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Showing papers by "Atul A. Gawande published in 2018"


Journal ArticleDOI
TL;DR: Racial and ethnic minorities may be disadvantaged in the quality of care they receive if they have a serious illness and are unable to make decisions for themselves because most have not talked to anyone about their goals, values, or preferences for care.
Abstract: Background: Few studies have focused on racial and ethnic differences in advance care planning other than advance directives among population-based samples of adults across the lifespan. M...

52 citations


Journal ArticleDOI
TL;DR: The World Health Organization's Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes.
Abstract: BackgroundThe prevalence of facility-based childbirth in low-resource settings has increased dramatically during the past two decades, yet gaps in the quality of care persist and mortality remains high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes. MethodsWe conducted a matched-pair, cluster-randomized, controlled trial in 60 pairs of facilities across 24 districts of Uttar Pradesh, India, testing the effect of the BetterBirth program, an 8-month coaching-based implementation of the Safe Childbirth Checklist, on a composite outcome of perinatal death, maternal death, or maternal severe complications within 7 days after delivery. Outcomes — assessed 8 to 42 days after delivery — were compared between the intervention group and the control group with adjustment for clustering and matching. We also compared birth attendants’ adherence to 18 essential birth pract...

44 citations


Journal ArticleDOI
TL;DR: 4D-CT localized parathyroid adenomas with higher sensitivity among patients with recurrent or persistent PHPT compared with sestamibi or US-based imaging.
Abstract: Recurrent primary hyperparathyroidism (PHPT) presents a diagnostic challenge in localizing a hyperfunctioning gland. Although several imaging modalities are available for preoperative localization, 4D-CT is increasingly utilized for its ability to locate both smaller and previously unlocalized lesions. Currently, there is a paucity of data evaluating the utility of 4D-CT in the reoperative setting compared with ultrasound (US) and sestamibi. We aimed to determine the sensitivity of 4D-CT in localizing parathyroid adenomas in recurrent or persistent PHPT. We performed a retrospective review of prospectively collected data from a tertiary-care hospital, and identified 58 patients who received preoperative 4D-CT with US and/or sestamibi between May 2008 and March 2016. Data regarding the size, shape, and number of parathyroid lesions were collected for each patient. A total of 62 lesions were identified intraoperatively among the 58 patients (6 with multigland disease) included in this investigation. 4D-CT missed 13 lesions identified intraoperatively, compared with 32 and 22 lesions missed by US and sestamibi, respectively. Sensitivity for correct lateralization of culprit lesions was 77.4% for 4D-CT, 38.5% for US, and 46% for sestamibi. 4D-CT was superior in lateralizing adenomas (49/62) compared with US (20/52; p < 0.001) and sestamibi (18/47; p < 0.001). The overall cure rate (6-month postoperative calcium < 10.7 mg/dL) was 89.7%. All patients with lesions correctly lateralized by 4D-CT were cured at 6 months. 4D-CT localized parathyroid adenomas with higher sensitivity among patients with recurrent or persistent PHPT compared with sestamibi or US-based imaging.

36 citations


Journal ArticleDOI
01 Apr 2018-Thyroid
TL;DR: For patients ≥70 years old, US and FNA are safe and prove helpful in identifying significant-risk thyroid cancer and benign cytology, however, the surgical management of patients ≥ 70 years old presenting without high-risk findings should be tempered, especially when comorbid illness is identified.
Abstract: Background: In older patients, thyroid nodules are frequently detected and referred for evaluation, though usually prove to be benign disease or low-risk cancer. Therefore, management should be gui...

31 citations


Journal ArticleDOI
01 May 2018-JAMA
TL;DR: Analysis of patient safety risks for Harvard-affiliated institutions by interviewing clinicians and convening system leaders both locally and nationally found 3 types of significant safety risks that are related to changes inpatient populations, infrastructure, or clinician practice settings.
Abstract: The health care system in the United States is undergoing substantial consolidation through mechanisms ranging from mergers and acquisitions to institutional affiliations tosingleserviceagreements,oftenwithexpectationsofimproving the safety and quality of care. However, there has beenlittleevaluationoftherisksthatsystemexpansionhas on patients.1,2 In a partnership between a medical liability insurer(CRICO/RiskManagementFoundation)andahealth systems research center (Ariadne Labs), we analyzed the patient safety risks for Harvard-affiliated institutions by interviewing clinicians and convening system leaders both locally and nationally. System expansions create 3 types of significant safety risks, often unrecognized and unaddressed,thatarerelatedtochangesinpatientpopulations, infrastructure, or clinician practice settings (Table).

22 citations


Journal ArticleDOI
TL;DR: Hospitals that reported completing implementation of the checklist in their operating rooms by 2017 had significantly higher levels of CEO and physician participation and engaged more in higher-touch activities such as in-person meetings and teamwork skills trainings than comparison hospitals did.
Abstract: Proven patient safety solutions such as the World Health Organization’s Surgical Safety Checklist are challenging to implement at scale. A voluntary initiative was launched in South Carolina hospit...

18 citations


Journal ArticleDOI
TL;DR: When surgical management of an indeterminate cytology thyroid nodule was performed, several PSFs were associated with a preference by surgeons and patients for initial TT, which may be useful to consider in making decisions on initial operative extent.
Abstract: Diagnostic hemithyroidectomy (HT) is the most widely recommended surgical procedure for a nodule with indeterminate cytology; however, additional details may make initial total thyroidectomy (TT) preferable. We sought to identify patient-specific factors (PSFs) associated with initial TT in patients with indeterminate thyroid nodules. Retrospective analysis of all patients with a thyroid nodule ≥ 1 cm and initial cytology of atypia of undetermined significance or suspicious for follicular neoplasm between 2012 and 2015 who underwent thyroidectomy. Medical records were reviewed for patient demographics, neck symptoms, nodule size, cytology, molecular test results, final histopathology, and additional PSFs influencing surgical management. Variables were analyzed to determine associations with the use of initial TT. Logistic regression analyses were performed to identify independent associations. Of 325 included patients, 182/325 (56.0%) had HT and 143/325 (44.0%) had TT. While patient age and sex, nodule size, and cytology result were not associated with initial treatment, five PSFs were associated with initial TT (p < 0.0001). These included contralateral nodules, hypothyroidism, fluorodeoxyglucose avidity on positron emission tomography scan, family history of thyroid cancer, and increased surgical risk. At least one PSF was present in 126/143 (88.1%) TT patients versus 47/182 (25.8%) HT patients (p < 0.0001). Multivariate logistic regression analysis demonstrated that these variables were the strongest independent predictor of TT (odds ratio 45.93, 95% confidence interval 18.80–112.23, p < 0.001). When surgical management of an indeterminate cytology thyroid nodule was performed, several PSFs were associated with a preference by surgeons and patients for initial TT, which may be useful to consider in making decisions on initial operative extent.

13 citations


Journal ArticleDOI
TL;DR: Surgical education can benefit from increased use of dialogue analyses performed by independent observers, which may represent a viewpoint distinct from that obtained by survey methodology, and the importance of seeking different perspectives, data sources, and methodologies when evaluating clinical education interventions.

12 citations


Journal ArticleDOI
TL;DR: To evaluate whether integration of the Opportunity‐Ability‐Motivation plus Supplies (OAMS) framework into coaching improved the delivery of essential birth practices in a low‐resource setting, the OAMS framework was integrated into coaching.

11 citations


Journal ArticleDOI
TL;DR: In this article, the authors defined, measured, and characterized key competencies of managing labor and delivery units in the United States and assessed the associations between unit management and maternal outcomes.
Abstract: OBJECTIVE:To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes.METHODS:We developed and administered a management measurement instrument using structured telephone int

4 citations


Journal ArticleDOI
27 Nov 2018-PLOS ONE
TL;DR: In areas with widespread mobile cell phone access and coverage, a call center is a viable and efficient approach for measurement of post-discharge childbirth outcomes.
Abstract: Background Maternal and neonatal outcomes in the immediate post-delivery period are critical indicators of quality of care. Data on childbirth outcomes in low-income settings usually require home visits, which can be constrained by cost and access. We report on the use of a call center to measure post-discharge outcomes within a multi-site improvement study of facility-based childbirth in Uttar Pradesh, India. Methods Of women delivering at study sites eligible for inclusion, 97.9% (n = 157,689) consented to follow-up. All consenting women delivering at study facilities were eligible to receive a phone call between days eight and 42 post-partum to obtain outcomes for the seven-day period after birth. Women unable to be contacted via phone were visited at home. Outcomes, including maternal and early neonatal mortality and maternal morbidity, were ascertained using a standardized script developed from validated survey questions. Data Quality Assurance (DQA) included accuracy (double coding of calls) and validity (consistency between two calls to the same household). Regression models were used to identify factors associated with inconsistency. Findings Over 23 months, outcomes were obtained by the call center for 98.0% (154,494/157,689) consenting women and their neonates. 87.9% of call center-obtained outcomes were captured by phone call alone and 12.1% required the assistance of a field worker. An additional 1.7% were obtained only by a field worker, 0.3% were lost-to-follow-up, and only 0.1% retracted consent. The call center captured outcomes with a median of 1 call (IQR 1–2). DQA found 98.0% accuracy; data validation demonstrated 93.7% consistency between the first and second call. In a regression model, significant predictors of inconsistency included cases with adverse outcomes (p<0.001), and different respondents on the first and validation call (p<0.001). Conclusions In areas with widespread mobile cell phone access and coverage, a call center is a viable and efficient approach for measurement of post-discharge childbirth outcomes.