Implementation and Evaluation of a Novel High-Value Care Curriculum in a Single Academic Surgery Department.

BACKGROUND: High value care (HVC), maximizing quality while minimizing cost, has become a major focus of surgical practice. Effective education in healthcare value concepts is critical during residency to ensure graduates are able to deliver high value surgical care and participate in interprofessional teams to improve the system. STUDY DESIGN: An HVC curriculum was implemented at a single academic medical center. Sixty-six residents from general surgery, plastic surgery, otolaryngology, and urology completed the curriculum over 3 academic years (2016 to 2019). The 1-year curriculum taught residents the concepts of HVC before participating in a value improvement project the following year. Residents' knowledge of value was assessed pre- and post-participation using a validated assessment tool, the Quality Improvement Knowledge Application Tool Revised (QIKAT-R), and a curriculum-specific assessment tool. The overall success of the program was evaluated by assessing residents' skills in completing value improvement projects using a novel scoring rubric. RESULTS: After completing the program, residents expressed improved confidence in their ability to complete a value improvement project. Residents also demonstrated improved knowledge on the curriculum-specific assessment (4.7/13 to 10.9/13) and the scenario assessment using the QIKAT-R tool (8.5/27 to 16.4/27). As the program underwent iterative improvements each year, the quality of the residents' projects also improved, as assessed by the novel scoring rubric. CONCLUSIONS: Multimodal assessment demonstrated improvement in residents' objective knowledge of HVC principles, residents' ability to design and lead clinical value improvement projects, and residents' confidence they could use HVC principles in their current and future practice.

Assessing the Training Costs and Work of Diagnostic Radiology Residents Using Key Performance Indicators - An Observational Study.

RATIONALE AND OBJECTIVES: To quantify the costs and work of diagnostic radiology (DR) residents using the radiology key performance indicator turn-around time (TAT) as the outcome measure. MATERIALS AND METHODS: In an Institutional Review Board-approved study, the annual cost of a DR resident was determined using salary, benefits, and a cost allocation of faculty effort. The volume of cases reported in the 2015-16 academic year and median and interquartile range (IQR) TAT for a trainee preliminary (Complete to Prelim, C-P) or an attending final (Complete to Final, C-F) radiology report were measured and stratified by time of day and patient location. Wilcoxon rank-sum tests were used (significance, p values < 0.05). RESULTS: The annual cost of a DR resident was $99,109, 34% greater than direct salary/benefits and 27% of the direct salary/benefits cost of an attending. The total per minute cost of rendering care was $4.36 with both trainee ($0.70/minute) and faculty ($3.66/minute). Residents participated in 139,084/235,417 (59%) imaging studies. The C-P TAT was 74 (IQR, 27-180) minutes compared to 51 (IQR, 18-129) minutes C-F TAT of faculty working alone and C-F TAT of 213 (IQR, 71-469) minutes with a resident (p < 0.001). The C-P TAT vs C-F TAT between 4 pm-9 am and weekends with residents is 44 (IQR, 18-119) minutes vs 60 (IQR, 18-179) minutes without. CONCLUSION: The cost of training DR residents exceeds the salary and benefits allocated to their training. Residents increase the absolute professional labor cost of caring for a patient. Overall TAT is slower with residents but the care delivered by residents after-hours is faster.

Financial Analysis of Pediatric Resident Physician Primary Care Longitudinal Outpatient Experience.

OBJECTIVE: To determine whether residency training represents a net positive or negative cost to academic medical centers, we analyzed the cost of a residency program and clinical productivity of residents and faculty in an outpatient primary care practice with or without residents. METHODS: Patient volume and revenue data (Current Procedural Terminology codes) from an academic primary care general pediatric clinic were evaluated for faculty clinics (faculty only) and resident teaching clinics (longitudinal outpatient experience [LOE]) with 1 to 4 residents per faculty. A detailed cost per resident was determined using a departmental financial model that included salary, benefits, faculty and administrative staff effort, nonpersonnel costs, and institutional graduate medical education support. RESULTS: The LOE clinics had a greater mean number of patient visits (11.6 vs 6.8) than faculty clinics per faculty member. In the LOE clinic, the number of patient visits per clinic was directly proportional to the number of residents per faculty. The cost for each resident was $250 per clinic ($112 per resident, $88 per medical assistant per resident, and $50 per room per resident). When factoring in clinic costs and faculty supervision time, the LOE clinics (average 3.5 residents with 1 supervising faculty) had greater average cost (+$687.00) and revenue (+$319.45) and lower operating margin (revenue minus cost, -$367.55) than the faculty clinics (1 faculty member). CONCLUSIONS: Pediatric resident LOE clinics had a greater average number of patient visits and revenue per faculty member but higher costs and lower operating margins than faculty clinics.

Dissecting Costs of CT Study: Application of TDABC (Time-driven Activity-based Costing) in a Tertiary Academic Center.

RATIONALE AND OBJECTIVES: The lack of understanding of the real costs (not charge) of delivering healthcare services poses tremendous challenges in the containment of healthcare costs. In this study, we applied an established cost accounting method, the time-driven activity-based costing (TDABC), to assess the costs of performing an abdomen and pelvis computed tomography (AP CT) in an academic radiology department and identified opportunities for improved efficiency in the delivery of this service. MATERIALS AND METHODS: The study was exempt from an institutional review board approval. TDABC utilizes process mapping tools from industrial engineering and activity-based costing. The process map outlines every step of discrete activity and duration of use of clinical resources, personnel, and equipment. By multiplying the cost per unit of capacity by the required task time for each step, and summing each component cost, the overall costs of AP CT is determined for patients in three settings, inpatient (IP), outpatient (OP), and emergency departments (ED). RESULTS: The component costs to deliver an AP CT study were as follows: radiologist interpretation: 40.1%; other personnel (scheduler, technologist, nurse, pharmacist, and transporter): 39.6%; materials: 13.9%; and space and equipment: 6.4%. The cost of performing CT was 13% higher for ED patients and 31% higher for inpatients (IP), as compared to that for OP. The difference in cost was mostly due to non-radiologist personnel costs. CONCLUSIONS: Approximately 80% of the direct costs of AP CT to the academic medical center are related to labor. Potential opportunities to reduce the costs include increasing the efficiency of utilization of CT, substituting lower cost resources when appropriate, and streamlining the ordering system to clarify medical necessity and clinical indications.

Embolization of iatrogenic uterine pseudoaneurysm.

Uterine artery pseudoaneurysms (UAPs) are rare vascular lesions that may be life threatening if not diagnosed and properly treated. The clinical presentation of UAPs includes a spectrum of symptoms that are often associated with other and more frequent gynecologic/obstetric pathologies, both with and without vaginal bleeding, and may span from postpartum hemorrhage to the absence of symptoms. We report cases of two patients with UAP, both of whom were diagnosed with ultrasonography and contrast-enhanced computed tomography and successfully treated with transcatheter embolization. The first patient presented delayed hypovolemic shock following surgery for endometriosis, whereas the second patient suffered from postpartum hemorrhage after cesarean section. Diagnosis of UAPs relies on noninvasive imaging; transcatheter arterial embolization is an effective treatment to control bleeding in both hemodynamically stable and unstable patients.

Process Improvement for Interinstitutional Research Contracting.

INTRODUCTION: Sponsored research increasingly requires multiinstitutional collaboration. However, research contracting procedures have become more complicated and time consuming. The perinatal research units of two colocated healthcare systems sought to improve their research contracting processes. METHODS: The Lean Process, a management practice that iteratively involves team members in root cause analyses and process improvement, was applied to the research contracting process, initially using Process Mapping and then developing Problem Solving Reports. RESULTS: Root cause analyses revealed that the longest delays were the individual contract legal negotiations. In addition, the "business entity" was the research support personnel of both healthcare systems whose "customers" were investigators attempting to conduct interinstitutional research. Development of mutually acceptable research contract templates and language, chain of custody templates, and process development and refinement formats decreased the Notice of Grant Award to Purchase Order time from a mean of 103.5 days in the year prior to Lean Process implementation to 45.8 days in the year after implementation (p = 0.004). CONCLUSIONS: The Lean Process can be applied to interinstitutional research contracting with significant improvement in contract implementation.

Correlation between US-PSV and 64-Row MDCTA with Advanced Vessel Analysis in the Quantification of 50-70% Carotid Artery Stenosis.

Purpose. To correlate ultrasonographic peak systolic velocity (US-PSV) and 64-row multidetector computed tomography angiography (MDCTA) with advanced vessel analysis (AVA) software in the quantification of 50-70% carotid artery stenosis. Materials and methods. 199 consecutive patients (247 arteries) with internal carotid artery (ICA) or third proximal bifurcation stenosis. Each patient was studied by duplex US (DUS) and 64-row MDCTA with AVA software. Results. DUS showed PSV measurements less than 125 cm/s in 51 carotid stenosis and a value greater than this in 196 arteries. 64-row MDCTA AVA software showed a grade of stenosis less than 50% in 42 carotid arteries while a greater 70% was found in 4 carotid arteries; then, carotid arteries with stenosis percentage between 50% and 70% were 201. Linear regression analysis showed a good linear correlation (r = 0.88) between MDCTA-AVA software percentage stenosis and PSV: between 50% grade of stenosis and PSV value corresponding to 133,6 cm/sec and between 70% stenosis and PSV value corresponding to 268 cm/sec. The sensitivity, specificity, positive predictive value(PPV), negative predictive value(NPV) of this analysis were 93%, 82%, 97%, 75%, respectively. Conclusion. Linear correlation between PSV data and grade of stenosis from 50% to 70% obtained with 64-row MDCTA AVA software. Main PSV value corresponding to 50% and 70% grade of stenosis at AVA analysis.

[Bodypackers syndrome. A case report and review of the literature]. / La sindrome "body packers". Caso clinico e revisione della letteratura.

INTRODUCTION: With the term Body packers we identify people who carry drugs hidden in their bodies especially on international flights. These event are constantly increasing all over the world. The accidental spontaneous opening of the drug packers is the major risk for patient's life, because the release cocaine inside the bowel can stir up the Body packers Syndrome. This eventuality is a medical surgical emergency that needs a wel timed diagnosis and a sudden treatment. CASE REPORT: We report a case of a 31 years old Caucasian woman, admitted from Rome International Airport to the nearest Emergency Unit and then moved to our Department because of suspected epilepsy hiding a diagnosis of Body packers Syndrome in acute phase. When the diagnosis was made, the woman was submitted to a colonoscopy and ciecotomy, and fifty-three packets were removed. In intensive care any complication occurred after surgery. CONCLUSION: The Body packing of drugs it's constantly a going problem. In Italy currently there aren't shared guide lines about the management of these patients. The international experience reports that in asymptomatic patients is enough a conservative treatment to help the spontaneous evacuation of packets but if the Body packers Syndrome is already present the best treatment is the surgical one. Quickness, accuracy and right use of radiology are the main factors to reach a correct diagnosis and to obtain a good result.

Ground-glass opacity: high-resolution computed tomography and 64-multi-slice computed tomography findings comparison.

OBJECTIVE: Comparative evaluation of ground-glass opacity using conventional high-resolution computed tomography technique and volumetric computed tomography by 64-row multi-slice scanner, verifying advantage of volumetric acquisition and post-processing technique allowed by 64-row CT scanner. METHODS: Thirty-four patients, in which was assessed ground-glass opacity pattern by previous high-resolution computed tomography during a clinical-radiological follow-up for their lung disease, were studied by means of 64-row multi-slice computed tomography. Comparative evaluation of image quality was done by both CT modalities. RESULTS: It was reported good inter-observer agreement (k value 0.78-0.90) in detection of ground-glass opacity with high-resolution computed tomography technique and volumetric Computed Tomography acquisition with moderate increasing of intra-observer agreement (k value 0.46) using volumetric computed tomography than high-resolution computed tomography. CONCLUSIONS: In our experience, volumetric computed tomography with 64-row scanner shows good accuracy in detection of ground-glass opacity, providing a better spatial and temporal resolution and advanced post-processing technique than high-resolution computed tomography.

Recanalization of the native artery in patients with bypass failure.

Our objective was to evaluate the possible role of endovascular recanalization of occluded native artery after a failed bypass graft in the case of either acute or chronic limb-threatening ischemia otherwise leading to amputation. In a single-center retrospective clinical analysis, from January 2004 to March 2007 we collected 31 consecutive high-surgical-risk patients (32 limbs) with critical limb ischemia following late ([30 days after surgery) failure of open surgery bypass graft reconstruction. All patients deemed unfit for surgery underwent tentative endovascular recanalization of the native occluded arterial tract. The mean follow-up period was 24 (range, 6-42) months. Technical success was achieved in 30 (93.7%) of 32 limbs. The cumulative primary assisted patency calculated by Kaplan-Meyer analysis was 92% and 88%, respectively, at 12 and 24 months. The limb salvage rate approached 90% at 30 months. In conclusion, our experience shows the feasibility of occluded native artery endovascular recanalization after a failed bypass graft, with optimal results in terms of midterm arterial patency and limb salvage. Our opinion is that successful recanalization of the arterial tract previously considered unsuitable for endovascular approach is allowed by improved competency and experience of vascular specialists, as well as the advances made in catheter and guidewire technology. This group of patients would previously have been relegated to repeat bypass grafts, with their inherently inferior patency and recognized added technical demands. We recognize previous surgical native artery disconnection and lack of pedal runoff to be the main cause of technical failure.