Long-Term Sustainability of a Quality Initiative Program on Transfusion Rates in Total Joint Arthroplasty: A Follow-Up Study.

BACKGROUND: There are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase awareness of the American Association of Blood Banks' transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program. METHODS: We reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study. RESULTS: We identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period. CONCLUSION: Application of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.

The Physician as the Provider at Risk: Rolling the Dice.

BACKGROUND: There is significant need for physician innovation and leadership in health care as we adapt to bundled payment models of health care delivery. METHODS: We engaged a collective of 16 different private company orthopedic physician groups to apply to become episode initiators under BPCI models 2 and 3. The application process itself provided historical cost data, enabling each group to independently decide whether or not to proceed with the BPCI initiative. RESULTS: Ultimately, 7 of the private orthopedic groups decided to continue with the BPCI initiative. At the first quarter reconciliation, savings ranged from 9% to 17% across the participating groups. CONCLUSION: The more leadership surgeons provide in value base care provision, the more our patients and health care system will benefit from optimization of care delivery.

Bundled Payments: Our Experience at an Academic Medical Center.

BACKGROUND: The landscape of health care is transitioning from a fee-for-service model to value-based purchasing. METHODS: We developed evidence-based clinical pathways and risk stratification measures to effectively implement the Bundled Payments for Care Improvement model of value-based purchasing. RESULTS: We decreased patients' length of stay, discharge to inpatient facilities, and cost of an episode of patient care. CONCLUSION: The bundled care payment initiative has been successfully implemented for Diagnosis Related Groups 469 and 470, delivering high-quality patient care at a reduced price.

Residues in the N-terminal domain of MutL required for mismatch repair in Bacillus subtilis.

Mismatch repair is a highly conserved pathway responsible for correcting DNA polymerase errors incorporated during genome replication. MutL is a mismatch repair protein known to coordinate several steps in repair that ultimately results in strand removal following mismatch identification by MutS. MutL homologs from bacteria to humans contain well-conserved N-terminal and C-terminal domains. To understand the contribution of the MutL N-terminal domain to mismatch repair, we analyzed 14 different missense mutations in Bacillus subtilis MutL that were conserved with missense mutations identified in the human MutL homolog MLH1 from patients with hereditary nonpolyposis colorectal cancer (HNPCC). We characterized missense mutations in or near motifs important for ATP binding, ATPase activity, and DNA binding. We found that 13 of the 14 missense mutations conferred a substantial defect to mismatch repair in vivo, while three mutant alleles showed a dominant negative increase in mutation frequency to wild-type mutL. We performed immunoblot analysis to determine the relative stability of each mutant protein in vivo and found that, although most accumulated, several mutant proteins failed to maintain wild-type levels, suggesting defects in protein stability. The remaining missense mutations located in areas of the protein important for DNA binding, ATP binding, and ATPase activities of MutL compromised repair in vivo. Our results define functional residues in the N-terminal domain of B. subtilis MutL that are critical for mismatch repair in vivo.