Variations In Care Of Patients Research Articles

Agreeing priority categories and items for inclusion in a future best practice delegation framework for musculoskeletal outpatient physiotherapy services: A consensus groups study

PurposeDelegation of clinical tasks from physiotherapists to physiotherapy support workers varies considerably in musculoskeletal outpatient physiotherapy services leading to variation in patient care. This study aimed to develop consensus amongst physiotherapists, support workers and managers about what components should be included in a future framework to guide effective and safe delegation of clinical tasks to physiotherapy support workers in United Kingdom's National Health Service musculoskeletal outpatient physiotherapy services. MethodsA consensus study was carried out, using Nominal Group Technique. Seven physiotherapists, ten physiotherapy support workers and ten physiotherapy operational/clinical leads from 13 musculoskeletal physiotherapy services within United Kingdom's National Health Service were recruited through the Chartered Society of Physiotherapy's professional networks and social media. Three separate, role-specific consensus groups were convened, involving participants generating, discussing and rating on a Likert scale, components for inclusion in a future delegation framework. Results32 out of 38 generated items reached consensus of ≥70%, i.e. a mean of ≥4.9 on a 7-point Likert scale, across the three groups. Items were grouped under five main categories: 1) training/Continuous Professional Development for physiotherapists and support workers; 2) need for a clear delegation process; 3) competencies 4) defining the role of support workers and 5) safety net. ConclusionKey stakeholder groups were able to reach consensus on five priority areas which will be developed into a best practice framework to standardise delegation and guide physiotherapists when delegating clinical tasks to support workers.

P077 The Yorkshire Bone Network- why every region needs a Bone Network!

Abstract Background/Aims The Yorkshire Bone Network (YBN) was formalised in 2019, from a founding group of Yorkshire clinicians with a special interest in osteoporosis, meeting every four months since 1994 to discuss new drugs as they were licensed, the research underpinning them, complex clinical cases and educational topics in osteoporosis. This group was formalised into a Network in order to expand the membership and invite contributions from an increased range of specialists from different disciplines and Trusts across Yorkshire. Further aims were to reach consensus on the management of key osteoporosis issues across Yorkshire and deliver Regional guidelines. Methods The YBN now has 35 members from Rheumatology, Endocrinology, Metabolic Bone and Elderly Medicine departments from 12 different Trusts across Yorkshire. Meetings are four-monthly, continuing on Zoom during the pandemic, and now in-person again. Each meeting involves discussion of complex clinical osteoporosis cases for management decisions, alongside an educational or guidelines development session, delivered by a member of the Network or an invited guest speaker. Results We have: Agreed a consensus statement on the use of Romosozumab in Yorkshire, specifically covering cardiovascular screening for potential patients. This has given clinicians confidence in identifying appropriate patients and prescribing this new drug. This should also ensure equity of drug access to patients across the region, who are being assessed using the same framework. We have written guidelines on the role of bone densitometry in patients with coeliac disease. This has been provided to local Gastroenterologists, with the aim of reducing unnecessary bone densitometry referrals, reducing the burden on patients and radiology departments. We have provided regional recommendations for the early (before 14 days) administration of IV zoledronate for inpatients post fractured neck of femur, avoiding discharge prior to treatment. This has been adopted and is being audited to assess impact in one of our District General Hospitals. We have provided educational sessions on bone turnover markers, FRAXPlus, glucocorticoid-induced osteoporosis and renal bone disease. Conclusion The Yorkshire Bone Network is an excellent example of collaborative working. It is a valuable forum for clinical decision making for complex patients across the region. It has allowed the development of guidelines and consensus statements which are in clinical use, thus minimising variation in patient care across the region and improving clinician confidence. It continues to be an enjoyable way of forming new links between colleagues both within our own Trusts and across the region, with new members joining each year. Time is needed to co-ordinate the meetings, provide minutes and liaise with colleagues but the benefits far outweigh the effort! We would strongly recommend the formation of similar networks across the UK, given the benefits to both patients and clinicians. Disclosure C.Y.J. Vandevelde: None. S. Sultan: None. L. Hordon: None.

The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative.

Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation. Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports. After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery. Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.

Variation in care for patients presenting with hip fracture in six high-income countries: A cross-sectional cohort study.

Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery. The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.

Preoperative assessment and optimisation prior to planned aortic aneurysm repair: a UK survey examining current practice and attitudes of vascular surgeons and vascular anaesthetists

BackgroundThe majority of those diagnosed with aortic aneurysm in the UK are older, multi-morbid patients. Decision-making as to who may benefit from intervention (open or endovascular aneurysm repair) is highly variable across the NHS (as is the mode of intervention), in part because there are no detailed guidelines or consensus on preoperative assessment. Thus, there is likely to be significant variation in the pre-operative assessment and optimisation of these patients.MethodsA survey was designed to understand current practice and attitudes of vascular surgeons and vascular anaesthetists in the UK regarding preoperative assessment and optimisation of patients undergoing elective aortic aneurysm repair. The survey was reviewed and validated by an expert panel, then distributed electronically to all vascular surgical and vascular anaesthetic leads in the UK.ResultsOverall, the response rate was 68%. The responses were varied between surgeons and anaesthetists, with differences reported in the preoperative assessment and optimisation of patients, the approach to shared decision-making, and the perioperative pathway.ConclusionsDespite initiatives such as Getting It Right First Time (GIRFT) and National Institute for Health and Care Excellence (NICE) guidelines, variation still exists between centres with some differences in opinion observed between surgeons and anaesthetists. These differences may be leading to duplication of work in the perioperative pathway, inconsistencies in how risk is assessed and communicated with consequent variation in patient care. Addressing these issues requires awareness and implementation of existing guidelines, transdisciplinary working, efficient data-driven pathways, and structured aortic aneurysm multi-disciplinary team to promote meaningful shared decision-making.

Clinical presentation and management of nephrotic syndrome in the first year of life: A report from the Pediatric Nephrology Research Consortium.

Background and objectivesNephrotic syndrome (NS) in the first year of life is called congenital (CNS) if diagnosed between 0–3 months, or infantile (INS) if diagnosed between 3–12 months of age. The aim of this study was to determine if there were clinically meaningful differences between CNS and INS patients, regarding clinical presentation, management and outcomes.Design, setting, participants, and measurementsEleven Pediatric Nephrology Research Consortium sites participated in the study, using IRB-approved retrospective chart reviews of CNS and INS patients born between 1998 and 2019. Data were collected on patient characteristics, pertinent laboratory tests, provided therapy, timing of unilateral/bilateral nephrectomy and initiation of renal replacement therapy (RRT).ResultsThe study included 69 patients, 49 with CNS and 20 with INS, with a median age at diagnosis of 1 and 6 months, respectively. Management for the two groups was similar regarding nutrition, thyroxin supplementation, immunoglobulin administration, and thrombosis prophylaxis. Within the first 2 months after diagnosis, daily albumin infusions were used more often in CNS vs. INS patients (79 vs. 30%; p = 0.006), while weekly infusions were more common in INS patients (INS vs. CNS: 50 vs. 3%; p = 0.001). During the 6 months preceding RRT, albumin infusions were more frequently prescribed in CNS vs. INS (51 vs. 15%; p = 0.007). Nephrectomy was performed more often in CNS (78%) than in INS (50%; p = 0.02). End-stage kidney disease tended to be more common in children with CNS (80%) vs. INS (60%; p = 0.09).ConclusionCompared to INS, patients with CNS had a more severe disease course, requiring more frequent albumin infusions, and earlier nephrectomy and RRT. Despite center-specific variations in patient care, 20–40% of these patients did not require nephrectomy or RRT.

Methodology paper for the General Medicine Inpatient Initiative Medical Education Database (GEMINI MedED): a retrospective cohort study of internal medicine resident case-mix, clinical care and patient outcomes

IntroductionUnwarranted variation in patient care among physicians is associated with negative patient outcomes and increased healthcare costs. Care variation likely also exists for resident physicians. Despite the global movement towards...

World Federation of Athletic Training and Therapy World Congress 2022 Peer-Reviewed Track Abstracts, May 5–7, 2022, Winnipeg, Manitoba, Canada

World Federation of Athletic Training and Therapy World Congress 2022 Peer-Reviewed Track Abstracts, May 5–7, 2022, Winnipeg, Manitoba, Canada

Understanding variation in patient care: A qualitative study of hospital (non-ST elevation myocardial infarction) practices

Background Variation in care is often poorly understood but has a big impact on patients. Non-ST segment elevation myocardial infarction (NSTEMI, also known as non-ST elevation acute coronary syndrome or NSTE-ACS) is the most common form of heart attack. NSTEMI is frequently hard to diagnose, its management pathway poorly defined and there is considerable variation in clinical practice. Methods A qualitative study based on site visits, observation, and interviews with managers, clinicians and patients. The setting was 10 hospitals in England and Wales selected to represent variation in 30-day mortality. 199 hospital staff and 68 patients were observed; 142 staff and 53 patients were interviewed. Analysis was thematic and guided by the principles of grounded theory. We triangulated interviews, observational data and medical records and interpreted these findings with reference to national guidelines. Results While the majority of hospitals in our sample had specialist cardiac roles, variation in their remits, specifically their involvement in close monitoring, significantly affected patient management. Close monitoring was important in the identification and prioritisation of patients. Rapid responses with diagnostic and treatment procedures were facilitated by close monitoring but also heavily dependent on effective and flexible bed and catheter laboratory management. Conclusions Close monitoring was a key area of variation. Guidelines for NSTEMI care specify what to do, but not how to do it. These findings are especially relevant for acute conditions with diagnostic and treatment uncertainty. Detailed examples of variation in care can inform quality improvement and potentially help improve patient outcomes.

Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard.

Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers. This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data. We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation. The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data. A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.

Empirically identified networks of healthcare providers for adults with mental illness

BackgroundPolicies target networks of providers who treat people with mental illnesses, but little is known about the empirical structures of these networks and related variation in patient care. The goal of this paper is to describe networks of providers who treat adults with mental illness in a multi-payer database based medical claims data in a U.S. state.MethodsProvider networks were identified and characterized using paid inpatient, outpatient and pharmacy claims related to care for people with a mental health diagnosis from an all-payer claims dataset that covers both public and private payers.ResultsThree nested levels of network structures were identified: an overall network, which included 21% of providers (N = 8256) and 97% of patients (N = 476,802), five communities and 24 sub-communities. Sub-communities were characterized by size, provider composition, continuity-of-care (CoC), and network structure measures including mean number of connections per provider (degree) and average number of connections who were connected to each other (transitivity). Sub-community size was positively associated with number of connections (r = .37) and the proportion of psychiatrists (r = .41) and uncorrelated with network transitivity (r = −.02) and continuity of care (r = .00). Network transitivity was not associated with CoC after adjustment for provider type, number of patients, and average connection CoC (p = .85).ConclusionsThese exploratory analyses suggest that network analysis can provide information about the networks of providers that treat people with mental illness that is not captured in traditional measures and may be useful in designing, implementing, and studying interventions to improve systems of care. Though initial results are promising, additional empirical work is needed to develop network-based measures and tools for policymakers.

Ultrasound of the Optic Nerve Does Not Appear to Be a Consistently Reliable or Generalizable Method to Monitor Changes in Intracranial Pressure.

Invasive intracranial pressure (ICP) monitoring is the gold standard, but is not always readily accessible or practical. Ultrasound of the optic nerve sheath diameter (ONSD) has been proposed for detecting both elevation and change in the ICP. Our study is a prospective observational trial that seeks to determine if ultrasound can be reliably used to identify changes in ICP with naturally occurring variations in patient care. A convenience sample of patients with invasive ICP monitoring were enrolled. Patients were identified prior to interventions that were suspected to cause a change in ICP. Measurement of ICP and ONSD was obtained prior to the intervention, with repeated measurements of both variables obtained immediately following the intervention. 36 total patients were enrolled. There was a positive correlation between the ICP and the right ONSD (r = 0.255, P = 0.0003) and the ICP and the left ONSD (r = 0.274, P < 0.0001). There was no statistically significant relationship between the change in either the ICP and the right ONSD (r -0.2 P = 0.282) or left ONSD (r 0.05 P = 0.805). The location of the lesion in the brain appears to significantly affect discordance between the ONSD and the ICP. Ultrasound of the ONSD has shown promise as both a marker of elevated ICP and as a method to identify changes in pressure. Although the size of the ONSD and the measurement of ICP were correlated in our study, the ability to follow changes in ICP was not statistically significant. This indicates that use of ultrasound to track changes in ICP cannot be generalized and may be limited to specific circumstances. The location of the intracranial pathology appears to be a significant factor in discordance between the ICP and ONS diameter.

Variations in care for patients undergoing cancer surgery in Pakistan - Exploration of Cancer Care Disparities in Low-Middle Income Countries

Background: Lower-middle-income countries (LMICs) face significant disparities in every aspect of cancer care. With the projected increase in the global cancer burden especially in the LMICs, significant strain on the healthcare resources is expected, which will likely further worsen the existing cancer care disparities. It is imperative to generate data regarding such variations in resources, practices and outcomes in LMICs. As part of this initiative, we aim to survey the variations in the care for patients undergoing cancer surgery across Pakistan.

Abstract A054: Sociodemographic disparities in gastric adenocarcinoma: A population-based study

Abstract Background: Gastric cancer is one of the leading causes of cancer-related mortality worldwide, with a global burden of 5.7% new cases each year and 8.2% of cancer-related deaths. Area of residence has been found to affect survival in different cancers but their impact on gastric cancer remains largely unknown. The purpose of this study is to address the potential disparities between the rural and urban populations affected specifically by gastric adenocarcinoma. Methods: We conducted a retrospective study, analyzing different socio-economic factors associated with populations affected by gastric adenocarcinoma between 2004 and 2013. Data was obtained from the National Cancer Database (NCDB). Univariate and multivariable analyses were performed to evaluate overall survival (OS). Different socio-demographic factors, location of residence were included, urban area (UA) or rural area (RA), gender, race, insurance status and marital status were included in the analyses. Results: A total of 88,246 [RA, N=12,365; UA, N=75,881] patients were included in the study. Majority of the study population was white (N = 67,792, 77%) and male (N = 59,574, 68%). Univariate and multivariable analysis showed that RA had the worst OS (univariate - HR=1.08, p&amp;lt;0.001; multivariate HR=1.04; p&amp;lt;0.001) compared to UA. When comparing different racial backgrounds, univariate and multivariable analysis showed Native American and African American population had poor OS when compared to the white population, however, Asian patients tend to have better OS (univariate HR=0.66, multivariable HR=0.68, p&amp;lt;0.01). From quality of care standpoint, UA patients median days to undergo surgery (28 vs. 33; p&amp;lt;0.01) post diagnosis was significantly sooner, with significantly fewer positive margins (6.3% vs. 6.9%; p&amp;lt;0.01) when compared to RA patients. Though, there is no minimum number of lymph nodes examined during resection, but total of 15 or above is an accepted practice. When comparing the lymph node dissection, 19.6% UA patients underwent more than or equal to 15 lymph nodes dissection in comparison to 18.7% patients in RA (p=0.03). Discussion: This study identifies socio-demographic disparities in gastric adenocarcinoma. Access to healthcare, variations in patient care, environmental and lifestyle factors as well as genomic differences are all potential factors that affect the OS. This is consistent with the available literature in gastric cancer, including studies demonstrating survival differences in different populations undergoing surgical treatment in the United States. Based on the above data, it is imperative for future health policy initiatives to address these disparities in an effort to improve OS. Citation Format: Rohit Gosain, Navpreet Rana, Riccardo Lemini, Chong Wang, Sarbajit Mukherjee. Sociodemographic disparities in gastric adenocarcinoma: A population-based study [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A054.

Harnessing the potential of electronic general practice pathology data in Australia: An examination of the quality use of pathology for type 2 diabetes patients

BackgroundDespite the importance of pathology testing in diagnosis and disease monitoring, there is little in-depth research about pathology test ordering in general practice and how it impacts patient outcomes. This is in part due to the limited availability of high-quality data. With the now-widespread use of electronic software in general practice comes the potential for electronic patient data to be used for research leading to better understanding of general practice activities, including pathology testing. ObjectivesThis study aimed to examine the usefulness of electronic general practice pathology data to: (1) identify patients’ characteristics, (2) monitor quality of care, (3) evaluate intervention effects, (4) identify variations in patient care, and (5) measure patient outcomes. An exemplar study evaluating kidney function testing in type 2 diabetes mellitus (type 2 diabetes) compared to guidelines was used to demonstrate the value of pathology data. Materials and methodsDe-identified electronic data from approximately 200 general practices in Victoria were extracted using Outcome Health’s Population Level Analysis & Reporting (POLAR) Aurora research platform. Our study population included patients ≥18 diagnosed with type 2 diabetes before July 2016. Data from July 2016 to June 2018 were used to i) determine frequency of kidney function tests (KFT), and ii) identify whether antihypertensive medications were prescribed for abnormal KFT results. ResultsThere were 20,514 active patients with type 2 diabetes identified from the data. The age and gender standardised estimate of diabetes prevalence was 4.9%, consistent with Australian estimates (5.2%). Sociodemographic features of prevalence, including higher prevalence in older males, were also consistent with previous Australian estimates.Kidney function testing was performed annually, as recommended by guidelines, in 75.7% of patients, with higher annual testing observed in patients managed under general practice incentive programs (80.1%) than those who were not (72.2%). Antihypertensive medications were prescribed as recommended in 77.4% of patients with suspected microalbuminuria or macroalbuminuria based on KFT results. DiscussionEvaluations using data from diabetes patients in this study illustrate the value of electronic data for identifying patients with the condition of interest (e.g. type 2 diabetes) along with sociodemographic characteristics. This allows for the ability to undertake analyses on pathology testing factors and the identification of variation compared to guidelines, which has a potential to ensure quality of care. Its potential to identify associations with incentive programs further demonstrates the advantages of the data’s longitudinal nature. These include the ability to assess temporal order and time interval of tests as a marker of quality of monitoring and evaluate intervention effects on a cohort over time. Finally, analyses on antihypertensive medication prescribing in patients with suspected micro/macroalbuminuria exemplified the electronic data’s usefulness in monitoring patient outcomes, such as appropriate prescribing based on pathology test results. ConclusionsElectronic general practice data is an important resource which can provide valuable insights about the quality use of pathology. There are clear benefits to patients for better monitoring, and consequent better outcomes, and to inform policymakers about the best ways to channel resources to enhance the quality of care.

Differing commissioning arrangements may contribute to geographic variation in clinical management of digital ulcers in systemic sclerosis

Phosphodiesterase inhibitors (such as sildenafil) and endothelin receptor antagonist, bosentan, are effective for digital ulcer disease in systemic sclerosis (SSc-DU) and are endorsed in international treatment recommendations. Commissioning of high-cost drugs, such as bosentan, however, differs across devolved nations of the UK. We report a multicentre service evaluation project to examine 'real world' management of SSc-DU before and following the 2015 UK Scleroderma Study Group (UKSSG) guidance, across south-west (SW) England and Wales. Results showed that iloprost and sildenafil use for SSc-DU was higher in patients in Wales prior to 2015. Between 2015-2017, sildenafil use for SSc-DU increased in SW England while remaining stable in Wales. Bosentan use for SSc-DU after 2015 in SW England increased, while remaining stable and proportionately lower in Wales. These findings demonstrate that differing commissioning guidance across devolved nations of the UK seems to contribute to geographic variation in patient care.

Anatomy SOAP Notes: Integrating an essential clinical tool into the anatomy lab

An essential component of patient care is documentation of each patient encounter. It is often said, “If it is not documented it didn’t happen.” Each encounter with a patient requires a medical record including: the patient’s symptoms, clinical signs, the diagnosis, and treatment plan. Documentation is important for continuity of care and communication between healthcare providers. This record of the patient encounter is also an important medico‐legal document. The widely adopted Subjective, Objective, Assessment, and Plan (SOAP) Note is one form of this documentation of the physician‐patient interaction.Human Gross Anatomy is the foundational course often seen as a rite of passage and one of the most memorable parts of the medical and dental students’ learning experience in the pre‐clinical years. The body donor in this course is considered the students’ first patient. To emphasize observation skills and promote record keeping of patient encounters we instituted a new activity for our medical and dental students enrolled in gross anatomy as part of the pre‐clinical curriculum. In the medical course, each “patient” encounter is documented by completion of a brief exercise (modified Anatomy SOAP note) at the conclusion of each lab dissection. A single SOAP note activity is instituted for the dental students to be completed at the conclusion of the dental anatomy course.Preliminary observations from medical student submissions indicates a collaborative effort to complete the dissections and document anatomical variations and pathologies observed during the dissections. Faculty observations note students taking a keen interest in finding any anatomical variations or pathology present in their patient. Our faculty have witnessed an increase in level of team‐work and discussion about novel findings during dissection by members of the dissection team. Students have demonstrated, in their actions in lab as well as their write‐ups, increased collaboration and greater awareness of anatomical variations and pathology present in the body donor. Specific comments regarding teamwork, attention to pathologic changes and anatomical variations include: “Team worked well together by sharing roles and responsibilities. When one person struggled with one area [of] knowledge [our] skill was shared.” “We found that our cadaver was missing a large chunk of the right cerebral hemisphere, including loss in both the parietal and temporal lobes. We believe that this was likely due to a severe stroke.” “We have a right hepatic artery coming off of our superior mesenteric artery.”At the conclusion of both medical and dental anatomy courses survey data will be evaluated for comparison of the two methods of integration of the Anatomy SOAP note exercise. The notes themselves will be evaluated for content and observed anatomical variations and pathology. Initial observations suggest improvement of collaboration in the dissection team. We also speculate that this novel activity will be a positive tool to help reinforce patient documentation and build observation skills in our students. In addition, a database of observed variations will further expose future clinicians to the critical role of normal anatomy and anatomical variations in patient care.

The next step in surgical quality improvement: outcome situational awareness

A similar theme unites proposed solutions for stagnant improvement in outcomes and rising health care costs: eliminate unnecessary variation in the care of surgical patients. While large quality-improvement projects like the Americal College of Surgeons National Surgical Quality Improvement Program have historically led to improved patient outcomes at the hospital level, the next step in surgical quality improvement is to eliminate unnecessary variation at the level of the individual surgeon. Critical examination of individualized clinical, financial and patient-reported outcomes — outcome situational awareness — along with peer group comparison will help surgeons to identify variation in patient care. We are piloting an interactive software platform at our institution to provide information on individualized clinical, financial and patient-reported outcomes in real time through automatic data population of a central REDCap database. These individualized data along with peer group comparison allow surgeons to objectively determine areas of potential improvement.

Textbook Outcomes Among Patients Undergoing Retroperitoneal Sarcoma Resection.

Recently, the concept of textbook outcome (TO) has emerged as a novel effort to develop a benchmark that reflects multiple domains of quality. The aims of the current study were to define TO for retroperitoneal sarcoma (RPS), evaluate the relationship of TO with hospital volume and assess the association of TO with overall survival. Patients who underwent resection for RPS diagnosed between 2004 and 2015 were identified in the National Cancer Database. The primary outcome was TO that was defined as: hospital length of stay<75th percentile, survival>90 days from surgery, no readmission within 30 days and grossly negative margins. Of the 11,032 patients analyzed, 54.0% had a TO. Among patients who had a TO, 57.8% were treated in high-volume hospitals. Undergoing surgery at high-volume centers was associated with a higher probability of a TO (p=0.009). TO were associated with significantly longer overall survival (p<0.001). In a subgroup analysis with grossly negative margins and no 90-day mortality, the association of TO with improved survival persisted (p<0.001). The concept of TO is a promising tool for measuring patient-level hospital performance and may be useful for identifying important variations in care for patients with RPS.

Variation in care of patients with elderly-onset inflammatory bowel disease in Ontario, Canada: A population-based cohort study.

BackgroundVariation in health care, when not based on patient preference, may result in poorer care. We determined whether variation in health services utilization, gastroenterologist care and outcomes existed among patients with elderly-onset inflammatory bowel disease (IBD).MethodsPatients with IBD (diagnosed ≥65 years) were identified from population-based health administrative data from Ontario, Canada (1999 to 2014). We assessed variation across multispecialty physician networks in gastroenterologist care and outcomes using multilevel logistic regression. Median odds ratios (MOR) described variation. We evaluated the association between gastroenterologist supply, specialist care and outcomes.ResultsIn 4806 patients, there was significant variation in having ever seen a gastroenterologist (MOR 3.35, P < 0.0001), having a gastroenterologist as the primary IBD care provider (MOR 4.16, P < 0.0001), 5-year colectomy risk in ulcerative colitis (MOR 1.38, P = 0.01), immunomodulator use (MOR 1.47, P = 0.001), and corticosteroid use (MOR 1.26, P = 0.006). No variation in emergency department visits, hospitalizations or intestinal resection (Crohn’s) was noted. Patients in networks with fewer gastroenterologists were less likely to see a gastroenterologist (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.56), have a gastroenterologist as their primary care provider (OR 0.27, 95% CI 0.12 to 0.59), be hospitalized within 5 years (OR 0.82, 95% CI 0.69 to 0.98), and be prescribed biologics within 1 year (OR 0.50, 95% CI 0.28 to 0.89).ConclusionsUtilization of gastroenterology care in patients with elderly-onset IBD varies greatly. Patients treated by gastroenterologists and in networks with more gastroenterologists have better outcomes. There is a need to ensure all individuals with IBD have equal access to and utilization of specialist care to ensure the best possible outcomes.