High-performing primary care clinics across high-need, high-cost Medicare populations.

BACKGROUND: To reduce spending and improve quality, some primary care clinics in the USA have focused on high-need, high-cost (HNHC) Medicare beneficiaries, which include clinically distinct subpopulations: older adults with frailty, adults under 65 years with disability and beneficiaries with major complex chronic conditions. Nationally, the extent to which primary care clinics are high-performing 'Bright Spots'-clinics that achieve favourable outcomes at lower costs across HNHC beneficiary subpopulations-is not known. OBJECTIVE: To determine the prevalence of primary care clinics that perform highly on commonly used cost or quality measures for HNHC subpopulations. DESIGN AND PARTICIPANTS: Cross-sectional study using Medicare claims data from 2014 to 2015. MAIN MEASURES: Annual spending, avoidable hospitalisations for ambulatory care-sensitive conditions, treat-and-release emergency department visits, all-cause 30-day unplanned hospital readmission rates and healthy days at home. Clinics were high performing when they ranked in the top quartile of performance for ≥4 measures for an HNHC subpopulation. 'Bright Spot' clinics were in the top quartile of performance for ≥4 measures across all the HNHC subpopulations. KEY RESULTS: A total of 2770 primary care clinics cared for at least 10 beneficiaries from each of the three HNHC subpopulations (adults under 65 with disability, older adults with frailty and beneficiaries with major complex chronic conditions). Less than 4% of clinics were high performing for each HNHC subpopulation; <0.5% of clinics were in the top quartile for all five measures for a given subpopulation. No clinics met the definition of a primary care 'Bright Spot'. CONCLUSIONS: High-performing primary care clinics that achieved favourable health outcomes or lower costs across subpopulations of HNHC beneficiaries in the Medicare programme in 2015 were rare. Efforts are needed to support primary care clinics in providing optimal care to HNHC subpopulations.

Difficulties in navigating the intersection of generalist and specialist palliative care services: A cross-sectional study of bereaved family's experiences of care at home in New Zealand.

A generalist-specialist model of palliative care is well established as a framework for the provision of community care in resource-rich countries. However, evidence is lacking regarding how the model is experienced by family carers and the extent to which access to both generalist and specialist palliative care is equitable. A cross-sectional postal survey was undertaken to explore bereaved family's experiences of generalist palliative care and its intersection with hospice services in the last 3 months of life. A modified version of the Views of Informal Carers-Evaluation of Services survey was sent to 4,778 bereaved family. Data were collected between February 2017 and October 2018. Chi-square was utilised to identify factors that impacted on experiences of generalist palliative care; analysis of free text data comprising 45,823 words was undertaken using a directed content analysis approach. Eight hundred and twenty-six questionnaires were returned (response rate = 21%). Seventy per cent of people (n = 579) spent some time at home in the last 3 months prior to death. People who received support from hospice were more likely to receive support from multiple other services. Those who received no community services were less likely to feel supported by their general practitioner, less likely to spend the last 2 days of life or die at home. Feeling supported had a strong association with services working well together, being involved in decision-making and being aware of the poor prognosis. The provision of palliative care is complicated by a lack of integration with specialist palliative care and may be the basis of continuing inequities in the provision of community care at the end of life. The assumption at a policy level that "generalists" are willing and able to play a key role in palliative care provision needs to be further challenged.

Factors associated with overall satisfaction with care at the end-of-life: Caregiver voices in New Zealand.

In New Zealand, as in other industrialised societies, an ageing population has led to an increased need for palliative care services. A cross-sectional postal survey of bereaved carers was conducted in order to describe both bereaved carer experience of existing services in the last 3 months of life, and to identify factors associated with overall satisfaction with care. A self-complete questionnaire, using a modified version of the Views of Informal Carers - Evaluation of Services (VOICES) instrument was sent to 4,778 bereaved carers for registered deceased adult (>18yrs) patients in one district health board (DHB) for the period between November 2015 and December 2016. Eight hundred and twenty-six completed questionnaires were returned (response rate = 21%). The majority of respondents (83.8%) rated their overall satisfaction with care (taking all care during the last 3 months into account), as high. However, satisfaction varied by care setting. Overall satisfaction with care in hospice was significantly higher compared to other settings. Additionally, patients who died in hospice were more likely to be diagnosed with cancer and under 65 years of age. The factors associated with overall satisfaction with care in the last 2 days of life were: caregiver perceptions of treatment with dignity and respect; adequate privacy; sufficient pain relief and decisions in line with the patient's wishes. A more in-depth exploration is required to understand the quality of, and satisfaction with, care in different settings as well as the factors that contribute to high/low satisfaction with care at the end-of-life.

Intraoperative bladder perforation during primary total hip arthroplasty.

We present a unique case of bladder perforation occurring intraoperatively during primary total hip arthroplasty. It is suspected that the patient's aberrant bladder anatomy, with idiopathic erosion of the quadrilateral space, predisposed the patient to bladder injury. Several preoperative risk factors for bladder injury were identified in the literature. These factors include cemented acetabular components, previous history of hip arthroplasty, history of pelvic trauma or intrapelvic surgery, and poor bone quality. Management of bladder injury, should it occur, includes bladder decompression with a Foley catheter, antibiotic administration, hemodynamic monitoring, and urology consult with close follow-up. This case reinforces the importance of urologic preoperative evaluation for anatomic variations of the bladder. In such cases, intraoperative Foley catheters to prevent distension may reduce the risk of perforation.

Strategies for reducing implant costs in the revision total knee arthroplasty episode of care.

BACKGROUND: Implant price has been identified as a significant contributing factor to high costs associated with revision total knee arthroplasty (rTKA). The goal of this study is to analyze the cost of implants used in rTKAs and to compare this pricing with 2 alternative pricing models. METHODS: Using our institutional database, we identified 52 patients from January 1, 2014 to December 31, 2014. Average cost of components for each case was calculated and compared to the total hospital cost for that admission. Costs for an all-component revision were then compared to a proposed "direct to hospital" (DTH) standardized pricing model and a fixed price revision option. Potential savings were calculated from these figures. RESULTS: On average, 28% of the total hospital cost was spent on implants for rTKA. The average cost for revision of all components was $13,640 and ranged from $3000 to $28,000. On average, this represented 32.7% of the total hospital cost. Direct to hospital implant pricing could potentially save approximately $7000 per rTKA, and the fixed pricing model could provide a further $1000 reduction per rTKA-potentially saving $8000 per case on implants alone. CONCLUSIONS: Alternative implant pricing models could help lower the total cost of rTKA, which would allow hospitals to achieve significant cost containment.

Revision of Total Knee Arthroplasties Performed in Young, Active Patients with Posttraumatic Arthritis and Osteoarthritis.

Rates of total knee arthroplasty (TKA) in younger patients are rising significantly. A recent study performed at our institute illustrated the excellent survivorship of TKAs in patients younger than 55 years at a mean follow-up period of 25 years. This study reports on the 25 knees in this series that required revision surgery. Twenty-five revisions were performed in 24 patients. Indication for revision, clinical outcomes, and radiographs were reviewed at their most recent follow-up. Revisions were performed in 5 cases of infection, 2 cases of fracture/trauma, 17 cases of wear/loosening, and 1 case of instability. The average duration from primary TKA to revision surgery for the 25 knees was 12.5 years (range, 2-26 years). Follow-up was obtained in 24 of 25 TKAs. Nine of the 24 patients (10 knees) had died at the time of follow-up. The average duration from revision surgery to follow-up examination for the remaining knees was 10.5 years. Using the Knee Society scoring system, the average knee score was 89.0 points and the average functional score was 75.6 points. The mean Tegner activity score was 4.6 which exceeded the mean score for unrevised TKAs (2.9). The average range of motion was 119 degrees. None of the knee radiographs showed evidence of component loosening. Young patients who undergo TKA that require revision surgery had good mid-term clinical outcomes. This information is important in completing the clinical picture and outcomes associated with young patients undergoing TKA.

Influence of podiatry on orthopedic surgery at a level I trauma center.

Level I trauma centers frequently see trauma at or below the ankle, which requires consultation with the orthopedic surgery department. However, as podiatry programs begin to firmly establish themselves in more Level I trauma centers, their consultations increase, ultimately taking those once seen by orthopedic surgery. A review of the literature demonstrates that this paradigm shift has yet to be discussed. The purpose of this study was to determine how many, if any, lower extremity fracture consultations a newly developed podiatry program would take from the orthopedic surgery department. A retrospective review was performed of emergency department records from January 2007 to December 2011. Seventeen different emergency department diagnoses were used to search the database. Ultimately, each patient's emergency department course was researched. Several trends were noted. First, if trauma surgery was involved, only the orthopedic surgery department was consulted for any injuries at or below the ankle. Second, the emergency department tended to consult the podiatry program only between the hours of 8 am and 6 pm. Third, as the podiatry program became more established, their number of consultations increased yearly, and, coincidentally, the orthopedic surgery department's consultations decreased. Finally, high-energy traumas involved only the orthopedic surgery department. Whether the orthopedic surgery department or podiatry program is consulted regarding trauma surgery is likely hospital dependent.

Performance outcomes after repair of complete achilles tendon ruptures in national basketball association players.

BACKGROUND: A complete rupture of the Achilles tendon is a devastating injury. Variables affecting return to competition and performance changes for National Basketball Association (NBA) players are not readily evident. HYPOTHESIS: Players in the NBA who ruptured their Achilles tendons and who underwent surgical repair would have more experience in the league, and the performance of those who were able to return to competition would be decreased when compared with their performance before injury and with their control-matched peers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data for 18 basketball players with Achilles tendon repair over a 23-year period (1988-2011) were obtained from injury reports, press releases, and player profiles. Variables included age, body mass index (BMI), player position, and number of years playing in the league. Individual season statistics were obtained, and the NBA player efficiency rating (PER) was calculated for 2 seasons before and after injury. Controls were matched by playing position, number of seasons played, and performance statistics. Univariate and multivariate analyses were performed to assess the effect of each factor. RESULTS: At the time of injury, the average age was 29.7 years, average BMI was 25.6, and average playing experience was 7.6 years. Seven players never returned to play an NBA game, whereas 11 players returned to play 1 season, with 8 of those players returning for ≥2 seasons. Players who returned missed an average of 55.9 games. The PER was reduced by 4.57 (P = .003) in the first season and by 4.38 (P = .010) in the second season. When compared with controls, players demonstrated a significant decline in the PER the first season (P = .038) and second season (P = .081) after their return. CONCLUSION: The NBA players who returned to play after repair of complete Achilles tendon ruptures showed a significant decrease in playing time and performance. Thirty-nine percent of players never returned to play.

Tibial tubercle avulsion fractures in adolescent basketball players.

Tibial tubercle avulsion fractures most commonly occur in adolescent boys and usually result from pushing off or landing while jumping. These fractures are relatively uncommon but can have a significant functional effect. The purpose of this study was to determine the long-term outcome with return to play in 8 adolescent basketball players with at least 4 years of postoperative reconditioning. Results with return to play at the preinjury level are favorable after treatment of acute tibial avulsion fractures in adolescent basketball players. Long-term outcome was excellent in all patients regardless of fracture type. Open reduction and internal fixation using 1 or 2 cancellous bone screws achieved union in all cases.

Improving healthcare through the use of co-design.

AIM: This paper describes how co-design methods can be used to improve patient experiences and services within healthcare organisations. Using the Patient Co-design of Breast Service Project as an example, we describe how patient experiences were captured and understood, the improvements made and implications for future work. METHOD: We used a six-step process: engage, plan, explore, develop, decide and change. Tools and techniques employed were based on service design approaches. These included patient journey mapping, experience-based surveys and co-design workshops. RESULTS: Information, communication, navigation and co-ordination, and environment emerged as key themes for the Breast Service. And as a result, a suite of improvements were made. Key methodological learnings included using co-design alongside traditional quality improvement methodologies, engaging with patients early, the importance of staff buy-in and the necessity of trying things outside one's comfort zone. CONCLUSION: Use of co-design within the Breast Service has resulted in tangible improvements and has demonstrated the value of engaging patients and focussing on their experiences. It is recommended that: evaluation phases are factored into future co-design work, further research is conducted on sustainability and funding and support is given to allow co-design to become more widespread throughout New Zealand.

Society's expectation of the role of the doctor in New Zealand: results of a national survey.

AIMS: To describe the perceptions of the New Zealand public as to the role of the doctor in 2010. METHODS: Telephone survey of 502 individuals throughout New Zealand during May 2010. The questions were based on a United Kingdom survey with added questions in respect of culture, equity and resource allocation. The data were weighted by gender and age according to the 2006 population census. RESULTS: Most respondents (82%) wanted to see a doctor first if they had a new concern about their health; 7% a nurse and 5% a pharmacist. Most respondents agreed (88%) that when visiting a doctor, getting an accurate diagnosis was their top priority. In respect of a doctor's personal qualities, integrity was expected (94%), as was compassion (89%). Most respondents (78%) agreed that they expected a doctor to be the leader of the healthcare team. Most agreed (70%) that there is limited money available and doctors must consider how best to use it for all patients and that doctors (82%) need to be involved in decisions about health spending. CONCLUSION: This comprehensive New Zealand survey provides important information about public perceptions of the role of the doctor and is a basis for workforce planning and future comparisons.

Nonunion of the clavicle treated with plate fixation: a review of forty-seven consecutive cases.

Forty-seven consecutive patients underwent superior plating for clavicular nonunion between 1995 and 2005. This retrospective analysis was performed to assess the efficacy of plate fixation and the need for iliac crest bone grafting. Forty-three patients were treated with pelvic reconstruction plates and four with straight dynamic compression plates. Of the patients, 30 were treated with local bone graft only, 14 with demineralized bone matrix, and 3 with distant autogenous bone graft. Of the fractures, 93% united after a single operation. Of the patients, 69% returned the Disabilities of the Arm, Shoulder and Hand questionnaire. The mean Disabilities of the Arm, Shoulder and Hand score was 14.6 (range, 0-53). Plate prominence or sensitivity resulted in removal in 20% of cases. We believe that superiorly applied plate fixation is effective for the treatment of clavicular nonunion. Distant autogenous bone graft is not necessary in most cases to obtain union.

Locked inferior fracture dislocation after total hip arthroplasty.

Acetabular fracture in conjunction with dislocation after total hip arthroplasty is a rarely reported event. We describe such a case with a unique fracture dislocation pattern, whereby the prosthetic femoral component dislocated inferiorly, fracturing the pelvis, and was locked in this position. The patient was treated with closed reduction under anesthesia and the fracture healed without further surgical intervention. However, she has experienced subsequent instability episodes and we have recommended revision surgery.

Delayed osteonecrosis following reduction and internal fixation of a femoral neck fracture.

Osteonecrosis (ON) is a common complication following femoral neck fracture and most studies have reported the incidence of ON after less than 3 years follow-up. Here we report a case of delayed osteonecrosis 7 years after initial treatment for a femoral neck fracture. This example supports the need for continued clinical and radiographic follow-up over an extended period after femoral neck fracture and suggests that 3 years is too short a time to reliably rule out ON as a postoperative complication.

Appropriate use of pagers in a New Zealand tertiary hospital.

AIMS: To identify the appropriateness of calls to on-call house officers in a major tertiary teaching hospital. METHODS: A prospective observational study was conducted at Auckland City Hospital over the months of June, July, and August 2004. Fourteen house officers from a range of medical and surgical services categorised calls received while on-call after-hours into one of three groups: 'appropriate and urgent'; 'appropriate but not urgent'; and 'inappropriate'. RESULTS: 844 calls were recorded and categorised, with approximately even distribution between medical services (431 calls) and surgical services (413 calls); 30% of calls were deemed clinically appropriate and required a response within 1 hour; 53% of calls were deemed clinically appropriate but did not require a response within an hour; while 17% of calls were deemed inappropriate. CONCLUSIONS: The most important function an on-call house officer performs is responding to urgent medical situations. Frequent interruptions mean that house officers may become less efficient and more prone to making mistakes. The majority of calls received by on-call house officers did not need immediate responses and would have been better communicated via a less intrusive system such as text-messaging or the keeping of a non-urgent jobs list. If house officers were paged more appropriately then they would be interrupted less frequently and would be able to provide safer, more efficient, and timelier patient care.

Frequency of calls to "on-call" house officer pagers at Auckland City Hospital, New Zealand.

AIMS: To quantify the number of calls made to specified on-call house officer pagers and to comment on possible implications for practice. METHODS: Seven on-call pagers, covering a range of surgical and medical specialties at Auckland City Hospital, were identified. Data for a 4-month period from April to August 2004 was recorded and analysed in two groups: surgical services and medical services. Statistical software was used to calculate mean times between calls in specified time periods, and to compare differences between surgical and medical services. RESULTS: 25,389 pages were recorded. These data are presented as mean frequency of calls to each pager, divided into four time periods. The highest recorded rate was 6.9 minutes (mean) between calls in general surgery (1600-2200 shift), with the lowest recorded rate a mean of one call per 5 hours (2200-0800 shift) in geriatric and general medicine. CONCLUSIONS: Pager frequency is a potentially useful marker of job acuity and consequent junior doctor stress levels. This study demonstrated a high degree of variability in paging frequency both between services and between time periods. We recommend ongoing monitoring of paging frequencies and more even distribution of after-hours workload.

Procedural skills of first-year postgraduate doctors at Auckland District Health Board, New Zealand.

AIMS: To determine whether the current skills list for postgraduate year 1 (PGY1) training in New Zealand is appropriate and an accurate reflection of the experience gained in this year. METHODS: PGY1 doctors at Auckland District Health Board were surveyed about their experience with 86 skills at the beginning and at the end of their first postgraduate year; 28 of these skills were from the Medical Council of New Zealand's (MCNZ) 'Indicative List of Skills' for PGY1. RESULTS: The response rate was 79% for the first survey and 66% for the follow-up. By the end of the PGY1 year, all doctors had performed 21% of the skills listed by the MCNZ, compared to 4% at the beginning of the year. Thirty-nine percent of the skills defined as important to achieve during PGY1 by the MCNZ had been performed by less than half our sample at the end of their PGY1 training. CONCLUSIONS: There is a significant discrepancy between the skills expected of graduates at the end of PGY1 (as indicated by the MCNZ) and those attained.

Implementation of an emergency and disaster medical response training network in the Commonwealth of Independent States.

A standardized curriculum in emergency and disaster medical response for use in the former Soviet Union was implemented under an American International Health Alliance partnership program involving over 60 healthcare and educational institutions in the United States and the Commonwealth of Independent States. The core curriculum was based on U.S. standards and developed in collaboration with local faculty to address emergency and disaster medical needs specific to the region. Local faculty members were trained by U.S. partners using a train-the-trainers methodology at U.S. partner institutions. This partnership program led to the development of 16 regional training centers in 11 countries over an 8-year period. Over 39,000 healthcare workers and first responders have now been trained throughout this network of regional training centers. Wide dissemination of standardized training encourages uniform delivery of medical care within regions and may facilitate provision of mutual aid between regional jurisdictions.

Resident Medical Officer working conditions in New Zealand: results of a recent survey.

AIMS: To survey Resident Medical Officers (RMOs) and Senior Medical Officers (SMOs) working at Auckland District Health Board (ADHB) on various aspects of RMO-working conditions and to trial the use of electronic keypad responders for this purpose. METHODS: In April 2004, the Physicians Grand Round at ADHB was used as a forum to conduct a survey on RMO working conditions in New Zealand. Results were collected anonymously using electronic keypad responders and recorded in a spreadsheet to allow analysis and comparison of the two professional groups. RESULTS: 27 RMOs and 32 SMOs attended and participated in the survey, answering 11 questions. Responses showed significant differences between the two groups in 7 of the 11 questions asked. In addition, both groups favoured changes to the status quo on a significant number of issues. CONCLUSIONS: RMOs and SMOs in New Zealand have differing opinions regarding the working conditions of RMOs. This study supports the need for wider scale, national discussion of these issues and the development of appropriate strategies to address these differences and their implications.

Health care systems in transition: New Zealand

The Health Systems in Transition (HiT) series provide detailed descriptions of health systems in the countries of the WHO European Region as well as some additional OECD countries. An individual health system review (HiT) examines the specific approach to the organization, financing and delivery of health services in a particular country and the role of the main actors in the health system. It describes the institutional framework, process, content, and implementation of health and health care policies. HiTs also look at reforms in progress or under development and make an assessment of the health system based on stated objectives and outcomes with respect to various dimensions (health status, equity, quality, efficiency, accountability).