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Bell S.K.,Beth Israel Deaconess Medical Center | Moorman D.W.,West Penn Allegheny Health System | Delbanco T.,Beth Israel Deaconess Medical Center
Academic Medicine | Year: 2010

The emotional toll of medical error is high for both patients and clinicians, who are often unsure with whom 'and whether' they can discuss what happened. Although institutions are increasingly adopting full disclosure policies, trainees frequently do not disclose mistakes, and faculty physicians are underprepared to teach communication skills related to disclosure and apology. The authors developed an interactive educational program for trainees and faculty physicians that assesses experiences, attitudes, and perceptions about error, explores the human impact of error through filmed patient and family narratives, develops communication skills, and offers a strategy to facilitate bedside disclosures. Between spring 2007 and fall 2008, 154 trainees (medical students/residents) and 75 medical educators completed the program. Among learners surveyed, 62% of trainees and 88% of faculty physicians reported making medical mistakes. Of those, 62% and 78%, respectively, reported they did not apologize. While 65% of trainees said they would turn to senior doctors for assistance after an error, 26% were not sure where to get help. Just 20% of trainees and 21% of physicians reported adequate training to respond to error. Following the session, all of the faculty physicians surveyed indicated they felt better prepared to address and teach this topic. At a time of increased attention to disclosure, actual faculty and trainee practices suggest that role models, support systems, and education strategies are lacking. Trainees' widespread experience with error highlights the need for a disclosure curriculum early in medical education. Educational initiatives focusing on communication after harm should target teachers and students. © 2010 Association of American Medical Colleges.

Ellis C.N.,West Penn Allegheny Health System
Seminars in Colon and Rectal Surgery | Year: 2010

Mechanical and antibiotic bowel preparation is a time tested procedure that when done appropriately, significantly reduces the risk of infectious complications of colorectal surgical procedures, surgical site infections, and anastomotic dehiscence. Currently, a 3-tier regimen, which includes preoperative mechanical cleansing to reduce the fecal load, preoperative nonabsorbed oral antimicrobials effective against both aerobic and anaerobic bacteria, and perioperative parenteral antibiotics is most commonly used in the US. The vast majority of surgeons in the US today consider this approach as the cornerstone of elective colorectal surgery. However, randomized clinical trials from several countries have concluded that the role of mechanical and antibiotic bowel preparation should be re-evaluated. To date, there have been numerous randomized clinical trials comparing preoperative mechanical preparation to no preparation in patients undergoing elective colorectal surgery. When combined in meta-analyses, however, there is no statistically significant evidence that patients benefit from either mechanical or antibiotic bowel preparation. The data are overwhelming that the dogma regarding bowel preparation before elective colorectal surgery should be abandoned. © 2010 Elsevier Inc.

Yazdanyar A.,Reading Hospital and Medical Center | Wasko M.C.,West Penn Allegheny Health System | Kraemer K.L.,University of Pittsburgh | Ward M.M.,U.S. National Institutes of Health
Arthritis and Rheumatism | Year: 2012

Objective Rheumatoid arthritis (RA) is associated with an increased cardiovascular (CV) burden similar to that of diabetes mellitus (DM). This risk may warrant preoperative CV assessment as is performed for patients with DM. We aimed to determine whether the risks of perioperative death and CV events among patients with RA differed from those among unaffected controls and patients with DM. Methods We used 1998-2002 data from the Nationwide Inpatient Sample (NIS) database of the Healthcare Cost Utilization Project (HCUP) to identify hospitalizations of patients undergoing elective noncardiac surgery. Using established guidelines, surgical procedures were categorized as either low risk, intermediate risk, or high risk of having CV events. Logistic models provided the adjusted odds of study end points in patients with RA, DM, or both relative to patients with neither condition. Results Among 7,756,570 patients undergoing a low-risk, intermediate-risk, or high-risk noncardiac procedure, 2.34%, 0.51%, and 2.12%, respectively, had a composite CV event, and death occurred in 1.47%, 0.50%, and 2.59%, respectively. Among those undergoing an intermediate-risk procedure, death was less likely in RA patients than in DM patients (0.30% versus 0.65%; P < 0.001), but the difference in mortality rates among those undergoing low-risk versus high-risk procedures was not significant. Patients with RA were less likely to have a CV event than were patients with DM for procedures of low risk (3.38% versus 5.30%; P < 0.001) and intermediate risk (0.34% versus 1.07%; P < 0.001). In adjusted models, RA was not independently associated with an increased risk of perioperative death or a CV event. Conclusion RA was not associated with adverse perioperative CV risk or mortality risk, which suggests that current perioperative clinical care does not need to be changed in this regard. Copyright © 2012 by the American College of Rheumatology.

Slawsky K.A.,Patients LikeMe | Fernandes A.W.,Med Immune Ltd. | Fusfeld L.,Boston Healthcare Associates Inc. | Manzi S.,West Penn Allegheny Health System | Goss T.F.,Boston Healthcare Associates Inc.
Arthritis Care and Research | Year: 2011

Objective A structured review of the literature was undertaken to examine the direct costs of adult systemic lupus erythematosus (SLE) in a US population. Methods English-language studies published from January 2000 to April 2010 were systematically reviewed from both Medline's PubMed and the Cochrane databases. Studies were included if they reported direct medical costs of SLE among adults in the US. Results Seven studies published since January 2000 that reported direct medical costs associated with SLE in the US were identified. Studies examined main cost categories of inpatient, outpatient, and pharmacy services; each contributed substantially to total costs. Wide SDs were reported, consistent with variability in disease manifestation. Mean annual direct costs of SLE patients ranged from $13,735-$20,926; the costs of those with and without nephritis ranged from $29,034-$62,651 and $12,273-$16,575, respectively. Across studies of a general SLE population, pharmaceutical costs composed 19-30% of total expenditures, with inpatient costs accounting for 16-50% and outpatient costs accounting for 24-56% of overall costs. Methodologies varied across studies, with patient self-reported resource utilization generating the lowest estimates versus claims-based analyses; Medicaid claims analyses generated lower incremental cost estimates for SLE patients versus control patients compared to estimates based on commercial claims analysis. Conclusion SLE is associated with substantial annual direct cost burden in the US; however, little research has been done examining costs associated with specific treatments or cost variation by disease severity and disease manifestations. Future research elucidating the causes in variation of costs will help in the appraisal of emerging therapies and in developing clinical management strategies. Copyright © 2011 by the American College of Rheumatology.

Essani R.,West Penn Allegheny Health System
Seminars in Colon and Rectal Surgery | Year: 2012

Stoma prolapse after formation of an ileostomy or colostomy is a late complication. Prolapse is less common than parastomal hernia. This article reviews the incidence of prolapse, technical factors related to the construction of the stoma that may influence the incidence, and different options for repair. Stoma prolapse affects 2%-47% of individuals with ostomies. Transverse loop colostomy has the highest rate of stoma prolapse, especially because of the large redundant distal loop. Loop ileostomies were thought to have a higher prevalence rate in the past, but recent literature shows only a 2% prolapse rate for ileostomy as opposed to 47% for loop colostomy. The role of extraperitoneal stoma construction is uncertain. Fascial fixation and size of the fascial defect have not been proven to affect the incidence of prolapse. Local care of stoma prolapse is possible, especially if stoma is not incarcerated; however, reversal of stoma is preferable if possible. The options of surgical repair include reversal, resection, revision, and relocation. © 2012 Elsevier Inc.

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