Quality Improvement Program Research Articles

Enhancing geriatric trauma mortality prediction: Modifying and assessing the Geriatric Trauma Outcome Score with net benefit and decision curve analysis.

Calibration and discrimination indicators alone are insufficient for evaluating the clinical usefulness of prediction models, as they do not account for the cost of misclassification errors. This study aimed to modify the Geriatric Trauma Outcome Score (GTOS) and assess the clinical utility of the modified model using net benefit (NB) and decision curve analysis (DCA) for predicting in-hospital mortality. The Trauma Quality Improvement Program (TQIP) 2017 was used to identify geriatric trauma patients (≥ 65 years) treated at Level I trauma centers. The outcome of interest was in-hospital mortality. The GTOS was modified to include additional patient, injury, and treatment characteristics identified through machine learning methods, focusing on early risk stratification. Calibration and discrimination indicators, along with NB and DCA, were utilized for evaluation. Of the 67,222 admitted geriatric trauma patients, 5.6% died in the hospital. The modified GTOS score included the following variables with associated weights: initial airway intervention (5), Glasgow Coma Scale ≤13 (5), packed red blood cell transfusion within 24 h (3), penetrating injury (2), age ≥ 75 years (2), preexisting comorbidity (1), and torso injury (1), with a total range from 0 to 19. The modified GTOS demonstrated a significantly higher area under the curve (0.92 vs. 0.84, p < 0.0001), lower misclassification error (4.9% vs. 5.2%), and lower Brier score (0.036 vs. 0.042) compared to the original GTOS. DCA showed that using the modified GTOS for predicting in-hospital mortality resulted in higher NB than treating all, treating none, and treating based on the original GTOS across a wide range of clinician preferences. The modified GTOS model exhibited superior predictive ability and clinical utility compared to the original GTOS. NB and DCA offer valuable complementary methods to calibration and discrimination indicators, comprehensively evaluating the clinical usefulness of prediction models and decision strategies.

The Buckeye Wellness Innovator Program: A Quality Improvement Evaluation

Background: Wellness champion networks are a best practice strategy to promote and sustain a culture of well-being in organizations and institutions of higher education. Aim: The purpose of this quality improvement evaluation was to determine program effectiveness and areas of opportunity for a university wellness champion program. Methods: An anonymous survey was sent to 700 wellness champions, the Buckeye Wellness Innovators (BWIs), to assess program components, identify areas of opportunity, and gather participant feedback. Results: A total of 202 BWIs (28.8%) responded to the survey. Seventy-five percent reported at least moderate engagement in the role. There was a strong desire among respondents to contribute to the university’s wellness initiative. Areas of opportunity include further colleague engagement in wellness services and programs, enhanced communication from program facilitators, and continued and increased support for the wellness champion role. Conclusions: Feedback on the program was positive overall. Several areas of opportunity for program improvement were identified. Wellness champions are an effective evidence-based strategy to support a culture of wellness in institutions of higher education and their feedback is important for program quality improvement.

Development of the Team Evaluation and Assessment Measure Quality Improvement (TEAM-QI) and Proof-Of-Concept Testing in Maternity Teams.

Poor teamwork is often implicated in serious healthcare delivery failings, leading to calls for effective team improvement interventions. Taking a complex, adaptive systems perspective, we adapted an oncology team quality improvement program to make it appropriate for other areas of clinical care. Study phases included: (1) meetings with National Health Service, policy and service user representatives (n = 19), a rapid review of existing maternity teamwork interventions, and mapping of the proposed program content to an evidence-based model of team effectiveness; (2) feasibility and acceptability testing of the team questionnaire component, and content analysis of free-text responses with four maternity teams within two NHS Trusts (n = 26). Meetings with representatives highlighted the importance of non-punitive, continuous team-led assessment, and the ability to compare performance to similar teams while enabling adaptability to different team types. Program content mapped well to known components of team effectiveness. Internal consistency of the questionnaire was acceptable (Cronbach alpha = 0.79-0.92). Most team members (76.9%) reported benefits in identifying priorities for improvement. Preliminary proof of concept was supported but larger-scale evaluation including testing in other clinical areas is warranted.

The effect of the proportion of low-titer O whole blood for resuscitation in pediatric trauma patients on 6-, 12- and 24-hour survival.

Hemorrhage is a leading cause of death in pediatric patients. Accumulating data suggest that low-titer group O whole blood (LTOWB) improves clinical outcomes in the pediatric population. We examined what ratio of LTOWB to total blood product conferred a survival benefit in transfused pediatric trauma patients. We retrospectively examined a cohort of injured subjects younger than 18 years from the Trauma Quality Improvement Program database who received any quantity of LTOWB and no documented prehospital cardiac arrest. We created a variable representing the volume of transfused LTOWB divided by the total volume of all transfused blood products administered within the first 4 hours of admission, that is, the proportion of LTOWB transfused. We analyzed increasing proportions of transfused LTOWB to determine whether there was an inflection point conferring increased survival. From 2020 to 2022, 1,122 subjects were included in the analysis. The median (interquartile range) age was 16 (14-17) years. Firearms were the most common mechanism at 47% followed by collisions at 44%. The median composite injury severity score was 25 (16-34). Survival was 91% at 6 hours, 89% at 12 hours, and 88% at 24 hours. We noted an inflection point with improved survival at an LTOWB proportion of ≥30% of total volume of blood products received. The odds of survival at 6, 12, and 24 hours for those receiving ≥30% LTOWB was 1.85 (1.02-3.38), 2.09 (1.20-3.36), and 1.80 (1.06-3.08), and 3.55 (1.66-7.58), 3.71 (1.89-7.27), and 2.69 (1.44-5.02) when excluding those who died within 1 hour, respectively. Among LTOWB recipients, we found that a strategy of using LTOWB comprising at least 30% of the total transfusion volume within the first 4 hours was associated with improved survival at 6, 12, and 24 hours. Therapeutic/Care Management; Level III.

Quality of care delivery in patients with acute heart failure: insights from the international REPORT-HF registry.

Heart Failure (HF) quality of care (QoC) is associated with clinical outcomes. Therefore, we investigated differences in HF QoC across worldwide regions (with differing national income) and the association of quality indicators with outcomes. We examined the quality of care (QoC) in acute heart failure (HF) patients across different regions using quality indicators (QIs) from the European Society of Cardiology (ESC) and the American Heart Association (AHA) to evaluate QoC. The analysis included 17,632 patients enrolled from 358 medical centres in 44 countries between 23 July 2014 and 24 March 2017, all part of the prospective REPORT-HF cohort study. We investigated how QoC varied by region and its relationship with mortality rates at 30 days and 1 year after hospital discharge. For each QI, percentage attainment of QI among eligible patients was calculated and compared across regions. Among 17,632 patients (median age: 67 years; 61% women) followed up for a median of two years, we assessed 16 QIs. QIs that were least often achieved included measurement of natriuretic peptides, performance of echocardiography, treatment with guideline medical therapy, and a scheduled follow-up consultation after discharge. QI achievement was significantly lower in lower-than higher-income countries. Higher (≥50% vs. <50%) achievement of cumulative QIs was associated with lower 30-day (hazard ratio [HR] 0.58, 95% Confidence Interval [CI] 0.40-0.83; p<0.001), and 1-year mortality (HR 0.58, 95% CI 0.50-0.68; p<0.001). QoC is lower in lower-than higher-income countries and lower QoC is associated with worse outcomes. Improving QoC by addressing structural barriers and quality improvement programs may improve the outcomes of patients with HF. Novartis.

Abstract TP145: Stroke INSPIRE Community Support Program for Stroke Survivors and Caregivers – An Overview

Background: Located in Twin Cities, Minnesota (MN), HealthPartners Stroke INSPIRE (HPSI) is a free stroke survivor support program which offers support groups, education, peer mentoring, and leisure-based engagement opportunities for stroke survivors and caregivers. This 25-year-old program, which originated out of one hospital, is experiencing significant growth throughout the Midwest. Program growth is facilitated by the addition of virtual and in-person programs and has expanded to support a healthcare system of eight hospitals. HPSI provides support to stroke survivors and caregivers throughout the state of MN and internationally. HPSI program growth is supported by stroke system leadership and statewide partners. Expansion of HPSI has prompted data collection about participant demographics, experiences and priorities of stroke survivors and caregivers. Methods: Analysis of HPSI participant demographic, quality of life, attendance and support group topic trends were gathered from the HPSI Impact Pilot Quality Improvement Project (SIIP-QIP) and program tracking tools were reviewed. The SIIP-QIP collected qualitative information regarding stroke survivor demographic information, and perceptions of their Quality of Life, Affect and Well Being via the NEURO-Quality of Life Short Form. Results: HPSI has experienced a 36.3% increase in average group attendance sizes since October of 2022, with the average group sizes ranging from approximately 9-23 participants (Fig. 1). The most common support group topics are represented in Fig. 2 and 3. Demographic analysis indicates that 29.5% of participants had their most recent stroke in the last 1-5 years, while 38.7% experienced their most recent stroke over 6 years ago. Additionally, 45% of participants drive themselves, 63.2% reside in a major metropolitan area, 92.7% are non-Hispanic/Latino, 88.4% are white, 75% are 61 years old or older, 54.5% are male, and 45.5% are female. Perceptions of quality of life were generally consistent those who were not participating in HPSI. Discussion: As evidenced by consistent growth, high participant engagement, and demographic review, there is a need for expansion of community-based stroke specific support programming. Further study is needed to determine strategies for implementation of such programs in culturally diverse and rural communities. Research should explore the effects of stroke type and severity on support group participation and perceptions of quality of life.

Identifying Best Practices for Improving the Evaluation and Management of Stroke in Rural Lower-Resourced Settings: A Scientific Statement From the American Heart Association.

Considerable variation exists in the delivery of acute stroke care and stroke outcomes across settings and population groups. This is attributable in part to variation in resources among emergency departments in the United States, most notably in rural regions. Structural constraints of the US health care system, including the geographic distribution of where patients live relative to the location of hospitals and certified stroke centers, will continue to mean that many patients with stroke initially present to community emergency departments that have fewer stroke-related resources. These sites also tend to serve populations in rural areas who experience disparities in care and outcomes. Reducing health disparities related to stroke for populations in rural areas requires investment in these more remote community settings as the anchor of the stroke chain of survival for their respective communities. This scientific statement performs a critical appraisal examining challenges in rural stroke care related to access and variation in stroke-related capabilities for the acute phase of care to inform strategies and propose solutions. The scientific statement considers the value of expansion of Acute Stroke Ready Hospital and Primary Stroke Center certification in rural areas, the role of telehealth and improved transfer processes, as well as increased engagement and mentorship from larger, comprehensive centers to the rural hospitals to which they are connected. Multistakeholder collaboration and policy interventions need to be directed to enhance public awareness, impart staff training, grow infrastructure, enhance access to clinical expertise, streamline data management, and implement quality assessment and improvement programs.

Lower Extremity Penetrating Trauma Care Associated With Race and Income in the United States of America.

For lower extremity penetrating traumas (LEPT), the impact of race and insurance status, as a surrogate of socioeconomic status, is still not fully elucidated. This study aims to explore the relationship between these variables and the likelihood of receiving an amputation for LEPT to further identify disparities in trauma care. We analyzed the 2017-2019 Trauma Quality Improvement Program databases to identify patients with LEPT. Univariate analysis of various patient factors was performed for mortality. Linear and logistic multivariate regressions were then conducted for the primary and secondary outcomes using significant variables from the univariate analysis. Finally, multivariate logistic regression identified associations between race, ethnicity, primary payor, and amputation rates. The independent factors significantly linked to amputation included Black race (odds ratio (OR) 0.745, P<0.001), Medicare (OR 0.557, P<0.001), Medicaid (OR 0.697, P<0.001), and uninsured status (OR 0.661, P<0.001). We additionally evaluated the incidence of death among the penetrating trauma victims and determined that male (OR 2.008, P<0.001), Black (OR 1.801, P=0.001), and uninsured patients (OR 1.910, P=0.003) were more likely to die during admission than the privately insured. Compared to privately insured victims, uninsured patients and those on Medicaid and Medicare experience lower amputation rates post-LEPT. Black patients were found to have not only a decreased likelihood of receiving an amputation following LEPT but also an increased rate of mortality during admission compared to Caucasian victims. These findings underscore the urgency to address institutional barriers hindering vulnerable populations from accessing appropriate care after trauma.

Blood transfusions in craniotomy for tumor resection: Incidence, risk factors, and outcomes.

Blood transfusions (BT) are often needed in neurosurgical procedures, especially craniotomies for tumor resections, due to risks of anemia, ischemic brain injury, and hemorrhage. However, BT may increase the risk of perioperative complications. This study aimed to determine the incidence, associated factors, and outcomes of BT in patients undergoing craniotomy for intracranial tumor resection. A retrospective cohort study was conducted using data from the National Surgical Quality Improvement Program (NSQIP). We included adult patients who underwent elective craniotomy for tumor resections from 2005 to 2021. Multivariable logistic regression was used to identify factors associated with BT as well as complications associated with receipt of BT within 30days of surgery. Among 40,883 patients, 3.65% required BT. Significant factors associated with BT included age>60years (OR 1.28 [95% CI 1.03-1.60]), female sex (1.41 [1.22-1.62]), underweight body mass index (BMI) (1.81 [1.27-2.57]), American Society of Anesthesiologists (ASA) class 3-4 (1.64 [1.39-1.95]), diabetes (1.23 [1.02-1.48]), chronic obstructive pulmonary disease (COPD) (1.64 [1.20-2.23]), preoperative anemia (2.84 [2.49-3.26]), bleeding disorders (2.37 [1.63-3.46]), preoperative transfusion (16.96 [8.09-35.56]), and meningioma indication (1.28 [1.03-1.60]). Patients with obesity were less likely to require BT (0.82 [0.69-0.98]). Patients requiring BT had higher odds of the following complications: prolonged ventilator use (OR 2.37 [1.60-3.50]), urinary tract infection (1.76 [1.03-3.00]), unplanned reoperation (1.49 [1.14-1.93]), prolonged length of stay (1.88 [1.60-2.21]), major morbidity (1.79 [1.32-2.44]), and all-cause mortality (1.34 [1.16-1.55]). In craniotomy patients for tumor resection, factors associated with BT include age>60, female sex, underweight BMI, ASA class 3-4, COPD, anemia, bleeding disorders, preoperative transfusion, and meningioma. BT is further associated with higher risks of major morbidity, mortality, longer hospital stays, and unplanned reoperations following surgery.

Prognostic Utility of Modified 5-Item Frailty Index on the Outcomes of Spine Surgeries: A Systematic Review and Meta-Analysis.

Frailty refers to a state of weakness that can arise due to age or illnesses, and frailty predisposes individuals to several adverse health outcomes. This has been postulated to prognosticate the outcome of various surgeries, including surgeries for various spine conditions; however, no meta-analysis has validated this finding. We conducted a systematic review and meta-analysis to investigate the prognostic utility of frailty for the outcome of spine surgeries. We performed a systematic search of the PubMed, EMBASE, and SCOPUS databases for studies investigating the ability of frailty to predict the outcome of spine surgeries. We analyzed the effect of high frailty using the 5-item Modified Frailty Index on the outcomes (extended length of stay, readmission, postoperative complications, in-hospital mortality, reoperation, and nonroutine discharge) of spine surgeries. Meta-analysis of the information provided in the 11 studies included a sample size of 89,137; all studies used the 5-item Modified Frailty Index ≥2 as their cutoff for high frailty, and most studies were performed in the United States based on the American College of Surgeons National Surgical Quality Improvement Program database. The outcomes of our analysis were extended hospital length of stay (effect size 1.64; 95% confidence interval [CI]: 1.49, 1.79), postoperative complications (effect size 1.49; 95% CI: 1.10, 1.88), readmission (effect size 1.69; 95% CI: 1.40, 1.99), nonroutine discharge (effect size 2.16; 95% CI: 1.80, 2.51), postoperative in-hospital mortality (effect size 2.11; 95% CI: 1.25, 2.96), and reoperation (effect size 1.32; 95% CI: 1.19, 1.45). This study revealed that high frailty according to the modified 5-Item Frailty Index is correlated with an increased risk of readmission, extended length of hospital stay, postoperative complications, nonroutine discharge, postoperative in-hospital mortality, and reoperation following spine surgeries for any pathology of the spine.

The impact of body mass index on surgical complications in minimally invasive hysterectomy for uterine fibroids.

We aimed to assess the impact of Body Mass Index (BMI) on 30-day postoperative complications in patients undergoing minimally invasive hysterectomy (MIH) for fibroids. Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2012-2020), we analyzed major and minor 30-day postoperative complications, stratified by BMI, in patients with uterine fibroids who underwent MIH. Complications were stratified according to the Clavien-Dindo classification. Among 61,192 patients, overall complication rates ranged from 6.3% to 8.1%, with the highest rates in obesity class 3. Significant differences were observed in minor complication rates across BMI groups, though major complication rates did not significantly vary. Higher BMI classes correlated with longer operative times, with mean durations ranging from 127.1min in the lowest BMI group to 158.1min in the highest BMI group (p<0.001). In multivariable regression, higher BMI was associated with increased odds of minor complications [</≥34.5kg/m2, aOR 95% CI=1.10 (1.01-1.21)]. There was no significant association between lower and higher BMI (</≥32.8kg/m2) and major complications. Additionally, overweight, obesity class 2 and 3 were independently associated with lower odds of major complications [aOR 95% CI 0.82 (0.71-0.94), 0.77 (0.64-0.92) and 0.82 (0.67-1.00), respectively], compared to the normal BMI group. BMI categories were not independently associated with any or minor complications compared to normal the normal BMI category. After adjusting for confounding factors, overweight, obesity class 2 and 3 are associated with a decreased risk of major complications compared to normal BMI. In contrast, BMI categories were not associated with any- or minor complications. Higher BMI classes were associated with longer operative times.

Metabolic Syndrome and the Risk of Postoperative Complications Following Esophagectomy: National Surgical Quality Improvement ProgramStudy.

Metabolic syndrome has become a major health risk affecting patients worldwide and has been shown to be a risk factor for postoperative complications following abdominal surgery. This study aims to elucidate the link between metabolic syndrome and postoperative complications and mortality following esophagectomy. This is a retrospective study analyzing the American College of Surgeons National Surgical Quality Improvement Program database (2017-2021). This study compared 30-d postoperative complications of patients undergoing esophagectomy with and without metabolic syndrome. Metabolic syndrome was defined as obesity (body mass index ≥30kg/m2), diabetes, and hypertension. A total of 4911 patients met the study criteria, and of these, 303 patients (6.17%) met the inclusion criteria for the modified definition of metabolic syndrome. The metabolic syndrome group had higher American Society of Anesthesiologists scores compared to the control group (American Society of Anesthesiologists 3 or 4: 96% versus 84%, P<0.001). Operative time was significantly higher in the metabolic syndrome group (378mins versus 361, P=0.004). Mortality was higher in the metabolic syndrome group (4.3% versus 2.3%, P=0.03), as was serious morbidity (35% versus 30%, P=0.05). Metabolic syndrome patients also had higher risks of postoperative complications of pneumonia (18.5% versus 14%, P=0.04), unplanned intubation (15.5% versus 9.9%, P=0.002), and sepsis (7.6% versus 4.9%, P=0.04). On multivariate analysis, 30-d mortality was increased in the metabolic syndrome group. Metabolic syndrome patients who undergo esophagectomy are associated with increased rates in morbidity and mortality. When controlled for other patient factors in multivariate analysis, 30-d mortality also had an associated increase. By focusing on modifiable risk factors with metabolic syndrome patients, mortality and morbidity for this high-risk procedure could be reduced in the future.

The Beginning of a Paradigm Shift: Increase in Perioperative Complications Following Vaginal Hysterectomy Compared to Laparoscopic Hysterectomy Using the ACS-NSQIP 2016 - 2019 Database.

In this study, we compare perioperative outcomes following laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) between 2016 and 2019. A retrospective cohort study. National database study. The American College of Surgeons National Surgical Quality Improvement Program (ACS - NSQIP) database to identify patients underwent elective LH or VH between 2016 and 2019. Our primary outcome of interest was a composite incidence of perioperative complications. We generated a propensity score using a multiple logistic regression model to adjust for confounding factors and to reduce the selection bias between the two groups. We matched patients who underwent elective LH to patients who underwent elective VH on the logit of the propensity score. Of the 76,706 women in the cohort (2016-2019), 62,124 (80.9%) underwent LH and 14,582 (19.0%) underwent VH. After propensity matching (n=8,991 per group), results in the matched cohort revealed significant differences on the primary composite outcome. The composite risk of death, complications, reoperation, and readmission was lower among patients who underwent LH compared to VH, such that the primary composite outcome occurred in 5.62% of LH patients compared to 6.65% of VH patients (relative risk (RR) 0.845, 95% confidence interval (CI) 0.753 - 0.947, p = 0.004). In addition, the risk of both transfusion and readmission was higher among patients who underwent VH compared to LH (transfusion: RR 1.372, 95% CI 1.078 - 1.745, p =0.010; readmission: RR 1.546, 95% CI 1.216 - 1.966, p = 0.001). We have found that there is a lower 30-day composite morbidity for patients when undergoing LH compared to VH. These data demonstrate a higher risk of perioperative complications in women undergoing VH and should further inform surgeon's surgical considerations when deciding the optimal route of hysterectomy, depending on the expertise of the surgeon.

An analysis of transfers into designated trauma centers from referring institutions - the potential for virtual consultation to reduce transfers.

Trauma care frequently happens in emergency departments (ED) outside of major trauma centers. Many injuries often exceed the specialty capabilities of referring hospitals, requiring transfer to larger trauma centers. However, the proportion of patients discharged home without admission from receiving facilities remains unclear, suggesting potential overutilization of transfers. We sought to determine the proportion of transfer patients that are discharged home from the receiving ED. We studied patients ≥15 years captured in the Trauma Quality Improvement Program (TQIP) database who were transferred from a referring institution and were subsequently discharged home from the receiving ED without additional services planned. From 2020 to 2022, there were 744,623 patients ≥15 years of age, of which, 82,316 (11 %) were discharged home with (1 %) or without (99 %) additional services planned. The median age was 40 (26-60), and 70 % were male. The most common mechanism of injury was a collision (40 %), followed by falls (30 %). The median composite injury severity score was 5 (1-5). Serious injury by body region was most frequent for the craniomaxillofacial (11 %) followed by the thorax (5 %). Most of the transfers were to level 1 centers (85 %). The most frequently performed procedures were CT brain followed by a CT cervical spine, abdominal ultrasound, MRI cervical spine, hand laceration repair, ocular evaluation, scalp repair, forearm fracture reduction, assessment of ocular pressure, and MRI of the lumbar spine. The most frequent diagnoses were nasal fracture, orbital floor fracture, macular fracture, subdural hematoma, dental fracture, pneumothorax, rib fracture, hand laceration, burns, and vertebral fracture. We found that approximately 1 in 9 patients transferred to a higher level of care are discharged home from the ED, with most requiring neurosurgical, ophthalmologic, dental and craniomaxillofacial services. These findings suggest that virtual communication technology could reduce unnecessary transfers and associated costs.

Outcomes of Colectomy for Nonmalignant Polyps and Colon Cancer: A Propensity Score-Matched Analysis.

In the United States, while most nonmalignant polyps are effectively treated through endoscopic removal, colectomy remains a treatment option for selected cases of nonmalignant polyps (NMPs) and colon cancer. This study aimed to compare postoperative outcomes for colectomies in these two conditions, hypothesizing similar complication rates. We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2021, including patients who underwent elective colectomies for colon cancer or NMPs. Using a 2:1 propensity score matching for demographics, American Society of Anesthesiologists classification, surgical methods, and comorbidities, we evaluated outcomes such as 30-d mortality, complications, anastomotic leakage, and hospital stay duration. A total of 47,960 patients, including 30,549 colon cancer patients and 17,411 NMP patients, were included after propensity score matching analysis. We concluded that there was no significant difference in mortality and reoperation rates which were 0.6% and 3.3% in patients undergoing colectomy with colon cancer, compared to 0.5% and 3.1% in those with NMP, respectively [P=0.64, P=0.21,]. In addition, the anastomotic leak rates were remarkably similar in both the colon cancer (2.4%) and NMP (2.2%) groups. [P=0.13]. Most of the 30-d postoperative surgical complications, such as sepsis, septic shock, wound disruption, and urinary tract infection exhibited similar incidence rates, however, some of them, such as readmission, pulmonary embolism, and length of stay, varied between the groups. Our findings underscore the similar postoperative outcomes between colon cancer and NMP groups, advocating for consideration of advanced endoscopic techniques for NMPs to potentially enhance patient care and outcomes.

Implementing Self-Measured Blood Pressure in Primary Care: A Feasible and Systematic Approach.

Randomized clinical trials and clinical practice guidelines recommend the use of self-measured blood pressure (SMBP) to help improve the treatment of patients with hypertension. Many clinicians use SMBP in their practices, but there is significant variability in how SMBP is implemented in their day-to-day practice. This quality improvement study details the pragmatic and real-world approach clinicians and administrators used at 3 sites of the IHA Medical Group, a part of Trinity Healthcare, to implement the American Medical Association (AMA) 7-Step SMBP framework as part of the larger AMA hypertension quality improvement program AMA MAP BP. The SMBP program included distributing SMBP devices, training patients on SMBP use, capturing and recording SMBP values in the electronic health record, using SMBP readings in treatment decisions, and receiving reimbursement for patient training and education. Of 331 patients enrolled, 98% of patients had at least 1 return visit within a year. Average systolic blood pressure was reduced by 8 mm Hg between the first and last office visit, and blood pressure control rates increased from 33.5% to 63.5% in these patients. Among patients with one return visit, 46% had documented SMBP readings and 71% were treated with medications. Payors reimbursed 95% of claims submitted for patient training.

Open Revascularization for Acute Mesenteric Ischemia is Associated with Increased Morbidity and Mortality when Compared to Endovascular Intervention

Historically, open approaches have been considered the primary treatment for acute mesenteric ischemia (AMI) due to the potential for bowel resection. However, the use of endovascular therapy is increasing. Given the paucity of current data, this study aims to compare outcomes between open and endovascular interventions for AMI. Patients treated for AMI between 2011 and 2022 were identified in the National Surgical Quality Improvement Program (NSQIP) by ICD-9 and ICD-10 codes. Intervention type (open vs. endovascular) was obtained from CPT codes. Demographics, comorbidities, pre-operative laboratory values, and 30-day outcomes were compared between intervention types. Multivariable analysis was utilized to adjust for differences between groups with a patient's need for bowel resection included to account for disease severity. A total of 1,172 patients underwent revascularization for AMI (1,023 open, 149 endovascular). Among those treated with open revascularization, 577 (56%) underwent thrombectomies/embolectomy, 125 (12%) underwent thromboendarterectomy, and 321 (31%) received bypasses. Of the patients who underwent endovascular revascularizations, 101 (68%) received a stent, 23 (15%) underwent angioplasty without stenting, and 25 (17%) underwent lysis/thrombectomy. Patients who underwent endovascular revascularization had higher rates of smoking (36% open vs. 47% endovascular; P<0.01), were more likely to have an eGFR less than 30 (6% open vs. 15% endovascular; P<0.01), and underwent more bowel resections at the time of the initial operation (33% open vs. 48% endovascular; P<0.01). For outcomes, patients who underwent open repair had longer median hospital stays (10days vs. 7days; P<0.01). All other outcomes including 30-day mortality were similar on univariate analysis. Following adjustment for the need for bowel resection and comorbidities, 30-day-mortality (OR 1.96, 95% CI: 1.28-3.02), failure to wean from ventilator (OR 1.56 95% CI: 1.05-2.34), and length of hospital stay (β 3.7days, 95% CI: 1.8-5.6) were higher among patients treated with open surgery. After accounting for the need for bowel resection and comorbidities, open revascularization for AMI is associated with higher peri-operative morbidity and mortality compared to endovascular intervention. Thus, the need for bowel resection should not preclude endovascular treatment for AMI.

Impact of islet autotransplantation on 30-day post-operative outcomes in patients undergoing Total Pancreatectomy: A NSQIP retrospective cohort analysis of 584 patients

Total pancreatectomy (TP) offers a surgical option for refractory pancreatitis, yet confers substantial long-term morbidity associated with resultant diabetes. While total pancreatectomy with islet autotransplantation (TPIAT) offers an intuitive solution, data evaluating its safety have been limited to single-center studies. The aim of this study is to evaluate whether the addition of islet autotransplantation to TP confers additional post-operative morbidity within the 30-day post-operative period. This is a retrospective cohort study of prospectively collected cases from the National Surgical Quality Improvement Program (NSQIP) database. Cases of TP with or without islet autotransplantation from 2016 to 2021 were included. Baseline demographics, and a comprehensive list of 30-day postoperative outcomes were evaluated. Multivariable logistic regression models were constructed to evaluate the impact of each factor on 30-day complications. A total of 584 cases were included with 171 (29.2%) patients undergoing TPIAT. TPIAT patients were younger (58.8 vs. 39.5; p<0.0001), and had lower incidences of pre-existing diabetes (41.4% vs. 19.9%; p<0.0001) and hypertension (48.2% vs. 24.6%; p<0.0001). TPIAT cohort had longer length of stay (10.3 days vs.12.2 days; p=0.0006). There was no difference in overall rates of serious complications between the two cohorts (50.1% vs. 45.0%; p=0.263). After adjusting for demographic differences between cohorts using multivariable logistic regression models, TPIAT was not associated with serious complications (OR 0.71; p=0.168) compared to TP alone. The results from this study suggest that TPIAT does not appear to be associated with increased 30-day morbidity, and should be considered in patients to mitigate the long-term morbidity associated with diabetes mellitus post TP.

Plasma transfusion and hospital mortality in moderate-severe traumatic brain injury.

Prior research suggests that plasma may improve outcomes in traumatic brain injury (TBI). We examined the association between plasma administration and mortality in moderate-severe TBI in a large retrospective cohort, hypothesizing plasma is associated with decreased mortality after accounting for confounding covariates. Patients from the 2017-2020 Trauma Quality Improvement Program (TQIP) dataset ≥18 years with moderate-severe TBI were included. We excluded patients with comorbidities associated with bleeding or sensitivity to volume (antiplatelet or anticoagulation medications, bleeding disorders, cirrhosis, congestive heart failure, chronic obstructive pulmonary disease). Multivariable logistic regression examined the association between plasma volume transfused in the first four hours and hospital mortality, adjusting for sociodemographics, severity of injury/illness, neurologic status, and volume of other blood products. We also adjusted for and included interactions with hemorrhage markers (shock; need for hemorrhage control). Of 63,918 patients included, hospital mortality was 37.0 %. 82.8 % received no plasma. Each unit of plasma was associated with greater unadjusted mortality, with odds ratio (OR): 1.13 (95 % confidence interval: 1.12-1.14), but after confounder adjustment, plasma units were not associated with greater mortality, with OR: 1.01 (0.99-1.03). While the overall adjusted effect of plasma was not significant, significant interactions between hemorrhage markers and plasma were present (p < 0.001). Administration of plasma within the first four hours after hospital presentation was not associated with decreased or increased mortality in adult patients with moderate to severe TBI after confounder adjustment. Interaction analysis suggests the presence of hemorrhage improves the effect of plasma on mortality in TBI. This important clinical question should be answered with a prospective randomized study of plasma for nonbleeding patients with TBI.

Improving colonoscopy quality in the national VA healthcare system.

Colorectal cancer (CRC) prevention is a Veterans Affairs (VA) priority. Colonoscopy quality, especially adenoma detection rate (ADR), is critical for effective screening. Our research indicates considerable variation in ADR among VA providers. Even a slight increase in ADR can reduce fatal CRC rates, and audit and feedback strategies have improved ADR in other settings. A recent report identified deficiencies in VA colonoscopy quality, highlighting the need for standardized documentation and reporting. To address this, we developed the VA Endoscopy Quality Improvement Program (VA-EQuIP), which aims to improve colonoscopy quality through benchmarking and collaborative learning, aligning with VA's modernization priorities and HSR&D and QUERI goals of accelerating evidence-based implementation. We will conduct a stepped wedge cluster randomized trial to evaluate whether VA-EQuIP improves provider ADR compared to usual care, the implementation of VA-EQuIP, site-level factors associated with colonoscopy quality improvement, and components of provider behavior change. Using mixed methods our study will measure outcomes like reach, implementation, adoption, maintenance of VA-EQuIP, and provider behavior change. The analysis will include primary and secondary outcomes, such as overall and screening ADR, cecal intubation rate, and bowel preparation quality, using mixed effects generalized linear models and interrupted time-series analyses. Adoption and implementation will be evaluated through usage statistics, surveys, and qualitative interviews to identify factors influencing success. This study will assess the impact of VA-EQuIP on colonoscopy quality metrics and factors associated with effective implementation. VA-EQuIP infrastructure allows for national-scale implementation and evaluation of quality reporting with minimal manual labor, guiding future quality improvement efforts to ensure optimal patient care.