Attitudes on Equal Health Care Access versus Efficient Clinical Decisions across a Not-for-Profit Health Care System.

BACKGROUND: Professional roles within a hospital system may influence attitudes behind clinical decisions. OBJECTIVE: To determine participants' preferences about clinical decisions that either value equal health care access or efficiency. DESIGN: Deidentified survey asking participants to choose between offering a low-cost screening test to a whole population ("equal access") or a more sensitive, expensive test that could be given to only half of the population but resulting in 10% more avoided deaths ("efficient"). Data collection took place from August 18, 2021, to January 24, 2022. Study 1644 was determined to be exempt by Tufts Health Sciences Institutional Review Board (IRB). SETTING: Tufts Medicine Healthcare System. PARTICIPANTS: Approximately 15,000 hospital employees received an e-mail from the Tufts Medicine Senior Vice President of Academic Integration. MEASUREMENTS: Analysis of survey responses with chi-square and 1-sample t tests to determine the proportion who chose each option. Logistic regression models fit to examine relationships between professional role and test choice. RESULTS: A total of 1,346 participants completed the survey (∼9.0% response rate). Overall, approximately equal percentages of respondents chose the "equal access" (48%) and "efficient" option (52%). However, gender, professional role (categorical), and clinical role (dichotomous) were significantly associated with test choice. For example, among those in nonclinical roles, women were more likely than men to choose equal health care access. In multivariable analyses, having clinical roles was significantly associated with 1.73 times the likelihood of choosing equal access (95% confidence interval = 1.33-2.25). LIMITATIONS: Generalizability concerns and survey question wording limit the study results. CONCLUSION: Clinicians were more likely than nonclinicians to choose the equal health care access option, and health care administrators were more likely to choose efficiency. These differing attitudes can affect patient care and health care quality. HIGHLIGHTS: Divergent preferences of valuing equal health care access and efficiency may be in conflict during clinical decision making.In this cross-sectional study that included 1,346 participants, approximately equal percentages of respondents chose the "equal access" (48%) and "efficient" option (52%), a nonsignificant difference. However, gender, professional role (categorical), and clinical role (dichotomous) were significantly associated with test choiceSince clinicians were more likely than nonclinicians to choose the equal health care access option and health care administrators were more likely to choose efficiency, these differing attitudes can affect patient care and health care quality.

Late-afternoon communication and patient planning (CAPP) rounds: an intervention to allow early patient discharges.

OBJECTIVE: Measure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO). METHODS: We enrolled 4485 patients discharged from six subspecialty medical services. We implemented late-afternoon CAPP rounds to identify patients who could have morning discharge the subsequent day. After an initial successful implementation of the intervention, we identified lack of sustainability. We made changes with sustained implementation of the intervention. This is a before-after study of a quality improvement intervention. PROGRAM EVALUATION: Primary measures of intervention effectiveness were percentage of patients who received EDO by 11 am and patients discharged by noon. Additional measure of effectiveness were percent of patients admitted to the correct ward, emergency department (ED)-to-ward transfer time compared between intervention and nonintervention periods. We compared the overall expected LOS and the average weekly discharges to assess for comparability across the control and intervention time periods. We used the readmission rate as balancing measure to ensure that the intervention was not have unintended negative patients consequences. RESULTS: Expected length of stay based upon discharge diagnosis/comorbidities and readmission rates were similar across the intervention and control time periods. The average weekly discharges were not statistically significant. Percentage of EDO by 11 am was higher in the first intervention period, second intervention period and combined intervention periods (28.9% vs. 21.8%, P < 0.001) compared with the respective control periods. Percent discharged before noon increased in the first intervention period, second intervention period and for the combined intervention periods (17 vs. 11.8%, P < 0.001). There was no difference in the percent admitted to the correct ward and ED-to-ward transfer time. CONCLUSION: Afternoon CAPP rounds to identify early patient discharges the following day led to increase in EDO entered by 11 am and discharges by noon without an adverse change in readmission rates and LOS.

Trends in Kidney Function Outcomes Following RAAS Inhibition in Patients With Heart Failure With Reduced Ejection Fraction.

RATIONALE & OBJECTIVE: Angiotensin-converting enzyme (ACE) inhibitors are beneficial in heart failure with reduced ejection fraction (HFrEF). We sought to describe longitudinal trends in estimated glomerular filtration rate (eGFR) in HFrEF and how ACE-inhibitor therapy influences these changes. STUDY DESIGN: Post hoc analysis of trial data. SETTINGS & PARTICIPANTS: Symptomatic (Treatment Trial, n=2,423) and asymptomatic (Prevention Trial, n=4,094) patients from the Studies of Left Ventricular Dysfunction (SOLVD). EXPOSURE: Enalapril versus placebo. OUTCOMES: Early and long-term eGFR slope (ie, within and after the first 6 weeks) and 4 kidney end points: (1) serum creatinine level increase by≥0.3mg/dL, (2)>30% eGFR decline, (3)>40% eGFR decline, and (4) incident eGFR<30mL/min/1.73m2. ANALYTICAL APPROACH: Shared parameter models, multivariable Cox regression models. RESULTS: Baseline mean eGFR was lower in the Treatment Trial than in the Prevention Trial, 69.5±19.8 (SD) versus 76.2±18.6mL/min/1.73m2. Following randomization, an early eGFR decline occurred in the enalapril group; however, slopes during the median 3-year follow-up were not statistically different by randomization arm in either the Treatment Trial (-0.84 in enalapril vs-1.36mL/min/1.73m2 per year in placebo; P=0.08) or Prevention Trial (-1.27 in enalapril vs-1.36mL/min/1.73m2 per year in placebo; P=0.7). Random assignment to enalapril treatment increased the risk for all 4 outcomes in the Treatment Trial in the first 6-week period (HRs were 1.48 [95% CI, 1.10-1.99] for creatinine increase by≥0.3mg/dL; 1.38 [95% CI, 0.98-1.94] for eGFR decline> 30%; 2.60 [95% CI, 1.30-5.21] for eGFR decline> 40%; and 4.71 [95% CI, 1.78-12.50] for eGFR<30mL/min/1.73m2), but after the first year was not significantly associated with increased risk. A similar albeit less pronounced pattern was observed in the Prevention Trial, with risks present only in the early period. LIMITATIONS: Creatinine results were not blinded, making it possible that ACE-inhibitor/placebo dosing was influenced by creatinine level. CONCLUSION: Kidney function decline is slow in HFrEF. Although random assignment to enalapril treatment results in a statistically increased risk for kidney surrogates, the risk is limited to the early phase and late eGFR slopes and risks are not different by randomly assigned group.

Acute declines in estimated glomerular filtration rate on enalapril and mortality and cardiovascular outcomes in patients with heart failure with reduced ejection fraction.

Angiotensin-converting enzyme inhibitors are beneficial in heart failure with reduced ejection fraction but are associated with acute declines in estimated glomerular filtration rate (eGFR). Prior studies evaluating thresholds of eGFR decline while using angiotensin-converting enzyme inhibitors in heart failure with reduced ejection have not taken into account this medication-driven decline. Here we used data from the Studies of Left Ventricular Dysfunction (SOLVD) trial of 6245 patients and performed Cox proportional hazards regression models to calculate hazard ratios of all-cause mortality and heart failure hospitalization-associated with percent eGFR decline at two- and six-weeks after randomization to enalapril versus placebo. In reference to placebo with equal degree of percent eGFR decline, any eGFR decline in the enalapril arm was associated with lower hazard of both outcomes. Under a conservative estimate using zero percent eGFR decline in the placebo arm as the reference, up to a 10% decline with enalapril was associated with mortality benefit (hazard ratio 0.87 [95% confidence interval 0.77, 0.99]) while up to a 35% decline was associated with decreased risk of heart failure hospitalization (0.78 [0.61, 0.98]). Under an intermediate estimate, up to a 15% decline with enalapril was associated with a mortality benefit (0.86 [0.77, 0.97]) and all levels of eGFR decline were associated with decreased risk of heart failure hospitalization. There was no percent eGFR decline, including up to 40%, in any models at either two- or six-weeks where enalapril was associated with higher mortality risk. Thus, in patients with reduced ejection fraction heart failure, enalapril is associated with decreased risk of mortality and heart failure hospitalizations. Hence, compelling reasons beyond moderate eGFR decline ought to be considered before its use is withdrawn.

An in vitro acoustic analysis and comparison of popular stethoscopes.

PURPOSE: To compare the performance of various commercially available stethoscopes using standard acoustic engineering criteria, under recording studio conditions. MATERIALS AND METHODS: Eighteen stethoscopes (11 acoustic, 7 electronic) were analyzed using standard acoustic analysis techniques under professional recording studio conditions. An organic phantom that accurately simulated chest cavity acoustics was developed. Test sounds were played via a microphone embedded within it and auscultated at its surface by the stethoscopes. Recordings were made through each stethoscope's binaurals and/or downloaded (electronic models). Recordings were analyzed using standard studio techniques and software, including assessing ambient noise (AMB) rejection. Frequency ranges were divided into those corresponding to various standard biological sounds (cardiac, respiratory, and gastrointestinal). RESULTS: Loudness and AMB rejection: Overall, electronic stethoscopes, when set to a maximum volume, exhibited greater values of perceived loudness compared to acoustic stethoscopes. Significant variation was seen in AMB rejection capability. Frequency detection: Marked variation was also seen, with some stethoscopes performing better for different ranges (eg, cardiac) vs others (eg, gastrointestinal). CONCLUSION: The acoustic properties of stethoscopes varied considerably in loudness, AMB rejection, and frequency response. Stethoscope choice should take into account clinical conditions to be auscultated and the noise level of the environment.

Attitudes on cost-effectiveness and equity: a cross-sectional study examining the viewpoints of medical professionals.

OBJECTIVE: To determine the attitudes of physicians and trainees in regard to the roles of both cost-effectiveness and equity in clinical decision making. DESIGN: In this cross-sectional study, electronic surveys containing a hypothetical decision-making scenario were sent to medical professionals to select between two colon cancer screening tests for a population. SETTING: Three Greater Boston academic medical institutions: Tufts University School of Medicine, Tufts Medical Centre and Lahey Hospital and Medical Centre. PARTICIPANTS: 819 medical students, 497 residents-in-training and 671 practising physicians were contacted electronically using institutional and organisational directories. MAIN OUTCOMES AND MEASURES: Stratified opinions of medical providers and trainee subgroups regarding cost-effectiveness and equity. RESULTS: A total of 881 respondents comprising 512 medical students, 133 medical residents-in-training and 236 practising physicians completed the survey (total response rate 44.3%). Thirty-six per cent of medical students, 44% of residents-in-training and 53% of practising physicians favoured the less effective and more equitable screening test. Residents-in-training (OR 1.49, CI 1.01 to 2.21; p=0.044) and practising physicians (OR 2.12, CI 1.54 to 2.92; p<0.001) were more likely to favour the equitable option compared with medical students. Moreover, female responders across all three cohorts favoured the more equitable screening test to a greater degree than did male responders (OR 1.70, CI 1.29 to 2.24; p<0.001). CONCLUSIONS: Cost-effectiveness analysis does not accurately reflect the importance that medical professionals place on equity. Among medical professionals, practising physicians appear to be more egalitarian than residents-in-training, while medical students appear to be most utilitarian and cost-effective. Meanwhile, female respondents in all three cohorts favoured the more equitable option to a greater degree than their male counterparts. Healthcare policies that trade off equity in favour of cost-effectiveness may be unacceptable to many medical professionals, especially practising physicians and women.

Effect of the Implementation of Barcode Technology and an Electronic Medication Administration Record on Adverse Drug Events.

BACKGROUND: Hospitals have attempted to reduce adverse drug events (ADEs) by investing in new technologies, but data regarding their efficacy are lacking. OBJECTIVES: This study evaluates the effects of the implementation of barcode medication administration (BCMA) and electronic medication administration record (eMAR) technology on the profile of ADEs in a hospital setting. METHODS: We conducted a before-and-after study examining the effects of the implementation of BCMA and eMAR technology on the profile of ADEs at a 400-bed academic medical center by using incident reports. We compared reported ADEs in pre- and post-implementation periods of 5 months to determine whether there was a reduction in the rate of ADEs within medication use phases. We further examined the severity of errors and described changes in the distribution of types of errors. RESULTS: A total of 775 electronic error-reporting system reports were included in this study: 397 (51%) in the pre-implementation period and 378 (49%) in the post-implementation period. The rate of ADEs significantly decreased from 0.26% to 0.20% after implementation of the technology (relative risk [RR], 0.78; 95% CI, 0.67-0.89). The rate of transcription errors decreased from 0.089% to 0.036% (RR, 0.40; 95% CI, 0.30-0.54), which was largely attributed to reduction of "wrong time" errors. The rate of administration errors was identical in both groups at 0.017% (RR, 0.98; 95% CI 0.58-1.66). The mean severity level of administration errors significantly decreased from 4.44 to 3.23 (p = .005). CONCLUSION: The implementation of eMAR and BCMA technology improved patient safety by decreasing the overall rate of ADEs and the rate of transcription errors. These technologies also reduced the harmful impact to patients caused by administration errors.

Shaken but prepared: Analysis of disaster response at an academic medical centre following the Boston Marathon bombings.

Over the last decade, there has been a rise in the number of mass casualty incidences (MCIs) and their subsequent effect on hospital systems. While there has been much discussion over improving procedures to treat victims of MCIs, there has not been a thorough, systems-based analysis concerning the costs incurred by hospitals during such events. Here the authors examine the history of the Hospital Incident Command Center and how its evolution at Tufts Medical Center helped mitigate the damage following the Boston Marathon Bombings. Tufts' unique variations to the Hospital Incident Command Center include strategic communication hierarchies and a 'zero cost centre' financial system which both provided for a quick and adaptive response. Operating in collaboration with the Conference of Boston Teaching Hospitals encouraged coordination and preparation during emergency situations such as mass casualty events. The direct and indirect effects on Tufts Medical Center stemming from the Boston Marathon Bombings were analysed. Tufts MC treated 36 victims immediately following the MCI. The estimated total cost during the week of April 15 to April 19, 2013 was $776,051. The cost was primarily comprised of lost revenue from cancelled outpatient and inpatient hospital services, as well as expenses incurred due to overtime pay, salary expenses, PPE kits and hospitality services. Finally, the authors examine ways to reduce the future costs during emergency situations through increasing communication with employees, understanding the source of all direct expenses, and mitigating excess risk by developing partnerships with other hospital systems.

Prevalence and cost of imaging in inpatient falls: the rising cost of falling.

OBJECTIVE: To quantify the type, prevalence, and cost of imaging following inpatient falls, identify factors associated with post-fall imaging, and determine correlates of positive versus negative imaging. DESIGN: Single-center retrospective cohort study of inpatient falls. Data were collected from the hospital's adverse event reporting system, DrQuality. Age, sex, date, time, and location of fall, clinical service, Morse Fall Scale/fall protocol, admitting diagnosis, and fall-related imaging studies were reviewed. Cost included professional and facilities fees for each study. SETTING: Four hundred and fifteen bed urban academic hospital over 3 years (2008-2010). PATIENTS: All adult inpatient falls during the study period were included. Falls experienced by patients aged <18 years, outpatient and emergency patients, visitors to the hospital, and staff were excluded. MEASUREMENTS AND MAIN RESULTS: Five hundred and thirty inpatient falls occurred during the study period, average patient age 60.7 years (range 20-98). More than half of falls were men (55%) and patients considered at risk of falls (56%). Falls were evenly distributed across morning (33%), evening (34%), and night (33%) shifts. Of 530 falls, 178 (34%) patients were imaged with 262 studies. Twenty percent of patients imaged had at least one positive imaging study attributed to the fall and 82% of studies were negative. Total cost of imaging was $160,897, 63% ($100,700) from head computed tomography (CT). CONCLUSION: Inpatient falls affect patients of both sexes, all ages, occur at any time of day and lead to expensive imaging, mainly from head CTs. Further study should be targeted toward clarifying the indications for head CT after inpatient falls and validating risk models for positive and negative imaging, in order to decrease unnecessary imaging and thereby limit unnecessary cost and radiation exposure.

Quantity Over Quality: How the Rise in Quality Measures is Not Producing Quality Results.

Over the past decade, quality measures (QMs) have been implemented nationally in order to establish standards aimed at improving the quality of care. With the expansion of their role in the Affordable Care Act and pay-for-performance, QMs have had an increasingly significant impact on clinical practice. However, adverse patient outcomes have resulted from adherence to some previously promulgated performance measures. Several of these QMs with unintended consequences, including the initiation of perioperative beta-blockers in noncardiac surgery and intensive insulin therapy for critically ill patients, were instituted as QMs years before large randomized trials ultimately refuted their use. The future of quality care should emphasize the importance of evidence-based, peer-reviewed measures.

In ... and out: open access publishing in scientific journals.

Open access (OA) journals are a growing phenomenon largely of the past decade wherein readers can access the content of scientific journals without paying for a subscription. The costs are borne by authors (or their institutions) who pay a fee to be published, thus allowing readers to access, search, print, and cite the journals without cost. Although the OA model, in and of itself, need not diminish scientific rigor, selectivity, or peer review, the "author pays" model creates an inherent conflict of interest: it operates with the incentive on the part of the journal to publish more and reject less. This is coupled with cost containment measures that affect the journals' ability to engage experienced editors and professional staff to scrutinize data, data analyses, and author conflicts of interest. While some OA journals appear to be comparable to their print competitors, others are "predatory" and have no legitimacy at all. Two recent "scams"--one recently published in Science--highlight the urgency of addressing the issues raised by OA publication so that OA does not lose its credibility just as it begins to gather substantial momentum. High-quality journals develop their reputations over time, and OA outlets will be no exception. For this to occur, however, the OA audience will need to be satisfied that OA can deliver high-quality publications utilizing rigorous peer review, editing, and conflict of interest scrutiny. Academic tenure and promotion committees that review scholarly credentials are understandably skeptical of publications in unrecognized journals, and the large number of new OA outlets contributes to this urgency from their perspective as well.

Exercise-induced acute changes in systolic blood pressure do not alter choroidal thickness as measured by a portable spectral-domain optical coherence tomography device.

PURPOSE: To measure choroidal thickness in patients manifesting an acute change in systemic arterial blood pressure using a portable spectral-domain optical coherence tomography device (iVue). METHODS: Fifteen patients (15 eyes) undergoing cardiac exercise stress testing were scanned using a portable spectral-domain optical coherence tomography system (iVue). Two scan protocols were used: cross line scan for measuring choroidal thickness and the retina map scan to measure retinal thickness. Each patient was scanned before and within 3 minutes after the stress test. Blood pressure was measured at the same time as the acquisition of the scans. Choroidal thickness was measured from the posterior edge of the retinal pigment epithelium to the choroid-sclera junction at 500-µm intervals up to 1,000 µm temporal and nasal to the fovea. Retinal thickness was measured by an automated software. All choroidal thickness measurements were performed by two independent observers. RESULTS: Fifteen patients (15 eyes) with a mean age of 60.6 (±10.4 years) were scanned. There was a significant increase in systolic but not diastolic pressure after stress testing (P < 0.05). The mean choroidal thickness measurements showed no significant difference before and after exercise stress testing (P > 0.05). In addition, there was no significant difference in retinal thickness before and after stress testing measurements (P > 0.05). CONCLUSION: There was no change in choroidal thickness or retinal thickness, despite an acute change in the systemic systolic blood pressure induced by exercise.

Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organizations.

Laboratory testing is essential for diagnosis, evaluation, and management. The objective was to describe the type of laboratory events reported in hospitals using a voluntary electronic error reporting system (e-ERS) via a cross-sectional analysis of reported laboratory events from 30 health organizations throughout the United States (January 1, 2000, to December 31, 2005). A total of 37,532 laboratory-related events were reported, accounting for 14.1% of all reported quality events. Preanalytic laboratory events were the most common (81.1%); the top 3 were specimen not labeled (18.7%), specimen mislabeled (16.3%), and improper collection (13.2%). A small number (0.08%) of laboratory events caused permanent harm or death; 8% caused temporary harm. Most laboratory events (55%) did not cause harm. Laboratory errors constitute 1 of 7 quality events. Laboratory errors often are caused by events that precede specimen arrival in the lab and should be preventable with a better labeling processes and education. Most laboratory errors do not lead to patient harm.