1.Describe the experience of advance care planning at liver transplant centers from the perspectives of patients.2.Describe the experience of advance care planning at liver transplant centers from the perspectives of providers. In the United States, patients with decompensated cirrhosis (DC) receive burdensome, costly care at the end of life that may not be consistent with their wishes. Advance care planning (ACP) is a process that supports adults in understanding and sharing their values, goals, and preferences regarding future medical care, but little is known about how ACP occurs in patients with DC. Our aim was to explore the experience of ACP in patients with DC at liver transplant (LT) centers. We conducted semi-structured interviews with 42 patients with DC and 46 LT providers across three LT centers in Los Angeles between July 2017 and May 2018. Audio-files were professionally transcribed. Two qualitative researchers developed a codebook corresponding to three major domains of ACP (prognosis; discussing values, goals and preferences; and surrogate decision makers [SDM]) and assigned codes to all transcripts. Data were imported to NVivo 12. “Pile-sorting” was used to generate themes. Providers frequently expressed prognosis to patients in terms of their chances of receiving a transplant but delayed conversations about death until the end of life (EOL). Patients often contemplated death, but seldom discussed these concerns with providers. Many patients engaged in discussions with family members about their values, goals, and preferences for EOL care. However, discussions were not initiated by LT providers, who found discussing limits to aggressive care was inconsistent with LT. Most patients reported having designated an SDM though only 5 (12%) had an available advance directive in their medical record. Providers engaged in discussions about SDMs when patients were hospitalized, whereas social workers discussed this routinely in all venues (Figure 1). Please contact first author for figure. Patients with DC performed components of ACP independently of providers. Providers rarely initiated conversations until patients were dying.

Background: The extent to which a surgeon's risk aversion influences their clinical decisions remains unknown. We assessed whether a surgeon's attitude toward risk ("risk aversion") influences their surgical decisions and whether the relationship can be explained by differences in surgeons' perception of treatment risks and benefits. Materials and methods: We presented a series of detailed clinical vignettes to a national sample of surgeons ( n = 1,769; 13.4% adjusted response rate) and asked them to complete an instrument that measured how risk averse they are within their clinical practice (scale 6-36; higher number indicates greater risk aversion). For each vignette, participants rated their likelihood of recommending an operation and judged the likelihood of complications or full recovery. We examined whether differences in perceived likelihood of complications versus recovery could explain why risk-averse surgeons may be less likely to recommend an operation. Results: Surgeons varied in their self-reported risk aversion score (median = 25, interquartile range[22,28]). Scores did not differ by level of surgeon experience or gender. Risk-averse surgeons were significantly less likely to recommend an operation for patients with exactly the same condition (65.5% for surgeons in highest quartile of risk aversion versus 62.3% for lowest quartile; P = 0.02). However, after controlling for surgeons' perception of the likeli-hood of complications versus recovery, there was no longer a significant association between surgeons' risk aversion and the decision to recommend an operation (64.7% versus 64.8%; P = 0.96). Conclusions: Surgeons vary widely in their self-reported risk aversion. Risk-averse surgeons were significantly less likely to recommend an operation, a finding that was explained by a higher perceived probability of post-operative complications than their colleagues. (c) 2021 Elsevier Inc. All rights reserved.

Background:. Little is known about the volume and scope of surgical procedures performed in ambulatory surgery centers (ASCs) and the resources that ASCs may provide to assist local health systems. The purpose of this study was to evaluate elective surgical procedures in the inpatient and outpatient ASC setting using currently available administrative claims data. Methods:. We used the 2019 Medicare Point of Service (POS) file to evaluate the geographic distribution of Medicare-certified ASCs in the U.S. To evaluate the volume and scope of elective procedures in the inpatient and outpatient ASC setting, we used the 2016 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the 2018 California HHS Open Data Portal ambulatory surgery database. HCUP software programs were used to clinically categorize procedures and determine Elixhauser comorbidity profiles for each patient. Results:. Among the 8,540 Medicare certified ASCs in 2019, the majority are freestanding (99.5%) and privately owned (92.9%). In the inpatient setting, 13.3% of elective operating room procedures occur in patients without any Elixhauser comorbidities and require < 2 days of hospital stay. However, the types of elective procedures performed in the inpatient setting are different from the types of procedures routinely performed in ASCs. Conclusions:. Current administrative data lack robust facility, provider, and procedure level information to inform surge capacity protocols for elective surgery. Plastic surgeons are uniquely positioned to work with other specialties and local health systems to guide future development of surge capacity protocols that maintain and improve patient care.

Importance The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis. Objective To describe the experience of ACP in patients with decompensated cirrhosis at liver transplant centers. Design, Setting, and Participants For this multicenter qualitative study, face-to-face semistructured interviews were conducted between July 1, 2017, and May 30, 2018, with clinicians and patients with decompensated cirrhosis at 3 high-volume transplant centers in California. Patient participants were adults and had a diagnosis of cirrhosis, at least 1 portal hypertension-related complication, and current or previous Model for End-Stage Liver Disease with sodium score of 15 or higher. Clinician participants were health care professionals who provided care during the illness trajectory. Main Outcomes and Measures Experiences with ACP reported by patients and clinicians. Participants were asked about the context, behaviors, thoughts, and decisions concerning elements of ACP, such as prognosis, health care preferences, values and goals, surrogate decision-making, and documentation. Results The study included 42 patients (mean [SD] age, 58.2 [11.2] years; 28 men [67%]) and 46 clinicians (13 hepatologists [28%], 11 transplant coordinators [24%], 9 hepatobiliary surgeons [20%], 6 social workers [13%], 5 hepatology nurse practitioners [11%], and 2 critical care physicians [4%]). Five themes that represent the experiences of ACP were identified: (1) most patient consideration of values, goals, and preferences occurred outside outpatient visits; (2) optimistic attitudes from transplant teams hindered the discussions about dying; (3) clinicians primarily discussed death as a strategy for encouraging behavioral change; (4) transplant teams avoided discussing nonaggressive treatment options with patients; and (5) surrogate decision makers were unprepared for end-of-life decision-making. Conclusions and Relevance This study found that, despite a guarded prognosis, patients with decompensated cirrhosis had inadequate ACP throughout the trajectory of illness until the end of life. This finding may explain excessively aggressive life-sustaining treatment that patients receive at the end of life.

Importance The Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1) is a quality metric based on a care bundle for early sepsis management. Published evidence on the association of SEP-1 with mortality is mixed and largely excludes cases of hospital-onset sepsis. Objective To assess the association of the SEP-1 bundle with mortality and organ dysfunction in cohorts with hospital-onset or community-onset sepsis. Design, Setting, and Participants This retrospective cohort study used data from 4 University of California hospitals from October 1, 2014, to October 1, 2017. Adult inpatients with a diagnosis consistent with sepsis or disseminated infection and laboratory or vital signs meeting the Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock) criteria were divided into community-onset sepsis and hospital-onset sepsis cohorts based on whether time 0 of sepsis occurred after arrival in the emergency department or an inpatient area. Data were analyzed from April to October 2019. Additional analyses were performed from December 2019 to January 2020. Exposures Administration of SEP-1 and 4 individual bundle components (serum lactate level testing, blood culture, broad-spectrum intravenous antibiotic treatment, and intravenous fluid treatment). Main Outcomes and Measures The primary outcome was in-hospital mortality. The secondary outcome was days requiring vasopressor support, measured as vasopressor days. Results Among the 6404 patient encounters identified (3535 men [55.2%]; mean [SD] age, 64.0 [18.2] years), 2296 patients (35.9%) had hospital-onset sepsis. Among 4108 patients (64.1%) with community-onset sepsis, serum lactate level testing within 3 hours of time 0 was associated with reduced mortality (absolute difference, -7.61%; 95% CI, -14.70% to -0.54%). Blood culture (absolute difference, -1.10 days; 95% CI, -1.85 to -0.34 days) and broad-spectrum intravenous antibiotic treatment (absolute difference, -0.62 days; 95% CI, -1.02 to -0.22 days) were associated with fewer vasopressor days. Among patients with hospital-onset sepsis, broad-spectrum intravenous antibiotic treatment was the only bundle component significantly associated with any improved outcome (mortality difference, -5.20%; 95% CI, -9.84% to -0.56%). Care that was adherent to the complete SEP-1 bundle was associated with increased vasopressor days in patients with community-onset sepsis (absolute difference, 0.31 days; 95% CI, 0.11-0.51 days) but was not significantly associated with reduced mortality in either cohort (absolute difference, -0.07%; 95% CI, -3.02% to 2.88% in community-onset; absolute difference, -0.42%; 95% CI, -6.77% to 5.93% in hospital-onset). Conclusions and Relevance SEP-1-adherent care was not associated with improved outcomes of sepsis. Although multiple components of SEP-1 were associated with reduced mortality or decreased days of vasopressor therapy for patients who presented with sepsis in the emergency department, only broad-spectrum intravenous antibiotic treatment was associated with reduced mortality when time 0 occurred in an inpatient unit. Current sepsis quality metrics may need refinement. This cohort study examines the association of a care bundle for early sepsis management with mortality and organ dysfunction in adult hospitalized patients with community-onset or hospital-onset sepsis. Question What is the association of a care bundle for early sepsis management, the Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1), and its components with mortality and organ dysfunction in hospitalized patients with community-onset or hospital-onset sepsis? Findings In this cohort study of 6404 patients, SEP-1-adherent care was not associated with reduced mortality or decreased vasopressor support among patients with sepsis in the emergency department (community-onset sepsis), patients first meeting sepsis criteria after arrival in an inpatient unit (hospital-onset sepsis), or the total sample. Multiple components of SEP-1 were associated with improved outcomes among patients with sepsis in the emergency department, a statistically significant finding. Meaning The SEP-1-adherent care was not associated with improved outcomes, but individual SEP-1 components were associated with benefit in patients with community-onset sepsis.

This Viewpoint describes the outbreak response infrastructure developed by the Taiwanese government following the SARS epidemic in 2003 and actions in response to COVID-19, including dedicated hotlines for symptom reporting, mobile phone messaging and case tracking, and the ramping up of facemask production.

OBJECTIVES:To determine the public health surveillance severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing volume needed, both for acute infection and seroprevalence. METHODS:Required testing volumes were developed using standard statistical methods based on test analytical performance, disease prevalence, desired precision, and population size. RESULTS:Widespread testing for individual health management cannot address surveillance needs. The number of people who must be sampled for public health surveillance and decision making, although not trivial, is potentially in the thousands for any given population or subpopulation, not millions. CONCLUSIONS:While the contributions of diagnostic testing for SARS-CoV-2 have received considerable attention, concerns abound regarding the availability of sufficient testing capacity to meet demand. Different testing goals require different numbers of tests and different testing strategies; testing strategies for national or local disease surveillance, including monitoring of prevalence, receive less attention. Our clinical laboratory and diagnostic infrastructure are capable of incorporating required volumes for many local, regional, and national public health surveillance studies into their current and projected testing capacity. However, testing for surveillance requires careful design and randomization to provide meaningful insights.

Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis. To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis. Retrospective cohort study using multivariable analysis of clinical data. A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection. Four university hospitals in California between 2014 and 2016. The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen. Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29–0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated—blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)—was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004). Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.

Yan Bai, MD; Lingsheng Yao, MD; Tao Wei, MD; Fei Tian, MD; Dong-Yan Jin, PhD; Lijuan Chen, PhD; Meiyun Wang, MD, PhD

BACKGROUND:Hospital benchmarking is essential to quality improvement, but its usefulness depends on the ability of statistical models to adequately control for inter-hospital differences in patient mix. We explored whether the addition of injury-specific clinical variables to the current American College of Surgeons-Trauma Quality Improvement Program (TQIP) algorithm would improve model fit.METHODS:We analyzed a prospective registry containing all adult patients who presented to a regional consortium of 14 trauma centers between 2010 and 2011 with severe traumatic brain injury (TBI). We used hierarchical logistic regression and stepwise forward selection to develop two novel risk-adjustment models. We then tested our novel models against the current TQIP model and ranked hospitals by their risk-adjusted mortality rates under each model to determine how model selection affects quality benchmarking.RESULTS:Seven hundred thirty-four patients met inclusion criteria. Stepwise selection resulted in two distinct models: one that added three TBI-specific variables (pupil reactivity, cerebral edema, loss of basal cisterns) to the model specification currently used by TQIP and another that combined two TBI-specific variables (pupil reactivity, cerebral edema) with a three-variable subset of TQIP (age, Abbreviated Injury Scale score for the head region, Glasgow Coma Scale motor score). Both novel models outperformed TQIP. Although rankings remained largely unchanged across model configurations, several hospitals moved across quality terciles.CONCLUSION:The inclusion of injury-specific variables improves risk adjustment for patients with severe TBI. Trauma Quality Improvement Program should consider replacing several of its general patient characteristics with injury-specific clinical predictors to increase efficiency, reduce the risk of overfitting, and improve the accuracy of hospital benchmarking.LEVEL OF EVIDENCE:Prognostic and epidemiological, level II.

This chapter proposes definitions for the key terms and explain how each concept relates to the idea of defining basic benefits using necessary-care guidelines. The scope and significance of the debate has increased substantially of late because of ever-rising health care costs, increasing concerns about inequitable access to care, and mounting evidence that inappropriate and unnecessary care continues to be delivered to patients in significant quantities. The notion of necessity as it pertains to health care rationing is not completely captured by commonly used words like "beneficial," "effective," or "appropriate." Indeed, it is clearly possible for a medical service to be beneficial or appropriate without being truly necessary. The critical term "basic benefit plan" has also been used inconsistently in the health policy debate. On its face, basic benefits would appear to denote a minimum or fundamental level of health insurance coverage.

Public debate over the cost and quality of, and access to health care in the United States has increased in volume and intensity over the last several years as society grapples with the question of how to allocate limited health resources. Rising health costs in the past two decades have ushered in policies to contain costs. Every method of allocation must confront the question of how to define and ensure access to essential services. Existing mechanisms allocate health resources on the basis of economic or administrative constraints. As such, it is our contention that neither of the existing mechanisms—namely cost sharing and prepayment—alone is sufficient to resolve the "tragic choice" confronting US society. Medicine has become sufficiently vast and complicated, technology changes sufficiently fast, and the magnitude of public resources expended sufficiently large, to warrant the explication of guidelines and the implementation of a system of voluntary audits and incentives.

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BACKGROUNDApproximately 30% of total US health care spending is thought to be "wasted" on activities like unnecessary and inefficiently delivered services.OBJECTIVESTo assess the perceptions of clinic-based physicians regarding their use of time and appropriateness of care provided.DESIGNCross-sectional online survey of all Southern California Permanente Medical Group partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers.MAIN OUTCOME MEASURESThe proportion of time spent on direct patient care tasks perceived to require the respondent's clinical/specialty training as a physician or another physician who has similar years of clinical training (vs physicians with fewer years of clinical training, nonphysicians, or automated or computerized systems), and the proportion of care provided by the respondent and by other physicians with whom they are familiar that is perceived to be appropriate (vs equivocal or inappropriate).RESULTSMore than 61% of respondents indicated that 15% of their time spent on direct patient care could be shifted to nonphysicians, and between 10% and 16% of care provided was equivocal or inappropriate.DISCUSSIONThe low proportion of care perceived as equivocal or inappropriate indicates there is little room for reducing such care or that physicians have difficulty assessing care appropriateness. The latter suggests that attempts to reduce or to eliminate inappropriate care may be unsuccessful until physician beliefs, knowledge, or behaviors are better understood and addressed.CONCLUSIONOn the basis of these findings, it is apparent that within at least one health care system, the opportunity to increase value through task shifting and avoiding inappropriate care is more narrow than commonly perceived on a national level.

Single-payer systems have been proposed as a health care reform alternative in the United States. However, there is no consensus on the definition of single-payer. Most definitions characterize single-payer as one entity that collects funds and pays for health care on behalf on an entire population. Increased flexibility for state health care reform may provide opportunities for state-based single-payer systems to be considered.To explore the concept of single-payer and to describe the contents of single-payer health care proposals.We compared single-payer definitions and proposals. We coded the proposal text for provisions that would change how the health care system functions and could impact health care access, quality, and cost.The share of proposals that include changes to the financing, pooling, purchasing, and delivery of health care; and possible impact on access, quality, and costs.We identified 25 proposals for national or state single-payer plans from journal and legislative databases. The proposals typically call for wide-ranging reform; nearly all include changes across the financing, pooling, purchasing, and delivery of health care services. Many provisions aiming to improve access, quality, and cost containment are also included, but the proposals vary in how they plan to achieve these improvements. Common provisions are related to comprehensive benefits, patient choice of providers, little or no cost sharing, the role of private insurance, provider guidelines and standards, periodic reviews of the benefits package, electronic medical records and billing, prescription drug formulary, global budgets, administrative cost thresholds, payment reform and studies, and the authority to implement cost-containment strategies.Single-payer systems are heterogeneous. Acknowledgment of what is considered as single-payer and the characteristics that are variable is important for nuanced policy discussions on specific reform proposals.