Showing papers by "Atul A. Gawande published in 2020"

Using Smartphones to Capture Novel Recovery Metrics After Cancer Surgery

Abstract: Importance Patient-generated health data captured from smartphone sensors have the potential to better quantify the physical outcomes of surgery. The ability of these data to discriminate between postoperative trends in physical activity remains unknown. Objective To assess whether physical activity captured from smartphone accelerometer data can be used to describe postoperative recovery among patients undergoing cancer operations. Design, Setting, and Participants This prospective observational cohort study was conducted from July 2017 to April 2019 in a single academic tertiary care hospital in the United States. Preoperatively, adults (age ≥18 years) who spoke English and were undergoing elective operations for skin, soft tissue, head, neck, and abdominal cancers were approached. Patients were excluded if they did not own a smartphone. Exposures Study participants downloaded an application that collected smartphone accelerometer data continuously for 1 week preoperatively and 6 months postoperatively. Main Outcomes and Measures The primary end points were trends in daily exertional activity and the ability to achieve at least 60 minutes of daily exertional activity after surgery among patients with vs without a clinically significant postoperative event. Postoperative events were defined as complications, emergency department presentations, readmissions, reoperations, and mortality. Results A total of 139 individuals were approached. In the 62 enrolled patients, who were followed up for a median (interquartile range [IQR]) of 147 (77-179) days, there were no preprocedural differences between patients with vs without a postoperative event. Seventeen patients (27%) experienced a postoperative event. These patients had longer operations than those without a postoperative event (median [IQR], 225 [152-402] minutes vs 107 [68-174] minutes;P Conclusions and Relevance Smartphone accelerometer data can describe differences in postoperative physical activity among patients with vs without a postoperative event. These data help objectively quantify patient-centered surgical recovery, which have the potential to improve and promote shared decision-making, recovery monitoring, and patient engagement.

COVID-19 preparedness within the surgical, obstetric, and anaesthetic ecosystem in sub-Saharan Africa

Abstract: Adesoji O. Ademuyiwa1, Abebe Bekele2, Ataklitie Baraki Berhea3, Eric Borgstein4, Nina Capo-Chichi5, Miliard Derbew6, Faye M. Evans7, Mekdes Daba Feyssa8, Moses Galukande9, Atul A. Gawande10, Serigne Magueye Gueye11, Ewen Harrison12, Pankaj Jani13, Neema Kaseje14, Louis Litswa15, Tihitena Negussie Mammo16, Jannicke Mellin-Olsen17, Godfrey Muguti18, Mary T. Nabukenya19, Eugene Ngoga20, Faustin Ntirenganya21, Stephen Rulisa22, Nichole Starr23, Stephen Tabiri24, Mahelet Tadesse25, Isabeau Walker26, Thomas G. Weiser27, Sherry M. Wren28

Surgeons' Coaching Techniques in the Surgical Coaching for Operative Performance Enhancement (SCOPE) Program.

Abstract: Objective To evaluate coaching techniques used by practicing surgeons who underwent dedicated coach training in a peer surgical coaching program. Background Surgical coaching is a developing strategy for improving surgeons' intraoperative performance. How to cultivate effective coaching skills among practicing surgeons is uncertain. Methods Through the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 surgeons within 4 US academic medical centers were assigned 1:1 into coach/coachee pairs. All attended a 3-hour Surgical Coaching Workshop-developed using evidence from the fields of surgery and education-then received weekly reminders. We analyzed workshop evaluations and audio transcripts of postoperative debriefs between coach/coachee pairs, co-coding themes based on established principles of effective coaching: (i) self-identified goals, (ii) collaborative analysis, (iii) constructive feedback, and (iv) action planning. Coaching principles were cross-referenced with intraoperative performance topics: technical, nontechnical, and teaching skills. Results For the 8 postoperative debriefs analyzed, mean duration was 24.4 min (range 7-47 minutes). Overall, 326 coaching examples were identified, demonstrating application of all 4 core principles of coaching. Constructive feedback (17.6 examples per debrief) and collaborative analysis (16.3) were utilized more frequently than goal-setting (3.9) and action planning (3.0). Debriefs focused more often on nontechnical skills (60%) than technical skills (32%) or teaching-specific skills (8%). Among surgeons who completed the workshop evaluation (82% completion rate), 90% rated the Surgical Coaching Workshop "good" or "excellent." Conclusions Short-course coach trainings can help practicing surgeons use effective coaching techniques to guide their peers' performance improvement in a way that aligns with surgical culture.

Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India

Abstract: Background Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality. Methods Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants’ practice adherence to perinatal mortality. Findings Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality. Interpretation Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex. Funding Bill & Melinda Gates Foundation. Trial registration details ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.

Earlier identification of seriously ill patients: An implementation case series

Abstract: Objective To describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values. Methods We present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP). Results Five sites across the USA and England described their individual experiences implementing patient selection as part of the SICP. They employed a combination of clinician screens (such as the ‘Surprise Question’), disease-specific criteria, existing registries or algorithms as a starting point. Notably, each describes adaptation and evolution of their patient selection methodology over time, with several sites moving towards using more advanced machine learning–based analytical approaches. Conclusions Involving clinical and programme staff to choose a simple initial method for patient identification is the ideal starting place for selecting patients for palliative care interventions. However, improving and refining methods over time is important and we need ongoing research into better patient selection methodologies that move beyond mortality prediction and instead focus on identifying seriously ill patients—those with poor quality of life, worsening functional status and medical care that is negatively impacting their families.