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Within the realm of health care quality assessment, quality assurance and safety grading systems play a vital role in gauging hospital performance and communicating results to the general public. The primary objective of this review is to analyze the hospitals in California through the lens of Leapfrog Safety Grades and discuss the complex interplay of geographical location, hospital size, and larger system affiliation status. Leapfrog Safety Grades, hospital characteristics, and geographic information were collected. Hospitals were categorized by geographic region, size, rural/urban classification, and larger system affiliation status. Of the 284 hospitals included in the study, 95 were given a grade of A, 68 given a grade of B, 93 given a grade of C, 23 given a grade of D, 2 given a grade of F, and 3 were not graded. The vast majority of hospitals in California were classified as urban, with 183 falling under this category. The average number of hospital beds and SD was 227 ± 47.57. On average, hospitals that received a grade of D were significantly smaller in size than those that received a grade of A, while hospitals that received a grade of B or C were similar in size. A total of 107 hospitals were affiliated with a larger health care system. About 70% of hospitals affiliated with a system received an A or B grade, while 50% of unaffiliated hospitals received an A or B grade. Results of this study demonstrate a need for improving health care access and quality in medically underserved urban and rural areas. Hospitals affiliated with a larger health care system received higher grades than unaffiliated hospitals, suggesting that affiliation may also play a role in the implementation and mitigation of factors that contribute to Leapfrog Safety Grades. [ABSTRACT FROM AUTHOR]

BackgroundThis study used case reports to review the role of systemic chemotherapy in oligometastatic colorectal cancer (CRC) and to suggest ways to integrate clinical research findings into the interdisciplinary management of this potentially curable subset of patients.MethodsThis educational review discusses the role of chemotherapy in the management of oligometastatic metastatic CRC.ResultsIn initially resectable oligometastatic CRC, the goal of chemotherapy is to eradicate micrometastatic disease. Perioperative 5-fluorouracil and oxaliplatin together with surgical resection can result in 5-year survival rates as high as 57 %. With the development of increasingly successful chemotherapy regimens, attention is being paid to chemotherapy used to convert patients with initially unresectable metastasis to patients with a chance of surgical cure. The choice of chemotherapy regimen requires consideration of the goals for therapy and assessment of both tumor- and patient-specific factors.ConclusionThis report discusses the choice and timing of chemotherapy in patients with initially resectable and borderline resectable metastatic CRC. Coordinated multidisciplinary care of such patients can optimize survival outcomes and result in cure for patients with this otherwise lethal disease.

BackgroundPatients often wait to have urgent or emergency surgery. The number of operating rooms (ORs) needed to minimize waiting time while optimizing resources can be determined using queuing theory and computer simulation. We developed a computer program using Monte Carlo simulation to determine the number of ORs needed to minimize patient wait times while optimizing resources.MethodsWe used patient arrival data and surgical procedure length from our institution, a tertiary-care academic medical center that serves a large diverse population. With ~4800 patients/year requiring non-elective surgery, and mean procedure length 185 min (median 150 min) we determined the number of ORs needed during the day and evening (0600-2200) and during the night (2200-0600) that resulted in acceptable wait times.ResultsSimulation of 4 ORs at day/evening and 3 ORs at night resulted in median wait time = 0 min (mean = 19 min) for emergency cases requiring surgery within 2 h, with wait time at the 95th percentile = 109 min. Median wait time for urgent cases needing surgery within 8-12 h was 34 min (mean = 136 min), with wait time at the 95th percentile = 474 min. The effect of changes in surgical length and volume on wait times was determined with sensitivity analysis.ConclusionsMonte Carlo simulation can guide decisions on how to balance resources for elective and non-elective surgical procedures.

BackgroundThe relationship between procedural relative value units (RVUs) for surgical procedures and other measures of surgeon effort are poorly characterized. We hypothesized that RVUs would poorly correlate with quantifiable metrics of surgeon effort.MethodsUsing the 2010 American College of Surgeons - National Surgical Quality Improvement Program (NSQIP) database, we selected 11 primary current procedural terminology codes associated with high volume surgical procedures. We then identified all patients with a single reported procedural RVU who underwent nonemergent, inpatient general surgical operations. We used linear regression to correlate length of stay (LOS), operative time, overall morbidity, frequency of serious adverse events (SAEs), and mortality with RVUs. We used multivariable logistic regression using all preoperative NSQIP variables to determine other significant predictors of our outcome measures.ResultsAmong 14,481 patients, RVUs poorly correlated with individual LOS (R(2) = 0.05), operative time (R(2) = 0.10), and mortality (R(2) = 0.35). There was a moderate correlation between RVUs and SAEs (R(2) = 0.79) and RVUs and overall morbidity (R(2) = 0.75). However, among low- to mid-level RVU procedures (11-35) there was a poor correlation between SAEs (R(2) = 0.15), overall morbidity (R(2) = 0.05), and RVUs. On multivariable analysis, RVUs were significant predictors of operative time, LOS, and SAEs (odds ratio 1.06, 95% confidence interval: 1.05-1.07), but RVUs were not a significant predictor of mortality (odds ratio 1.02, 95% confidence interval: 0.99-1.05).ConclusionsFor common, index general surgery procedures, the current RVU assignments poorly correlate with certain metrics of surgeon work, while moderately correlating with others. Given the increasing emphasis on measuring and tracking surgeon productivity, more objective measures of surgeon work and productivity should be developed.

This case report describes the radical subtotal palliative resection of a massive recurrent desmoid tumor encompassing the abdomen, pelvis, and groin in a child who was 13 years old at the time of initial resection. Given the extensive distribution of the tumor en bloc resection, which is the standard treatment of desmoid tumors, would have meant performing a hemipelvectomy and repair of a large abdominal wall defect, likely with skin grafts and mesh. The patient’s personal goals however were to alleviate the pain and limited mobility that would allow her to re-attend high school and appear normal to her peers. Therefore, palliative surgery was pursued and currently the patient is 5 years out from her last surgery doing well. We believe that the option of surgical palliation in this case was warranted and should be an option for similar cases in the future.