Journal of the American College of Surgeons
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Our objective was to use a human factors and systems engineering approach to understand contributors to surgical readmissions from a patient and provider perspective. Previous studies on readmission have neglected the patient perspective. To address this gap and to better inform intervention design, we evaluated how transitions of care relate to and influence readmission from the patient and clinician perspective using the Systems Engineering Initiative for Patient Safety (SEIPS) model. ⋯ This is the first study to use a human factors and systems engineering approach to evaluate the impact of the quality of the transition of care and its influence on readmission from the patient and clinician perspective. Important targets for future interventions include enhancing the discharge process, improving education materials, and increasing care team coordination, with the overarching theme that improved patient and caregiver understanding and engagement are essential to decrease readmission and postdischarge health care use.
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Glycosylated hemoglobin (HbA1c) is diagnostic of and a measure of the quality of control of diabetes mellitus. Both HbA1c and perioperative hyperglycemia have been targeted as modifiable risk factors for postoperative complications. The HbA1c percent cutoff that best predicts major complications has not been defined. ⋯ Elevated HbA1c ≥ 6.5% and perioperative hyperglycemia were associated with an increased rate of major complications after abdominal surgery. Elevated peak postoperative glucose levels were correlated with elevated HbA1c and were independently associated with major complications. More liberal HbA1c testing should be considered in high-risk patients before elective surgery. Safe, feasible, and effective strategies to reduce both HbA1c and perioperative hyperglycemia need to be developed to optimize patient outcomes.
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Systems that report hospital-based risk-adjusted surgical outcomes are potentially sensitive to the underlying methods used for risk adjustment. If a body of operations has a true level of risk that is higher than the estimated risk, then these operations might generate bias in the output of these reports. The objective of this study was to quantify the impact of unaccounted risk on the results of a surgical outcomes report. ⋯ This study shows that even a small proportion of patients with substantial levels of unaccounted risk can have a dramatic impact on the assessment of hospital-level risk-adjusted surgical outcomes. To avoid the unintended consequences associated with risk-averse behavior from providers, policy should be constructed to address this potential source of bias.
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Multicenter Study
Can 360-Degree Reviews Help Surgeons? Evaluation of Multisource Feedback for Surgeons in a Multi-Institutional Quality Improvement Project.
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. ⋯ 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.
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Laparoscopic treatment for gallbladder cancer (GBC) has long been contraindicated, but few studies have demonstrated the oncologic outcomes of this treatment. The purpose of this study was to evaluate long-term survival after intended laparoscopic surgery for early-stage GBC based on our 10 years of experience. ⋯ The favorable long-term oncologic results shown in this study confirm the oncologic safety of laparoscopic cholecystectomy, including laparoscopic lymphadenectomy in selected patients with GBC.