Travel Time Influences Readmission Risk: Geospatial Mapping of Surgical Readmissions

2017 ◽  
Vol 83 (6) ◽  
pp. 573-582 ◽  
Author(s):  
Florence E. Turrentine ◽  
Patrick J. Buckley ◽  
Min-Woong Sohn ◽  
Michael D. Williams
Keyword(s):  
Travel Time ◽  
General Surgery ◽  
Rural Areas ◽  
Graphical Representation ◽  
Discharge Planning ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Care Organization ◽  
Improvement Program ◽  
The Impact

The University of Virginia (UVA) has recently become an Accountable Care Organization (ACO), intensifying efforts to provide better care for individuals. UVA's ACO population resides across the entire Commonwealth, with a large percentage of patients living in rural areas. To provide better health for this population, the central tenet of the ACO mission, we identified geographic risk factors influencing hospital readmission. We analyzed the relationship between the distance of patients’ residence to the nearest hospital and 30-day readmission in general surgery patients. A retrospective chart review using January 1, 2011 through October 31, 2013 American College of Surgeons National Surgical Quality Improvement Program data for general surgery procedures was conducted. ArcGIS mapped street addresses provided graphical representation of distance between surgical population and the nearest hospital. We analyzed the impact on readmission, of time traveled, insurance status, and median household income. Each increase of 10 minutes in travel time from the patient's residence to the nearest hospital, not just UVA, was associated with a 9 per cent increase in the probability of readmission after adjusting for patient characteristics, preoperative comorbidities, laboratory values, and postoperative complications before or after discharge (odds ratio = 1.09; 95% confidence interval = 1.01–1.17; P = 0.019). Unlike urban hospitals, those serving rural populations may be at particular risk of postsurgical readmissions. Patients living furthest from a hospital facility are most at risk for readmission after a general surgery procedure. This vulnerable population may benefit most from comprehensive discharge planning.

scholarly journals Diagnostic Disparity of Previous and Revised American Thoracic Society Guidelines for Idiopathic Pulmonary Fibrosis

2015 ◽  
Vol 22 (2) ◽  
pp. 86-90 ◽  
Author(s):  
Lee Fidler ◽  
Shane Shapera ◽  
Shikha Mittoo ◽  
Theodore K Marras
Keyword(s):  
Idiopathic Pulmonary Fibrosis ◽  
Pulmonary Fibrosis ◽  
Diagnostic Criteria ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Disease Diagnosis ◽  
American Thoracic Society ◽  
Patient Classification ◽  
High Resolution Computed Tomography ◽  
The Impact

BACKGROUND: A revised guideline for the diagnosis of idiopathic pulmonary fibrosis (IPF) was formulated by the American Thoracic Society (ATS) in 2011 to improve disease diagnosis and provide a simplified algorithm for clinicians. The impact of these revisions on patient classification, however, remain unclear.OBJECTIVE: To examine the concordance between diagnostic guidelines to understand how revisions impact patient classification.METHODS: A cohort of 54 patients with either suspected IPF or a working diagnosis of IPF was evaluated in a retrospective chart review, in which patient data were examined according to previous and revised ATS guidelines. Patient characteristics influencing the fulfillment of diagnostic criteria were compared using one-way ANOVA and χ2tests.RESULTS: Revised and previous guideline criteria for IPF were met in 78% and 83% of patients, respectively. Revised guidelines modified a classification based on previous guidelines in 28% of cases. Fifteen percent of patients meeting previous ATS guidelines failed to meet revised criteria due to a lack of honeycombing on high-resolution computed tomography and the absence of a surgical lung biopsy. Patients failing to meet previous and revised diagnostic criteria for IPF were younger.CONCLUSION: The revised guidelines for the diagnosis of IPF classify a substantial proportion of patients differently than the previous guidelines.

scholarly journals PCR Cycle-Threshold-Derived Toxin Identifies Patients at Low-Risk for Complications of C. difficile Infection Who Do Not Require Treatment

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S395-S395 ◽  
Author(s):  
Matthew Hitchcock ◽  
Marisa Holubar ◽  
Lucy Tompkins ◽  
Niaz Banaei
Keyword(s):  
Treated Patient ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Low Risk ◽  
Review Time ◽  
Cycle Threshold ◽  
Crude Mortality ◽  
Chi Squared ◽  
High Negative Predictive Value ◽  
The Impact

Abstract Background Literature suggests that toxin detection differentiates those who require treatment for C. difficile infection (CDI) from those who do not. In-house studies have shown that free toxin can be predicted with high negative predictive value at a predefined cycle threshold (CT) using Xpert tcdB PCR (Cepheid, Sunnyvale, CA). In October 2016, CT-toxin was added to the PCR result and a comment recommends against CDI therapy if CT-toxin is negative (CTtox-). Here we evaluate the effect of this reporting on treatment rates and outcomes of CTtox- patients. Methods Patients tested from October 2016 to Apr. 2017 with a positive Xpert PCR and CTtox- result were included. Clinical data were collected by retrospective chart review and analyzed with the Chi squared and Student t-tests using SPSS. Due to multiple comparisons, α=0.01. Results Of 1516 Xpert PCR tests, 248 (16.4%) were positive and 98 (39.5%) were CTtox-. Of these, 54 (55.7%) were treated. Patient characteristics and data at testing are shown below. There were no cases of CDI-related septic shock or toxic megacolon on review. Time to diarrhea resolution was significantly shorter in untreated patients and there was no difference in crude mortality or later onset of CTtox+ CDI. Conclusion This study demonstrates the impact of stand-alone PCR assay with toxin prediction on reducing CDI therapy rates and provides further evidence that PCR+/toxin- patients are at low risk for CDI-related complications and do not require treatment, though more data is needed in transplant populations. Disclosures N. Banaei, Cepheid: Collaborator, Research Contractor and Scientific Advisor, honorarium for advisory role and Research support

Novel Technique to Reduce the Incidence of SSI after Colorectal Surgery

2019 ◽  
Vol 85 (7) ◽  
pp. 695-699
Author(s):  
Danielle Kay ◽  
Avinash Bhakta ◽  
Jitesh A. Patel ◽  
Jon S. Hourigan ◽  
Shyanie Kumar ◽  
...  
Keyword(s):  
Health Care Cost ◽  
Demographic Data ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
University Of Kentucky ◽  
Significant Difference ◽  
Acs Nsqip Database ◽  
The University ◽  
The Impact ◽  
Wound Class

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure ( P = 0.037) and a higher wound class ( P < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure ( P = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI ( P = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.

scholarly journals The Impact of Frailty on Postoperative Cardiopulmonary Complications in the Emergency General Surgery Population

2018 ◽  
Vol 04 (02) ◽  
pp. e66-e77 ◽  
Author(s):  
Serra Akyar ◽  
Sarah Armenia ◽  
Parita Ratnani ◽  
Aziz Merchant
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Arrest ◽  
General Surgery ◽  
Emergency General Surgery ◽  
Improvement Program ◽  
Prolonged Ventilation ◽  
Cardiopulmonary Complications ◽  
Postoperative Cardiopulmonary Complications ◽  
The Impact ◽  
Complications And Mortality

Background The burden of frail patients undergoing emergency general surgery (EGS) is increasing rapidly and this population is particularly susceptible to postoperative cardiopulmonary complications and mortality. We aimed to determine the association between frailty, as defined by the previously described modified frailty index (mFI), and postoperative respiratory complications (unplanned reintubation, pneumonia, and prolonged ventilation), cardiac complications (myocardial infarction and cardiac arrest), and mortality. We also sought to identify the most significant determinants of frailty in the highest risk patients based on the specific variables comprising the mFI. Methods We performed a retrospective observational analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database. Files from 2005 to 2015 identified 132,765 inpatients who underwent EGS. mFI scores were calculated for each patient. The effect of increasing frailty on unplanned reintubation, pneumonia, prolonged ventilation, myocardial infarction, cardiac arrest, and mortality was evaluated using bivariate analysis. Multivariable logistic regression was used to compare mFI with additional predictor variables including race, gender, physical status as defined by the American Society of Anesthesiologists, disseminated cancer, renal failure, smoking status, sepsis, wound presence/classification, dyspnea, and previous ventilator dependence. Results Unplanned reintubation, pneumonia, prolonged ventilation, myocardial infarction, cardiac arrest, and mortality were significantly associated with frailty, and the odds of each postoperative complication increased with increasing mFI score. Of the frailest patients (mFI ≥3) that experienced cardiopulmonary complications or mortality, the variables of the mFI that contributed most to frailty were hypertension requiring medication and functional status before surgery. Conclusions A higher mFI score is associated with increased odds of postoperative cardiopulmonary complications and mortality in the EGS population. Specific variables of the mFI can also provide valuable information for assessing odds in the frailest patients undergoing EGS.

The Impact of Income on Emergency General Surgery Outcomes in Urban and Rural Areas

2020 ◽  
Vol 245 ◽  
pp. 629-635 ◽  
Author(s):  
Elzerie de Jager ◽  
Muhammad Ali Chaudhary ◽  
Fatima Rahim ◽  
Molly P. Jarman ◽  
Tarsicio Uribe-Leitz ◽  
...  
Keyword(s):  
General Surgery ◽  
Rural Areas ◽  
Emergency General Surgery ◽  
Surgery Outcomes ◽  
Urban And Rural Areas ◽  
The Impact

Predictors of toxicity to concurrent chemoradiation (CRT) in patients (pts) with locally advanced head and neck squamous cell cancer (HNSCC)

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 16540-16540
Author(s):  
R. Yelamanchili ◽  
S. Hotte ◽  
J. Julian ◽  
J. Wright
Keyword(s):  
Alcohol Intake ◽  
Cell Cancer ◽  
Locally Advanced ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Cancer Center ◽  
Alcohol Abusers ◽  
Heavy Alcohol ◽  
Significant Difference ◽  
The Impact

16540 Background: A number of studies have evaluated the impact of prognostic factors on survival but very few have studied their role as determinants of toxicity, especially outside of the context of clinical trials. We set out to identify patient characteristics that are likely to predict toxicity to chemotherapy (CT) with daily cisplatin 6mg/m2 and radiation therapy (RT) in pts with locally advanced HNSCC. Methods: Retrospective chart review of above pts at the Juravinski Cancer Center from 2000 through 2004. A number of pt characteristics were analysed. Toxicity outcomes evaluated were completion of CT and of RT, rise in serum Cr , hematologic suppression, need for extra hydration, and need for extra antiemetics. Results: The charts of 108 pts were reviewed. Median follow-up was 36 months. Five year projected OS and PFS were 78% and 57% in our study compared to 53% and 47% in a published EORTC trial (NEJM, 2004). Median duration of PFS was 64 months in our study compared to 55 months in the EORTC trial. Median OS was not reached in our study. Nineteen percent completed CT and 81% completed RT, 17% had full course of CRT. Thirty-nine percent required extra hydration and 50% required extra antiemetics. Twenty four percent had elevated creatinine levels and 20.4% had hematologic suppression. Logistic regression was used to search for significant correlations between pt characteristics and outcomes. Pts with occasional alcohol intake were more likely to complete RT than heavy alcohol abusers (OR 8.9; P 0.04). Pts with occasional alcohol intake were more likely to get extra hydration than heavy alcohol abusers (OR 5.1; P 0.008).Hematologic suppression was more likely with increasing age (OR 1.08;P 0.015).No significant difference in toxicity outcomes was observed between males and females. Conclusions: This review demonstrated that CRT with daily cisplatin is associated with significant toxicity and most pts are unable to receive full treatment . A number of pt variables might predict increased susceptibility to toxicity. This should be validated in a prospective study. Median PFS in our series appear to be at least as good as previously published reports of CRT using daily cisplatin as well as dose schedules but toxicity does not appear greatly reduced. No significant financial relationships to disclose.

scholarly journals Optimizing Locations of Primary Schools in Rural Areas of China

Complexity ◽  
2021 ◽  
Vol 2021 ◽  
pp. 1-13
Author(s):  
Yulong Chen
Keyword(s):  
Travel Time ◽  
Rural Areas ◽  
Primary Schools ◽  
Simulated Annealing Algorithm ◽  
Programming Model ◽  
Transportation Network ◽  
Mixed Integer ◽  
Practical Case ◽  
Traffic Network ◽  
The Impact

Scientific location selection of schools is an important way to optimize the allocation of educational resources, improve the efficiency of operating schools, and realize the balanced development of education, especially in rural areas. Many studies have considered the location of schools, but most have omitted the impact of transportation network conditions and the time cost differences caused by different travel speeds under different road conditions. The object of this study is to minimize the total transportation costs for students, construction costs for new schools, and the construction and upgrading costs for roads on a traffic network with travel time uncertainty indicated by different travel time scenarios. A mixed-integer programming model for this problem was proposed. Furthermore, a hybrid simulated annealing algorithm was used to solve the problem. Finally, a practical case study was used to illustrate the application of the proposed mathematical model. The results showed that the traffic network has an important influence on the optimization location of rural schools, and the improvement of traffic network conditions can greatly reduce the time required for students to travel to school.

A PROPOSED EVALUATION PLAN TO ASSESS THE IMPACT OF A YOUTH DEVELOPMENT PROGRAMME FACILITATED BY THE STATE INFORMATION TECHNOLOGY AGENCY (SITA) IN RURAL SOUTH AFRICA

2017 ◽  
Vol 14 (1) ◽  
pp. 174-181
Author(s):  
Maura Mbunyuza-deHeer Menlah
Keyword(s):  
Information Technology ◽  
Youth Development ◽  
Rural Areas ◽  
Secondary Data ◽  
The State ◽  
State Information ◽  
Evaluation Plan ◽  
Lessons Learnt ◽  
Slow Development ◽  
The Impact

This article reports on a proposed evaluation plan that has been developed to assess the work done by the State Information Technology Agency (SITA). The SITA programme was implemented in response to the South African government’s call to improve the lives of the populations in some rural areas through technology. The programme was meant to address slow development in  rural  areas  that  lack  technological  innovations  and  advances.  In  the proposed evaluation plan a review is made of secondary data, deciding how strategic priorities are to be determined, as well as analysis of the rural context environment. The researcher gives an account of how the evaluation strategies are to be piloted and rolled out thereafter. Lessons learnt are recorded and reported upon. A proposed evaluation plan will be developed, based on the lessons learnt in line with the objectives of the project.

The Institute for Healthcare Improvement–NeuroPoint Alliance collaboration to decrease length of stay and readmission after lumbar spine fusion: using national registries to design quality improvement protocols

2020 ◽  
Vol 33 (6) ◽  
pp. 812-821
Author(s):  
Scott L. Zuckerman ◽  
Clinton J. Devin ◽  
Vincent Rossi ◽  
Silky Chotai ◽  
E. Hunter Dyer ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Length Of Stay ◽  
Discharge Planning ◽  
Lumbar Fusion ◽  
Nonparametric Tests ◽  
Learning System ◽  
Design Quality ◽  
Implementation Phase ◽  
Healthcare Improvement ◽  
The Impact

OBJECTIVENational databases collect large amounts of clinical information, yet application of these data can be challenging. The authors present the NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) program as a novel attempt to create a quality improvement (QI) tool informed through registry data to improve the quality of care delivered. Reducing the length of stay (LOS) and readmission after elective lumbar fusion was chosen as the pilot module.METHODSThe NPA-IHI program prospectively enrolled patients undergoing elective 1- to 3-level lumbar fusions across 8 institutions. A three-pronged approach was taken that included the following phases: 1) Research Phase, 2) Development Phase, and 3) Implementation Phase. Primary outcomes were LOS and readmission. From January to June 2017, a learning system was created utilizing monthly conference calls, weekly data submission, and continuous refinement of the proposed QI tool. Nonparametric tests were used to assess the impact of the QI intervention.RESULTSThe novel QI tool included the following three areas of intervention: 1) preoperative discharge assessment (location, date, and instructions), 2) inpatient changes (LOS rounding checklist, daily huddle, and pain assessments), and 3) postdischarge calls (pain, primary care follow-up, and satisfaction). A total of 209 patients were enrolled, and the most common procedure was a posterior laminectomy/fusion (60.2%). Seven patients (3.3%) were readmitted during the study period. Preoperative discharge planning was completed for 129 patients (61.7%). A shorter median LOS was seen in those with a known preoperative discharge date (67 vs 80 hours, p = 0.018) and clear discharge instructions (71 vs 81 hours, p = 0.030). Patients with a known preoperative discharge plan also reported significantly increased satisfaction (8.0 vs 7.0, p = 0.028), and patients with increased discharge readiness (scale 0–10) also reported higher satisfaction (r = 0.474, p < 0.001). Those receiving postdischarge calls (76%) had a significantly shorter LOS than those without postdischarge calls (75 vs 99 hours, p = 0.020), although no significant relationship was seen between postdischarge calls and readmission (p = 0.342).CONCLUSIONSThe NPA-IHI program showed that preoperative discharge planning and postdischarge calls have the potential to reduce LOS and improve satisfaction after elective lumbar fusion. It is our hope that neurosurgical providers can recognize how registries can be used to both develop and implement a QI tool and appreciate the importance of QI implementation as a separate process from data collection/analysis.

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