Morbidity and Mortality of the Transmetatarsal Amputation: A Comparative NSQIP Analysis.

The objective of this investigation was to compare the morbidity and mortality of transmetatarsal amputation to other frequently performed surgical procedures utilizing a large US database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated for the purposes of this investigation. We initially extracted data related to the Current Procedural Terminology (CPT) code 28805 (amputation, foot; transmetatarsal) and the variable labels "estimated probability of morbidity" and "estimated probability of mortality." We subsequently performed a CPT code search for those procedures occurring at a frequency greater than 10,000 in the database, and additionally extracted data for estimated probability of morbidity and estimated probability of mortality for these procedures. This resulted in identification of 17 additional procedures. CPT code 28805 was associated with the highest estimated probability of morbidity of the cohort (0.1360 ± 0.0669), and this demonstrated statistical significance higher than all other CPT codes (p < .001). CPT code 28805 was associated with the second-highest estimated probability of mortality of the cohort (0.0327 ± 0.0596). This demonstrated statistical significance less than that of CPT code 27245 (0.0327 ± 0.0596 vs 0.0547 ± 0.0661; p < .0001), but statistical significance higher than all other CPT codes (p<0.001). The results of this investigation indicate that transmetatarsal amputation carries a substantial risk for morbidity and mortality in comparison to other commonly performed surgical procedures.

The role of skill development in improving the performance of agricultural extension agents in Iran using structural equation modeling and grounded theory / O papel do desenvolvimento de competências na melhoria do desempenho dos promotores agrícolas no Irã usando modelagem de equações estruturais e teoria fundamentada

Abstract Performance improvement is the main concept of development policy. Belief in strengthening and improving the performance of individuals and institutions in developing countries for success in development policy has gradually formed among development agents. Performance improvement at the individual level pays attention to individual needs in order to enhance performance. Development requires developed and trained people. Therefore, the better the human resources as wealth and national capital are cultivated, the smoother the development path will be. The dimensions of improving performance at the individual level include things such as abilities, needs, attitudes, psychology, motivations, talents and skills, which also raises the need for skill development. In this regard, the current research seeks to investigate the relationship between skill development and performance improvement in extension in Iranian agriculture. The statistical population includes agricultural jihad centers in five regions of the country (the division of the country's provinces according to the Ministry of Agricultural Jihad, where each region includes 6 provinces) which is 8142 people, and accordingly, Cochran's formula was used to determine the sample size and the number of sample size 366 people were obtained. A structured questionnaire was developed to collect data. Structural equation modeling was used to examine the skill development measurement model, the performance improvement measurement model, and the skill development model. The research results show the significant relationship of all the indicators extracted from the interview in the structural equations.

Resumo A melhoria do desempenho é o principal conceito da política de desenvolvimento. A crença no fortalecimento e na melhoria do desempenho de indivíduos e instituições nos países em desenvolvimento para o sucesso da política de desenvolvimento tem se formado gradualmente entre os agentes de desenvolvimento. A melhoria do desempenho a nível individual presta atenção às necessidades individuais, a fim de melhorar o desempenho. O desenvolvimento requer pessoas desenvolvidas e treinadas. Portanto, quanto melhores forem os recursos humanos cultivados como riqueza e capital nacional, mais suave será o caminho de desenvolvimento. As dimensões da melhoria do desempenho no nível individual incluem coisas como habilidades, necessidades, atitudes, psicologia, motivações, talentos e habilidades, o que também levanta a necessidade de desenvolvimento de habilidades. Nesse sentido, a presente pesquisa busca investigar a relação entre o desenvolvimento de habilidades e a melhoria do desempenho na extensão na agricultura iraniana. A população estatística inclui centros de jihad agrícola em cinco regiões do país (a divisão das províncias do país de acordo com o Ministério da Jihad Agrícola, onde cada região inclui 6 províncias) que é de 8142 pessoas e, nesse sentido, a fórmula de Cochran foi utilizada para determinar o tamanho da amostra e o número de tamanho amostral de 366 pessoas foram obtidas. Para a coleta de dados foi elaborado um questionário estruturado. A modelagem de equações estruturais foi usada para examinar o modelo de medida de desenvolvimento de habilidades, o modelo de medição de melhoria de desempenho e o modelo de desenvolvimento de habilidades. Os resultados da pesquisa mostram a relação significativa de todos os indicadores extraídos da entrevista nas equações estruturais.

Clinical Indices Can Standardize and Monitor Pediatric Care: A Novel Mechanism to Improve Quality and Safety.

OBJECTIVE: The Cancer Care Index (CCI), a single metric that sums the number of undesirable patient events in a given time frame (either preventable harm events or missed opportunities to provide optimal care), resulted in a 42% improvement in performance. Our objective was to test the index concept in other service lines to determine whether similar performance improvement occurred. STUDY DESIGN: Care indices were developed and introduced in 3 additional service lines: Nephrology (Chronic Kidney Disease Care Index; CKDCI), Pulmonology (Lung Transplantation Care Index; LTCI), and Otolaryngology (Tracheostomy Care Index; TCI). After reaching agreement on specific harms to be avoided and elements of optimal care that should be reliably delivered, these items were compiled into indices that were updated monthly. Reports included each element individually and the total for all elements. Baseline performance was calculated retrospectively for the previous year. RESULTS: Significant improvement in performance occurred in each program following implementation of the clinical indices. The CKDCI was decreased by 63.2% (P < .001), the LTCI was decreased by 89.5% (P < .001), and the TCI was decreased by 53.0% (P < .001). Surveyed staff indicated satisfaction with use of the metric. CONCLUSIONS: Clinical indices are useful for evaluating and managing the overall reliability of a program's ability to deliver optimal care, and are associated with improved clinical performance and satisfaction by service line staff when incorporated into a program's operation.

Performance Optimization in Sport: A Psychophysiological Approach

In the last 20 years, there was a growing interest in the study of the theoretical and applied issues surrounding psychophysiological processes underlying performance. The psychophysiological monitoring, which enables the study of these processes, consists of the assessment of the activation and functioning level of the organism using a multidimensional approach. In sport, it can be used to attain a better understanding of the processes underlying athletic performance and to improve it. The most frequently used ecological techniques include electromyography (EMG), electrocardiography (ECG), electroencephalography (EEG), and the assessment of electrodermal activity and breathing rhythm. The purpose of this paper is to offer an overview of the use of these techniques in applied interventions in sport and physical exercise and to give athletes, coaches and sport psychology experts new insights for performance improvement.(AU)

Improving the Rate of Colposcopy in an Urban Population of Patients With Known Abnormal Pap Smears.

This project was designed to improve the colposcopy rate in an urban patient population with known abnormal Pap smears within 75 days of the test to rapidly identify and treat premalignant lesions. Using Plan-Do-Study-Act cycles, Lean techniques, and the electronic health record, the authors created a protocol to verify all Pap smears, then created a process whereby a phone-triage team contacted patients with abnormal Pap smears to educate them and schedule colposcopy. As a result, 100% of Pap smears were verified, compared with 95% prior to plan implementation. The mean time from Pap to colposcopy was 38.5 days, with 85% of patients having colposcopy performed after plan implementation, compared with 50% prior-a 70% improvement. If patients with medical contraindications were excluded, the percentage rose to 91%-an 82% improvement. Patient and provider satisfaction improved, staff and provider workload did not increase, and there was the potential for substantial economic savings.

Incorporating discrete event simulation into quality improvement efforts in health care systems.

Quality improvement (QI) efforts are an indispensable aspect of health care delivery, particularly in an environment of increasing financial and regulatory pressures. The ability to test predictions of proposed changes to flow, policy, staffing, and other process-level changes using discrete event simulation (DES) has shown significant promise and is well reported in the literature. This article describes how to incorporate DES into QI departments and programs in order to support QI efforts, develop high-fidelity simulation models, conduct experiments, make recommendations, and support adoption of results. The authors describe how DES-enabled QI teams can partner with clinical services and administration to plan, conduct, and sustain QI investigations.

How to Attain an Ultralow Interfacial Tension and a Three-Phase Behavior with a Surfactant Formulation for Enhanced Oil Recovery: A Review. Part 2. Performance Improvement Trends from Winsor's Premise to Currently Proposed Inter- and Intra-Molecular Mixtures.

The minimum interfacial tension occurrence along a formulation scan at the so-called optimum formulation is discussed to be related to the interfacial curvature. The attained minimum tension is inversely proportional to the domain size of the bicontinuous microemulsion and to the interfacial layer rigidity, but no accurate prediction is available. The data from a very simple ternary system made of pure products accurately follows the correlation for optimum formulation, and exhibit a linear relationship between the performance index as the logarithm of the minimum tension at optimum, and the formulation variables. This relation is probably too simple when the number of variables is increased as in practical cases. The review of published data for more realistic systems proposed for enhanced oil recovery over the past 30 years indicates a general guidelines following Winsor's basic studies concerning the surfactant-oil-water interfacial interactions. It is well known that the major performance benefits are achieved by blending amphiphilic species at the interface as intermolecular or intramolecular mixtures, sometimes in extremely complex formulations. The complexity is such that a good knowledge of the possible trends and an experienced practical know-how to avoid trial and error are important for the practitioner in enhanced oil recovery.

Implementing the physician quality reporting system in an academic multispecialty group practice: lessons learned and policy implications.

The Centers for Medicare and Medicaid Services (CMS) introduced the Physician Quality Reporting System (PQRS) in 2007. PQRS was developed as a value-based, pay-for-reporting initiative intended to increase quality and decrease costs. Jefferson University Physicians (JUP) was an early participant in this voluntary program. In this article, the policy context for CMS's launch of PQRS and JUP's implementation strategy, lessons learned, and an account of benefits and barriers to participation are reviewed. In 2010, JUP achieved 94% provider participation and an average incentive of $772 per participating provider. Net incentives earned across JUP in 2010 topped $171 000, although these earnings were significantly offset by implementation and maintenance costs. PQRS represents CMS's first step toward aligning quality and cost in the ambulatory care setting. Faculty practice plans must be prepared to meet this challenge in order to avoid future penalties and to advance quality of care.