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Background Many patients with keloids experience symptoms, such as pain and pruritus, and may present with significant psychosocial burdens. However, no single therapeutic regimen has been firmly established for treatment of keloids. Objectives The aim of this study was to assess patients’ perspectives on their keloids after treatment by comparing preoperative and postoperative surveys. Methods All patients seen at the keloid clinic, both preoperatively and postoperatively, were contacted by telephone call. Information about demographics, keloid characteristics, and levels of pain and pruritus were recorded. Participants also completed all 3 parts (appearance, symptoms, and psychosocial impact) of the SCAR-Q, a validated patient-reported outcome measure questionnaire. Statistical analysis was performed with SPSS version 23 (IBM Corp., Armonk, NY). Results Of the 60 patients who participated in the study, 35 preoperative and 34 postoperative surveys were completed. Patients experienced significant reductions in mean [standard deviation] pain levels (from 5.6 [4.0] to 0.1 [0.4], P Conclusions Patients with keloids experience significant improvement in their symptomatic and psychosocial burden after treatment. Although management modalities are not well established, it is essential that plastic surgeons do not overlook the therapeutic benefits for their patients’ well-being.

Background: There is an evident need for Negative Pressure Wound Therapy (NPWT) systems specifically designed for use in resource-constrained settings to aid in the treatment of open wounds. Methods: Prospective single-arm interventional pilot study of 14 patients with complex wounds was conducted at Kirtipur Hospital in Kathmandu, Nepal. A novel NPWT device, the Kyron Suction Unit, was used by 4 plastic surgeons. Primary outcomes were ease of use (10-point Likert scale) and device safety (adverse events recorded). Pain (Visual Analogue Scale score), quality of life (modified EuroQol Derived Single Index scores), and wound dimensions were recorded. Results: User ratings on the 10-point Likert scale indicated high confidence and ease of use: median confidence setting up the device of 1.0 [interquartile range (IQR), 1.0; mean 2.3], median confidence maintaining the device of 1.0 (IQR, 1.0; mean, 1.5), and median ease of disassembly of 1.0 (IQR, 1.0; mean, 1.4). Significant improvement in Visual Analogue Scale scores (P = 0.03), modified EuroQol Derived Single Index scores (P < 0.001), and a reduction in wound volume [median, 47.25–9.75 cm3 (P = 0.01)]. Image analysis of wounds pretreatment and posttreatment demonstrated increase in granulation tissue surface area [median, 7.6–28.7 cm2 (P = 0.003)] and decrease in open wound surface area [median, 48.33–33.6 cm2 (P = 0.01)]. Conclusions: The Kyron Suction Unit was safe and easily managed by plastic surgeons. The device design promoted access to NPWT, a therapy proven to reduce healing time and decrease complications for patients with open wounds, in a resource-constrained setting.

Introduction: Memorial Hermann (MH) Healthcare System in Houston historically did not have a coordinated approach to triage of incoming neuroscience transfers. From July 2015 to June 2016, there were a total of 867 cancellations/denials for neurology or neurosurgery transfers that could not be accommodated through the existing acceptance process where the majority were sent to the MH-Texas Medical Center (TMC). Hypothesis: We hypothesized that creation of a streamlined approach to triaging transfer requests would allow for the following outcomes: Reduction in time of initial transfer request to acceptance Elimination of denials/cancellations due to capacity Leveraging of integrated physician network across TMC, Southwest, and Memorial City campuses Methods: In collaboration with the MH System Transfer Center, we created a model where one physician or “quarterback” is able to triage system transfers and accept on behalf of the admitting/specialist physicians at a MH receiving facility. We met with all stakeholders to understand individual campus challenges related to universal acceptance process, established a script/resource tool, and built up tertiary capabilities (comprehensive stroke) in the community so we could ensure a high-quality alternative to our TMC quaternary hospital. Results: Both stroke and neurosurgery populations are managed through the Rapid Transfer Program as of January 2017. Since the start of this program, there has been an approximate 18% increase in neuroscience transfers in the system and a drastic reduction of denials dues to capacity. Time of initial transfer request to time of acceptance decreased from almost 60 min to an average of 20 minutes. In June 2018, we had zero denials for neuroscience and 297 patients accepted by MH. Conclusion: The creation of an integrated and efficient model improved the customer experience for our referring partners. We met all goals and increased overall neuroscience transfer volume to our system.

The passage of the Affordable Care Act saw the creation of Accountable Care Organizations (ACOs), a new approach to healthcare delivery moving from fee-for-service toward population health. This paper presents a case study of the Memorial Hermann ACO (MHACO), launched in response to the Medicare Shared Savings Program, with goals to align physician and hospital incentives, practice evidence-based medicine, develop care coordination, and increase efficiency. Building blocks included an affiliated primary care network, a clinical integration program (involving shared electronic medical record platforms and quality data reporting), and significant investments in information technology. Presented is the approach taken to form MHACO; the management structure, technology developed, and a 2-year experience. Incorporated in July 2012, the MHACO involved 22 000 Medicare patients. In 2015, Centers for Medicare and Medicaid Services released data showing a composite quality score between 80 and 85 (from a maximum 100) and nearly $53 million in total savings (or 11% of expected expenditure), making MHACO one of the most successful nationally.1 In fewer than 5 years, almost 500 ACOs have developed, and by some estimates, a quarter of Medicare patients are currently enrolled in an ACO. Although ACOs to date have focused on primary care, the future will increasingly involve specialists. At Memorial Hermann, neurosurgeons took an early role in forming collaborative partnerships with the hospital, and started programs that served as precursors to the ACO model. This paper ends with an overview of ACO development, likely changes going forward, and a discussion of the role of specialists in general, and of neurosurgeons in particular.

The importance of outcome measures is steadily increasing due to the rise of "pay for performance" and the advent of population health. In 2007, a quality initiative was started due to poor performance on rankings such as the University Health Consortium (UHC) report card. Inherent to all such efforts are common challenges: how to engage the providers; how to gather and ensure the accuracy of the data; how to attribute results to individuals; how to ensure permanent improvements. After analysis, a strategy was developed that included an initial focus on 3 metrics (mortality, infection rates, and complications), leadership from practicing neurosurgeons, protocol development and adherence, and subspecialization. In addition, it was decided that the metrics would initially apply to attending physicians only, but that the entire team would need to be involved. Once the fundamental elements were established, the process could be extended to other measures and providers. To support this effort, special information system tools were developed and a support team formed. As the program matured, measured outcomes improved and more metrics were added (to a current total of 48). For example, UHC mortality ratios (observed over expected) decreased by 75%. Infection rates decreased 80%. The program now involves all trainee physicians, advanced practice providers, nurses, and other staff. This paper describes the design, implementation, and results of this effort, and provides a practical guide that may be useful to other groups undertaking similar initiatives.