Showing papers by "Atul A. Gawande published in 2015"

Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality

Abstract: Importance Based on older analyses, the World Health Organization (WHO) recommends that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes. Objectives To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality. Design, Setting, and Participants Cross-sectional, ecological study estimating annual cesarean delivery rates from data collected during 2005 to 2012 for all 194 WHO member states. The year of analysis was 2012. Cesarean delivery rates were available for 54 countries for 2012. For the 118 countries for which 2012 data were not available, the 2012 cesarean delivery rate was imputed from other years. For the 22 countries for which no cesarean rate data were available, the rate was imputed from total health expenditure per capita, fertility rate, life expectancy, percent of urban population, and geographic region. Exposures Cesarean delivery rate. Main Outcomes and Measures The relationship between population-level cesarean delivery rate and maternal mortality ratios (maternal death from pregnancy related causes during pregnancy or up to 42 days postpartum per 100 000 live births) or neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births). Results The estimated number of cesarean deliveries in 2012 was 22.9 million (95% CI, 22.5 million to 23.2 million). At a country-level, cesarean delivery rate estimates up to 19.1 per 100 live births (95% CI, 16.3 to 21.9) and 19.4 per 100 live births (95% CI, 18.6 to 20.3) were inversely correlated with maternal mortality ratio (adjusted slope coefficient, −10.1; 95% CI, −16.8 to −3.4; P = .003) and neonatal mortality rate (adjusted slope coefficient, −0.8; 95% CI, −1.1 to −0.5; P P P = .004). Conclusions and Relevance National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.

Development of the Serious Illness Care Program: a randomised controlled trial of a palliative care communication intervention

Abstract: Introduction: Ensuring that patients receive care that is consistent with their goals and values is a critical component of high-quality care. This article describes the protocol for a cluster randomised controlled trial of a multicomponent, structured communication intervention. Methods and analysis: Patients with advanced, incurable cancer and life expectancy of <12 months will participate together with their surrogate. Clinicians are enrolled and randomised either to usual care or the intervention. The Serious Illness Care Program is a multicomponent, structured communication intervention designed to identify patients, train clinicians to use a structured guide for advanced care planning discussion with patients, ‘trigger’ clinicians to have conversations, prepare patients and families for the conversation, and document outcomes of the discussion in a structured format in the electronic medical record. Clinician satisfaction with the intervention, confidence and attitudes will be assessed before and after the intervention. Self-report data will be collected from patients and surrogates approximately every 2 months up to 2 years or until the patient’s death; patient medical records will be examined at the close of the study. Analyses will examine the impact of the intervention on the patient receipt of goal-concordant care, and peacefulness at the end of life. Secondary outcomes include patient anxiety, depression, quality of life, therapeutic alliance, quality of communication, and quality of dying and death. Key process measures include frequency, timing and quality of documented conversations.

Hospital Board and Management Practices are Strongly Related to Hospital Performance on Clinical Quality Metrics

Abstract: National policies to improve health care quality have largely focused on clinical provider outcomes and, more recently, payment reform. Yet the association between hospital leadership and quality, although crucial to driving quality improvement, has not been explored in depth. We collected data from surveys of nationally representative groups of hospitals in the United States and England to examine the relationships among hospital boards, management practices of front-line managers, and the quality of care delivered. First, we found that hospitals with more effective management practices provided higher-quality care. Second, higher-rated hospital boards had superior performance by hospital management staff. Finally, we identified two signatures of high-performing hospital boards and management practice. Hospitals with boards that paid greater attention to clinical quality had management that better monitored quality performance. Similarly, we found that hospitals with boards that used clinical quality met...

Disease Control Priorities, Third Edition : Volume 1. Essential Surgery

Abstract: Essential Surgery is the first volume in the Disease Control Priorities, third edition (DCP3) series. DCP3 endeavors to inform program design and resource allocation at the global and country levels by providing a comprehensive review of the effectiveness, cost, and cost-effectiveness of priority health interventions. The volume presents data on the surgical burden of disease, disability, congenital anomalies, and trauma, along with health impact and economic analyses of procedures, platforms, and packages to improve care in settings with severe budget limitations. Essential Surgery identifies 44 surgical procedures that meet the following criteria: they address substantial needs, are cost effective, and are feasible to implement in low- and middle-income countries. If made universally available, the provision of these 44 procedures would avert 1.5 million deaths a year and rank among the most cost effective of all health interventions. Existing health care delivery structures can be leveraged to provide affordable and quality care, with first-level hospitals capable of delivering the majority of procedures, while addressing substantial disparities in safety. Existing infrastructure can also expand access to surgery by implementing measures such as task sharing, which has been shown to be safe and effective while countries build workforce capacity. Nearly ten years after the second iteration of Disease Control Priorities was released, increased attention to the importance of health systems in providing access to quality care is once again reshaping the global health landscape. Low- and middle-income countries are continuing to set priorities for funding and are making decisions across an increasingly complex set of policy and intervention choices with a greater appreciation for the value of program and economic evaluations. By reviewing the large burden of surgical disorders, the cost-effectiveness of surgical procedures, and the strong public demand for surgical services, Essential Surgery makes a compelling case for improving global access to surgical care.

The variable phenotype and low-risk nature of RAS -positive thyroid nodules

Abstract: Oncogenic mutations are common in thyroid cancers While the frequently detected RAS-oncogene mutations have been studied for diagnostic use in cytologically indeterminate thyroid nodules, no investigation has studied such mutations in an unselected population of thyroid nodules No long-term study of RAS-positive thyroid nodules has been performed We performed a prospective, blinded cohort study in 362 consecutive patients presenting with clinically relevant (>1 cm) thyroid nodules Fine needle aspiration cytology and mutational testing were obtained for all nodules Post-operative histopathology was obtained for malignant or indeterminate nodules, and benign nodules were sonographically followed Histopathological features were compared between RAS- and BRAF-positive malignancies RAS-positive benign nodules were analyzed for growth or cellular change from prior aspirations Overall, 17 of 362 nodules were RAS-positive Nine separate nodules were BRAF-positive, of which eight underwent surgery and all proved malignant (100 %) Out of the 17 RAS-positive nodules, ten underwent surgery, of which eight proved malignant (47 %) All RAS-positive malignancies were low risk – all follicular variants of papillary carcinoma, without extrathyroidal extension, metastases, or lymphovascular invasion RAS-positivity was associated with malignancy in younger patients (P = 0028) Of the nine RAS-positive benign nodules, five had long-term prospective sonographic follow-up (mean 83 years) showing no growth or signs of malignancy Four of these nodules also had previous aspirations (mean 58 years prior), all with similar benign results While RAS-oncogene mutations increase malignancy risk, these data demonstrate a low-risk phenotype for most RAS-positive cancers Furthermore, cytologically benign, yet RAS-positive nodules behave in an indolent fashion over years RAS-positivity alone should therefore not dictate clinical decisions

False negative cytology in large thyroid nodules.

Abstract: Controversy exists regarding the accuracy of fine-needle aspiration (FNA) in large thyroid nodules. Recent surgical series have documented false-negative rates ranging from 0.7 to 13 %. We examined the accuracy of benign FNA cytology in patients with thyroid nodules ≥3 cm who underwent surgical resection and identified features characteristic of false-negative results. We retrospectively studied all thyroidectomy specimens between January 2009 and October 2011 and identified nodules ≥3 cm with corresponding benign preoperative FNA cytology. We collected clinical information regarding patient demographics, nodule size, symptoms, sonographic features, FNA results, and final surgical pathology. For comparison, we analyzed nodules <3 cm from this cohort also with benign FNA cytology. A total of 323 nodules with benign preoperative cytology were identified. Eighty-three nodules were <3 cm, 94 nodules were 3–3.9 cm, and 146 nodules were ≥4 cm in size. The false-negative rate was 11.7 % for all nodules ≥3 cm and 4.8 % for nodules <3 cm (p = 0.03). Subgroup analysis of nodules ≥3 cm revealed a false-negative rate of 12.8 % for nodules 3–3.9 cm and 11 % for nodules ≥4 cm. Age ≥55 years and asymptomatic clinical status were the only patient characteristics that reached statistical significance as risk factors. Final pathology of the false-negative specimens consisted mainly of follicular variant of papillary thyroid cancer and follicular thyroid cancer. When referred for thyroidectomy, patients with large thyroid nodules demonstrate a modest, yet significant, false-negative rate despite initial benign aspiration cytology. Therefore, thyroid nodules ≥3 cm may be considered for removal even when referred with benign preoperative cytology.

Sustainability and Long-term Effectiveness of the WHO Surgical Safety Checklist Combined With Pulse Oximetry in a Resource-Limited Setting: Two-Year Update From Moldova

Abstract: Importance Little is known about the sustainability and long-term effect of surgical safety checklists when implemented in resource-limited settings. A previous study demonstrated the marked, short-term effect of a structured hospital-wide implementation of a surgical safety checklist in Moldova, a lower–middle-income country, as have studies in other low-resource settings. Objectives To assess the long-term reduction in perioperative harm following the introduction of a checklist-based surgical quality improvement program in a resource-limited setting and to understand the long-term effects of such programs. Design, Setting, and Participants Twenty months after the initial implementation of a surgical safety checklist and the provision of pulse oximetry at a referral hospital in Moldova, a lower–middle-income, resource-limited country in Eastern Europe, we conducted a prospective study of perioperative care and outcomes of 637 consecutive patients undergoing noncardiac surgery (the long-term follow-up group), and we compared the findings with those from 2106 patients who underwent surgery shortly after implementation (the short-term follow-up group). Preintervention data were collected from March to July 2010. Data collection during the short-term follow-up period was performed from October 2010 to January 2011, beginning 1 month after the implementation of the launch period. Data collection during the long-term follow-up period took place from May 25 to July 6, 2012, beginning 20 months after the initial intervention. Main Outcomes and Measures The primary end points of interest were surgical morbidity (ie, the complication rate), adherence to safety process measures, and frequency of hypoxemia. Results Between the short- and long-term follow-up groups, the complication rate decreased 30.7% ( P = .03). Surgical site infections decreased 40.4% ( P = .05). The mean (SD) rate of completion of the checklist items increased from 88% (14%) in the short-term follow-up group to 92% (11%) in the long-term follow-up group ( P P = .10). Conclusions and Relevance Sustained use of the checklist was observed with continued improvements in process measures and reductions in 30-day surgical complications almost 2 years after a structured implementation effort that demonstrated marked, short-term reductions in harm. The sustained effect occurred despite the absence of continued oversight by the research team, indicating the important role that local leadership and local champions play in the success of quality improvement initiatives, especially in resource-limited settings.

Essential Surgery: Key Messages of This Volume

Abstract: Conditions that are treated primarily or frequently by surgery constitute a significant portion of the global burden of disease. In 2011, injuries killed nearly 5 million people; 270,000 women died from complications of pregnancy (WHO 2014). Many of these injury- and obstetric-related deaths, as well as deaths from other causes such as abdominal emergencies and congenital anomalies, could be prevented by improved access to surgical care.Despite this substantial burden, surgical services are not being delivered to many of those who need them most. An estimated 2 billion people lack access to even the most basic surgical care (Funk and others 2010). This need has not been widely acknowledged, and priorities for investing in health systems’ surgical capacities have only recently been investigated. Indeed, until the 1990s, health policy in resource-constrained settings focused sharply on infectious diseases and undernutrition, especially in children. Surgical capacity was developing in urban areas but was often viewed as a secondary priority that principally served those who were better off.In the 1990s, a number of studies began to question the perception that surgery was costly and low in effectiveness. Economic evaluations of cataract surgery found the procedure to be cost-effective, even under resource-constrained circumstances; Javitt pioneered cost-effectiveness analysis (CEA) for surgery, including his chapter on cataract in Disease Control Priorities, first edition (DCP1) in 1993 (Javitt 1993). In 2003, McCord and Chowdhury enriched the approach to economic evaluation in surgery in a paper looking at the overall cost-effectiveness of a surgical platform in Bangladesh (McCord and Chowdhury 2003). By design, DCP2, published in 2006, placed much more emphasis on surgery than had previous health policy documents. DCP2 included a dedicated chapter on surgery that amplified the approach of McCord and Chowdhury and provided an initial estimate of the amount of disease burden that could be addressed by surgical intervention in LMICs (Debas and others 2006). DCP3 places still greater emphasis on surgery by dedicating this entire volume (out of a total of nine volumes) to the topic. There is also a growing academic literature on surgery’s importance in health system development; for example, Paul Farmer and Jim Kim’s paper observes that “surgery may be thought of as the neglected stepchild of global public health” (Farmer and Kim 2008, 533). The WHO is paying increasing attention to surgical care through such vehicles as its Global Initiative for Emergency and Essential Surgical Care. Finally, the creation of The Lancet Commission on Global Surgery, now well into its work, points to a major change in the perceived importance of surgery.The chapter seeks to do the following:Box 1.1 describes the history, objectives, and contents of DCP3 (Jamison 2015).

Can 360-Degree Reviews Help Surgeons? Evaluation of Multisource Feedback for Surgeons in a Multi-Institutional Quality Improvement Project

Abstract: Background Medical organizations have increased interest in identifying and improving behaviors that threaten team performance and patient safety. Three hundred and sixty degree evaluations of surgeons were performed at 8 academically affiliated hospitals with a common Code of Excellence. We evaluate participant perceptions and make recommendations for future use. Study Design Three hundred and eighty-five surgeons in a variety of specialties underwent 360-degree evaluations, with a median of 29 reviewers each (interquartile range 23 to 36). Beginning 6 months after evaluation, surgeons, department heads, and reviewers completed follow-up surveys evaluating accuracy of feedback, willingness to participate in repeat evaluations, and behavior change. Results Survey response rate was 31% for surgeons (118 of 385), 59% for department heads (10 of 17), and 36% for reviewers (1,042 of 2,928). Eighty-seven percent of surgeons (95% CI, 75%-94%) agreed that reviewers provided accurate feedback. Similarly, 80% of department heads believed the feedback accurately reflected performance of surgeons within their department. Sixty percent of surgeon respondents (95% CI, 49%-75%) reported making changes to their practice based on feedback received. Seventy percent of reviewers (95% CI, 69%-74%) believed the evaluation process was valuable, with 82% (95% CI, 79%-84%) willing to participate in future 360-degree reviews. Thirty-two percent of reviewers (95% CI, 29%-35%) reported perceiving behavior change in surgeons. Conclusions Three hundred and sixty degree evaluations can provide a practical, systematic, and subjectively accurate assessment of surgeon performance without undue reviewer burden. The process was found to result in beneficial behavior change, according to surgeons and their coworkers.

Demand-side interventions for maternal care: evidence of more use, not better outcomes

Abstract: Background: Reducing maternal and neonatal mortality is essential to improving population health. Demand-side interventions are designed to increase uptake of critical maternal health services, but associated change in service uptake and outcomes is varied. We undertook a literature review to understand current evidence of demand-side intervention impact on improving utilization and outcomes for mothers and newborn children. Methods: We completed a rapid review of literature in PubMed. Title and abstracts of publications identified from selected search terms were reviewed to identify articles meeting inclusion criteria: demand-side intervention in low or middle-income countries (LMIC), published after September 2004 and before March 2014, study design describing and reporting on >1 priority outcome: utilization (antenatal care visits, facility-based delivery, delivery with a skilled birth attendant) or health outcome measures (maternal mortality ratio (MMR), stillbirth rate, perinatal mortality rate (PMR), neonatal mortality rate (NMR)). Bibliographies were searched to identify additional relevant papers. Articles were abstracted using a standardized data collection template with double extraction on a sample to ensure quality. Quality of included studies was assessed using McMaster University’s Quality Assessment Tool from the Effective Public Health Practice Project (EPHPP). Results: Five hundred and eighty two articles were screened with 50 selected for full review and 16 meeting extraction criteria (eight community mobilization interventions (CM), seven financial incentive interventions (FI), and one with both). We found that demand-side interventions were effective in increasing uptake of key services with five CM and all seven FI interventions reporting increased use of maternal health services. Association with health outcome measures were varied with two studies reporting reductions in MMR and four reporting reduced NMR. No studies found a reduction in stillbirth rate. Only four of the ten studies reporting on both utilization and outcomes reported improvement in both measures. Conclusions: We found strong evidence that demand-side interventions are associated with increased utilization of services with more variable evidence of their impact on reducing early neonatal and maternal mortality. Further research is needed to understand how to maximize the potential of demand-side interventions to improve maternal and neonatal health outcomes including the role of quality improvement and coordination with supply-side interventions.

What do we know about the safe surgery checklist now

Abstract: I n 2009, when The New England Journal of Medicine published the 8-city trial of the World Health Organization’s Safe Surgery Checklist, the idea that a formal system of planning and communication could significantly improve patient outcomes was outside the surgical mainstream. The pre-post study found substantial reductions in complications and deaths, with the improvements significant in both higher and lower income settings.1 However, the study had notable weaknesses. There was no control group, nor was the intervention applied on all units in the study hospitals. The program had not been demonstrated to be replicable at a large scale, and the sustainability of the effect had not been proved. A series of subsequent studies with strong control groups have since replicated the substantial value of using a systematic checklist-based approach to surgical team planning and communication. For instance, van Klei et al2 demonstrated in more than 25,000 patients that the odds ratio of 30-day mortality was 0.44 for patients whose teams completed the checklist compared with 1.16 for those whose teams did not. Beneficial findings were also demonstrated at a large scale: the SURPASS trial showed that a comprehensive surgical checklist approach reduced mortality rates by 47% in 7 Dutch hospitals compared with controls,3 and Neily et al4 demonstrated using a step-wedge methodology that introduction of a checklist-driven system of briefing and debriefing in 74 Veterans Administration (VA) hospitals through a concerted team training program led to an 18% reduction in mortality. As a result, several countries have introduced a safe surgery checklist program nationally. For instance, after several years of flat surgical inpatient mortality, NHS Scotland carried out a concerted nationwide implementation program that it credited with making major reductions in inpatient mortality that meant more than 9000 fewer lives lost.5 Recently, however, Urbach et al6 examined the effects of a law mandating surgical checklist use in Ontario hospitals and found only a modest mortality reduction that did not reach statistical significance. Given these conflicting data, a remaining concern about the validity of even the prior controlled studies was that they had not been randomized. The study by Haugen and colleagues7 in the current issue of Annals of Surgery therefore makes a major contribution by reporting the results of the first cluster randomized trial of a surgical safety checklist, in this case employing random allocation of dates of implementation of the intervention among different units within 2 hospitals in Norway. Analysis of outcomes focused on a cohort of patients with a significant rate of morbidity and in-hospital mortality (19.9% and 1.6%, respectively) and followed a step-wedge methodology. The study confirmed that use of the checklist resulted in substantial improvement in outcomes—with a relative risk reduction in major complications of 0.42 (95% confidence interval, 0.33–0.50). The number needed to treat to prevent morbidity was just 12. Deaths fell from 1.6% to 1.0%, which is potentially substantial, but the study was not powered to detect if this was a significant difference (P = 0.151). Importantly, the authors also confirmed a dose effect by assessing the actual use of the checklist through direct observation: they found an even larger reduction in major complications when teams completed all portions of the checklist—a finding consistent with that of van Klei et al.2 Such findings confirm that research on the effectiveness of quality tools such as checklists must include assessment of use, as no quality tool, particularly one that relies upon team communication and interaction, can be expected to make a difference if it is not actually used in any meaningful sense. This work also affirms emerging evidence that institution of an effective safe surgery checklist program at a large scale requires a deliberate implementation process and at least some form of monitoring and learning with frontline teams.8 Haugen and colleagues7,9 are to be complimented not only for the thoroughness of the process but also for the details on the implementation efforts shared in this article and in prior publications. They detail several precepts of their implementation that we believe may be key to success in team-based interventions. First, they modified the checklist to fit with local context. Although modification must be undertaken in a thoughtful manner, this is key to ensuring that the instrument fits the local workflow and circumstances. Second, after modification,

Learning before leaping: integration of an adaptive study design process prior to initiation of BetterBirth, a large-scale randomized controlled trial in Uttar Pradesh, India

Abstract: Pragmatic and adaptive trial designs are increasingly used in quality improvement (QI) interventions to provide the strongest evidence for effective implementation and impact prior to broader scale-up. We previously showed that an on-site coaching intervention focused on the World Health Organization Safe Childbirth Checklist (SCC) improved performance of essential birth practices (EBPs) in one facility in Karnataka, India. We report on the process and outcomes of adapting the intervention prior to larger-scale implementation in a randomized controlled trial in Uttar Pradesh (UP), India. Initially, we trained a local team of physicians and nurses to coach birth attendants in SCC use at two public facilities for 4–6 weeks. Trained observers evaluated adherence to EBPs before and after coaching. Using mixed methods and a systematic adaptation process, we modified and strengthened the intervention. The modified intervention was implemented in three additional facilities. Pre/post-change in EBP prevalence aggregated across facilities was analyzed. In the first two facilities, limited improvement was seen in EBPs with the exception of post-partum oxytocin. Checklists were used <25 % of observations. We identified challenges in physicians coaching nurses, need to engage district and facility leadership to address system gaps, and inadequate strategy for motivating SCC uptake. Revisions included change to peer-to-peer coaching (nurse to nurse, physician to physician); strengthened coach training on behavior and system change; adapted strategy for effective leadership engagement; and an explicit motivation strategy to enhance professional pride and effectiveness. These modifications resulted in improvement in multiple EBPs from baseline including taking maternal blood pressure (0 to 16 %), post-partum oxytocin (36 to 97 %), early breastfeeding initiation (3 to 64 %), as well as checklist use (range 32 to 88 %), all p < 0.01. Further adaptations were implemented to increase the effectiveness prior to full trial launch. The adaptive study design of implementation, evaluation, and feedback drove iterative redesign and successfully developed a SCC-focused coaching intervention that improved EBPs in UP facilities. This work was critical to develop a replicable BetterBirth package tailored to the local context. The multi-center pragmatic trial is underway measuring impact of the BetterBirth program on EBP and maternal-neonatal morbidity and mortality. Clinical trials identifier: NCT02148952 .

Proposed Minimum Rates of Surgery to Support Desirable Health Outcomes: An Observational Study Based on Three Strategies.

Abstract: The global volume of surgery is estimated at 312.9 million operations annually, but rates of surgery vary dramatically. Identifying surgical rates associated with improved health outcomes would be useful for benchmarking and targeted health system strengthening. We identified rates of surgery associated with a life expectancy (LE) of 74–75 years, a maternal mortality ratio (MMR) of less than or equal to 100 per 100,000 live births, and the estimated need for surgery in the seven global burden of disease (GBD) super-regions based on the prevalence of surgical conditions. We compared our findings to surgical rates from Chile, China, Costa Rica, and Cuba (“4C”), countries with moderate resources but high health outcomes. The median surgical rates associated with LE of 74–75 years (N = 17) and MMR below 100 (N = 109) are 4392 (IQR 2897–4873) and 5028 (IQR 4139–6778) operations per 100,000 people annually, respectively. The mean surgical rate estimated for the seven super-regions was 4723 (95 % CI 3967–5478) operations per 100,000 people annually. The “4C” countries had a mean surgical rate of 4344 (95 % CI 2620–6068) operations per 100,000 people annually. Thirteen of the twenty-one GBD regions, accounting for 78 % of the world’s population, do not achieve rates of surgery at the lowest end of this range. We identified a narrow range of surgical rates associated with important health indicators. This target range can be used for benchmarking of surgical services, and as part of a policy aimed at strengthening health care systems and surgical capacity.

Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals.

Abstract: We assessed surgical team member perceptions of multiple dimensions of safe surgical practice in 38 South Carolina hospitals participating in a statewide initiative to implement surgical safety checklists. Primary data were collected using a novel 35-item survey. We calculated the percentage of 1,852 respondents with strongly positive, positive, and neutral/negative responses about the safety of surgical practice, compared results by hospital and professional discipline, and examined how readiness, teamwork, and adherence related to staff perception of care quality. Overall, 78% of responses were positive about surgical safety at respondent's hospitals, but in each survey dimension, from 16% to 40% of responses were neutral/negative, suggesting significant opportunity to improve surgical safety. Respondents not reporting they would feel safe being treated in their operating rooms varied from 0% to 57% among hospitals. Surgeons responded more positively than nonsurgeons. Readiness, teamwork, and practice adherence related directly to staff perceptions of patient safety (p < .001).

Use of Public Data to Target Variation in Providers’ Use of CT and MR Imaging among Medicare Beneficiaries

Abstract: Using public data, we can better identify potential geographic and procedure targets for improving providers’ use of diagnostic CT and MR imaging.

Delivering more, earlier, and better goals-of-care conversations to seriously ill oncology patients.

Abstract: 39 Background: Patients with serious illness routinely receive treatments that are not aligned with their goals. Earlier clinical conversations about patients’ values and priorities lead to more goal-concordant care and improved quality of life, but these conversations often happen too late or not at all. The Serious Illness Care Program has designed a systematic approach to train and support clinicians in conducting more, earlier, and better conversations about goals of care with their patients. Objectives: Evaluate clinician adoption and acceptability of the training program and the Serious Illness Conversation Guide; determine the frequency, timing, and quality of goals of care documentation before death. Methods: Cluster-randomized trial including oncology clinicians and their patients. Intervention: clinician identification of high risk patients; 2½ hour clinician training on the Serious Illness Conversation Guide; email trigger/reminder; EMR documentation. Preliminary chart review to extract goals-o...

Projections for Achieving the Lancet Commission Recommended Surgical Rate of 5000 Operations per 100,000 Population by Region-Specific Surgical Rate Estimates

Abstract: We previously identified a range of 4344–5028 annual operations per 100,000 people to be related to desirable health outcomes. From this and other evidence, the Lancet Commission on Global Surgery recommends a minimum rate of 5000 operations per 100,000 people. We evaluate rates of growth and estimate the time it will take to reach this minimum surgical rate threshold. We aggregated country-level surgical rate estimates from 2004 to 2012 into the twenty-one Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size for each year and assessed the rate of growth over time. We then extrapolated the time it will take each region to reach a surgical rate of 5000 operations per 100,000 population based on linear rates of change. All but two regions experienced growth in their surgical rates during the past 8 years. Fourteen regions did not meet the recommended threshold in 2012. If surgical capacity continues to grow at current rates, seven regions will not meet the threshold by 2035. Eastern Sub-Saharan Africa will not reach the recommended threshold until 2124. The rates of growth in surgical service delivery are exceedingly variable. At current rates of surgical and population growth, 6.2 billion people (73 % of the world’s population) will be living in countries below the minimum recommended rate of surgical care in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met in a timely fashion as part of the integrated health system development.

The utility of the surprise question in identifying patients most at risk of death.

Abstract: 8 Background: Understanding the cancer patient’s prognosis in all illness phases is important. Evidence suggests that the “Surprise Question” (SQ) -- “Would you be surprised if this patient died within the next year?” -- may be useful in identifying those most at risk of death, but prior studies are limited by the relatively small number of patients and clinicians included. Methods: From July 2012 to October 2014, oncology clinicians at Dana-Farber Cancer Institute were invited to enroll in a randomized controlled trial on the impact of a structured intervention to improve conversations about end-of-life goals -- the Serious Illness Care Program. The SQ was asked about each patient seen by the enrolled clinician. We used a weighted propensity score approach to calculate adjusted proportions of survival at 6 months and 1 year, clustering by SQ clinician. To determine which variable was most predictive of death, we fit a multivariable Cox model, and found the variable that led to the largest increase in the...

Effect of conversations about values and goals on anxiety in patients.

Abstract: 9 Background: Patients with serious illness routinely receive treatments that do not align with their goals. Earlier clinical conversations about patients’ values and priorities lead to more goal-concordant care and improved quality of life, but clinician concerns about harming patients and taking away hope are barriers to appropriately timed discussions. Methods: A cluster-randomized controlled trial with oncology patients at high risk of death, identified by the surprise question. The intervention included a structured, patient-centered discussion about values and priorities conducted by trained oncology clinicians using the Serious Illness Conversation Guide. Patient anxiety (GAD-7) was measured by survey at baseline and every 2 months; anxiety, patient acceptability, and patient-reported behavior change were measured by survey 1 week after the intervention and at a matching time point for controls. Results: 342 patients enrolled (median age 62y): 176 intervention; 166 control. 102 conversations were c...