Showing papers by "Atul A. Gawande published in 2014"

Being Mortal: Medicine and What Matters in the End

Abstract: Medicine has triumphed in modern times, transforming birth, injury and infectious disease from harrowing to manageable. But in the inevitable condition of aging and death, the goals of medicine seem too frequently to run counter to the interest of the human spirit. Nursing homes, preoccupied with safety, pin patients into railed beds and wheelchairs. Hospitals isolate the dying, checking for vital signs long after the goals of cure have become moot. Doctors, committed to extending life, continue to carry out devastating procedures that in the end extend suffering.

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

Abstract: Objective:To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives.Background:Failures in intraoperative teamwork are among the leading causes of preventable patient

Pitfalls in communication that lead to nonbeneficial emergency surgery in elderly patients with serious illness: description of the problem and elements of a solution.

Abstract: Objective:To provide a description of communication breakdowns and to identify interventions to improve surgical decision making for elderly patients with serious illness and acute, life-threatening surgical conditions.Background:Communication between surgeons, patients, and surrogates about goals o

Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review

Abstract: Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries. We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews. Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified. Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.

Conversations about Treatment Preferences before High-Risk Surgery: A Pilot Study in the Preoperative Testing Center

Abstract: Background: It is important to engage patients and surrogates in conversations about goals and preferences for medical treatment before high-risk surgery. However, few interventions have been tested to facilitate these discussions. Objective: To assess the acceptability and feasibility of a facilitated, structured conversation with patients and surrogates about patient goals and preferences for medical treatment during their visit to a preoperative testing center before high-risk surgery. Design: A randomized controlled pilot study in the preoperative testing center at a tertiary academic hospital over a 4-month period. Measurements: We used baseline and preoperative surveys to assess feasibility, and to compare differences in worry, surrogate burden, and patient–surrogate concordance about treatment preferences in conversation and control groups. We assessed acceptability of the conversation qualitatively and through surveys. Results: Of 146 eligible patients, 79 were approached, and 65 declined...

Beyond volume: does hospital complexity matter?: an analysis of inpatient surgical mortality in the United States.

Abstract: Background Hospitals show wide variation in outcomes and systems of care. It is unclear whether hospital complexity-the range of services and technologies provided-affects outcomes and in what direction. We sought to determine whether complexity was associated with inpatient surgical mortality. Methods Using national Medicare data, we identified all fee-for-service inpatients who underwent 1 of 5 common high-risk surgical procedures in 2008-2009 and measured complexity by the number of unique primary diagnoses admitted to each hospital over the 2-year period. We calculated 30-day postoperative mortality rates, adjusting for patient and hospital characteristics, and used multivariable Poisson regression models to test for an association between hospital complexity and mortality rates. We then used this model to generate predicted mortality rates for low-volume and high-volume hospitals across the spectrum of hospital complexity. Results A total of 2691 hospitals were analyzed, representing a total of 382,372 admissions. After adjusting for hospital characteristics, including hospital volume, increasing hospital complexity was associated with lower surgical mortality rates. Patients receiving care at the hospitals in the lowest quintile of unique diagnoses had a 27% higher risk of death than those at the highest quintile. The effect of complexity was largest for low-volume hospitals, which were capable of achieving mortality rates similar to high-volume hospitals when in the most complex quintile. Conclusions Hospital complexity matters and is associated with lower surgical mortality rates, independent of hospital volume. The effect of complexity on outcomes for nonsurgical services warrants investigation.

Evaluation of a large-scale donation of Lifebox pulse oximeters to non-physician anaesthetists in Uganda

Abstract: Pulse oximetry is widely accepted as essential monitoring for safe anaesthesia, yet is frequently unavailable in resource-limited settings. The Lifebox pulse oximeter, and associated management training programme, was delivered to 79 non-physician anaesthetists attending the 2011 Uganda Society of Anaesthesia Annual Conference. Using a standardised assessment, recipients were tested for their knowledge of oximetry use and hypoxia management before, immediately following and 3–5 months after the training. Before the course, the median (IQR [range]) test score for the anaesthetists was 36 (34–39 [26–44]) out of a maximum of 50 points. Immediately following the course, the test score increased to 41 (38–43 [25–47]); p < 0.0001 and at the follow-up visit at 3–5 months it was 41 (39–44 [33–49]); p = 0.001 compared with immediate post-training test scores, and 75/79 (95%) oximeters were in routine clinical use. This method of introduction resulted in a high rate of uptake of oximeters into clinical practice and a demonstrable retention of knowledge in a resource-limited setting.

Avoiding Low-Value Care

Abstract: The enormous cost of health care in the United States has inspired new efforts to assess the true value of commonly provided services Carrie Colla, Scott Halpern, and Bruce Landon discuss decision making regarding low-value care in a video roundtable moderated by Atul Gawande

Almost efficient estimation of relative risk regression.

Abstract: Relative risks (RRs) are often considered the preferred measures of association in prospective studies, especially when the binary outcome of interest is common. In particular, many researchers regard RRs to be more intuitively interpretable than odds ratios. Although RR regression is a special case of generalized linear models, specifically with a log link function for the binomial (or Bernoulli) outcome, the resulting log-binomial regression does not respect the natural parameter constraints. Because log-binomial regression does not ensure that predicted probabilities are mapped to the [0,1] range, maximum likelihood (ML) estimation is often subject to numerical instability that leads to convergence problems. To circumvent these problems, a number of alternative approaches for estimating RR regression parameters have been proposed. One approach that has been widely studied is the use of Poisson regression estimating equations. The estimating equations for Poisson regression yield consistent, albeit inefficient, estimators of the RR regression parameters. We consider the relative efficiency of the Poisson regression estimator and develop an alternative, almost efficient estimator for the RR regression parameters. The proposed method uses near-optimal weights based on a Maclaurin series (Taylor series expanded around zero) approximation to the true Bernoulli or binomial weight function. This yields an almost efficient estimator while avoiding convergence problems. We examine the asymptotic relative efficiency of the proposed estimator for an increase in the number of terms in the series. Using simulations, we demonstrate the potential for convergence problems with standard ML estimation of the log-binomial regression model and illustrate how this is overcome using the proposed estimator. We apply the proposed estimator to a study of predictors of pre-operative use of beta blockers among patients undergoing colorectal surgery after diagnosis of colon cancer.

Peri-operative pulse oximetry in low-income countries: a cost–effectiveness analysis

Abstract: Objective To evaluate the cost–effectiveness of pulse oximetry – compared with no peri-operative monitoring – during surgery in low-income countries. Methods We considered the use of tabletop and portable, hand-held pulse oximeters among patients of any age undergoing major surgery in low-income countries. From earlier studies we obtained baseline mortality and the effectiveness of pulse oximeters to reduce mortality. We considered the direct costs of purchasing and maintaining pulse oximeters as well as the cost of supplementary oxygen used to treat hypoxic episodes identified by oximetry. Health benefits were measured in disability-adjusted life-years (DALYs) averted and benefits and costs were both discounted at 3% per year. We used recommended cost–effectiveness thresholds – both absolute and relative to gross domestic product (GDP) per capita – to assess if pulse oximetry is a cost–effective health intervention. To test the robustness of our results we performed sensitivity analyses. Findings In 2013 prices, tabletop and hand-held oximeters were found to have annual costs of 310 and 95 United States dollars (US$), respectively. Assuming the two types of oximeter have identical effectiveness, a single oximeter used for 22 procedures per week averted 0.83 DALYs per annum. The tabletop and hand-held oximeters cost US$ 374 and US$ 115 per DALY averted, respectively. For any country with a GDP per capita above US$ 677 the hand-held oximeter was found to be cost–effective if it prevented just 1.7% of anaesthetic-related deaths or 0.3% of peri-operative mortality. Conclusion Pulse oximetry is a cost–effective intervention for low-income settings.

Surgery at the End of Life: A Pilot Study Comparing Decedents and Survivors at a Tertiary Care Center

Abstract: BACKGROUND More than a quarter of medical costs for Medicare beneficiaries are incurred in the last year of life; surgical intensity during this time is significant. This study was performed to determine types of operations patients undergo in their terminal year, and compare characteristics of decedents with those of survivors. METHODS Population of 747 consecutive all-payer patients seen at the preoperative assessment center of a tertiary care hospital. Patient characteristics were obtained from the electronic medical record. Surgical indication (palliative, curative, diagnostic, elective) was assessed based on procedure performed and underlying diagnosis. Vital status was determined using the electronic medical record with confirmation via social security national death master file. Descriptive statistics were performed to compare patient characteristics and procedures performed on those who died within 1 yr of procedure with those of survivors. RESULTS Thirty-seven patients (5%) were confirmed dead at 1 yr. Ten (27%) of these had palliative procedures, 11 (30%) diagnostic, 14 (38%) curative, and 2 (5%) elective. Decedents were more likely to have undergone a palliative (27 vs. 3%) or diagnostic (30 vs. 14%) procedure and less likely to have undergone an elective procedure (5 vs. 42%) than survivors (P < 0.0001). Nearly half of decedents did not have an advanced directive by the date of surgical intervention. CONCLUSIONS Nearly 1 in 20 patients seen at the preoperative assessment clinic of a tertiary care hospital died within 1 yr of their procedure. Patient characteristics and procedure indication for decedents differed from those of survivors. Similar analyses based on institution and region may provide methodologies to compare variation in surgical intensity and assist preoperative care providers in evaluating appropriateness of resource allocation.

Simple methods of determining confidence intervals for functions of estimates in published results.

Abstract: Often, the reader of a published paper is interested in a comparison of parameters that has not been presented. It is not possible to make inferences beyond point estimation since the standard error for the contrast of the estimated parameters depends upon the (unreported) correlation. This study explores approaches to obtain valid confidence intervals when the correlation is unknown. We illustrate three proposed approaches using data from the National Health Interview Survey. The three approaches include the Bonferroni method and the standard confidence interval assuming (most conservative) or (when the correlation is known to be non-negative). The Bonferroni approach is found to be the most conservative. For the difference in two estimated parameter, the standard confidence interval assuming yields a 95% confidence interval that is approximately 12.5% narrower than the Bonferroni confidence interval; when the correlation is known to be positive, the standard 95% confidence interval assuming is approximately 38% narrower than the Bonferroni. In summary, this article demonstrates simple methods to determine confidence intervals for unreported comparisons. We suggest use of the standard confidence interval assuming if no information is available or if the correlation is known to be non-negative.