Search

Patients with receding or high hairlines have traditionally been considered unfavorable candidates for endoscopic brow lift as this can further lengthen the hairline. We analyzed outcomes in patients that underwent a novel endoscopic brow lift technique with placement of incisions and anchoring Endotine Forehead Devices (CoApt Systems Inc, Palo Alto, CA, USA) directly at the natural forehead crease lines, in an effort to minimize elevation of the hairline, whereas providing well-hidden scars. We retrospectively reviewed all patients who underwent this new Endotine and incision placement between 2016 and 2020. Preoperative and postoperative photographs of all patients were analyzed to determine the postoperative changes in brow elevation and forehead length proportion (defined as length from cranium to chin).The forehead length proportion was unchanged pre- and post-operatively, with no statistically significant differences noted (P = 0.48). The average brow position elevation ranged from 2.78 mm in the medial location to 5.05 mm in the lateral location. All patients were happy with their appearance and had improved visual fields postoperatively. The forehead scars healed well and were well hidden in forehead rhytids at long term follow-up.This novel endoscopic brow lift technique provides an option to utilize a minimally invasive approach in patients with receding hairline. With this technique, visible scars were minimized, whereas still being able to achieve reasonable brow elevation. Thus, our approach enables long term maintenance of brow elevation with inconspicuous scars in the forehead.

Case-control analysis and systematic literature review.To illustrate the prognosis and perioperative risk factors associated with this condition.Ischemic optic neuropathy (ION) is the most common pathological diagnosis underlying postoperative vision loss. It comes in two primary forms-anterior (AION)-affecting the optic disc or posterior (PION) affecting the optic nerve proximal to the disc. Spine surgery remains one of the largest sources of acute perioperative visual loss.We performed a 1:4 case-control analysis (by age and year of surgery) for patients with ION and those who didn't develop ION following spine surgery at our institution. A systematic literature search of Medline, Embase, Scopus from inception to September 2017 as also performed.We identified 12 cases from our institution. Comparison to 48 matched controls revealed fusion, higher number of operative levels, blood loss, and change in hemoglobin, hematocrit to be significantly associated with ION. Majority were diagnosed with PION (83%, 10/12) and had bilateral presentation (75%, 9/12). Only 30% patients (3/10) demonstrated improvement in visual acuity while the rest remained either unchanged (40%, 4/10) or worsened (20%, 2/10) at last follow-up. Literature review identified 182 cases from 42 studies. Posterior ischemic optic neuropathy (PION) was found in 58.7% (114/194) of cases, anterior ischemic optic neuropathy (AION) in 17% (33/19) and unspecified ION in 24% (47/194). PION was associated with higher odds of severe visual deficit at immediate presentation (odds ratio [OR]: 6.45, confidence interval [CI]: 1.04-54.3, P = 0.04) and last follow-up.PION is the most common cause of vision loss following spine surgery and causes more severe visual deficits compared with AION. Prone spine surgery especially multi-level fusions with longer operative time, higher blood loss, and intraoperative hypotension are most associated with the development of this devastating complication.3.

Background Hospitals across the United States are pursuing strategies to reduce avoidable readmissions but the evidence on how best to accomplish this goal is mixed, with no specific clinical practice shown to reduce readmissions consistently. Changes to hospital organizational practices, a key component of context, also may be critical to improving performance on readmissions, but this has not been studied. Objective The aim of this study was to understand how high-performing hospitals improved risk-stratified readmission rates, and whether their changes to clinical practices and organizational practices differed from low-performing hospitals. Design This was a qualitative study of 10 hospitals in which readmission rates had decreased (n=7) or increased (n=3). Participants A total of 82 hospital staff drawn from hospitals that had participated in the State Action on Avoidable Readmissions quality improvement initiative. Results High-performing hospitals were distinguished by several organizational practices that facilitated readmissions reduction, that is, collective habits of action or interpretation shared by organization members. First, high-performing hospitals reported focused efforts to improve collaboration across hospital departments. Second, they helped postacute providers improve care by sharing the hospital's clinical and quality improvement expertise and data. Third, high performers enthusiastically engaged in trial and error learning to reduce readmissions. Fourth, they emphasized that readmissions represented bad outcomes for patients, de-emphasizing the role of financial penalties. Both high-performing and low-performing hospitals had implemented most clinical practice changes commonly recommended to reduce readmissions. Conclusions Our findings highlight several organizational practices that hospitals may be able to use to enhance the effectiveness of their readmissions reduction efforts.

Hospice use has increased substantially during the past decade by an increasingly diverse patient population; however, little is known about patterns of hospice use and how these patterns have changed during the past decade.To characterize Medicare hospice users in 2000 and 2010 and estimate the prevalence of (1) very short (≤1 wk) hospice enrollment; (2) very long (6 mo) hospice enrollment; and (3) hospice disenrollment and how these utilization patterns have varied over time and by patient and hospice characteristics.Cross-sectional analysis of Medicare hospice claims data from 2000 and 2010.All US Medicare Hospice Benefit enrollees in 2000 (N=529,573) and 2010 (N=1,150,194).As of 2010, more than half (53.4%) of all Medicare decedents who used hospice had either very short (≤1 wk, 32.4%) or very long (6 mo, 13.9%) hospice enrollment or disenrolled from hospice before death (10.6%). This represents an increase of 4.9 percentage points from 2000. In multivariable analysis, patients with noncancer diagnoses, the fastest growing group of hospice users, were approximately twice as likely as those with cancer to have very short or long enrollment periods and to disenroll from hospice.The substantial proportion of hospice users with very short or long enrollment, or enrollments that end before death, underscores the potential for interventions to improve the timing and appropriateness of hospice referral so that the full benefits of hospice are received by patients and families.

Article, see p 154 Nallamothu and colleagues1 take a leap forward in their study, “How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed?:A Qualitative Study.” The article asks a life-or-death question, applies qualitative methods with sophistication, and cleverly takes advantage of naturally occurring diversity across institutions. In so doing, the authors uncover practical strategies for addressing a pressing clinical problem in affordable ways. At the end of the article, I am left with an inspiring question: What other nuggets of wisdom might we find if we were open to learning from diversity the way Nallamothu and colleagues have done? The question Nallamothu and colleagues tackle is important. Data from hospitals participating in the Get With The Guidelines–Resuscitation registry indicate a 3-fold difference in risk-standardized survival after in-hospital cardiac arrest,2 even as average rates improved from 13.7% in 2000 to 22.3% in 2009.3 Elevating hospitals from median to top performance in risk-standardized survival rates (median, 23.7%; top, 37.5% in the work by …

Reducing readmissions is a national priority, but many hospitals lack practical tools to identify patients at increased risk of unplanned readmission.To estimate the association between a composite measure of patient condition at discharge, the Rothman Index (RI), and unplanned readmission within 30 days of discharge.Adult medical and surgical patients in a major teaching hospital in 2011.The RI is a composite measure updated regularly from the electronic medical record based on changes in vital signs, nursing assessments, Braden score, cardiac rhythms, and laboratory test results. We developed 4 categories of RI and tested its association with readmission within 30 days, using logistic regression, adjusted for patient age, sex, insurance status, service assignment (medical or surgical), and primary discharge diagnosis.Sixteen percent of the sample patients (N=2730) had an unplanned readmission within 30 days of discharge. The risk of readmission for a patient in the highest risk category (RI70) was1 in 5 while the risk of readmission for patients in the lowest risk category was about 1 in 10. In multivariable analysis, patients with an RI70 (the highest risk category) or 70-79 (medium risk category) had 2.65 (95% confidence interval, 1.72-4.07) and 2.40 (95% confidence interval, 1.57-3.67) times higher odds of unplanned readmission, respectively, compared with patients in the lowest risk category.Clinicians can use the RI to help target hospital programs and supports to patients at highest risk of readmission.

Mixed methods studies, in which qualitative and quantitative methods are combined in a single program of inquiry, can be valuable in biomedical and health services research, where the complementary strengths of each approach can yield greater insight into complex phenomena than either approach alone. Although interest in mixed methods is growing among science funders and investigators, written guidance on how to conduct and assess rigorous mixed methods studies is not readily accessible to the general readership of peer-reviewed biomedical and health services journals. Furthermore, existing guidelines for publishing mixed methods studies are not well known or applied by researchers and journal editors. Accordingly, this paper is intended to serve as a concise, practical resource for readers interested in core principles and practices of mixed methods research. We briefly describe mixed methods approaches and present illustrations from published biomedical and health services literature, including in cardiovascular care, summarize standards for the design and reporting of these studies, and highlight four central considerations for investigators interested in using these methods.

One of the fundamental guiding principles of hospice is that the patient and family is the unit of care,1 reflecting the critical importance of including surviving family in the care of people with terminal illnesses. Consistent with this principle, services for family members, both before and following the patient’s death, are recognized as core components of high quality palliative care.2 This holistic model of caring for grieving family members dates back to the historical roots of the hospice movement in the United Kingdom, and was adopted by American hospices.3,4 Medicare, the primary payer of hospice care in the U.S., defines bereavement counseling as emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss and adjustment.5 Centers for Medicare & Medicaid Services (CMS) (2010) specifically require hospices to provide an initial and ongoing bereavement assessment of the needs of the patient’s family members and these assessments must be incorporated into the plan of care (§418.54(c)(7)). In addition, hospices must have an organized program established to provide bereavement services to family members for up to a year following the patient’s death (§418.64(d)).6 Evidence indicates that supportive services for grieving families can improve their post-loss adjustment,7,8,9 particularly if provided soon after a loss7 and to those at risk for prolonged or complicated grief.10,11,12,13,8 Despite the importance of serving families, we know little about the scope and intensity of hospice services provided to family members. Although Medicare certified hospice programs are required to provide support to bereaved family members, services are not separately billable, and the specific services provided are left to the discretion of the hospice. Because Medicare reimbursement is not tied to the level or quality of services provided to family members, limited financial incentives exist to provide more than a minimal level of care. One prior study by Carlson (2007) examined caregiver support services provided by hospices and found that although 59% of hospices provided personal care services, only 13% provided homemaker/household services and 7% provided respite care.14 A second study conducted with California hospices found substantial variation in the types of bereavement services provided.15 However, both of these studies focus on only a subset of family services and used data from more than a decade ago. Thus, we have limited information on the degree to which hospices provide care to families and how hospices may differ in their provision of family services. Accordingly, we conducted a national survey of hospices to better understand the scope and intensity of services provided to family members. We examined whether family services differed by hospice ownership status or by other organizational characteristics including: hospice chain affiliation, vertical integration with non-hospice health care facilities, age, region of the country, urbanicity, size (i.e., patients per day), patient-to-staff ratio, religious affiliation, concern about losing market share to competitors, and proportion of revenue from Medicare. We hypothesized that non-profit hospices would provide a richer array of services compared with for-profit hospices given the strong historical commitment to family-based care as hospice first emerged (under almost exclusively not-for-profit auspices) in the 1970s. Prior research indicated that hospice ownership affects length of stay, patient diagnosis, and other important outcomes,16,17,18 but no information is currently available on how ownership affects the scope of care provided to family members. In addition to the research on ownership, prior research has indicated that hospice organizational capacity including size, chain affiliation, years providing hospice care, nd share of revenue from Medicare are associated with hospice enrollment and disenrollment practices.19,20,21 Thus, we hypothesized that the organizational capacity of the hospice might be associated with available resources for providing services to family members. To test these hypotheses, we examined whether larger hospices, chain hospices, vertically integrated hospices, hospices with lower patient-to-staff ratios, older hospices and hospices in urban areas were more likely to provide comprehensive services to family member. Alternatively, financial constraints might prompt some hospices to provide a minimum level of bereavement care. Those with a smaller share of revenue from Medicare may provide fewer services to family members, in an effort to conserve scarce resources. In addition, we expected that religiously affiliated hospices might be predisposed toward providing more comprehensive bereavement services for families due to their greater emphasis on spirituality in the face of death. In prior work, researchers have speculated that religious affiliation might be associated with quality of care differences.22 Finally, we hypothesized that hospices reporting a concern about losing market share would provide more services to families. Findings from this study may be important to highlight key gaps in family services.

Background— Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know whether improvements in door-to-balloon times were shared equally among patient and hospital groups. Methods and Results— This analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention (acute myocardial infarction-8) inpatient measure from January 1, 2005, through September 30, 2010. For each calendar year, we summarized the characteristics of patients reported for the measure, including the number and percentage in each group, the median time to primary percutaneous coronary intervention, and the percentage with time to primary percutaneous coronary intervention within 75 minutes and within 90 minutes. Door-to-balloon time declined from a median of 96 minutes in the year ending December 31, 2005, to a median of 64 minutes in the 3 quarters ending September 30, 2010. There were corresponding increases in the percentage of patients who had times 75 years of age (median decline, 38 minutes), women (35 minutes), and blacks (42 minutes). Conclusion— National progress has been achieved in the timeliness of treatment of patients with ST-segment–elevation myocardial infarction who undergo primary percutaneous coronary intervention.

Background— In 2009, the Centers for Medicare & Medicaid Services is publicly reporting hospital-level risk-standardized 30-day mortality and readmission rates after acute myocardial infarction (AMI) and heart failure (HF). We provide patterns of hospital performance, based on these measures. Methods and Results— We calculated the 30-day mortality and readmission rates for all Medicare fee-for-service beneficiaries ages 65 years or older with a primary diagnosis of AMI or HF, discharged between July 2005 and June 2008. We compared weighted risk-standardized mortality and readmission rates across Hospital Referral Regions and hospital structural characteristics. The median 30-day mortality rate was 16.6% for AMI (range, 10.9% to 24.9%; 25th to 75th percentile, 15.8% to 17.4%; 10th to 90th percentile, 14.7% to 18.4%) and 11.1% for HF (range, 6.6% to 19.8%; 25th to 75th percentile, 10.3% to 12.0%; 10th to 90th percentile, 9.4% to 13.1%). The median 30-day readmission rate was 19.9% for AMI (range, 15.3% to 29.4%; 25th to 75th percentile, 19.5% to 20.4%; 10th to 90th percentile, 18.8% to 21.1%) and 24.4% for HF (range, 15.9% to 34.4%; 25th to 75th percentile, 23.4% to 25.6%; 10th to 90th percentile, 22.3% to 27.0%). We observed geographic differences in performance across the country. Although there were some differences in average performance by hospital characteristics, there were high and low hospital performers among all types of hospitals. Conclusions— In a recent 3-year period, 30-day risk-standardized mortality rates for AMI and HF varied among hospitals and across the country. The readmission rates were particularly high.

Outcomes research examines the effects of healthcare interventions and policies on health outcomes for individual patients and populations in routine practice, as opposed to the idealized setting of clinical trials. A national survey from 1998 to 2000 that evaluated the extent to which patients received established processes of care for 30 medical conditions illustrated the importance of outcomes research.1 Among adults living in 12 metropolitan areas in the United States, only half of patients received proven elements of preventive care, treatments for acute illness, and chronic disease management for which they were eligible. For cardiovascular conditions, the use of proven therapies varied widely from 68% to 25% of patients who received recommended care for coronary artery disease and atrial fibrillation, respectively.1 Despite these gaps between ideal and actual care, patient outcomes have improved in many fields. For instance, the age-adjusted mortality from cardiovascular disease in the United States fell by >40% from 1980 to 2000 as a result of improvements in risk factor modification and uptake of evidence-based treatments for coronary artery disease, myocardial infarction, and heart failure.2,3 Nevertheless, many Americans do not receive the ideal recommended care (either at all or in a timely fashion), whereas others receive too much or the wrong care.4,5 In the field of cardiovascular diseases, substantial opportunities for improvement remain. Outcomes research has generated a foundation of knowledge about what constitutes ideal care and what gaps exist between ideal and actual care, but we have less understanding about how to deliver this ideal care to every patient every day. The potential for basic science breakthroughs to reach and improve the health of individual patients and populations may be substantially delayed or may not be realized if science is not efficiently translated to action. Moreover, in many cases, increased delivery of …

Despite substantial improvement in recent years in hospital performance in many quality measures for acute myocardial infarction (AMI), national performance lags in a key publicly reported quality indicator for AMI--door-to-balloon time, the period from patient (with ST-segment elevation myocardial infarction or STEMI) arrival to provision of percutaneous coronary intervention or balloon angioplasty. Previous research has elucidated distinguishing features of hospitals that routinely achieved recommended door-to-balloon times for patients with STEMI. However, what has not been fully explored is how top-performing hospitals handle setbacks during the improvement process. In this study, we used qualitative methods to characterize the range of setbacks in door-to-balloon improvement efforts and the strategies used to address these barriers among hospitals that were ultimately successful in reducing door-to-balloon time to meet clinical guidelines. Setbacks included (1) failure to anticipate and address implications of initial changes in door-to-balloon processes for the system as a whole; (2) tension between and within departments and disciplines, which needed to gain consensus about how to reduce door-to-balloon time; and (3) waning attention to door-to-balloon performance as a top priority after the perceived goal of reducing treatment times had been reached. Our findings demonstrate key aspects of technical capacity, organizational culture, and environmental conditions that were factors in maintaining improvement efforts despite setbacks and hence may be critical to sustaining top performance. Understanding how top-performing hospitals recognize and respond to setbacks can help senior management promote organizational resiliency, leading to an environment in which learning, growth, and quality improvement can be sustained.

Background: Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospitals, clinicians, and policymakers. Evidence suggests hospital organizational culture is linked to patient outcomes; however, few studies have attempted to change organizational culture in order to improve patient outcomes, and none have addressed mortality for patients with AMI. We seek to address these gaps through a novel longitudinal intervention study, Leadership Saves Lives (LSL). We hypothesize that we will observe: 1) positive shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) increased use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) reduced in-hospital AMI mortality. Methodology and Results: We describe the methodology of LSL, a 3-year intervention study using a concurrent mixed methods design, guided by open systems theory and the AIDED model of diffusion, implemented in a national sample of 10 diverse U.S. hospitals and hospitals in their peer networks. Intervention hospital teams participate in: 1) annual convenings of the 10 hospitals; 2) semiannual workshops at each intervention hospital; and 3) a web-based learning community that includes a discussion board and a repository for resources and tools. We describe features of program design that allow us to promote and measure intervention fidelity, while also allowing for tailoring of the intervention to the unique local context in each hospital. We quantify changes in hospital practices, culture, and mortality through annual surveys of both intervention hospitals in their peer networks. In-person, in-depth interviews and selective observations of key interactions in care for patients with AMI allow us to describe the change process. The intervention began with an annual meting of the 10 intervention hospitals in June 2014. The first wave of survey data collection, hospital-specific workshops and qualitative data collection were completed between September and November 2014. Conclusions: LSL is novel in its use of a prospective longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, its attention to maintaining fidelity of the intervention across diverse hospital settings, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This study adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change, with direct impact on patients with AMI.

With the aging of the population, healthcare executives are paying increased attention to fostering safe and high-quality care for older adults who become hospitalized. The Hospital Elder Life Program (HELP) is an evidence-based program that has been shown to be cost-effective in reducing episodes of delirium, functional decline, and long-term nursing home placement for older hospitalized adults. Senior administrators are known to play a role in quality improvement, but little is known about their roles in adopting clinical improvement programs such as HELP. Therefore, we conducted a mixed-methods study of 63 hospitals at different stages of adopting HELP to identify key roles and motivations of senior management to adopt HELP and the perceived impact of HELP on patient and staff outcomes. Our findings can be used by hospital management teams as they identify ways to influence and benefit from efforts to improve clinical quality, safety, and the experiences of older adults treated in their hospitals.

Background— The success of prehospital triage protocols for patients with ST-elevation myocardial infarction (STEMI) will depend, in part, on how patients are geographically distributed around hospitals that perform percutaneous coronary intervention (PCI). Accordingly, we determined the proportion of the adult population in the United States with timely access to PCI hospitals using driving times and distances. Methods and Results— We performed a cross-sectional study using hospital-level data from the American Hospital Association Annual Survey and Census tract-level data on adults 18 years of age or older from the 2000 United States Census. Our aims were to determine the proportion of the adult population who (1) lived within 60 minutes of a PCI hospital and (2) had additional transport times within 30 minutes if directly referred to a PCI hospital as opposed to a closer, non-PCI hospital. Median times and distances to the closest PCI hospital were 11.3 (interquartile range [IQR] 5.7 to 28.5) minutes and 7.9 (IQR 3.5 to 22.4) miles, respectively. A total of 79.0% of the adult population lived within 60 minutes of a PCI hospital. Among those with a non-PCI hospital as their closest facility, 74.0% required additional transport times of Conclusions— Nearly 80% of the adult population in the United States lived within 60 minutes of a PCI hospital in 2000. Even among those living closer to non-PCI hospitals, almost three fourths would experience

Background— Treatment delays in patients with ST-segment–elevation myocardial infarction (STEMI) transferred for primary percutaneous coronary intervention (PCI) may decrease the advantage of this strategy over on-site fibrinolytic therapy that has been demonstrated in recent clinical trials. Accordingly, we sought to describe patterns of times to treatment in patients undergoing interhospital transfer for primary PCI in the United States. Methods and Results— We analyzed patients with STEMI undergoing interhospital transfer for primary PCI between January 1999 and December 2002 in the National Registry of Myocardial Infarction. The primary outcome was “total” door-to-balloon time measured from time of arrival at the initial hospital to time of balloon inflation at the PCI hospital. Multivariable hierarchical models were used to assess the relationship of total door-to-balloon time with patient and hospital characteristics. Among 4278 patients transferred for primary PCI at 419 hospitals, the median total door-to-balloon time was 180 minutes, with only 4.2% of patients treated within 90 minutes, the benchmark recommended by national quality guidelines. Comorbid conditions, absence of chest pain, delayed presentation after symptom onset, less specific ECG findings, and hospital presentation during off-hours were associated with longer total door-to-balloon times. Patients at teaching hospitals in rural areas also had significantly longer times to treatment. Conclusions— Total door-to-balloon times for transfer patients undergoing primary PCI in the United States rarely achieve guideline-recommended benchmarks, and current decision making should take these times into account. For the full benefits of primary PCI to be realized in transfer patients, improved systems are urgently needed to minimize total door-to-balloon times.

PURPOSE To compare Goldmann manual perimetry and Humphrey automated perimetry for sensitivity in detecting visual field loss, efficiency, and patient preference. METHODS This prospective study compared Goldmann manual perimetry and Humphrey automated perimetry testing techniques in 20 consecutive preoperative blepharoptosis patients with unilateral or bilateral blepharoptosis with a marginal reflex distance of ≤+2.5 mm, no dermatochalasis overhanging the eyelid margin, and no superior visual field defects due to glaucoma, neurologic disease, or other causes. Main outcome measures included efficiency, patient preference, and sensitivity in detecting visual field loss. Institutional review board approval was obtained prior to the start of the study. RESULTS Goldmann perimetry had significantly shorter examination times (-Δ6.4 minutes, 95% confidence interval: 4.5-8.3, p < 0.001) and was preferred by most patients (70%). There was no statistically significant difference between the 2 techniques in detecting superior visual field loss at 90° meridian. CONCLUSIONS Goldmann manual perimetry for assessing visual field loss in blepharoptosis patients is more efficient than Humphrey automated perimetry and is preferred by patients. Both techniques are sensitive in detecting ptosis-related visual field loss.

The number of for-profit hospices increased nearly 4-fold over the past decade, more than 6 times the growth of nonprofit hospices. Despite this growth, the impact of ownership on hospice care is largely unknown. We sought to assess differences in the provision of services to patients of for-profit and nonprofit hospices.Using the 1998 National Home and Hospice Care Survey, we examined services used by patients (N = 2080) cared for by 422 hospices nationwide. We used multivariable ordered logistic and logistic regression to assess the effect of profit status on service use, adjusting for potentially confounding patient and organizational characteristics. We calculated point estimates adjusted for sampling weights and standard errors adjusted for the clustering of patients within hospices.In ordered logistic models controlling for organizational and patient factors, patients of for-profit hospices received a significantly narrower range of services (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.22-0.92) than patients of nonprofit hospices. This result is driven by patients of for-profit hospices receiving significantly fewer types of hospice services that federal regulations term "noncore" or more discretionary services (adjusted OR, 0.34; 95% CI, 0.15-0.75).The pattern of care differs in for-profit and nonprofit hospices. As the industry develops a substantial for-profit presence, it is critical for clinicians and other healthcare professionals to be alert to the potential impact of profit status on the care their patients receive.

With increasing attention directed at quality problems and medical errors in healthcare organizations, the ability of senior management to promote and sustain effective quality improvement efforts is paramount to their organizational success. We sought to define key roles and activities that comprise senior managers' involvement in improvement efforts directed at physicians' prescription of beta-blockers after acute myocardial infarction (AMI). We also developed a taxonomy to organize the diverse roles and activities of managers in quality improvement efforts and proposed key elements that might be most central to successful improvement efforts. Results are based on a qualitative study of 8 hospitals across the country and included in-depth interviews with 45 clinical and administrative staff from these hospitals. The findings help identify a checklist that senior managers may use to assess their own and others' participation in quality improvement efforts in their institutions. By reinforcing their current involvement or by identifying potential gaps in their involvement in quality improvement efforts, practitioners may enhance their effectiveness in promoting and sustaining quality in clinical care.

Purpose Health care institutions are examining ways to improve physicians' skills in the delivery of end-of-life (EOL) care. Experts have suggested that influencing physicians' knowledge and attitudes concerning EOL care can influence subsequent EOL practices, including hospice use for appropriate patients; yet few studies have examined empirically the influence of physicians' knowledge and attitudes on such practices. The authors assessed the influences of self-rated knowledge and attitudes on physicians' discussions and referrals for hospice care. Method In 1998 and 1999 the authors conducted a cross-sectional study of physicians affiliated with six randomly selected community hospitals in Connecticut with more than 200 licensed medical and surgical beds. Physicians completed a self-administered questionnaire (response rate 52.4%) that assessed self-rated knowledge of terminal care and hospice, a set of attitudinal items, and practices related to hospice discussion and referrals, as well as standard sociodemographic data. Bivariate and multivariate analyses were conducted. Results Self-rated knowledge was significantly associated with referral practices in unadjusted analyses (unadjusted odds ratio [OR]: 0.70; 95% confidence interval [CI]: 0.52, 0.95), although this association was attenuated in adjusted analyses by specialty and other physicians' characteristics (adjusted OR: 0.80; 95% CI: 0.55, 1.18). Attitudes representing support for hospice practices and philosophy were associated with referral practices in adjusted and unadjusted analyses (adjusted OR:0.52; 95% CI: 0.35, 0.77). Conclusions This study demonstrated that self-rated knowledge and attitudes may influence hospice referral. The results support current efforts to develop medical school curricula and continuing education programs that better cover the many aspects of caring for the dying, including hospice use.

Purpose To review the clinical features and outcomes of patients with radiation-induced meningiomas involving the orbit. Design Retrospective case series. Participants Eight patients with radiation-induced meningiomas affecting the orbit. Methods Clinical and pathologic data of the patients were reviewed. Main outcome measures Age at diagnosis, mean interval between radiation therapy and meningioma diagnosis, tumor recurrence, histologic atypia, and mean follow-up time after initial diagnosis. Results The mean age at diagnosis was 42 years (range, 21 years to 70 years). The mean interval between radiation therapy and meningioma diagnosis was 26 years (range, 3 years to 54 years). All patients underwent gross total resection or subtotal resection of the meningioma. Five tumors (62.5%) recurred, based on clinical findings and CT imaging. The mean interval between resection of the meningioma and recurrence was 3 years (range, 9 months to 9 years). Three patients (37.5%) had atypical meningiomas. One patient (12.5%) had multiple tumors. The mean follow-up interval was 7 years after initial diagnosis of the meningioma (range, 15 months to 19 years). Conclusions This series of radiation-induced meningiomas, the first in the ophthalmic literature, illustrates the aggressive nature of this tumor.

Purpose: To describe the clinical course and histopathologic features of a patient with adrenocortical carcinoma metastatic to the orbit. Methods: Case report and literature review. Results: A 24-year-old man first came to medical attention because of symptoms referable to a 4.47-kg, nonfunctioning carcinoma of the left adrenal cortex. Several metastases ensued, including a large tumor to the right superior lateral bony orbit with extension to the brain, temporalis fossa, and orbit proper. The tumor was resected with the use of a combined neurosurgical, ophthalmic, and craniofacial approach. The patient died of widespread metastatic disease 15 months after the orbital operation. Conclusions: Metastasis to the orbit from adrenocortical carcinoma is rare. Surgical resection is the treatment of choice, with adjunctive radiation therapy and chemotherapy in some cases. The prognosis is poor.

Despite the many graduate programs that specialize in health administration, healthcare leaders and practitioners have expressed concern about the quality of preparation of health administration graduates. The purpose of this study was to facilitate one part of an integrated approach to leadership development that spans academic and practitioner settings. The approach was to design a competency assessment tool for early careerists who have two to five years of postgraduate experience and who aspire to fill senior leadership positions in complex, provider-based healthcare organizations. Open-ended interviews with key informants and a comprehensive review of relevant literature were done to identify and categorize a set of competencies relevant to early careerists. Based on data from key informants, specific work experiences and academic courses were mapped to each competency, indicating where and how such competencies might be developed. A simple rating system was then added to assess each competency, which resulted in the completion of the tool. Finally, the tool was piloted in a practitioner setting at the Massachusetts General Hospital Administrative Fellowship Program and in an academic setting at the Yale University Health Management Program. The resulting tool includes 52 competencies categorized into four domains: (1) technical skills (operations, finance; information resources, human resources, and strategic planning/external affairs); (2) industry knowledge (clinical process and healthcare institutions); (3) analytic and conceptual reasoning; and (4) interpersonal and emotional intelligence. Early experience with the tool suggests that it can facilitate career planning among graduate students, early careerists, and their mentors. Further, the tool can help directors of both academic and practitioner programs identify strengths and gaps in their existing curricula or training programs. By offering specific competencies linked to work experiences and graduate courses, the tool is an initial step toward promoting collaborative efforts between academic and practitioner programs.

Purpose: To describe the results of surgical correction of blepharoptosis in a series of patients with myasthenia gravis (MG). Methods: In this retrospective case series, we reviewed the medical records of all patients with MG who did not respond to medical therapy and underwent surgical correction for blepharoptosis at the Mayo Clinic between 1985 and 1999. The primary outcome measure was change in interpalpebral eyelid fissure height. Results: Sixteen blepharoptosis procedures were performed on 10 patients with MG. Eight of the 10 patients had ocular MG. Two of the 10 patients had systemic MG. Of the 16 procedures performed, 9 were external levator advancements (ELA), six were frontalis slings, and one was a tarsomyectomy. Patients were followed postoperatively for an average of 34 months (range, 14-126 months). The amount of ptosis was quantified pre- and postoperatively for seven of the nine eyelids that underwent ELA. For these seven eyelids (five patients), there was a statistically significant improvement in the mean interpalpebral eyelid fissure height from 3.7 mm preoperatively to 7.8 mm postoperatively, with a mean difference of 4.1 mm (95% confidence interval 1.9 mm to 6.25 mm, p = 0.0038). Postoperative complications included worsened diplopia in one patient with ELA and exposure keratopathy in one patient with frontalis sling. Two of the ELA eyelids developed recurrent ptosis requiring additional surgery more than 2 years after the initial procedure. Conclusions: Blepharoptosis surgery can achieve eyelid elevation in patients who have failed to respond to medical therapy for MG. Potential complications include worsened diplopia and exposure keratopathy.

Medical ethics and professionalism have come to play an increasingly important role in medical practice since the 1980s, but there still is widespread concern about unethical and unprofessional behavior. This survey, based on in-depth interviews held in 2001 with 31 internal medicine residents in 1 traditional and 1 primary care residency at Yale University, was intended to identify the work-related ethical conflicts experienced by these medical house officers. The interviews, which took 18 to 60 minutes, used a standardized guide with probes for clarification and additional detail. Without exception, the participants reported having uncomfortable, improper, unethical, or unprofessional experiences with patients. In 90% of cases, the respondent had been directly involved. These experiences were classified into 5 broad categories: 1) Telling the truth. Many ways of manipulating information were used to avoid telling patients the truth, including delaying or omitting information and, in some instances, lying. These behaviors were variably ascribed to pressure from attending physicians, families, peers, or patients themselves. Relevant topics were diagnoses, prognoses, and statements about how experienced residents were with specific procedures. 2) Respecting patients' wishes. Residents sometimes were unable to ensure that the patient's wishes were respected because of disagreement on the part of the medical team, the patient, or the family about what the patient truly wished and what was in the patient's best interest. 3) Preventing harm. Several residents were distressed by having to accept the risks inherent in needed treatments or procedures. Occasionally, there was concern about the risk arising from the resident's limited experience with a given procedure. 4) Managing the limits of one's competence. Some residents felt inadequately prepared to perform their duties and were uncertain of what to do about it. They often were concerned about how their attending physician, peers, and patients would perceive the situation. Some residents felt it necessary to act as if they were more experienced than they believed they actually were. Some had trouble acknowledging their shortcomings. 5) Addressing the performance of others that is perceived as inappropriate. Residents experienced conflict when they viewed a peer's or an attending physician's performance as inadequate or inappropriate. They were uncertain about whether to challenge, intervene, or report the behavior while at the same time being accepted and approved by their colleagues. Hopefully, the challenges faced by medical residents will lead to better education in ethics and professionalism. Ultimately, residents must learn when compromising ethical standards might be acceptable and when it is not.

Background: High quality emergency medical services (EMS) care is important for the care of patients with acute myocardial infarction (AMI). Evidence suggests that active collaboration between EMS and hospital clinicians caring for patients with AMI is significantly associated with AMI mortality rates; however, the nature of such collaborations has not been examined. We sought to understand collaborations between EMS and hospitals in the care of patients hospitalized with AMI. Methods: We performed a qualitative study of key clinical and administrative hospital staff most closely involved with AMI care. We arrayed hospitals based on their 30-day risk-standardized AMI mortality rates (RSMRs) using Centers for Medicare and Medicaid Services data from 2005-2007. We selected hospitals that ranked in the top 5% and bottom 5% of performance for both years. We conducted site visits and in-depth interviews (n=158) until successive site visits generated no new concepts, which occurred after 11 site visits. A multidisciplinary team analyzed the data using the constant comparative method to generate recurrent themes. Atlas Ti software facilitated data organization and retrieval. Results: Although both high and low performing hospitals perceived that EMS plays an important role in AMI care, high performing hospitals reported a close collaborative relationship that differed in nature and intensity from that described by the low performers in several aspects: 1) high level of respect for EMS as valued professionals and colleagues; 2) investment in diverse strategies to facilitate communication between the hospital and EMS, such as employing a hospital-based EMS liaison to provide training and support to prehospital providers and to ensure smooth and timely flow of information; and 3) active engagement of EMS in AMI care quality improvement efforts, including providing data feedback to EMS agencies on their performance. Conclusion: The relationship between EMS and the AMI care teams differed between high and low performing hospitals, with the high performing hospitals describing multifaceted strategies to support collaboration with EMS in providing AMI care. These strategies may be useful for hospitals seeking to improve the care of patients with AMI.

In an effort to improve DTB times, the D2B Alliance enrolled ~900 PCI hospitals across the U.S. in a large quality improvement initiative. We compared changes in DTB times for hospitals in the GWTG Registry that enrolled in the D2B Alliance with those that did not. We used data on DTB times from Jul 06 to Mar 08 to allow for 1 quarter of baseline data prior to the D2B Alliance launch and 1 year of follow-up data. We limited our analysis to STEMI patients undergoing primary PCI and excluded transfer-in cases. DTB times were defined from hospital arrival to first device. We evaluated the % of patients treated within 90 minutes using GEE models to examine trends over time, with interaction terms added to assess the specific effect of the D2B Alliance. 5801 patients at 167 hospitals - 98 in the D2B Alliance and 69 that were not - were included. No significant differences were noted in age, gender, race, prior CAD and rates of compliance with composite AMI performance measures between patients at D2B Alliance and non-D2B Alliance hospitals; however, more D2B Alliance hospitals had on-site cardiac surgery (89% vs. 74%). At baseline 54.6% and 53.1% of patients at D2B Alliance and non-D2B Alliance hospitals were treated within 90 minutes, respectively; these numbers increased to 75.3% and 71.6% (both p ). However, no significant differences were noted in rate of change between D2B Alliance and non-D2B Alliance hospitals. The proportion of STEMI patients treated within 90 minutes improved since initiation of the D2B Alliance. Among GWTG hospitals, this improvement was not limited to facilities that directly participated.

CHD claims the lives of more women than any other disease, yet few women perceive that they are at risk for this serious health condition. Public education campaigns have been implemented to heighten women’s awareness of CHD. The aim of this study was to determine factors associated with the perception of one’s lifetime risk for AMI in women residing in an area in which great effort was made to educate the public about women and CHD. This longitudinally-repeated, cross-sectional study involved five annual random-digit dialing surveys conducted before (2001) and after (2002 – 2005) implementing a local women and CHD public education campaign. The mean age in this sample of 1,470 women was 54 ± 8 years and the majority were White (91%), with >high school education (67%). Only 45% perceived that they were at risk for AMI, yet 84% had one or more cardiac risk factors. Logistic regression analysis, adjusted for demographic characteristics; CHD risk factors, sources of information, and knowledge; lifestyle behaviors; and survey year, revealed that the perception of lifetime AMI risk increases with every additional risk factor (OR = 1.77; 95% CI = 1.60, 1.95), knowing other women with an AMI (OR = 1.76; 95% CI = 1.40, 2.22), having discussed heart-health concerns with physician (OR = 1.42; 95% CI = 1.02, 1.98), knowledge of AMI signs common in women (OR = 1.39; 95% CI = 1.10, 1.74), and receipt of primary care from an internal medicine or family practice physician (OR = 1.36; 95% CI = 1.02, 1.81). Public education campaigns alone may not be the most effective means of increasing women’s perception of their lifetime risk of AMI. These results underscore the importance of gender-specific, individualized CHD education. Women personalize their risk for AMI when the sources of information are valued human resources, such as healthcare professionals and women who have had an AMI.

Background: Whether patients with STEMI with longer times from symptom onset to hospital presentation are less likely to be treated with any reperfusion therapy or treated with less urgency resulting in longer door-to-balloon and door-to-needle times is not known. The relationship between delay in hospital presentation and the quality of reperfusion therapy for patients with STEMI has not been examined Methods: We constructed 3 cohorts of STEMI patients to analyze use of any reperfusion (n=440,398), door-to-balloon time (n=67,207), and door-to-drug time (n=183,441) as a function of delay in hospital presentation. We constructed multivariable generalized linear models for each outcome to estimate the associations between delay in hospital presentation adjusted for all patient and hospital characteristics. Results: In adjusted analysis, longer times from symptom onset to hospital presentation was associated with lower use of any reperfusion therapy (p1 to 2 hours, and >2 to 3 hours, 77%, 77%, and 73% of patients received any reperfusion therapy, respectively, and late presenters with times >9 to 10 hours, >10 to 11 hours, and >11 to 12 hours were treated with any reperfusion therapy in 53%, 50%, and 46%, respectively. Delay in hospital presentation was associated with longer drug-to-balloon and door-to-drug times (p1 to 2 hours, >2 to 3 hours, >9 to 10 hours, >10 to 11 hours, and >11 to 12 hours, patients with STEMI were treated with door-to-balloon times of 99, 101, 106, 123, 125, and 123 minutes respectively. For delay time intervals of ≤ 1 hour, >1 to 2 hours, >2 to 3 hours, >9 to 10 hours, >10 to 11 hours, and >11 to 12 hours, patients were treated with door-to-drug times of 32, 34, 36, 46, 44, and 46 minutes, respectively. Conclusions: Longer time from symptom onset to hospital presentation has important implications for subsequent treatment and was associated with lower use of any reperfusion therapy and longer door-to-balloon and door-to-drug times. Longer delay in hospital presentation is associated with worse system performance for reperfusion therapy quality and represents an opportunity to improve quality of care for STEMI patients.

Young diabetics can sometimes have difficulty with insulin compliance for various reasons. This can be exacerbated if associated with body dysmorphic disorder or other eating disorders. The manipulation of insulin to lose weight can have devastating consequences. The authors describe a fatal case of rhino-orbital-cerebral mucormycosis secondary to insulin manipulation for the purpose of weight loss.