Changes in resuscitation and end-of-life documentation in older patients' clinical case notes: A comparison of 2011 and 2017 practice.

OBJECTIVE: To compare 2011 and 2017 documentation of resuscitation decisions in older patients, including the frequency and clarity of documentation. METHODS: The clinical case notes of 130 patients aged 70 years and over were examined to identify how resuscitation decisions are discussed and documented at a major teaching hospital. Results were compared to 2011 data. RESULTS: The proportion of patients with a documented order significantly increased, from 34 to 63%, with a concurrent increased number of patients identified as Not For Cardiopulmonary Resuscitation (Not for CPR). The standardised documentation has also improved rates of documented discussion, legibility and identification of the involved doctor. CONCLUSION: The Resuscitation Plan 7-Step Pathway has markedly improved the frequency of documented discussion, the rate of recorded Not For CPR status and clarity of documentation. There is scope for improvement as this policy is embraced across South Australia.

Comparison of knowledge to antimicrobial stewardship institution policies targeting Staphylococcus aureus bacteremia and candidemia between medical doctors and pharmacists in an academic teaching hospital in Japan.

Staphylococcus aureus bacteremia (SAB) and candidemia have significant impacts on mortality. Both have important implications for antimicrobial stewardship programs (ASPs). However, there are limited data regarding who should be educated and what components should be considered for the ASPs. Hence, we investigated the possibility of the key elements for implications of SAB and candidemia managements for ASPs. We conducted a cross-sectional study on the knowledge of antimicrobial stewardship institution policies targeting SAB and candidemia for all medical doctors (MDs) and pharmacists to using an E-learning system. To compare the differences in proportions of appropriate knowledge between junior residents and other MDs, and all MDs and pharmacists, we performed bivariate analyses using Fisher's exact test and χ2 test with odds ratios (ORs) with 95% confidence intervals (CIs). In total, all 395 MDs (71 junior residents, 137 senior residents and fellows, and 187 attending doctors) and all 63 pharmacists including 4 antimicrobial stewardship teams pharmacists responded to survey. MDs other than junior residents responded significantly inappropriately to the questions on the candidemia than junior residents (OR = 0.6, 95% CI: 0.4-1.0). Pharmacists had a significantly lower proportion of appropriate knowledge to the candidemia than MDs (OR = 0.4, 95% CI: 0.2-0.8). The major pitfall was failure to consult an ophthalmologist (82.5%). Next step, we will conduct educational intervention about institution policies, and evaluate whether to improve the knowledges and practices by pre-post test and chart review.

Epidemiology of malpractice claims in the orthopedic and trauma surgery department of a French teaching hospital: A 10-year retrospective study.

INTRODUCTION: Orthopedic and trauma surgery is the specialty for which claims for compensation are most often filed. Little data exists on the subject in France, especially in a teaching hospital. We conducted a retrospective study aimed at (1) identifying the epidemiological characteristics of patients filing claims against the orthopedic surgery and traumatology department of a teaching hospital in France, (2) analyzing the surgical procedures involved, the type of legal proceedings, and the financial consequences. HYPOTHESIS: The epidemiological profile of proceedings seeking damages in France is consistent with the data from European and American studies. MATERIALS AND METHODS: An observational, retrospective, single-center study of all claims for damages between 2007 and 2016 involving the orthopedic and trauma surgery department of a teaching hospital was carried out. Patients' epidemiological data, the surgical procedure, type of legal proceeding, and financial consequences were analyzed. RESULTS: Of the 51,582 surgical procedures performed, 71 claims (0.0014%) were analyzed (i.e., 1/726 procedures). A significant increase in the number of cases (p=0.040) was found over a 10-year period. Of these, 36/71 (53.7%) were submitted to the French regional conciliation and compensation commission (CRCI), 23/71 (32.8%) were filed with the administrative court, and 12/71 (13.4%) were submitted for an amicable settlement. The most common reason for which patients filed claims was hospital-acquired infections, with 36/71 (50.7%) cases. Twenty-nine complaints (40.8%) resulted in monetary damages being awarded to the patient, with an average award of € 28,301 (€ 2,400-299,508). Damage awards were significantly higher (p<0.05) for cases involving surgery on a lower limb than those involving an upper limb. CONCLUSION: Claims against orthopedic surgeons have been increasing significantly over the last 10 years. Although rare, they represent a significant cost to society. Hospital-acquired infections are the main reason for disputes in our specialization. LEVEL OF EVIDENCE: IV, retrospective study.

Litigation in orthopedic surgery: What can we do to prevent it? Systematic analysis of 126 legal actions involving four university hospitals in France.

INTRODUCTION: Orthopedic surgery produces 20% of medical malpractice claims. However only a few studies have examined the reasons for and consequences of these disputes, and they have usually been limited to a single hospital. This led us to perform a retrospective analysis of the claims at four teaching hospitals in northwestern France. The goals were (1) to describe the circumstances that led to these claims and recommend ways to prevent them, and (2) to describe the conduct of the proceedings and their financial and social outcomes. HYPOTHESIS: A systematic analysis of litigation cases will provide accurate information on the circumstances leading to these claims. METHODS: The study included 126 disputes settled between 2000 and 2010 and related to orthopedic or trauma care given at one of four teaching hospitals in northwestern France. The method of recourse, grounds of the complaint, type of surgical procedure, expert findings and amount of the award were systematically analyzed. RESULTS: Of these 126 cases, 54 (43%) of them were submitted to the French CRCI (regional conciliation and compensation commission), 48 (39%) to the French administrative courts and 51 (41%) were settled amicably. Multiple methods of recourse were used in 21% of cases (n=27/126). The average length of administrative court proceedings was 36.7±27 months [4-102], which was significantly longer than the CRCI proceedings (22.7±17.9 months [3-80]) or out-of-court settlement (23.7±21.5 months [0-52]) (p<0.0001). Damages were sought for medical error or treatment-related risk in 67.5% of the complaints (n=85/126), and for failure to inform in 15.8% of cases (n=20/126). There was a suspected surgical site infection in 79.3% of cases (n=100/126). There were multiple grounds for complaint in 68.3% of cases (n=86/126). Poor communication between the physician and patient was identified in 26.2% of cases (n=33/126). Damages were awarded in 25% of cases (n=31/126), with an average award of €58,303±€91,601 [0-357,970]. CONCLUSION: The primary grounds for legal action are infection-related complications combined with a deterioration in the doctor-patient relationship. Disputes could be prevented by continuing efforts to combat hospital-acquired infections and providing better communications training. LEVEL OF PROOF: IV (retrospective study).

Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; quality reporting requirements for specific providers; reasonable compensation equivalents for physician services in excluded hospitals and certain teaching hospitals; provider administrative appeals and judicial review; enforcement provisions for organ transplant centers; and electronic health record (EHR) incentive program. Final rule.

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Protecting Access to Medicare Act of 2014, and other legislation. These changes are applicable to discharges occurring on or after October 1, 2014, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits are effective for cost reporting periods beginning on or after October 1, 2014. We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014. In addition, we discuss our proposals on the interruption of stay policy for LTCHs and on retiring the "5 percent" payment adjustment for collocated LTCHs. While many of the statutory mandates of the Pathway for SGR Reform Act apply to discharges occurring on or after October 1, 2014, others will not begin to apply until 2016 and beyond. In addition, we are making a number of changes relating to direct graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or revising requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. In addition, we are making technical corrections to the regulations governing provider administrative appeals and judicial review; updating the reasonable compensation equivalent (RCE) limits, and revising the methodology for determining such limits, for services furnished by physicians to certain teaching hospitals and hospitals excluded from the IPPS; making regulatory revisions to broaden the specified uses of Medicare Advantage (MA) risk adjustment data and to specify the conditions for release of such risk adjustment data to entities outside of CMS; and making changes to the enforcement procedures for organ transplant centers. We are aligning the reporting and submission timelines for clinical quality measures for the Medicare HER Incentive Program for eligible hospitals and critical access hospitals (CAHs) with the reporting and submission timelines for the Hospital IQR Program. In addition, we provide guidance and clarification of certain policies for eligible hospitals and CAHs such as our policy for reporting zero denominators on clinical quality measures and our policy for case threshold exemptions. In this document, we are finalizing two interim final rules with comment period relating to criteria for disproportionate share hospital uncompensated care payments and extensions of temporary changes to the payment adjustment for low-volume hospitals and of the Medicare-Dependent, Small Rural Hospital (MDH) Program.

Health policy basics: the Physician Payment Sunshine Act and the Open Payments program.

The Open Payments program is a government initiative through which financial relationships between applicable industries and covered physicians or teaching hospitals are publicly reported. The program does not assess these relationships but rather facilitates transparency and allows stakeholders to use this information in making informed decisions. This article outlines the program and its goals, reviews its requirements and when they go into effect, examines the implications for physicians and their patients, and makes recommendations to help physicians and teaching hospitals prepare for its implementation.

The effect of duty hour regulations on outcomes of neurological surgery in training hospitals in the United States: duty hour regulations and patient outcomes.

OBJECT: The effects of sleep deprivation on performance have been well documented and have led to changes in duty hour regulation. New York State implemented stricter duty hours in 1989 after sleep deprivation among residents was thought to have contributed to a patient's death. The goal of this study was to determine if increased regulation of resident duty hours results in measurable changes in patient outcomes. METHODS: Using the Nationwide Inpatient Sample (NIS), patients undergoing neurosurgical procedures at hospitals with neurosurgery training programs were identified and screened for in-hospital complications, in-hospital procedures, discharge disposition, and in-hospital mortality. Comparisons in the above outcomes were made between New York hospitals and non-New York hospitals before and after the Accreditation Council for Graduate Medical Education (ACGME) regulations were put into effect in 2003. RESULTS: Analysis of discharge disposition demonstrated that 81.9% of patients in the New York group 2000-2002 were discharged to home compared with 84.1% in the non-New York group 2000-2002 (p = 0.6, adjusted multivariate analysis). In-hospital mortality did not significantly differ (p = 0.7). After the regulations were implemented, there was a nonsignificant decrease in patients discharged to home in the non-New York group: 84.1% of patients in the 2000-2002 group compared with 81.5% in the 2004-2006 group (p = 0.6). In-hospital mortality did not significantly change (p = 0.9). In New York there was no significant change in patient outcomes with the implementation of the regulations; 81.9% of patients in the 2000-2002 group were discharged to home compared with 78.0% in the 2004-2006 group (p = 0.3). In-hospital mortality did not significantly change (p = 0.4). After the regulations were in place, analysis of discharge disposition demonstrated that 81.5% of patients in the non-New York group 2004-2006 were discharged to home compared with 78.0% in the New York group 2004-2006 (p = 0.01). In-hospital mortality was not significantly different (p = 0.3). CONCLUSIONS: Regulation of resident duty hours has not resulted in significant changes in outcomes among neurosurgical patients.

A comprehensive obstetric patient safety program reduces liability claims and payments.

Begun in 2003, the Yale-New Haven Hospital comprehensive obstetric safety program consisted of measures to standardize care, improve teamwork and communication, and optimize oversight and quality review. Prior publications have demonstrated improvements in adverse outcomes and safety culture associated with this program. In this analysis, we aimed to assess the impact of this program on liability claims and payments at a single institution. We reviewed liability claims at a single, tertiary-care, teaching hospital for two 5-year periods (1998-2002 and 2003-2007), before and after implementing the safety program. Connecticut statute of limitations for professional malpractice is 36 months from injury. Claims/events were classified by event-year and payments were adjusted for inflation. We analyzed data for trends as well as differences between periods before and after implementation. Forty-four claims were filed during the 10-year study period. Annual cases per 1000 deliveries decreased significantly over the study period (P < .01). Claims (30 vs 14) and payments ($50.7 million vs $2.9 million) decreased in the 5-years after program inception. Compared with before program inception, median annual claims dropped from 1.31 to 0.64 (P = .02), and median annual payments per 1000 deliveries decreased from $1,141,638 to $63,470 (P < .01). Even estimating the monetary awards for the 2 remaining open cases using the median payments for the surrounding 5 years, a reduction in the median monetary amount per case resulting in payment to the claimant was also statistically significant ($632,262 vs $216,815, P = .046). In contrast, the Connecticut insurance market experienced a stable number of claims and markedly increased cost per claim during the same period. We conclude that an obstetric safety initiative can improve liability claims exposure and reduce liability payments.

An analytical framework for assessing drug and therapeutics committee structure and work processes in tertiary Brazilian hospitals.

University teaching hospitals usually provide tertiary care and are subject to early adoption of new technologies, which may compromise healthcare systems when uncritically adopted. Knowledge on the decision-making process - drug selection by drug selection committees or DTCs - is crucial to improve the quality of care. There are no models for studying the selection of drugs in Brazilian healthcare services. This study aims to discuss DTC structure and the processes regarding adoption of medicines in tertiary university hospitals in Brazil and to propose an analytical structure for providing direction for the future. State of the art content regarding drug selection processes and DTC procedures was reviewed in three databases. Information on the medicine selection process in a Brazilian gold standard teaching hospital was collected through observations and a review of existing procedures. A structured discussion on medicine selection and DTC procedures in tertiary hospitals ensued. This discussion resulted in findings that were organized in three dimensions, composing an analytical framework for the application in tertiary Brazilian hospitals (i) motivations for the adoption of drugs; (ii) necessary structural and organizational aspects for decision-making; and (iii) criteria and methods employed by the decision-making process. We believe that the suggested framework is compatible with tertiary Brazilian hospitals, because a gold standard in the country was able to conduct all its procedures in the light of WHO and international recommendations. We hope to contribute in producing knowledge which may hopefully be adopted in tertiary hospitals across Brazil.

Shadows amid sunshine: regulating financial conflicts in medical research.

Under brand new rules implementing the Physician Payments Sunshine Act (Sunshine Act), a wide range of financial relationships, including many research-related payments, between industry, physicians, and teaching hospitals will be publicly disclosed through comprehensive, standardized payment reporting. The Sunshine Act represents the latest in a series of regulatory attempts to address financial conflicts of interest that may bias research conduct and threaten subject safety. This article summarizes the major aspects of the Sunshine Act affecting medical research, how it interacts with existing laws and policies, and identifies important unresolved issues and implementation challenges that still lie ahead with the rollout of the legislation underway. The Sunshine Act primarily depends on disclosure as a regulatory tool. As such, its long-term impact remains open to question. Disclosure in this context may have limited utility given, among other reasons, uncertainty about who the intended recipients are and their ability to use the information effectively. Apart from the insufficiency of transparency, this article further explores how proportionality, fairness, and accountability considerations make optimal regulation of financial conflicts in medical research quite challenging.

Control costs, enhance quality, and increase revenue in three top general public hospitals in Beijing, China.

BACKGROUND: With market-oriented economic and health-care reform, public hospitals in China have received unprecedented pressures from governmental regulations, public opinions, and financial demands. To adapt the changing environment and keep pace of modernizing healthcare delivery system, public hospitals in China are expanding clinical services and improving delivery efficiency, while controlling costs. Recent experiences are valuable lessons for guiding future healthcare reform. Here we carefully study three teaching hospitals, to exemplify their experiences during this period. METHODS: We performed a systematic analysis on hospitalization costs, health-care quality and delivery efficiencies from 2006 to 2010 in three teaching hospitals in Beijing, China. The analysis measured temporal changes of inpatient cost per stay (CPS), cost per day (CPD), inpatient mortality rate (IMR), and length of stay (LOS), using a generalized additive model. FINDINGS: There were 651,559 hospitalizations during the period analyzed. Averaged CPS was stable over time, while averaged CPD steadily increased by 41.7% (P<0.001), from CNY 1,531 in 2006 to CNY 2,169 in 2010. The increasing CPD seemed synchronous with the steady rising of the national annual income per capita. Surgical cost was the main contributor to the temporal change of CPD, while medicine and examination costs tended to be stable over time. From 2006 and 2010, IMR decreased by 36%, while LOS reduced by 25%. Increasing hospitalizations with higher costs, along with an overall stable CPS, reduced IMR, and shorter LOS, appear to be the major characteristics of these three hospitals at present. INTERPRETATIONS: These three teaching hospitals have gained some success in controlling costs, improving cares, adopting modern medical technologies, and increasing hospital revenues. Effective hospital governance and physicians' professional capacity plus government regulations and supervisions may have played a role. However, purely market-oriented health-care reform could also misguide future healthcare reform.

The physician payments sunshine act: what the average radiologist and manager need to know.

The Physician Payments Sunshine Act (PPSA) was enacted in 2010 and requires applicable manufacturers of medical devices, drugs, biological material, or medical supplies to report payments or transfers of value that are provided to physicians or teaching hospitals. PPSA has value in creating greater transparency in the financial relationships between industry, physicians, and teaching hospitals, and in potentially reducing problematic conflicts of interest. PPSA requires that this data be published, in searchable form, on a public website. CMS has delayed the reporting under PPSA until after January 1, 2013, and has yet to issue its final rules for PPSA; however, Physician Payments data already exist in a publically searchable database. It is important to realize that names of individuals may appear in the PPSA public database, even if those individuals did not actually receive a transfer of value. As with all broad-stroke legislation, consequences not anticipated or not considered sufficiently important for our government leaders may well present a problem for individuals. It behooves all physicians and healthcare managers to carefully follow the CMS PPSA regulations. In advance of meeting or interacting with any PPSA-applicable manufacturer, obtain a clear and mutual understanding regarding what reportable value, if any, will be prepared for and provided by the applicable manufacturer. In this, as in all situations in which government regulations are at play, "knowledge is strength."