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OBJECTIVE To examine the financial impact of quality improvement using Medicare payment data. BACKGROUND Demonstrating a business case for quality improvement--that is, that fewer complications translates into lower costs--is essential to justify investment in quality improvement. Prior research is limited to cross-sectional studies showing that patients with complications have higher costs. We designed a study to better evaluate the relationship between payments and complications by using quality improvement itself as a measured outcome. METHODS We used national Medicare data for patients undergoing general (n = 1,485,667) and vascular (n = 531,951) procedures. We calculated hospitals' rates of serious complications in 2 time periods: 2003-2004 and 2009-2010. We sorted hospitals into quintiles by the change in complication rates across these time periods. Costs were assessed using price-standardized Medicare payments, and regression analyses used to determine the average change in payments over time. RESULTS There was significant change in serious complication rates across the 2 time periods. The top 20% of hospitals demonstrated a 38% decrease (14.3% vs 11.6%, P < 0.001) in complications; in contrast the bottom 20% demonstrated a 25% increase (11.1% vs 16.5%, P < 0.001). There was a strong relationship between quality improvement and payments. The top hospitals reduced their payments by $1544 per patient (95% confidence interval: $1334-1755), whereas the bottom of hospitals had no significant change (average $67 increase, 95% confidence interval: -$123 to $258). CONCLUSIONS Hospitals that reduced their complications over time had significant reductions in Medicare payments. This demonstrates that payers are clearly incentivized to invest in quality improvement.

Background In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented additional restrictions on resident work hours. Although the impact of these restrictions on the education of surgical trainees has been examined, the effect on patient safety remains poorly understood. Methods We used national Medicare Claims data for patients undergoing general (n = 1,223,815) and vascular (n = 475,262) surgery procedures in the 3 years preceding the duty hour changes (January, 2009–June, 2011) and the 18 months thereafter (July, 2011–December, 2012). Hospitals were stratified into quintiles by teaching intensity using a resident to bed ratio. We utilized a difference-in-differences analytic technique, using nonteaching hospitals as a control group, to compare risk-adjusted 30-day mortality, serious morbidity, readmission, and failure to rescue (FTR) rates before and after the duty hour changes. Results After duty hour reform, no changes were seen in the measured outcomes when comparing teaching with nonteaching hospitals. Even when stratifying by teaching intensity, there were no differences. For example, at the highest intensity teaching hospitals (resident/bed ratio of ≥0.6), mortality rates before and after the duty hour changes were 4.2% and 4.0%, compared with 4.7% and 4.4% for nonteaching hospitals (relative risk [RR], 0.98; 95% CI, 0.89–1.07). Similarly, serious complication (RR, 1.02; 95% CI, 0.98–1.06), FTR (RR, 0.95; 95% CI, 0.87–1.04), and readmission (odds ratio, 1.00; 95% CI, 0.96–1.03) rates were unchanged. Conclusion In Medicare beneficiaries undergoing surgery at teaching hospitals, outcomes have not improved since the 2011 ACGME duty hour regulations.

The ring transformation of 3-aryl-5-methyl-1,3,4-oxadiazolin-2-ones 1a–n into 4-amino-2-aryl-5-methyl-2,4-dihydro-3 H-1,2,4-triazol-3-ones 3a–n, by reaction with hydrazine hydrate, is described. The products were screened for biological activity, and were found to be active against fungal strains.

Importance In the United States, reports about perioperative complications associated with bariatric surgery led to the establishment of accreditation criteria for bariatric centers of excellence and many bariatric centers obtaining accreditation. Currently, most bariatric procedures occur at these centers, but to what extent they uniformly provide high-quality care remains unknown. Objective To describe the variation in surgical outcomes across bariatric centers of excellence and the geographic availability of high-quality centers. Design, Setting, and Participants This retrospective review analyzed the claims data of 145 527 patients who underwent bariatric surgery at bariatric centers of excellence between January 1, 2010, and December 31, 2013. Data were obtained from the Healthcare Cost and Utilization Project’s State Inpatient Database. This database included unique hospital identification numbers in 12 states (Arkansas, Arizona, Florida, Iowa, Massachusetts, Maryland, North Carolina, Nebraska, New Jersey, New York, Washington, and Wisconsin), allowing comparisons among 165 centers of excellence located in those states. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Those included in the study cohort were patients with a primary diagnosis of morbid obesity and who underwent laparoscopic Roux-en-Y gastric bypass, open Roux-en-Y gastric bypass, laparoscopic gastric band placement, or laparoscopic sleeve gastrectomy. Excluded from the cohort were patients younger than 18 years or who had an abdominal malignant neoplasm. Data were analyzed July 1, 2016, through January 10, 2017. Main Outcomes and Measures Risk-adjusted and reliability-adjusted serious complication rates within 30 days of the index operation were calculated for each center. Centers were stratified by geographic location and operative volume. Results In this analysis of claims data from 145 527 patients, wide variation in quality was found across 165 bariatric centers of excellence, both nationwide and statewide. At the national level, the risk-adjusted and reliability-adjusted serious complication rates at each center varied 17-fold, ranging from 0.6% to 10.3%. At the state level, variation ranged from 2.1-fold (Wisconsin decile range, 1.5%-3.3%) to 9.5-fold (Nebraska decile range, 1.0%-10.3%). After dividing hospitals into quintiles of quality on the basis of their adjusted complication rates, 38 of 132 (28.8%) had a center in a higher quintile of quality located within the same hospital service area. Variation in rates of complications existed at centers with low volume (annual mean [SD] procedure volume, 156 [20] patients; complication range, 0.6%-6.4%; 9.8-fold variation), medium volume (annual mean [SD] procedure volume, 239 [27] patients; complication range, 0.6%-10.3%; 17.5-fold variation), and high volume (annual mean [SD] procedure volume, 448 [131] patients; complication range, 0.6%-4.9%; 7.5-fold variation). Conclusions and Relevance Even among accredited bariatric surgery centers, wide variation exists in rates of postoperative serious complications across geographic location and operative volumes. Given that a large proportion of centers are geographically located near higher-performing centers, opportunities for improvement through regional collaboratives or selective referral should be considered.

Importance Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important. Objective To describe the use of medical consultations for hospitalized surgical patients, factors associated with use, and practice variation across hospitals. Design, Setting, and Participants Observational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. Main Outcomes and Measures Number of inpatient medical consultations. Results More than half of patients undergoing colectomy (91 684) or THR (339 319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). Median consultant visits from a medicine physician were 9 (interquartile range [IQR], 4-19) for colectomy and 3 for THR (IQR, 2-5). The likelihood of having at least 1 medical consultation varied widely among hospitals (interquartile range [IQR], 50%-91% for colectomy and 36%-90% for THR). For colectomy, settings associated with greater use included nonteaching (adjusted risk ratio [ARR], 1.14 [95% CI, 1.04-1.26]) and for-profit (ARR, 1.10 [95% CI, 1.01-1.20]). Variation in use of medical consultations was greater for colectomy patients without complications (IQR, 47%-79%) compared with those with complications (IQR, 90%-95%). Results stratified by complications were similar for THR. Conclusions and Relevance The use of medical consultations varied widely across hospitals, particularly for surgical patients without complications. Understanding the value of medical consultations will be important as hospitals prepare for bundled payments and strive to enhance efficiency.

Objective: We sought to determine whether the changes in incentive design in phase 2 of Medicare's flagship pay-for-performance program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals. Background: The Premier HQID was initiated in 2003 to reward high-performing hospitals. The program redesigned its incentive structure in 2006 to also reward hospitals that achieved significant improvement. The impact of the change in incentive structure on outcomes in surgical populations is unknown. Methods: We examined discharge data for patients who underwent coronary artery bypass (CABG), hip replacement, and knee replacement at Premier hospitals and non-Premier hospitals in Hospital Compare from 2003 to 2009 in 12 states (n = 861,411). We assessed the impact of incentive structural changes in 2006 on serious complications and 30-day mortality. In these analyses, we adjusted for patient characteristics using multiple logistic regression models. To account for improvement in outcomes over time, we used difference-in-difference techniques that compare trends in Premier versus non-Premier hospitals. We repeated our analyses after stratifying hospitals into quintiles according to risk-adjusted mortality and serious complication rates. Results: After restructuring incentives in 2006 in Premier hospitals, there were lower risk-adjusted mortality and complication rates for both cardiac and orthopedic patients. However, after accounting for temporal trends in non-Premier hospitals, there were no significant improvements in mortality for CABG [odds ratio (OR) = 1.09; 95% confidence interval (CI), 0.92–1.28] or joint replacement (OR = 0.81; 95% CI, 0.58–1.12). Similarly, there were no significant improvements in serious complications for CABG (OR = 1.05; 95% CI, 0.97–1.14) or joint replacement (OR = 1.12; 95% CI, 1.01–1.23). Analysis of the “worst” quintile hospitals that were targeted in the incentive structural changes also did not reveal a change in mortality [(OR = 1.01; 95% CI, 0.78–1.32) for CABG and (OR = 0.96; 95% CI, 0.22–4.26) for joint replacement] or serious complication rates [(OR = 1.08; 95% CI, 0.88–1.34) for CABG and (OR = 0.92; 95% CI, 0.67–1.28) for joint replacement]. Conclusions: Despite recent enhancements to incentive structures, the Premier HQID did not improve surgical outcomes at participating hospitals. Unless significantly redesigned, pay-for-performance may not be a successful strategy to improve outcomes in surgery.

We describe handwashing practices, the association of handwashing with upper respiratory and gastrointestinal symptoms, and the effects of gender on handwashing practices among male (n = 215) and female (n = 243) college students. Self-reported frequency of handwashing was not associated with infectious illness symptom reporting. Only a small proportion of males (10%) and females (7%) reported "always" washing their hands before eating. Females were more likely than males to always wash their hands after urinating (69% vs 43%; P.0001) and after a bowel movement (84% vs 78%; P = .14). Identifying new strategies to increase handwashing may help prevent infectious disease transmission in residence hall environments.

Summary Introduction This study was conducted to determine the effect of oral midazolam (OM) or intranasal dexmedetomidine (IND) on the EC50 of sevoflurane for successful laryngeal mask airway placement in children. We hypothesize that premedication with either agent might reduce the sevoflurane EC50 for laryngeal mask airway placement in children to a similar extent. Methods Fifty-two American Society of Anesthesiologists (ASA) I children (aged 1–6 years) scheduled for general anesthesia with laryngeal mask airway were randomized to one of the three groups: group M received 0.5 mg·kg−1 OM with honey and intranasal saline, group D received 2 μg·kg−1 IND along with oral honey, and group P received oral honey and intranasal saline at least 30 min prior to induction of anesthesia. Anesthesia was induced with incremental sevoflurane up to 8% in 100% O2. A predetermined target endtidal sevoflurane (ETsevo) concentration (2% in the first child of all three groups) was sustained for 10 min before the attempt of laryngeal mask airway insertion by adjusting dial concentration. No intravenous anesthetic or neuromuscular blockade was used. ETsevo was increased/decreased (step size 0.2%) using Dixon's and Massey's up and down method in next patient depending upon previous patient's response. Placement of the laryngeal mask airway without movement, coughing, biting, or bucking was considered as successful. EC50 of sevoflurane was calculated as the average of the crossover midpoints in each group, which was further confirmed by probit analysis. Results The EC50 of sevoflurane for laryngeal mask airway placement after OM (1.66 ± 0.31) and IND (1.57 ± 0.14) premedications was significantly lower than the placebo group (2.00 ± 0.17, P

Some of the successful applications of the image processing techniques are in the area of medical imaging. The development of sophisticated imaging devices coupled with the advances in algorithms specific to the medical image processing both for diagnostics and therapeutic planning is the key to the wide popularity of the image processing techniques in the field of medical imaging. Ultrasound imaging is one of the methods of obtaining images from inside the human body through the use of high frequency sound waves. The reflected sound wave echoes are recorded and displayed as a real time visual image. It is a useful way of examining many of the body’s internal organs including heart, liver, gall bladder, kidneys and ovaries. The detection of follicles in ultrasound images of ovaries is concerned with the follicle monitoring during the diagnostic process of infertility treatment of patients.

Critical access hospitals are a predominant source of care for many rural populations. Previous reports suggest these centers provide lower quality of care for common medical admissions. Little is known about the outcomes and costs of patients admitted for surgical procedures.To compare the surgical outcomes and associated Medicare payments at critical access hospitals vs non-critical access hospitals.Cross-sectional retrospective review of 1,631,904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3676) for 1 of 4 common types of surgical procedures-appendectomy, 3467 for critical access and 151,867 for non-critical access; cholecystectomy, 10,556 for critical access and 573,435 for non-critical access; colectomy, 10,198 for critical access and 577,680 for non-critical access; hernia repair, 4291 for critical access and 300,410 for non-critical access-between 2009 and 2013. We compared risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation.Undergoing surgical procedures at critical access vs non-critical access hospitals.Thirty-day mortality, postoperative serious complications (eg, myocardial infarction, pneumonia, or acute renal failure and a length of stay75th percentile). Hospital costs were assessed using price-standardized Medicare payments during hospitalization.Patients (mean age, 76.5 years; 56.2% women) undergoing surgery at critical access hospitals were less likely to have chronic medical problems, and they had lower rates of heart failure (7.7% vs 10.7%, P .0001), diabetes (20.2% vs 21.7%, P .001), obesity (6.5% vs 10.6%, P .001), or multiple comorbid diseases (% of patients with ≥2 comorbidities; 60.4% vs 70.2%, P .001). After adjustment for patient factors, critical access and non-critical access hospitals had no statistically significant differences in 30-day mortality rates (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89-1.03; P = .28). However, critical access vs non-critical access hospitals had significantly lower rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.32-0.39; P .001). Medicare expenditures adjusted for patient factors and procedure type were lower at critical access hospitals than non-critical access hospitals ($14,450 vs $15,845; difference, -$1395, P .001).Among Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with non-critical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower-adjusted Medicare expenditures, but were less medically complex.

Knowledge about the status of the female reproductive system is important for fertility problems and age related family planning. The volume of these fertility requests in our emancipated society is steadily increasing. Transvaginal ultrasound imaging of the follicles in the ovary gives important information about the ovarian aging, i.e., number of follicles, size, position and response to hormonal stimulation. Manual analysis of many follicles is laborious and error-prone. In this paper, a new method for recognition of follicles in ultrasound images of ovaries is proposed. This fully automated segmentation method is based on active contours without edge method. The proposed technique is tested on ultrasonographic images of ovaries. The experimental results are compared with inferences drawn by medical expert and demonstrate the efficacy of the method.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Tumor necrosis factor (TNF)-alpha is an important player in granuloma formation, and recent clinical trials have investigated the efficacy of TNF-alpha inhibitors in sarcoidosis. Paradoxically, there are several case reports in the medical literature describing the development of sarcoidosis in patients treated with TNF-alpha inhibitors. We describe 3 cases of TNF-alpha antagonist-induced sarcoidosis: 1 case of pulmonary, ocular and cutaneous sarcoidosis developing in a patient receiving infliximab for erosive rheumatoid arthritis, 1 case of etanercept-induced sarcoidosis in a patient with seronegative rheumatoid arthritis, and 1 case of sarcoidosis developing in a patient receiving etanercept for erosive rheumatoid arthritis. We also provide a brief discussion on the role of TNF alpha in granuloma formation and implications in the use of TNF-alpha antagonists in autoimmune disease.