundObesity is a major risk factor for the development of type 2 diabetes (T2DM) and its complications. Significant weight loss has been shown to improve glycaemia in people with T2DM and obesity. National and international guidelines recommend considering bariatric surgery for body mass index (BMI) ≥ 35 kg/m2. We assessed the proportion of people with T2DM meeting criteria for surgery, how many had been offered a bariatric/obesity service referral, and compared the characteristics of people with BMI ≥ 35 kg/m2 and BMI < 35 kg/m2.MethodsRetrospective data were collected for all people with T2DM aged ≥18 years, attending a hospital specialist diabetes outpatient service over three calendar years, 2017–2019.ResultsOf 700 people seen in the service, 291 (42%) had BMI ≥ 35 kg/m2 (the “BMI ≥ 35 group”) and met criteria for bariatric surgery, but only 54 (19%) of them were offered referral to an obesity service. The BMI ≥ 35 group was younger than those with a BMI < 35 kg/m2 (56.1 ± 14.8 vs 61.4 ± 14.6 years, p < 0.001) (mean ± SD), with similar diabetes duration (11.0 ± 9.0 vs 12.3 ± 8.9 years, p = 0.078), and there was no significant difference in initial HbA1c (75 ± 27 vs 72 ± 26 mmol/mol, p = 0.118) (9.0 ± 2.5 vs 8.7 ± 2.4%) or proportion treated with insulin (62% vs 58%). There was more GLP1 agonist use in the BMI ≥ 35 group (13% vs 7%, p = 0.003) but similar rates of SGLT2 inhibitor use (25% vs 21%, p = 0.202). The BMI ≥ 35 group received more new medication and/or dose adjustments (74% vs 66%, p = 0.016). Only 29% in the BMI ≥ 35 kg group achieved HbA1c < 53 mmol/mol (7.0%).ConclusionsIn spite of frequently meeting the criteria for bariatric surgery and not achieving glycaemic targets, people with T2DM in this specialist clinic received limited medical or surgical management of their obesity. This study suggests opportunities for improvement in care of people with T2DM at several levels including increased referrals from T2DM services to weight management/bariatric services, as well as an increased use of GLP1 agonists and SGLT2 inhibitors where appropriate. Our data support the need to prioritise obesity management in the treatment of type 2 diabetes.

675 The childbirth experience survey (CBEX): an analysis of qualitative survey data

In collaboration with community research partners, a national cross-sectional online Childbirth Experience Survey of pregnant and postpartum birthing people (CBEX) was conducted in 2016. The antepartum-postpartum survey includes items across 19 domains (including patient expectations, preferences and outcomes), and identified 23 childbirth-specific postpartum patient-reported outcomes (PROs) that were predictors of hospital satisfaction. It is currently being offered in 12 California hospitals to identify hospital-specific opportunities for improvement in care. We analyzed postpartum qualitative survey responses to validate the CBEX domains and to assess for any potential new domains. This was an exploratory analysis of qualitative survey data. Using Atlas.ti, we mapped participant responses to the 19 domains and 23 key childbirth-specific PROs. A total of 547 postpartum surveys were completed between October 30, 2018 and September 7, 2020. Of the completed surveys, 175 patients responded to the question, “Is there anything else you would like to share about your birth experience?” Patients could provide multiple comments. A total of 235 comments were analyzed and mapped to the 19 domains (Table 1). Qualitative responses highlighted issues in several subdomains: 1) interventions in labor: pressure from the care team to be induced comparable to pressure about cesareans; 2) pain management: issues related to epidural effectiveness, timing, dosage and education; 3) empathy and respect: issues related to students and residents; and 4) newborn feeding: rough physical handling of patients by nurses, specifically during lactation consults. Postpartum patient comments were entirely mapped to existing CBEX domains, confirming its content validity. These nuances emphasize the importance of patient input into research development and suggest the need for further refinement of topics to be explored and developed into standardized items. The potential for expanding CBEX subdomains and developing additional standardized items will be explored with community research partners.

417 A difficult to tell reality: care improvement opportunities for fatal cases of placenta accreta spectrum

Almost all cases of maternal death (MD) due to postpartum hemorrhage (PPH) are preventable. Placenta Accreta Spectrum (PAS) is a common cause of massive PPH. Few studies analyze PAS cases that result in MD. This paper aims to identify “delays” in the care of patients who died because of PAS in Latin America. We conducted a retrospective, descriptive, observational multicentric study in Latin American hospitals. We analyzed the care of patients who died from PAS, under The California Pregnancy-Associated Mortality Review Committee model, and take into account management standards of centers of excellence in PAS. The information was collected through a predesigned survey and discussed by telephone contact between the principal investigators and each local team. Thirty-four patients in eight Latin American countries (Colombia, Guatemala, Paraguay, Bolivia, Peru, Ecuador, Brazil and Venezuela) were included. Delays were identified in all cases (Table 1). The most prevalent type of delay was associated with health providers (97%), followed by health institutions (94%) and related to patients (76.5%). The principal cause of death was PPH (31 cases), followed by sepsis (2 cases) and pulmonary thromboembolism (1 case). Most delays were associated with the quality of health services, identifying as the main factors associated with death: failure to diagnose PAS with prenatal ultrasounds (35.3%) and underestimation of risk on suspicion of PAS (35.3%). The analysis groups defined maternal deaths as avoidable in all cases and determined that the interventions needed to change the outcome would have low, moderate, and high difficulty in 29, 50, and 21% of cases, respectively In all cases of PAS related to maternal death, we identify multiple improvement opportunities. All maternal deaths due to PAS were preventable, most of them with low to moderate complexity interventions.

When falls become fatal-Clinical care sequence.

ObjectivesThis study encompassed fall-related deaths, including those who died prior to medical care, that were admitted to multiple healthcare institutions, regardless of whether they died at home, in long-term care, or in hospice. The common element was that all deaths resulted directly or indirectly from injuries sustained during a fall, regardless of the temporal relationship. This comprehensive approach provides an unusual illustration of the clinical sequence of fall–related deaths. Understanding this pathway lays the groundwork for identification of gaps in healthcare needs.DesignThis is a retrospective study of 2014 fall-related deaths recorded by one medical examiner’s office (n = 511) within a larger dataset of all trauma related deaths (n = 1848). Decedent demographic characteristics and fall-related variables associated with the deaths were coded and described.ResultsOf those falling, 483 (94.5%) were from heights less than 10 feet and 394 (77.1%) were aged 65+. The largest proportion of deaths (n = 267, 52.3%) occurred post-discharge from an acute care setting. Of those who had a documented prior fall, 216 (42.3%) had a history of one fall while 31 (6.1%) had ≥2 falls prior to their fatal incident. For the 267 post-acute care deaths, 440 healthcare admissions were involved in their care. Of 267 deaths occurring post-acute care, 129 (48.3%) were readmitted within 30 days. Preventability, defined as opportunities for improvement in care that may have influenced the outcome, was assessed. Of the 1848 trauma deaths, 511 (27.7%) were due to falls of which 361 (70.6%) were determined to be preventable or potentially preventable.ConclusionOur data show that readmissions and repeated falls are frequent events in the clinical sequence of fall fatalities. Efforts to prevent fall-related readmissions should be a top priority for improving fall outcomes and increasing the quality of life among those at risk of falling.

Management of hepatoblastoma in the United States: Can we do better?

BackgroundHepatoblastoma is the most common type of liver cancer in children. Refined therapeutic approaches combining risk-adapted chemotherapy along with complete tumor resection has led to improved survival. We aimed to evaluate the current state of management and outcomes for hepatoblastoma in the United States. MethodsWe retrospectively reviewed 794 children (<18 years) with hepatoblastoma from the National Cancer Database (2004–2015). We assessed overall survival by means of Kaplan-Meier method, log-rank tests, and multivariable Cox regression. ResultsMedian age was 1 year (interquartile range: 0–2) and 170 (21.4%) presented with metastatic disease. Surgical resection was included in the treatment of 614 (77.3%) children (resection in 66.8% and liver transplantation in 10.6%). In the entire cohort, 95.1% of children received chemotherapy. In the surgical cohort, 575 (93.6%) received chemotherapy (34.5% neoadjuvant, 28.7% adjuvant, 30.5% both neoadjuvant and adjuvant). The 5-year overall survival was 76.6% for the entire cohort (no-surgery group: 55.3% vs surgery group: 82.8%). In multivariable analysis for all children, age ≥8 years (P = .009), metastasis (P < .001), surgery only (P = .009), and chemotherapy only (P < .001) were risk factors for mortality. In multivariable analysis for the surgical cohort, metastasis (P = .001), multifocality (P = .02), no chemotherapy (P = .03), and margin-positive resection (P = .02) were risk factors for mortality. ConclusionExcellent long-term overall survival is achievable with a combination of chemotherapy and surgical resection when a negative resection margin is achieved. However, nearly a quarter of children never received surgical treatment, representing a potential opportunity for improvement in care.

Towards a unified approach for multiple myeloma care in Kenya - proceedings of the Inaugural Multiple Myeloma Congress

The rising burden of multiple myeloma in Kenya has not been met by a commensurate effort for control. Patients and practitioners struggle with unavailability and unaffordability of diagnostics, drugs and stem cell transplant leading to presentation at advanced stages and under-treatment with increased morbidities and mortality. A concerted effort among stakeholders is urgently needed to develop strategies for myeloma control. The scarcity of providers also carries grave consequences for Kenyan patients. The Academic Model Providing Access To Healthcare (AMPATH) multiple myeloma program organized the Inaugural Virtual Multiple Myeloma Congress to achieve both interactive specialist instruction and stakeholder engagement. Expert presenters and panellists from diverse disciplines were invited to offer in-depth presentations on myeloma care and case studies from panellists´ practice were used to contextualize learning points and form a basis for generating debate on the challenges facing providers and opportunities for care improvement. An audience of health professionals offering care to myeloma patients was invited. The underlying principle of recommendations developed during the congress was collaboration among in-country and international practitioners, researchers and policy experts from private and public sector. This partnership of stakeholders bears the potential of pooling scarce resources and for collective advocacy towards better patient care

Identifying areas for quality improvement through outpatient mortality review.

230 Background: Inpatient mortality review is commonly used to improve patient care. Individual review of outpatient deaths is less common, yet 30-day mortality after hospital stay is an important quality metric. In this study, we sought to identify opportunities for care improvement by reviewing outpatient mortalities for cancer patients who died within 30 days of hospitalization. Methods: We identified 48 patients at Mayo Clinic Florida, with a hematologic (heme) or solid tumor (onc) cancer, who died within 30 days of an index hospital stay in 2018. We created a 32-question review survey to address quality of care around the hospital stay. The review team consisted of 1) heme or onc attendings, 2) heme/onc fellows, and 3) palliative care attendings. Each case was reviewed by one member of each of the 3 groups, split into heme or onc cases. Discrepancies in objective data points were resolved by the research team. Results: Of 143 surveys sent to 13 physicians (3 heme), 112 responses from 11 physicians (1 heme) for 47 patients were received. Twenty-one patients (45%) received cancer therapy within 30 days of death, and 23 (49%) were admitted &gt;2 times in 2 months prior to death. For onc cases, attendings rated prognosis as discussed 83% of the time, vs 65% of fellows and 39% of palliative care; in heme cases, the attending rated prognosis as discussed 11% of the time, vs 86% of fellows and 50% of palliative care. In heme cases, the attending rated expected survival &lt;3 months in 33% of cases vs 71% by fellows and 89% by palliative care; in onc cases, the reviews were more consistent (79% attending, 85% fellow, 93% palliative care). See Table for timing of prognosis discussions and palliative care involvement. Conclusions: The most common improvement opportunities identified by reviewing heme/onc patients who died within 30 days of a hospital stay included documented prognosis discussion and involvement of palliative care. Opportunities differed between heme and onc patients. Future directions include identifying and mitigating barriers that providers face in reaching these goals for their patients. [Table: see text]

Routine Multidisciplinary Review of Severe Maternal Morbidity Is Associated with a Reduction in Preventable Cases of Severe Maternal Morbidity.

Severe maternal morbidity (SMM) has increased by 45% in the United States and is estimated to affect up to 1.5% of all deliveries. Research has not yet been conducted that demonstrates a benefit to multidisciplinary review of SMM. The aim of our study was to determine if standardized, routine review of the cases of SMM by a multidisciplinary committee results in a reduction of potentially preventable cases of SMM. A retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from March 1, 2012 to September 30, 2016. Our cohort was separated into two groups: a preintervention group composed of women admitted for delivery prior to the implementation of the obstetric Quality and Peer Review Committee (OBQPRC), and a postintervention group where the committee had been well established. Cases of confirmed SMM were presented to a multidisciplinary research committee, and the committee determined whether opportunities for improvement in care existed. The groups were compared with determine if there was a decreased incidence of preventable SMM following the implementation of the OBQPRC standardized review process. There were 30,319 deliveries during the study period; 13,120 deliveries in the preintervention group; and 13,350 deliveries in the postintervention group (2,649 deliveries during the transition period). There was no difference in the rate of SMM between the preintervention (125; 0.95%) and postintervention (129; 0.97%) groups, (p = 0.91). There was a significantly lower rate of opportunity for the improvement in care in the postintervention group (29.5%) compared with the preintervention group (46%; p = 0.005). We demonstrated a significant reduction in the rate of potentially preventable SMM following the implementation of routine review of all SMM suggesting that this process plays an important role in improving maternal care and outcomes. · Benefit to routine review of SMM has not been demonstrated.. · Routine review of SMM is associated with 36% reduction in potentially preventable SMM.. · This is the first study to demonstrate the benefit of routine review of SMM..

Mortality review of US Special Operations Command battle-injured fatalities.

Comprehensive analyses of battle-injured fatalities, incorporating a multidisciplinary process with a standardized lexicon, is necessary to elucidate opportunities for improvement (OFIs) to increase survivability. A mortality review was conducted on United States Special Operations Command battle-injured fatalities who died from September 11, 2001, to September 10, 2018. Fatalities were analyzed by demographics, operational posture, mechanism of injury, cause of death, mechanism of death (MOD), classification of death, and injury severity. Injury survivability was determined by a subject matter expert panel and compared with injury patterns among Department of Defense Trauma Registry survivors. Death preventability and OFI were determined for fatalities with potentially survivable or survivable (PS-S) injuries using tactical data and documented medical interventions. Of 369 United States Special Operations Command battle-injured fatalities (median age, 29 years; male, 98.6%), most were killed in action (89.4%) and more than half died from injuries sustained during mounted operations (52.3%). The cause of death was blast injury (45.0%), gunshot wound (39.8%), and multiple/blunt force injury (15.2%). The leading MOD was catastrophic tissue destruction (73.7%). Most fatalities sustained nonsurvivable injuries (74.3%). For fatalities with PS-S injuries, most had hemorrhage as a component of MOD (88.4%); however, the MOD was multifactorial in the majority of these fatalities (58.9%). Only 5.4% of all fatalities and 21.1% of fatalities with PS-S injuries had comparable injury patterns among survivors. Accounting for tactical situation, a minority of deaths were potentially preventable (5.7%) and a few preventable (1.1%). Time to surgery (93.7%) and prehospital blood transfusion (89.5%) were the leading OFI for PS-S fatalities. Most fatalities with PS-S injuries requiring blood (83.5%) also had an additional prehospital OFI. Comprehensive mortality reviews of battlefield fatalities can identify OFI in combat casualty care and prevention. Standardized lexicon is essential for translation to civilian trauma systems. Epidemiological, level IV.

Management of Lupus Nephritis in Children

Lupus nephritis affects 50-75% of all children with systemic lupus erythematosus with a higher prevalence in Asians. It remains a major contributor to morbidity and mortality in childhood onset lupus. Proliferative lupus nephritis (class III and class IV) warrants aggressive treatment to prevent progression to end stage renal disease. Newer immunosuppressive agents available in the last decade offer more options to treat lupus nephritis. Despite guidelines from professional bodies, there remains a lack of consensus on the treatment of refractory disease and duration of maintenance therapy. We review the treatment options for pediatric patients with lupus nephritis based on studies and published guidelines in the last decade, and highlight opportunities for continued improvement in care.

Complications and Failure to Rescue After Abdominal Surgery for Trauma in Obese Patients

BackgroundAlthough obesity is considered an epidemic in the United States, there is mixed evidence regarding the impact of obesity on outcomes after traumatic injury and major surgery. We hypothesized that obese patients undergoing trauma laparotomy would be at increased risk of failure to rescue (FTR), defined as death after a complication. MethodsWe analyzed trauma registry data for adult patients who underwent abdominal exploration for trauma at all 30 level I and II Pennsylvania trauma centers, 2011-2014. We used competing risks regression to identify significant risk factors for complications. We used multivariable logistic regression to identify significant risk factors for FTR. ResultsOf 95,806 admitted patients, 15,253 (15.9%) were categorized as obese. Overall, 3228 (3.4%) underwent laparotomy, including 2681 (83.1%) nonobese and 547 (17.0%) obese patients. Among obese patients, 47.2% had at least one complication and 28.7% had two or more complications, compared with 33.5% and 18.7% of nonobese patients, respectively. The most common complication was pneumonia (15.0% of obese and 10.5% of nonobese patients; P = 0.003), followed by sepsis (8.8% versus 4.2%; P < 0.001) and deep vein thrombosis (8.4% versus 5.9%; P < 0.001). Obesity was independently associated with complications (hazard ratio, 1.4; 95% confidence interval, 1.2-1.6). In multivariable analysis, obesity was not associated with FTR (odds ratio, 1.3; 95% confidence interval, 0.9-2.0). ConclusionsObesity is a risk factor for complications after traumatic injury but not for FTR. The increased risk of complications may reflect processes of care that are not attuned to the needs of this population, offering opportunities for improvement in care.

Failure to Rescue in Emergency Surgery: Is Precedence a Problem?

BackgroundMortality in emergency general surgery (EGS) is often attributed to patient condition, which may obscure opportunities for improvement in care. Identifying failure to rescue (FTR), or death after complication, may reveal these opportunities. FTR has been problematic in trauma secondary to low precedence rates (proportion of deaths preceded by complication). We sought to evaluate this in EGS, hypothesizing that precedence is lower in EGS than in similar elective operations. MethodsNational Inpatient Sample data from January 2014 through September 2015 were used. 150,027 adult operative EGS complete cases were defined by emergent admission, one of seven International Classification of Diseases, ninth revision (ICD-9) procedure group codes for common EGS operations, and timing to operation (<48 h); these represent 750,135 patients under the National Inpatient Sample sampling design. Deaths were precedented if one of eight prespecified complications was identified. Chi-squared tests were used to compare precedence rates between selected emergent and elective operations. ResultsThere was a 2.5% mortality rate in this cohort of operative EGS patients, with an 84.1% (95% CI: 82.7%-85.4%) precedence rate. Among the seven listed procedure groups, those with clinically reasonable elective analogs were cholecystectomy, colon resection, and laparotomy. Emergent versus elective precedence rates were 90.2% versus 82.0% (P = 0.004) for colon resection, 81.3% versus 86.8% (P = 0.26) for cholecystectomy, and 68.8% versus 92.7% (P < 0.001) for laparotomy. ConclusionsPrecedence rates in EGS were higher than expected and were similar to previously published rates in nonemergent surgery, suggesting that FTR is likely to be reliable using standard methodology. Management of complications after emergency operation may represent significant opportunities to prevent mortality.

Trends in Hospital-Based Specialty Palliative Care in the United States From 2013 to 2017

Although palliative care (PC) historically focused on patients with cancer and those near the end of life, evidence increasingly demonstrates a benefit to patients with a broad range of serious illnesses and to those earlier in their illness. The field of PC has expanded and evolved rapidly, resulting in a need to characterize practice over time to understand whether it reflects evolving evidence and guidelines. To characterize current practice and trends among patients cared for and outcomes achieved by inpatient specialty PC services in the United States. This retrospective cohort study was performed from January 1, 2013, to December 31, 2017, at 88 US hospitals in which PC teams voluntarily participate in the Palliative Care Quality Network (PCQN), a national quality improvement collaborative. A total of 135 197 patients were referred to PCQN teams during the study period. Initial analyses of the study data were conducted from March 3 to March 21, 2018. Inpatient PC consultation. A total of 23 standardized data elements collected by PCQN teams that provided information about the characteristics of referred patients, including age, sex, Palliative Performance Scale score, and primary diagnosis leading to PC consult; reason(s) given for the consultation; and processes of care provided by the PC team, including disciplines involved, number of family meetings held, advance care planning documentation completed, and screened for and intervened on needs. A total of 135 197 patients were referred to inpatient PC (51.0% female; mean age, 71.3 years [range, 57.8-82.5 years]) and were significantly debilitated (mean Palliative Performance Scale score, 34.7%; range, 14.9%-56.8%). Cancer was the most common primary diagnosis (32.0%; range, 11.3%-93.9%), although rates decreased from 2013 to 2017 (odds ratio [OR], 0.84; 95% CI, 0.79-0.91; P < .001). Pain and other symptoms were common and improved significantly during the consultation period (pain: χ2 = 5234.4, P < .001; anxiety: χ2 = 2020.7, P < .001; nausea: χ2 = 1311.8, P < .001; dyspnea: χ2 = 1993.5, P < .001). Most patients were discharged alive (78.7%; range, 44.7%-99.4%), and this number increased over time (OR, 1.36; 95% CI, 1.27-1.46; P < .001). Compared with 2013, rates of discharge referral to clinic-based (OR, 4.00; 95% CI, 2.95-5.43; P < .001) and home-based PC (OR, 2.63; 95% CI, 1.92-3.61; P < .001) also increased significantly by 2017, whereas referrals to hospice decreased (OR, 0.56; 95% CI, 0.51-0.62; P < .001). Inpatient PC teams cared for an increasing percentage of patients with diagnoses other than cancer and saw more patients discharged alive, consistent with guidelines recommending specialty PC for all patients with serious illness earlier in their illnesses. Most patients with symptoms improved quickly. Variation in practice and outcomes among PCQN members suggests that there are opportunities for further improvements in care.

Creation of a Patient-Centered Journey Map to Improve the Patient Experience: A Mixed Methods Approach.

ObjectiveTo use a mixed methods approach to focus quality improvement efforts to enhance patient experience through human-centered design.Patients and MethodsA mixed method approach began with returned Press Ganey Medical Practice Surveys from a large, multidisciplinary, outpatient medicine practice from July 1, 2016, through June 30, 2017, using correlation and gap analysis. The second phase deployed human-centered design approaches to process map patient journeys and generate opportunities for care improvement and to generate a theoretical framework for designing optimal care experiences.ResultsOur outpatient medical practices have the greatest ability to improve patient experience scores by focusing on how care teams deliver and educate patients on medications, instructions for follow-up care, and explanations about problems or conditions. By leveraging communication, the expertise of our care team members, and connection between patients and care team members, we can employ a variety of observed opportunities to enhance patient experience. Specific opportunities include leveraging tools in the electronic health record, fostering connection through empathy between patients and members of the care team, and capitalizing on the expertise of nurses on the care team.ConclusionA mixed methods approach to the analysis and observation of clinical care and business operations allows for the detection of opportunities with the highest potential impact for improvement when resources are constrained.

Adherence to quality breast cancer survivorship care in four Canadian provinces: a CanIMPACT retrospective cohort study

BackgroundIn order to maximize later health, there are established components and guidelines for quality follow-up care of breast cancer survivors. However, adherence to quality follow-up in Canada may not be optimal, and may vary by province. We determined and compared the proportion of patients in each province who received adherent and non-adherent surveillance for recurrence, new cancers and late effects, recommended preventive care, and recommended physician visits for comorbidities.MethodsCohorts consisted of all adult women diagnosed with incident invasive breast cancer between 2007 and 2010/2012 in four Canadian provinces (British Columbia (BC) N = 9338; Manitoba N = 2688; Ontario N = 23,700; Nova Scotia (NS) N = 2735), identified from provincial cancer registries, alive and cancer-free at 30 months post-diagnosis. Their healthcare utilization was determined from one to 5 years post-treatment, using linked administrative databases. Adherence, underuse, and overuse of recommended services were evaluated yearly and compared using descriptive statistics.ResultsIn all provinces and follow-up years, the majority of survivors had more than the recommended number of visits to either an oncologist or primary care physician (range 53.8% NS Year 3; 85.8% Ontario Year 4). The proportion of patients with the guideline-recommended number of oncologist visits varied by province (range 29.8% BC Year 5; 74.8% Ontario Year 5), and the proportion of patients with less than the recommended number of specified breast cancer-related visits with either an oncologist or primary care physician ranged from 32.6% (Ontario Year 2) to 84.4% (NS Year 3). Underuse of surveillance breast imaging was identified in NS and BC. The proportion of patients receiving imaging for metastatic disease (not recommended in the guidelines) in BC, Manitoba, and Ontario (not reported in NS) ranged from 20.3% (BC Year 5) to 53.3% (Ontario Year 2). Compliance with recommended physician visits for patients with several chronic conditions was high in Ontario and NS. Preventive care was less than optimal in all provinces with available data.ConclusionsQuality of breast cancer survivor follow-up care varies among provinces. Results point to exploration of factors affecting differences, province-specific opportunities for care improvement, and the value of administrative datasets for health system assessment.

International Analgesia, Sedation, and Delirium Practices: a prospective cohort study

BackgroundWhile understanding of critical illness and delirium continue to evolve, the impact on clinical practice is often unknown and delayed. Our purpose was to provide insight into practice changes by characterizing analgesia and sedation usage and occurrence of delirium in different years and international regions.MethodsWe performed a retrospective analysis of two multicenter, international, prospective cohort studies. Mechanically ventilated adults were followed for up to 28 days in 2010 and 2016. Proportion of days utilizing sedation, analgesia, and performance of a spontaneous awakening trial (SAT), and occurrence of delirium were described for each year and region and compared between years.ResultsA total of 14,281 patients from 6 international regions were analyzed. Proportion of days utilizing analgesia and sedation increased from 2010 to 2016 (p < 0.001 for each). Benzodiazepine use decreased in every region but remained the most common sedative in Africa, Asia, and Latin America. Performance of SATs increased overall, driven mostly by the US/Canada region (24 to 35% of days with sedation, p < 0.001). Any delirium during admission increased from 7 to 8% of patients overall and doubled in the US/Canada region (17 to 36%, p < 0.001).ConclusionsAnalgesia and sedation practices varied widely across international regions and significantly changed over time. Opportunities for improvement in care include increasing delirium monitoring, performing SATs, and decreasing use of sedation, particularly benzodiazepines.

A Multidisciplinary Model for Reviewing Severe Maternal Morbidity Cases and Teaching Residents Patient Safety Principles

Residents attend a patient safety and quality improvement (PSQI) course at orientation, learn in serial PSQI educational sessions, and receive individual training on the SMM review. The multidisciplinary SMM review process determines contributory factors, identifies best practices, recognizes care improvement opportunities, and facilitates adoption of appropriate interventions. How the process educated residents on the Clinical Learning Environment Review (CLER) focus areas was explored. From January 2015 to June 2017, 45 SMM cases were reviewed. Reviewers were primarily residents/fellows (64.4% of cases), nurses (11.1%), and maternal-fetal medicine faculty (24.4%). Transfusion > 4 units occurred in 44.4% of cases, and ICU admission in 68.9%. Causes of SMM included obstetric bleeding (57.8%), hypertensive crisis (42.2%), and cardiac disease (24.4%). Preterm delivery occurred in 60.0% of cases; 71.1% were postpartum, and 80.0% had cesarean deliveries. Contributory provider factors included diagnostic delays (55.6%) and treatment delays or errors (44.4%). Contributory patient factors included psychiatric/behavioral health (20.0%) and health care barriers (22.2%). Morbidity could have been prevented by provider factors in 53.3% of cases and by patient factors in 37.8%. Interventions initiated included recruiting a safety nurse, TeamSTEPPS® training, and adoption of hypertension and postpartum hemorrhage safety bundles. SMM reviews can be successfully implemented and provide training on safety and quality.