- Email: [email protected]
Factors Influencing Delayed Hospital Presentation in Patients with Appendicitis
Scientific Forum Abstracts
S108
J Am Coll Surg
as well (Table), with the cost per case of FP increasing by 85% between 2009 and 2012.
Table.
Table. Cost per Case by Year
Variable
Pre
Post
Diff
Pre
Post
Diff
DID
% SCs
28.6
14.3
-14.3
37.4
48.3
+10.9
-25.2
0.003
% of population living in SCs
19.8
15.8
-4.0
14.3
23.1
+8.8
-12.8
0.002
2003, $ Case AP TA MY FP HFR UHR
CH 5,246 6,064 8,799 * 6,084 4,994
2006, $
2009, $
2012, $
NCH CH NCH CH NCH CH NCH 5,724 7,261 7,499 7,358 7,396 7,898 7,881 4,511 8,964 5,883 7,732 5,667 9,570 5,876 5,762 9,717 7,278 9,028 8,430 16,304 7,729 * 29,599 31,879 31,935 34,660 58,935 46,828 8,765 9,383 11,758 8,629 11,581 10,113 10,626 5,582 8,059 6,701 10,501 7,665 9,169 6,269
*HCUP KID data unavailable
CONCLUSIONS: The proportion of pediatric operations being performed at CH is continuing to grow alongside disproportionate increases in surgical costs. Further investigation is needed to explore cost containment at CH while maintaining the delivery of high quality care.
Expanded Insurance Coverage Improves General Surgeon Workforce Distribution Scott Dolejs, MD*, Teresa M Bell, PhD, Ben L Zarzaur, MD, MPH, FACS Indiana University, Indianapolis, IN INTRODUCTION: The number of general surgeons is decreasing while the distribution is increasingly inequitable. It is unknown how improved access to insurance coverage will affect surgeon distribution. METHODS: The Area Health Resources File was used to investigate changes in the surgical workforce from 2005 to 2013. Massachusetts (MA), which underwent an insurance expansion similar to the Affordable Care Act (ACA) in 2006, was compared with similar northeast states. Shortage counties (SCs) were defined as counties with < 6 active general surgeons/100,000 persons. Bivariate data analysis was performed and difference-in-difference estimates were determined. RESULTS: There was no baseline difference between MA and the control in the percentage of poverty (9.7% vs 10.4%, p¼0.2), minorities (17.6% vs 13.3%, p¼0.1), or rural counties (21.4% vs 37.9%, respectively, p¼0.2). There were increased rates of insurance in MA compared with control. The number of SCs decreased from 28.6% to 14.3% in MA after implementation of health care expansion, but increased from 37.4% to 48.3% in control states (difference-in-difference [DID] -25.2%, p¼0.003). The percentage of people living in SCs decreased from 19.8% to 15.8% in MA, but increased from 14.3% to 23.1% in control states (DID -12.8%, p¼0.002) (Table). There was no significant difference in the median number of surgeons per 100,000 people in MA vs control over this time period.
Massachusetts
Control states p Value
% of patients without insurance
11.5
4.7
-6.8
14.1
12.8
-1.3
-5.5
0.03
No. of surgeons/100,00
16.4
15.8
-0.6
13.6
12.8
-0.8
0.2
0.8
CONCLUSIONS: Implementation of the MA insurance expansion resulted in decreased surgeon shortage counties and fewer people living in surgeon shortage counties in MA compared with similar states. This occurred despite no changes in the number of surgeons in MA compared with similar states. The ACA may help improve surgeon distribution. Factors Influencing Delayed Hospital Presentation in Patients with Appendicitis Anne P Ehlers, MD, Frederick T Drake, MD, MPH, Meera Kotagal, MD, Vlad V Simianu, MD, MPH, Nidhi Agrawal, PhD, MBA, Susan Joslyn, PhD, David R Flum, MD, FACS University of Washington, Seattle, WA INTRODUCTION: In patients with acute appendicitis (AA), perforation is thought to be associated with symptom duration before treatment. Perforation rates vary widely between hospitals, even within the same community, raising the possibility that some perforations are preventable. The factors that compel patients to present earlier or later are unknown, but are critical in developing quality improvement interventions aimed at reducing perforation rates. METHODS: The Appendicitis Patient Pre-Hospital Experience (APPE) Survey is a prospective study of adults and parents of children with AA in 6 hospitals participating in Washington State’s Comparative Effectiveness Research Translation Network (20142015). The APPE survey includes questions about symptom duration before presentation (“early” defined as 24 hours), sociodemographics, clinical characteristics, health behaviors, social support, personality, and risk-taking characteristics. RESULTS: Among 80 patients (50% male), perforation occurred more frequently in late presenters (44% vs 11%, p<0.01). Early presenters were younger (mean age 32 vs 42 years, p¼0.05) and more frequently had someone other than themselves drive to the hospital (38% vs 22%, p¼0.05). Late presenters more often described their health behavior as “waiting it out” when something is wrong (71% vs 46%, p¼0.03). We found similar sociodemographics, clinical characteristics, health care use, optimism, health care trust, and risk-taking between the 2 cohorts. CONCLUSIONS: Late presenters were older, more frequently described reduced social support and a tendency to “wait it out,” and had higher rates of perforation than early presenters. Future interventions might target older individuals, those with low social
Vol. 223, No. 4S1, October 2016
support, or those who are reluctant to seek care early to decrease rates of perforation. Fertility and Pregnancy Outcomes in Female Physicians in Procedural Specialties: A Large National Survey Rebecca Scully, MD, Nelya Melnitchouk, MD, Jennifer S Davids, MD Brigham and Women’s Hospital Boston, MA, University of Massachusetts Medical School, Worcester, MA INTRODUCTION: Concern exists that female physicians in procedural specialties may have higher risk of pregnancy complications and decreased fertility than women in non-procedural specialties. We hypothesized that women in procedural specialties face greater self-reported challenges with fertility and pregnancy complications, leading to increased time out of work. METHODS: Data from 1,559 US attending female physicians was gathered via an anonymous, IRB-approved online survey. Univariate analysis was performed using Chi-squared and Student’s Ttest. A multivariable model was constructed to determine impact of procedural status on use of in-vitro fertilization (IVF) and pregnancy complications. RESULTS: Proceduralists (n¼400, 25%) were more likely to report older age at first pregnancy than non-proceduralists (>30 years old: 75.0 % vs 67.7%, p¼0.006). Controlling for age at first pregnancy, there was no difference between proceduralists and non-proceduralists in IVF use (OR 1.13, 95% CI 0.85-1.49, p¼0.40) or delayed conception (>1 year: OR 0.89, 95% CI 0.67-1.19, p¼0.44). While overall 28.5% of respondents reported missing work during pregnancy, there was no difference between proceduralists and non-proceduralists (29.5% vs 25.5%, p¼0.13). Controlling for age, proceduralists were less likely to be placed on bedrest (OR 0.62, 95% CI 0.42-0.92, p¼0.02) and there was no difference between groups in the frequency of missed work due to preterm labor, preeclampsia, or hyperemesis gravidarum. CONCLUSIONS: Although proceduralists were more likely to delay pregnancy, they had lower rates of bedrest and comparable rates of reproductive assistance and missed work due to pregnancy-related complications. Data from this large-scale national survey suggest that pregnancy outcomes are not worse for proceduralists.
Scientific Forum Abstracts
S109
Commission (JC) Error Taxonomy is used to classify such events in real patients. We hypothesized that JC taxonomy classification of errors identified in repeated, in situ simulations after trauma center relocation would demonstrate fewer errors over time. METHODS: After a mature trauma center was relocated to a different hospital (February 2015), weekly or bimonthly multidisciplinary in situ simulations were conducted in the trauma bay, operating room, post-anesthesia care unit, surgical ward, or ICU. With IRB approval, 23 simulations (FebruaryeSeptember) were reviewed and identified 167 errors/adverse events that were classified into the 4 spheres of the JC taxonomy. Number of events (Median [IQR]) identified per simulation are reported for each of 3 time periods. The Kruskall Wallis test with post-hoc subgroup Bonferroni correction was used for analysis. RESULTS: Most events were seen early after the trauma center relocation. Less severe impact events decreased significantly after the first period (Table) but more severe harm events remained rare throughout (5 [1-7] to 3.5 [1-5] events/simulation). Event types related to patient management decreased but not significantly while those related to communication remained stable. Provider domain remained unchanged for both nurses and physicians, many of whom had transferred from the old hospital. Organizational system causes were significantly less frequent in both later time periods (Table). Table.
Event
All significant Period 2 p values Period 3 Apr/May Period 1 between Jun/Sept (n¼8), (n¼8), Feb/Mar (n¼7), time periods Median [IQR] Median [IQR] Median [IQR]
IMPACT: all less severe harm 5 [3-8]
2.5 [2-4]
3[2.5-4]
1 vs 2, p¼0.01
IMPACT: minimal temporary harm 4 [2-5]
1 [1-1.5]
2[1-3]
1 vs 2, p¼0.003
TYPE: Patient communication
2 [1-2]
1 [0-1.5]
2[1-3]
All NS
TYPE: Patient management
7 [3-10]
2.5 [0.5-4.5]
2.5[1-3]
All NS
DOMAIN: Physician
3 [1-4]
1.5 [1-3.5]
3.5[2.5-4.5]
All NS
DOMAIN: Nurse
1 [1-3]
1 [0.5-1.5]
1[0-1.5]
All NS
2.5 [0.5-3]
3[2-3]
1 vs 2, p¼0.004 1 vs 3, p¼0.01
0.5 [0-1]
1[0-1]
1 vs 2, p¼0.006 1 vs 3, p¼0.02
CAUSE: Total Systems -organizational
5 [4-7]
CAUSE: Systems- organizational- culture 2 [1-3]
CONCLUSIONS: Using the JC taxonomy to classify adverse events discovered during repeated In situ simulations is an excellent method to track system processes and demonstrate changes in provider care.
Gauging Trauma Center Quality Improvement by Classifying Adverse Events from Recurring in Situ Simulations Using the JC Taxonomy Kinza Akhunzada, Daniel N Holena, MD, FACS, Patricia Abel-Baker, Gregory Motuk, Janet Mcmaster, Patrick K Kim, MD, FACS, Mook M Megan, Sara Holland, Brian P Smith, MD, Jose L Pascual, MD, FACS, FCCM Perelman School of Medicne at the University of Pennsylvania, Philadelphia, PA
Identifying Quality Markers of a Safe Surgical Ward: An Interview Study of Patients, Clinical Staff and Administrators Yasmin AM Hassen, MBBS, Pritam Singh, MBBS, PhD, Philip H Pucher, MD, Maximilian J Johnston, MBBCh, PhD, Ara W Darzi, MB BCH, FACS(Hon) Imperial College, London, UK
INTRODUCTION: In situ simulations are used in healthcare to identify errors, adverse events, and latent threats. The Joint
INTRODUCTION: Patient safety within the operating theatre has been examined extensively. However, errors in the perioperative
S108
J Am Coll Surg
as well (Table), with the cost per case of FP increasing by 85% between 2009 and 2012.
Table.
Table. Cost per Case by Year
Variable
Pre
Post
Diff
Pre
Post
Diff
DID
% SCs
28.6
14.3
-14.3
37.4
48.3
+10.9
-25.2
0.003
% of population living in SCs
19.8
15.8
-4.0
14.3
23.1
+8.8
-12.8
0.002
2003, $ Case AP TA MY FP HFR UHR
CH 5,246 6,064 8,799 * 6,084 4,994
2006, $
2009, $
2012, $
NCH CH NCH CH NCH CH NCH 5,724 7,261 7,499 7,358 7,396 7,898 7,881 4,511 8,964 5,883 7,732 5,667 9,570 5,876 5,762 9,717 7,278 9,028 8,430 16,304 7,729 * 29,599 31,879 31,935 34,660 58,935 46,828 8,765 9,383 11,758 8,629 11,581 10,113 10,626 5,582 8,059 6,701 10,501 7,665 9,169 6,269
*HCUP KID data unavailable
CONCLUSIONS: The proportion of pediatric operations being performed at CH is continuing to grow alongside disproportionate increases in surgical costs. Further investigation is needed to explore cost containment at CH while maintaining the delivery of high quality care.
Expanded Insurance Coverage Improves General Surgeon Workforce Distribution Scott Dolejs, MD*, Teresa M Bell, PhD, Ben L Zarzaur, MD, MPH, FACS Indiana University, Indianapolis, IN INTRODUCTION: The number of general surgeons is decreasing while the distribution is increasingly inequitable. It is unknown how improved access to insurance coverage will affect surgeon distribution. METHODS: The Area Health Resources File was used to investigate changes in the surgical workforce from 2005 to 2013. Massachusetts (MA), which underwent an insurance expansion similar to the Affordable Care Act (ACA) in 2006, was compared with similar northeast states. Shortage counties (SCs) were defined as counties with < 6 active general surgeons/100,000 persons. Bivariate data analysis was performed and difference-in-difference estimates were determined. RESULTS: There was no baseline difference between MA and the control in the percentage of poverty (9.7% vs 10.4%, p¼0.2), minorities (17.6% vs 13.3%, p¼0.1), or rural counties (21.4% vs 37.9%, respectively, p¼0.2). There were increased rates of insurance in MA compared with control. The number of SCs decreased from 28.6% to 14.3% in MA after implementation of health care expansion, but increased from 37.4% to 48.3% in control states (difference-in-difference [DID] -25.2%, p¼0.003). The percentage of people living in SCs decreased from 19.8% to 15.8% in MA, but increased from 14.3% to 23.1% in control states (DID -12.8%, p¼0.002) (Table). There was no significant difference in the median number of surgeons per 100,000 people in MA vs control over this time period.
Massachusetts
Control states p Value
% of patients without insurance
11.5
4.7
-6.8
14.1
12.8
-1.3
-5.5
0.03
No. of surgeons/100,00
16.4
15.8
-0.6
13.6
12.8
-0.8
0.2
0.8
CONCLUSIONS: Implementation of the MA insurance expansion resulted in decreased surgeon shortage counties and fewer people living in surgeon shortage counties in MA compared with similar states. This occurred despite no changes in the number of surgeons in MA compared with similar states. The ACA may help improve surgeon distribution. Factors Influencing Delayed Hospital Presentation in Patients with Appendicitis Anne P Ehlers, MD, Frederick T Drake, MD, MPH, Meera Kotagal, MD, Vlad V Simianu, MD, MPH, Nidhi Agrawal, PhD, MBA, Susan Joslyn, PhD, David R Flum, MD, FACS University of Washington, Seattle, WA INTRODUCTION: In patients with acute appendicitis (AA), perforation is thought to be associated with symptom duration before treatment. Perforation rates vary widely between hospitals, even within the same community, raising the possibility that some perforations are preventable. The factors that compel patients to present earlier or later are unknown, but are critical in developing quality improvement interventions aimed at reducing perforation rates. METHODS: The Appendicitis Patient Pre-Hospital Experience (APPE) Survey is a prospective study of adults and parents of children with AA in 6 hospitals participating in Washington State’s Comparative Effectiveness Research Translation Network (20142015). The APPE survey includes questions about symptom duration before presentation (“early” defined as 24 hours), sociodemographics, clinical characteristics, health behaviors, social support, personality, and risk-taking characteristics. RESULTS: Among 80 patients (50% male), perforation occurred more frequently in late presenters (44% vs 11%, p<0.01). Early presenters were younger (mean age 32 vs 42 years, p¼0.05) and more frequently had someone other than themselves drive to the hospital (38% vs 22%, p¼0.05). Late presenters more often described their health behavior as “waiting it out” when something is wrong (71% vs 46%, p¼0.03). We found similar sociodemographics, clinical characteristics, health care use, optimism, health care trust, and risk-taking between the 2 cohorts. CONCLUSIONS: Late presenters were older, more frequently described reduced social support and a tendency to “wait it out,” and had higher rates of perforation than early presenters. Future interventions might target older individuals, those with low social
Vol. 223, No. 4S1, October 2016
support, or those who are reluctant to seek care early to decrease rates of perforation. Fertility and Pregnancy Outcomes in Female Physicians in Procedural Specialties: A Large National Survey Rebecca Scully, MD, Nelya Melnitchouk, MD, Jennifer S Davids, MD Brigham and Women’s Hospital Boston, MA, University of Massachusetts Medical School, Worcester, MA INTRODUCTION: Concern exists that female physicians in procedural specialties may have higher risk of pregnancy complications and decreased fertility than women in non-procedural specialties. We hypothesized that women in procedural specialties face greater self-reported challenges with fertility and pregnancy complications, leading to increased time out of work. METHODS: Data from 1,559 US attending female physicians was gathered via an anonymous, IRB-approved online survey. Univariate analysis was performed using Chi-squared and Student’s Ttest. A multivariable model was constructed to determine impact of procedural status on use of in-vitro fertilization (IVF) and pregnancy complications. RESULTS: Proceduralists (n¼400, 25%) were more likely to report older age at first pregnancy than non-proceduralists (>30 years old: 75.0 % vs 67.7%, p¼0.006). Controlling for age at first pregnancy, there was no difference between proceduralists and non-proceduralists in IVF use (OR 1.13, 95% CI 0.85-1.49, p¼0.40) or delayed conception (>1 year: OR 0.89, 95% CI 0.67-1.19, p¼0.44). While overall 28.5% of respondents reported missing work during pregnancy, there was no difference between proceduralists and non-proceduralists (29.5% vs 25.5%, p¼0.13). Controlling for age, proceduralists were less likely to be placed on bedrest (OR 0.62, 95% CI 0.42-0.92, p¼0.02) and there was no difference between groups in the frequency of missed work due to preterm labor, preeclampsia, or hyperemesis gravidarum. CONCLUSIONS: Although proceduralists were more likely to delay pregnancy, they had lower rates of bedrest and comparable rates of reproductive assistance and missed work due to pregnancy-related complications. Data from this large-scale national survey suggest that pregnancy outcomes are not worse for proceduralists.
Scientific Forum Abstracts
S109
Commission (JC) Error Taxonomy is used to classify such events in real patients. We hypothesized that JC taxonomy classification of errors identified in repeated, in situ simulations after trauma center relocation would demonstrate fewer errors over time. METHODS: After a mature trauma center was relocated to a different hospital (February 2015), weekly or bimonthly multidisciplinary in situ simulations were conducted in the trauma bay, operating room, post-anesthesia care unit, surgical ward, or ICU. With IRB approval, 23 simulations (FebruaryeSeptember) were reviewed and identified 167 errors/adverse events that were classified into the 4 spheres of the JC taxonomy. Number of events (Median [IQR]) identified per simulation are reported for each of 3 time periods. The Kruskall Wallis test with post-hoc subgroup Bonferroni correction was used for analysis. RESULTS: Most events were seen early after the trauma center relocation. Less severe impact events decreased significantly after the first period (Table) but more severe harm events remained rare throughout (5 [1-7] to 3.5 [1-5] events/simulation). Event types related to patient management decreased but not significantly while those related to communication remained stable. Provider domain remained unchanged for both nurses and physicians, many of whom had transferred from the old hospital. Organizational system causes were significantly less frequent in both later time periods (Table). Table.
Event
All significant Period 2 p values Period 3 Apr/May Period 1 between Jun/Sept (n¼8), (n¼8), Feb/Mar (n¼7), time periods Median [IQR] Median [IQR] Median [IQR]
IMPACT: all less severe harm 5 [3-8]
2.5 [2-4]
3[2.5-4]
1 vs 2, p¼0.01
IMPACT: minimal temporary harm 4 [2-5]
1 [1-1.5]
2[1-3]
1 vs 2, p¼0.003
TYPE: Patient communication
2 [1-2]
1 [0-1.5]
2[1-3]
All NS
TYPE: Patient management
7 [3-10]
2.5 [0.5-4.5]
2.5[1-3]
All NS
DOMAIN: Physician
3 [1-4]
1.5 [1-3.5]
3.5[2.5-4.5]
All NS
DOMAIN: Nurse
1 [1-3]
1 [0.5-1.5]
1[0-1.5]
All NS
2.5 [0.5-3]
3[2-3]
1 vs 2, p¼0.004 1 vs 3, p¼0.01
0.5 [0-1]
1[0-1]
1 vs 2, p¼0.006 1 vs 3, p¼0.02
CAUSE: Total Systems -organizational
5 [4-7]
CAUSE: Systems- organizational- culture 2 [1-3]
CONCLUSIONS: Using the JC taxonomy to classify adverse events discovered during repeated In situ simulations is an excellent method to track system processes and demonstrate changes in provider care.
Gauging Trauma Center Quality Improvement by Classifying Adverse Events from Recurring in Situ Simulations Using the JC Taxonomy Kinza Akhunzada, Daniel N Holena, MD, FACS, Patricia Abel-Baker, Gregory Motuk, Janet Mcmaster, Patrick K Kim, MD, FACS, Mook M Megan, Sara Holland, Brian P Smith, MD, Jose L Pascual, MD, FACS, FCCM Perelman School of Medicne at the University of Pennsylvania, Philadelphia, PA
Identifying Quality Markers of a Safe Surgical Ward: An Interview Study of Patients, Clinical Staff and Administrators Yasmin AM Hassen, MBBS, Pritam Singh, MBBS, PhD, Philip H Pucher, MD, Maximilian J Johnston, MBBCh, PhD, Ara W Darzi, MB BCH, FACS(Hon) Imperial College, London, UK
INTRODUCTION: In situ simulations are used in healthcare to identify errors, adverse events, and latent threats. The Joint
INTRODUCTION: Patient safety within the operating theatre has been examined extensively. However, errors in the perioperative