Practice Management

A California nurse practitioner was fined nearly $20,000 for false advertising and fraud after referring to herself as “Dr. Sarah” and failing to file necessary business paperwork, according to a settlement announced on Nov. 14.  

Last month, the San Luis Obispo County, California, District Attorney Dan Dow filed a complaint against Sarah Erny, RN, NP, citing unfair business practices and unprofessional conduct.

According to court documents, California’s Medical Practice Act does not permit individuals to refer to themselves as “doctor, physician, or any other terms or letters indicating or implying that he or she is a physician and surgeon ... without having ... a certificate as a physician and surgeon.”

Individuals who misrepresent themselves are subject to misdemeanor charges and civil penalties. 

In addition to the fine, Ms. Erny agreed to refrain from referring to herself as a doctor in her practice and on social media. She has already deleted her Twitter account.

The case underscores tensions between physicians fighting to preserve their scope of practice and the allied professionals that U.S. lawmakers increasingly see as a less expensive way to improve access to health care.

The American Medical Association and specialty groups strongly oppose a new bill, the Improving Care and Access to Nurses Act, that would expand the scope of practice for nurse practitioners and physician assistants.

Court records show that Ms. Erny earned a doctor of nursing practice (DNP) degree from Vanderbilt University, Nashville, Tenn., and that she met the state requirements to obtain licensure as a registered nurse and nurse practitioner. In 2018, she opened a practice in Arroyo Grande, California, called Holistic Women’s Healing, where she provided medical services and drug supplements to patients.

She also entered a collaborative agreement with ob.gyn. Anika Moore, MD, for approximately 3 years. Dr. Moore’s medical practice was in another county and state, and the physician returned every 2 to 3 months to review a portion of Ms. Erny’s patient files.

Ms. Erny and Dr. Moore terminated the collaborative agreement in March, according to court documents.

However, Mr. Dow alleged that Ms. Erny regularly referred to herself as “Dr. Sarah” or “Dr. Sarah Erny” in her online advertising and social media accounts. Her patients “were so proud of her” that they called her doctor, and her supervising physician instructed staff to do the same.

Mr. Dow said Ms. Erny did not clearly advise the public that she was not a medical doctor and failed to identify her supervising physician. “Simply put, there is a great need for health care providers to state their level of training and licensing clearly and honestly in all of their advertising and marketing materials,” he said in a press release.

In California, nurse practitioners who have been certified by the Board of Registered Nursing may use the following titles: Advanced Practice Registered Nurse; Certified Nurse Practitioner; APRN-CNP; RN and NP; or a combination of other letters or words to identify specialization, such as adult nurse practitioner, pediatric nurse practitioner, obstetrical-gynecological nurse practitioner, and family nurse practitioner.

As educational requirements shift for advanced practice clinicians, similar cases will likely emerge, said Grant Martsolf, PhD, MPH, RN, FAAN, professor at the University of Pittsburgh School of Nursing.

“Scope of practice is governed by states, [so they] will have to figure [it] out as more professional disciplines move to clinical doctorates as the entry to practice. Pharma, [physical therapy], and [occupational therapy] have already done this, and advanced practice nursing is on its way. [Certified registered nurse anesthetists] are already required to get a DNP to sit for certification,” he said.

More guidance is needed, especially when considering other professions like dentists, clinical psychologists, and individuals with clinical or research doctorates who often call themselves doctors, Dr. Martsolf said.

“It seems that the honorific of ‘Dr.’ emerges from the degree, not from being a physician or surgeon,” he said.

Beyond the false advertising, Mr. Dow alleged that Ms. Erny did not file a fictitious business name statement for 2020 and 2021 – a requirement under the California Business and Professions Code to identify who is operating the business.

A version of this article first appeared on Medscape.com.

A California nurse practitioner was fined nearly $20,000 for false advertising and fraud after referring to herself as “Dr. Sarah” and failing to file necessary business paperwork, according to a settlement announced on Nov. 14.  

Last month, the San Luis Obispo County, California, District Attorney Dan Dow filed a complaint against Sarah Erny, RN, NP, citing unfair business practices and unprofessional conduct.

According to court documents, California’s Medical Practice Act does not permit individuals to refer to themselves as “doctor, physician, or any other terms or letters indicating or implying that he or she is a physician and surgeon ... without having ... a certificate as a physician and surgeon.”

Individuals who misrepresent themselves are subject to misdemeanor charges and civil penalties. 

In addition to the fine, Ms. Erny agreed to refrain from referring to herself as a doctor in her practice and on social media. She has already deleted her Twitter account.

The case underscores tensions between physicians fighting to preserve their scope of practice and the allied professionals that U.S. lawmakers increasingly see as a less expensive way to improve access to health care.

The American Medical Association and specialty groups strongly oppose a new bill, the Improving Care and Access to Nurses Act, that would expand the scope of practice for nurse practitioners and physician assistants.

Court records show that Ms. Erny earned a doctor of nursing practice (DNP) degree from Vanderbilt University, Nashville, Tenn., and that she met the state requirements to obtain licensure as a registered nurse and nurse practitioner. In 2018, she opened a practice in Arroyo Grande, California, called Holistic Women’s Healing, where she provided medical services and drug supplements to patients.

She also entered a collaborative agreement with ob.gyn. Anika Moore, MD, for approximately 3 years. Dr. Moore’s medical practice was in another county and state, and the physician returned every 2 to 3 months to review a portion of Ms. Erny’s patient files.

Ms. Erny and Dr. Moore terminated the collaborative agreement in March, according to court documents.

However, Mr. Dow alleged that Ms. Erny regularly referred to herself as “Dr. Sarah” or “Dr. Sarah Erny” in her online advertising and social media accounts. Her patients “were so proud of her” that they called her doctor, and her supervising physician instructed staff to do the same.

Mr. Dow said Ms. Erny did not clearly advise the public that she was not a medical doctor and failed to identify her supervising physician. “Simply put, there is a great need for health care providers to state their level of training and licensing clearly and honestly in all of their advertising and marketing materials,” he said in a press release.

In California, nurse practitioners who have been certified by the Board of Registered Nursing may use the following titles: Advanced Practice Registered Nurse; Certified Nurse Practitioner; APRN-CNP; RN and NP; or a combination of other letters or words to identify specialization, such as adult nurse practitioner, pediatric nurse practitioner, obstetrical-gynecological nurse practitioner, and family nurse practitioner.

As educational requirements shift for advanced practice clinicians, similar cases will likely emerge, said Grant Martsolf, PhD, MPH, RN, FAAN, professor at the University of Pittsburgh School of Nursing.

“Scope of practice is governed by states, [so they] will have to figure [it] out as more professional disciplines move to clinical doctorates as the entry to practice. Pharma, [physical therapy], and [occupational therapy] have already done this, and advanced practice nursing is on its way. [Certified registered nurse anesthetists] are already required to get a DNP to sit for certification,” he said.

More guidance is needed, especially when considering other professions like dentists, clinical psychologists, and individuals with clinical or research doctorates who often call themselves doctors, Dr. Martsolf said.

“It seems that the honorific of ‘Dr.’ emerges from the degree, not from being a physician or surgeon,” he said.

Beyond the false advertising, Mr. Dow alleged that Ms. Erny did not file a fictitious business name statement for 2020 and 2021 – a requirement under the California Business and Professions Code to identify who is operating the business.

A version of this article first appeared on Medscape.com.

A California nurse practitioner was fined nearly $20,000 for false advertising and fraud after referring to herself as “Dr. Sarah” and failing to file necessary business paperwork, according to a settlement announced on Nov. 14.  

Last month, the San Luis Obispo County, California, District Attorney Dan Dow filed a complaint against Sarah Erny, RN, NP, citing unfair business practices and unprofessional conduct.

According to court documents, California’s Medical Practice Act does not permit individuals to refer to themselves as “doctor, physician, or any other terms or letters indicating or implying that he or she is a physician and surgeon ... without having ... a certificate as a physician and surgeon.”

Individuals who misrepresent themselves are subject to misdemeanor charges and civil penalties. 

In addition to the fine, Ms. Erny agreed to refrain from referring to herself as a doctor in her practice and on social media. She has already deleted her Twitter account.

The case underscores tensions between physicians fighting to preserve their scope of practice and the allied professionals that U.S. lawmakers increasingly see as a less expensive way to improve access to health care.

The American Medical Association and specialty groups strongly oppose a new bill, the Improving Care and Access to Nurses Act, that would expand the scope of practice for nurse practitioners and physician assistants.

Court records show that Ms. Erny earned a doctor of nursing practice (DNP) degree from Vanderbilt University, Nashville, Tenn., and that she met the state requirements to obtain licensure as a registered nurse and nurse practitioner. In 2018, she opened a practice in Arroyo Grande, California, called Holistic Women’s Healing, where she provided medical services and drug supplements to patients.

She also entered a collaborative agreement with ob.gyn. Anika Moore, MD, for approximately 3 years. Dr. Moore’s medical practice was in another county and state, and the physician returned every 2 to 3 months to review a portion of Ms. Erny’s patient files.

Ms. Erny and Dr. Moore terminated the collaborative agreement in March, according to court documents.

However, Mr. Dow alleged that Ms. Erny regularly referred to herself as “Dr. Sarah” or “Dr. Sarah Erny” in her online advertising and social media accounts. Her patients “were so proud of her” that they called her doctor, and her supervising physician instructed staff to do the same.

Mr. Dow said Ms. Erny did not clearly advise the public that she was not a medical doctor and failed to identify her supervising physician. “Simply put, there is a great need for health care providers to state their level of training and licensing clearly and honestly in all of their advertising and marketing materials,” he said in a press release.

In California, nurse practitioners who have been certified by the Board of Registered Nursing may use the following titles: Advanced Practice Registered Nurse; Certified Nurse Practitioner; APRN-CNP; RN and NP; or a combination of other letters or words to identify specialization, such as adult nurse practitioner, pediatric nurse practitioner, obstetrical-gynecological nurse practitioner, and family nurse practitioner.

As educational requirements shift for advanced practice clinicians, similar cases will likely emerge, said Grant Martsolf, PhD, MPH, RN, FAAN, professor at the University of Pittsburgh School of Nursing.

“Scope of practice is governed by states, [so they] will have to figure [it] out as more professional disciplines move to clinical doctorates as the entry to practice. Pharma, [physical therapy], and [occupational therapy] have already done this, and advanced practice nursing is on its way. [Certified registered nurse anesthetists] are already required to get a DNP to sit for certification,” he said.

More guidance is needed, especially when considering other professions like dentists, clinical psychologists, and individuals with clinical or research doctorates who often call themselves doctors, Dr. Martsolf said.

“It seems that the honorific of ‘Dr.’ emerges from the degree, not from being a physician or surgeon,” he said.

Beyond the false advertising, Mr. Dow alleged that Ms. Erny did not file a fictitious business name statement for 2020 and 2021 – a requirement under the California Business and Professions Code to identify who is operating the business.

A version of this article first appeared on Medscape.com.

On one of the first days of medical school, Adaira Landry, MD, applied her favorite dark shade of lipstick and headed to her orientation. She was eager to learn about program expectations and connect with fellow aspiring physicians. But when Dr. Landry got there, one of her brand-new peers turned to her and asked, “Why do you wear your lipstick like an angry Black woman?”

“Imagine hearing that,” Dr. Landry, now an emergency medical physician in Boston, says. “It was so hurtful.”

So, what is a “standard-issue doctor” expected to look like? Physicians manage their appearances in myriad ways: through clothes, accessories, hair style, makeup; through a social media presence or lack thereof; in the rhythms and nuances of their interactions with patients and colleagues. These things add up to a professional “persona” – the Latin word for “mask,” or the face on display for the world to see.

Professional personae exist across various industries, but some standards for professionalism in medicine reflect a particularly narrow view of what a physician can or should be. While the health care field itself is diversifying, its guidelines for professionalism appear slower to change, often excluding or frowning upon expressions of individual personality or identity.

“Medicine is run primarily by men. It’s an objective truth,” Dr. Landry says. “Currently and historically, the standard of professionalism, especially in the physical sense, was set by them. As we increase diversity and welcome people bringing their authentic self to work, the prior definitions of professionalism are obviously in need of change.”
 

Split social media personalities

In August 2020, the Journal of Vascular Surgery published a study on the “prevalence of unprofessional social media content among young vascular surgeons.” The content that was deemed “unprofessional” included opinions on political issues like abortion and gun control. Photos of physicians holding alcoholic drinks or wearing “inappropriate/offensive attire,” including underwear, “provocative Halloween costumes,” and “bikinis/swimwear” were also censured. Six men and one woman worked on the study, and three of the male researchers took on the task of seeking out the “unprofessional” photos on social media. The resulting paper was reviewed by an all-male editorial board.

The study sparked immediate backlash and prompted hundreds of health care professionals to post photos of themselves in bathing suits with the hashtag “#medbikini.” The journal then retracted the study and issued an apology on Twitter, recognizing “errors in the design of the study with regards to conscious and unconscious bias.”

The researchers’ original definition of professionalism suggests that physicians should manage their personae even outside of work hours. “I think medicine in general is a very conservative and hierarchical field of study and of work, to say the least,” says Sarah Fraser, MD, a family medicine physician in Nova Scotia, Canada. “There’s this view that we have to have completely separate personal and professional lives, like church and state.”

The #medbikini controversy inspired Dr. Fraser to write an op-ed for the British Medical Journal blog about the flaws of requiring physicians to keep their personal and professional selves separate. The piece referenced Robert Louis Stevenson’s 1886 Gothic novella “The Strange Case of Dr. Jekyll and Mr. Hyde,” in which the respected scientist Dr. Jekyll creates an alter ego so he can express his evil urges without experiencing guilt, punishment, or loss of livelihood. Dr. Fraser likened this story to the pressure physicians feel to shrink or split themselves to squeeze into a narrow definition of professionalism.

But Dr. Landry points out that some elements of expression seen as unprofessional cannot be entirely separated from a physician’s fundamental identity. “For Black women, our daily behaviors and forms of expression that are deemed ‘unprofessional’ are much more subtle than being able to wear a bikini on social media,” she says. “The way we wear our hair, the tone of our voice, the color of our lipstick, the way we wear scrub caps are parts of us that are called into question.”
 

Keeping up appearances

The stereotype of what a doctor should look like starts to shape physicians’ professional personae in medical school. When Jennifer Caputo-Seidler, MD, started medical school in 2008, the dress code requirements for male students were simple: pants, a button-down shirt, a tie. But then there were the rules for women: Hair should be tied back. Minimal makeup. No flashy jewelry. Nothing without sleeves. Neutral colors. High necklines. Low hemlines. “The message I got was that we need to dress like the men in order to be taken seriously and to be seen as professional,” says Dr. Caputo-Seidler, now an assistant professor of medicine at the University of South Florida, Tampa, “and so that’s what I did.”

A 2018 analysis of 78 “draw-a-scientist” studies found that children have overwhelmingly associated scientific fields with men for the last 50 years. Overall, children drew 73% of scientists as men. The drawings grew more gender diverse over time, but even as more women entered scientific fields, both boys and girls continued to draw significantly more male than female scientists.

Not everyone at Dr. Caputo-Seidler’s medical school adhered to the environment’s gendered expectations. One resident she worked with often wore voluminous hairstyles, lipstick, and high heels. Dr. Caputo-Seidler overheard her peers as they gossiped behind the resident’s back, ridiculing the way she looked.

“She was good at her job,” Dr. Caputo-Seidler says. “She knew her patients. She had things down. She was, by all measures, very competent. But when people saw her dressing outside the norm and being forward with her femininity, there was definitely a lot of chatter about it.”

While expectations for a conservative appearance may disproportionately affect women, and particularly women of color, they also affect men who deviate from the norm. “As an LGBTQ+ person working as a ‘professional,’ I have countless stories and moments where I had my professionalism questioned,” Blair Peters, MD, a plastic surgeon and assistant professor at Oregon Health & Science University, Portland, wrote on Twitter. “Why is it ‘unprofessional’ to have colored hair? Why is it ‘unprofessional’ to have a visible tattoo? Why is it ‘unprofessional’ to wear bright colors and patterns?”

Dr. Fraser remembers a fellow medical student who had full-sleeve tattoos on both of his arms. A preceptor made a comment about it to Dr. Fraser, and then instructed the student to cover up his tattoos. “I think that there are scenarios when having tattoos or having different-colored hair or expressing your individual personality could help you even better bond with your patients,” Dr. Fraser says, “especially if you’re, for example, working with youth.”
 

Unmasking health care

Beyond the facets of dress codes and social media posts, the issue of professional personae speaks to the deeper issue of inclusion in medicine. As the field grows increasingly diverse, health care institutions and those they serve may need to expand their definitions of professionalism to include more truthful expressions of who contemporary health care professionals are as people.

Dr. Fraser suggests that the benefits of physicians embracing self-expression – rather than assimilating to an outdated model of professionalism – extend beyond the individual.

“Whether it comes to what you choose to wear to the clinic on a day-to-day basis, or what you choose to share on a social media account, as long as it’s not harming others, then I think that it’s a positive thing to be able to be yourself and express yourself,” she says. “I feel like doctors are expected to have a different personality when we’re at the clinic, and usually it’s more conservative or objective or aloof. But I think that by being open about who we are, we’ll actually help build a trusting relationship with both patients and society.”

A version of this article first appeared on Medscape.com.

On one of the first days of medical school, Adaira Landry, MD, applied her favorite dark shade of lipstick and headed to her orientation. She was eager to learn about program expectations and connect with fellow aspiring physicians. But when Dr. Landry got there, one of her brand-new peers turned to her and asked, “Why do you wear your lipstick like an angry Black woman?”

“Imagine hearing that,” Dr. Landry, now an emergency medical physician in Boston, says. “It was so hurtful.”

So, what is a “standard-issue doctor” expected to look like? Physicians manage their appearances in myriad ways: through clothes, accessories, hair style, makeup; through a social media presence or lack thereof; in the rhythms and nuances of their interactions with patients and colleagues. These things add up to a professional “persona” – the Latin word for “mask,” or the face on display for the world to see.

Professional personae exist across various industries, but some standards for professionalism in medicine reflect a particularly narrow view of what a physician can or should be. While the health care field itself is diversifying, its guidelines for professionalism appear slower to change, often excluding or frowning upon expressions of individual personality or identity.

“Medicine is run primarily by men. It’s an objective truth,” Dr. Landry says. “Currently and historically, the standard of professionalism, especially in the physical sense, was set by them. As we increase diversity and welcome people bringing their authentic self to work, the prior definitions of professionalism are obviously in need of change.”
 

Split social media personalities

In August 2020, the Journal of Vascular Surgery published a study on the “prevalence of unprofessional social media content among young vascular surgeons.” The content that was deemed “unprofessional” included opinions on political issues like abortion and gun control. Photos of physicians holding alcoholic drinks or wearing “inappropriate/offensive attire,” including underwear, “provocative Halloween costumes,” and “bikinis/swimwear” were also censured. Six men and one woman worked on the study, and three of the male researchers took on the task of seeking out the “unprofessional” photos on social media. The resulting paper was reviewed by an all-male editorial board.

The study sparked immediate backlash and prompted hundreds of health care professionals to post photos of themselves in bathing suits with the hashtag “#medbikini.” The journal then retracted the study and issued an apology on Twitter, recognizing “errors in the design of the study with regards to conscious and unconscious bias.”

The researchers’ original definition of professionalism suggests that physicians should manage their personae even outside of work hours. “I think medicine in general is a very conservative and hierarchical field of study and of work, to say the least,” says Sarah Fraser, MD, a family medicine physician in Nova Scotia, Canada. “There’s this view that we have to have completely separate personal and professional lives, like church and state.”

The #medbikini controversy inspired Dr. Fraser to write an op-ed for the British Medical Journal blog about the flaws of requiring physicians to keep their personal and professional selves separate. The piece referenced Robert Louis Stevenson’s 1886 Gothic novella “The Strange Case of Dr. Jekyll and Mr. Hyde,” in which the respected scientist Dr. Jekyll creates an alter ego so he can express his evil urges without experiencing guilt, punishment, or loss of livelihood. Dr. Fraser likened this story to the pressure physicians feel to shrink or split themselves to squeeze into a narrow definition of professionalism.

But Dr. Landry points out that some elements of expression seen as unprofessional cannot be entirely separated from a physician’s fundamental identity. “For Black women, our daily behaviors and forms of expression that are deemed ‘unprofessional’ are much more subtle than being able to wear a bikini on social media,” she says. “The way we wear our hair, the tone of our voice, the color of our lipstick, the way we wear scrub caps are parts of us that are called into question.”
 

Keeping up appearances

The stereotype of what a doctor should look like starts to shape physicians’ professional personae in medical school. When Jennifer Caputo-Seidler, MD, started medical school in 2008, the dress code requirements for male students were simple: pants, a button-down shirt, a tie. But then there were the rules for women: Hair should be tied back. Minimal makeup. No flashy jewelry. Nothing without sleeves. Neutral colors. High necklines. Low hemlines. “The message I got was that we need to dress like the men in order to be taken seriously and to be seen as professional,” says Dr. Caputo-Seidler, now an assistant professor of medicine at the University of South Florida, Tampa, “and so that’s what I did.”

A 2018 analysis of 78 “draw-a-scientist” studies found that children have overwhelmingly associated scientific fields with men for the last 50 years. Overall, children drew 73% of scientists as men. The drawings grew more gender diverse over time, but even as more women entered scientific fields, both boys and girls continued to draw significantly more male than female scientists.

Not everyone at Dr. Caputo-Seidler’s medical school adhered to the environment’s gendered expectations. One resident she worked with often wore voluminous hairstyles, lipstick, and high heels. Dr. Caputo-Seidler overheard her peers as they gossiped behind the resident’s back, ridiculing the way she looked.

“She was good at her job,” Dr. Caputo-Seidler says. “She knew her patients. She had things down. She was, by all measures, very competent. But when people saw her dressing outside the norm and being forward with her femininity, there was definitely a lot of chatter about it.”

While expectations for a conservative appearance may disproportionately affect women, and particularly women of color, they also affect men who deviate from the norm. “As an LGBTQ+ person working as a ‘professional,’ I have countless stories and moments where I had my professionalism questioned,” Blair Peters, MD, a plastic surgeon and assistant professor at Oregon Health & Science University, Portland, wrote on Twitter. “Why is it ‘unprofessional’ to have colored hair? Why is it ‘unprofessional’ to have a visible tattoo? Why is it ‘unprofessional’ to wear bright colors and patterns?”

Dr. Fraser remembers a fellow medical student who had full-sleeve tattoos on both of his arms. A preceptor made a comment about it to Dr. Fraser, and then instructed the student to cover up his tattoos. “I think that there are scenarios when having tattoos or having different-colored hair or expressing your individual personality could help you even better bond with your patients,” Dr. Fraser says, “especially if you’re, for example, working with youth.”
 

Unmasking health care

Beyond the facets of dress codes and social media posts, the issue of professional personae speaks to the deeper issue of inclusion in medicine. As the field grows increasingly diverse, health care institutions and those they serve may need to expand their definitions of professionalism to include more truthful expressions of who contemporary health care professionals are as people.

Dr. Fraser suggests that the benefits of physicians embracing self-expression – rather than assimilating to an outdated model of professionalism – extend beyond the individual.

“Whether it comes to what you choose to wear to the clinic on a day-to-day basis, or what you choose to share on a social media account, as long as it’s not harming others, then I think that it’s a positive thing to be able to be yourself and express yourself,” she says. “I feel like doctors are expected to have a different personality when we’re at the clinic, and usually it’s more conservative or objective or aloof. But I think that by being open about who we are, we’ll actually help build a trusting relationship with both patients and society.”

A version of this article first appeared on Medscape.com.

On one of the first days of medical school, Adaira Landry, MD, applied her favorite dark shade of lipstick and headed to her orientation. She was eager to learn about program expectations and connect with fellow aspiring physicians. But when Dr. Landry got there, one of her brand-new peers turned to her and asked, “Why do you wear your lipstick like an angry Black woman?”

“Imagine hearing that,” Dr. Landry, now an emergency medical physician in Boston, says. “It was so hurtful.”

So, what is a “standard-issue doctor” expected to look like? Physicians manage their appearances in myriad ways: through clothes, accessories, hair style, makeup; through a social media presence or lack thereof; in the rhythms and nuances of their interactions with patients and colleagues. These things add up to a professional “persona” – the Latin word for “mask,” or the face on display for the world to see.

Professional personae exist across various industries, but some standards for professionalism in medicine reflect a particularly narrow view of what a physician can or should be. While the health care field itself is diversifying, its guidelines for professionalism appear slower to change, often excluding or frowning upon expressions of individual personality or identity.

“Medicine is run primarily by men. It’s an objective truth,” Dr. Landry says. “Currently and historically, the standard of professionalism, especially in the physical sense, was set by them. As we increase diversity and welcome people bringing their authentic self to work, the prior definitions of professionalism are obviously in need of change.”
 

Split social media personalities

In August 2020, the Journal of Vascular Surgery published a study on the “prevalence of unprofessional social media content among young vascular surgeons.” The content that was deemed “unprofessional” included opinions on political issues like abortion and gun control. Photos of physicians holding alcoholic drinks or wearing “inappropriate/offensive attire,” including underwear, “provocative Halloween costumes,” and “bikinis/swimwear” were also censured. Six men and one woman worked on the study, and three of the male researchers took on the task of seeking out the “unprofessional” photos on social media. The resulting paper was reviewed by an all-male editorial board.

The study sparked immediate backlash and prompted hundreds of health care professionals to post photos of themselves in bathing suits with the hashtag “#medbikini.” The journal then retracted the study and issued an apology on Twitter, recognizing “errors in the design of the study with regards to conscious and unconscious bias.”

The researchers’ original definition of professionalism suggests that physicians should manage their personae even outside of work hours. “I think medicine in general is a very conservative and hierarchical field of study and of work, to say the least,” says Sarah Fraser, MD, a family medicine physician in Nova Scotia, Canada. “There’s this view that we have to have completely separate personal and professional lives, like church and state.”

The #medbikini controversy inspired Dr. Fraser to write an op-ed for the British Medical Journal blog about the flaws of requiring physicians to keep their personal and professional selves separate. The piece referenced Robert Louis Stevenson’s 1886 Gothic novella “The Strange Case of Dr. Jekyll and Mr. Hyde,” in which the respected scientist Dr. Jekyll creates an alter ego so he can express his evil urges without experiencing guilt, punishment, or loss of livelihood. Dr. Fraser likened this story to the pressure physicians feel to shrink or split themselves to squeeze into a narrow definition of professionalism.

But Dr. Landry points out that some elements of expression seen as unprofessional cannot be entirely separated from a physician’s fundamental identity. “For Black women, our daily behaviors and forms of expression that are deemed ‘unprofessional’ are much more subtle than being able to wear a bikini on social media,” she says. “The way we wear our hair, the tone of our voice, the color of our lipstick, the way we wear scrub caps are parts of us that are called into question.”
 

Keeping up appearances

The stereotype of what a doctor should look like starts to shape physicians’ professional personae in medical school. When Jennifer Caputo-Seidler, MD, started medical school in 2008, the dress code requirements for male students were simple: pants, a button-down shirt, a tie. But then there were the rules for women: Hair should be tied back. Minimal makeup. No flashy jewelry. Nothing without sleeves. Neutral colors. High necklines. Low hemlines. “The message I got was that we need to dress like the men in order to be taken seriously and to be seen as professional,” says Dr. Caputo-Seidler, now an assistant professor of medicine at the University of South Florida, Tampa, “and so that’s what I did.”

A 2018 analysis of 78 “draw-a-scientist” studies found that children have overwhelmingly associated scientific fields with men for the last 50 years. Overall, children drew 73% of scientists as men. The drawings grew more gender diverse over time, but even as more women entered scientific fields, both boys and girls continued to draw significantly more male than female scientists.

Not everyone at Dr. Caputo-Seidler’s medical school adhered to the environment’s gendered expectations. One resident she worked with often wore voluminous hairstyles, lipstick, and high heels. Dr. Caputo-Seidler overheard her peers as they gossiped behind the resident’s back, ridiculing the way she looked.

“She was good at her job,” Dr. Caputo-Seidler says. “She knew her patients. She had things down. She was, by all measures, very competent. But when people saw her dressing outside the norm and being forward with her femininity, there was definitely a lot of chatter about it.”

While expectations for a conservative appearance may disproportionately affect women, and particularly women of color, they also affect men who deviate from the norm. “As an LGBTQ+ person working as a ‘professional,’ I have countless stories and moments where I had my professionalism questioned,” Blair Peters, MD, a plastic surgeon and assistant professor at Oregon Health & Science University, Portland, wrote on Twitter. “Why is it ‘unprofessional’ to have colored hair? Why is it ‘unprofessional’ to have a visible tattoo? Why is it ‘unprofessional’ to wear bright colors and patterns?”

Dr. Fraser remembers a fellow medical student who had full-sleeve tattoos on both of his arms. A preceptor made a comment about it to Dr. Fraser, and then instructed the student to cover up his tattoos. “I think that there are scenarios when having tattoos or having different-colored hair or expressing your individual personality could help you even better bond with your patients,” Dr. Fraser says, “especially if you’re, for example, working with youth.”
 

Unmasking health care

Beyond the facets of dress codes and social media posts, the issue of professional personae speaks to the deeper issue of inclusion in medicine. As the field grows increasingly diverse, health care institutions and those they serve may need to expand their definitions of professionalism to include more truthful expressions of who contemporary health care professionals are as people.

Dr. Fraser suggests that the benefits of physicians embracing self-expression – rather than assimilating to an outdated model of professionalism – extend beyond the individual.

“Whether it comes to what you choose to wear to the clinic on a day-to-day basis, or what you choose to share on a social media account, as long as it’s not harming others, then I think that it’s a positive thing to be able to be yourself and express yourself,” she says. “I feel like doctors are expected to have a different personality when we’re at the clinic, and usually it’s more conservative or objective or aloof. But I think that by being open about who we are, we’ll actually help build a trusting relationship with both patients and society.”

A version of this article first appeared on Medscape.com.

From Milwaukee County Behavioral Health Services, Milwaukee, WI.

Abstract

Objectives: The goal of this study was to determine whether a single-item quality of life (QOL) measure could serve as a useful population health–level metric within the Quadruple Aim framework in a publicly funded behavioral health system.

Design: This was a retrospective, cross-sectional study that examined the correlation between the single-item QOL measure and several other key measures of the social determinants of health and a composite measure of acute service utilization for all patients receiving mental health and substance use services in a community behavioral health system.

Methods: Data were collected for 4488 patients who had at least 1 assessment between October 1, 2020, and September 30, 2021. Data on social determinants of health were obtained through patient self-report; acute service use data were obtained from electronic health records.

Results: Statistical analyses revealed results in the expected direction for all relationships tested. Patients with higher QOL were more likely to report “Good” or better self-rated physical health, be employed, have a private residence, and report recent positive social interactions, and were less likely to have received acute services in the previous 90 days.

Conclusion: A single-item QOL measure shows promise as a general, minimally burdensome whole-system metric that can function as a target for population health management efforts in a large behavioral health system. Future research should explore whether this QOL measure is sensitive to change over time and examine its temporal relationship with other key outcome metrics.

Keywords: Quadruple Aim, single-item measures, social determinants of health, acute service utilization metrics.

The Triple Aim for health care—improving the individual experience of care, increasing the health of populations, and reducing the costs of care—was first proposed in 2008.¹ More recently, some have advocated for an expanded focus to include a fourth aim: the quality of staff work life.² Since this seminal paper was published, many health care systems have endeavored to adopt and implement the Quadruple Aim^3,4; however, the concepts representing each of the aims are not universally defined,³ nor are the measures needed to populate the Quadruple Aim always available within the health system in question.⁵

Although several assessment models and frameworks that provide guidance to stakeholders have been developed,^6,7 it is ultimately up to organizations themselves to determine which measures they should deploy to best represent the different quadrants of the Quadruple Aim.⁶ Evidence suggests, however, that quality measurement, and the administrative time required to conduct it, can be both financially and emotionally burdensome to providers and health systems.^8-10 Thus, it is incumbent on organizations to select a set of measures that are not only meaningful but as parsimonious as possible.^6,11,12

Quality of life (QOL) is a potential candidate to assess the aim of population health. Brief health-related QOL questions have long been used in epidemiological surveys, such as the Behavioral Risk Factor Surveillance System survey.¹³ Such questions are also a key component of community health frameworks, such as the County Health Rankings developed by the University of Wisconsin Population Health Institute.¹⁴ Furthermore, Humana recently revealed that increasing the number of physical and mental health “Healthy Days” (which are among the Centers for Disease Control and Prevention’s Health-Related Quality of Life questions¹⁵) among the members enrolled in their insurance plan would become a major goal for the organization.^16,17 Many of these measures, while brief, focus on QOL as a function of health, often as a self-rated construct (from “Poor” to “Excellent”) or in the form of days of poor physical or mental health in the past 30 days,¹⁵ rather than evaluating QOL itself; however, several authors have pointed out that health status and QOL are related but distinct concepts.^18,19

Brief single-item assessments focused specifically on QOL have been developed and implemented within nonclinical²⁰ and clinical populations, including individuals with cancer,²¹ adults with disabilities,²² individuals with cystic fibrosis,²³ and children with epilepsy.²⁴ Despite the long history of QOL assessment in behavioral health treatment,²⁵ single-item measures have not been widely implemented in this population.

Milwaukee County Behavioral Health Services (BHS), a publicly funded, county-based behavioral health care system in Milwaukee, Wisconsin, provides inpatient and ambulatory treatment, psychiatric emergency care, withdrawal management, care management, crisis services, and other support services to individuals in Milwaukee County. In 2018 the community services arm of BHS began implementing a single QOL question from the World Health Organization’s WHOQOL-BREF²⁶: On a 5-point rating scale of “Very Poor” to “Very Good,” “How would you rate your overall quality of life right now?” Previous research by Atroszko and colleagues,²⁰ which used a similar approach with the same item from the WHOQOL-BREF, reported correlations in the expected direction of the single-item QOL measure with perceived stress, depression, anxiety, loneliness, and daily hours of sleep. This study’s sample, however, comprised opportunistically recruited college students, not a clinical population. Further, the researchers did not examine the relationship of QOL with acute service utilization or other measures of the social determinants of health, such as housing, employment, or social connectedness.

The following study was designed to extend these results by focusing on a clinical population—individuals with mental health or substance use issues—being served in a large, publicly funded behavioral health system in Milwaukee, Wisconsin. The objective of this study was to determine whether a single-item QOL measure could be used as a brief, parsimonious measure of overall population health by examining its relationship with other key outcome measures for patients receiving services from BHS. This study was reviewed and approved by BHS’s Institutional Review Board.

Methods

All patients engaged in nonacute community services are offered a standardized assessment that includes, among other measures, items related to QOL, housing status, employment status, self-rated physical health, and social connectedness. This assessment is administered at intake, discharge, and every 6 months while patients are enrolled in services. Patients who received at least 1 assessment between October 1, 2020, and September 30, 2021, were included in the analyses. Patients receiving crisis, inpatient, or withdrawal management services alone (ie, did not receive any other community-based services) were not offered the standard assessment and thus were not included in the analyses. If patients had more than 1 assessment during this time period, QOL data from the last assessment were used. Data on housing (private residence status, defined as adults living alone or with others without supervision in a house or apartment), employment status, self-rated physical health, and social connectedness (measured by asking people whether they have had positive interactions with family or friends in the past 30 days) were extracted from the same timepoint as well.

Also included in the analyses were rates of acute service utilization, in which any patient with at least 1 visit to BHS’s psychiatric emergency department, withdrawal management facility, or psychiatric inpatient facility in the 90 days prior to the date of the assessment received a code of “Yes,” and any patient who did not receive any of these services received a code of “No.” Chi-square analyses were conducted to determine the relationship between QOL rankings (“Very Poor,” “Poor,” “Neither Good nor Poor,” “Good,” and “Very Good”) and housing, employment, self-rated physical health, social connectedness, and 90-day acute service use. All acute service utilization data were obtained from BHS’s electronic health records system. All data used in the study were stored on a secure, password-protected server. All analyses were conducted with SPSS software (SPSS 28; IBM).

Results

Data were available for 4488 patients who received an assessment between October 1, 2020, and September 30, 2021 (total numbers per item vary because some items had missing data; see supplementary eTables 1-3 for sample size per item). Demographics of the patient sample are listed in Table 1; the demographics of the patients who were missing data for specific outcomes are presented in eTables 1-3.

Statistical analyses revealed results in the expected direction for all relationships tested (Table 2). As patients’ self-reported QOL improved, so did the likelihood of higher rates of self-reported “Good” or better physical health, which was 576% higher among individuals who reported “Very Good” QOL relative to those who reported “Very Poor” QOL. Similarly, when compared with individuals with “Very Poor” QOL, individuals who reported “Very Good” QOL were 21.91% more likely to report having a private residence, 126.7% more likely to report being employed, and 29.17% more likely to report having had positive social interactions with family and friends in the past 30 days. There was an inverse relationship between QOL and the likelihood that a patient had received at least 1 admission for an acute service in the previous 90 days, such that patients who reported “Very Good” QOL were 86.34% less likely to have had an admission compared to patients with “Very Poor” QOL (2.8% vs 20.5%, respectively). The relationships among the criterion variables used in this study are presented in Table 3.

Discussion

The results of this preliminary analysis suggest that self-rated QOL is related to key health, social determinants of health, and acute service utilization metrics. These data are important for several reasons. First, because QOL is a diagnostically agnostic measure, it is a cross-cutting measure to use with clinically diverse populations receiving an array of different services. Second, at 1 item, the QOL measure is extremely brief and therefore minimally onerous to implement for both patients and administratively overburdened providers. Third, its correlation with other key metrics suggests that it can function as a broad population health measure for health care organizations because individuals with higher QOL will also likely have better outcomes in other key areas. This suggests that it has the potential to broadly represent the overall status of a population of patients, thus functioning as a type of “whole system” measure, which the Institute for Healthcare Improvement describes as “a small set of measures that reflect a health system’s overall performance on core dimensions of quality guided by the Triple Aim.”⁷ These whole system measures can help focus an organization’s strategic initiatives and efforts on the issues that matter most to the patients and community it serves.

The relationship of QOL to acute service utilization deserves special mention. As an administrative measure, utilization is not susceptible to the same response bias as the other self-reported variables. Furthermore, acute services are costly to health systems, and hospital readmissions are associated with payment reductions in the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program for hospitals that fail to meet certain performance targets.²⁷ Thus, because of its alignment with federal mandates, improved QOL (and potentially concomitant decreases in acute service use) may have significant financial implications for health systems as well.

This study was limited by several factors. First, it was focused on a population receiving publicly funded behavioral health services with strict eligibility requirements, one of which stipulated that individuals must be at 200% or less of the Federal Poverty Level; therefore, the results might not be applicable to health systems with a more clinically or socioeconomically diverse patient population. Second, because these data are cross-sectional, it was not possible to determine whether QOL improved over time or whether changes in QOL covaried longitudinally with the other metrics under observation. For example, if patients’ QOL improved from the first to last assessment, did their employment or residential status improve as well, or were these patients more likely to be employed at their first assessment? Furthermore, if there was covariance, did changes in employment, housing status, and so on precede changes in QOL or vice versa? Multiple longitudinal observations would help to address these questions and will be the focus of future analyses.

Conclusion

This preliminary study suggests that a single-item QOL measure may be a valuable population health–level metric for health systems. It requires little administrative effort on the part of either the clinician or patient. It is also agnostic with regard to clinical issue or treatment approach and can therefore admit of a range of diagnoses or patient-specific, idiosyncratic recovery goals. It is correlated with other key health, social determinants of health, and acute service utilization indicators and can therefore serve as a “whole system” measure because of its ability to broadly represent improvements in an entire population. Furthermore, QOL is patient-centered in that data are obtained through patient self-report, which is a high priority for CMS and other health care organizations.²⁸ In summary, a single-item QOL measure holds promise for health care organizations looking to implement the Quadruple Aim and assess the health of the populations they serve in a manner that is simple, efficient, and patient-centered.

Acknowledgments: The author thanks Jennifer Wittwer for her thoughtful comments on the initial draft of this manuscript and Gary Kraft for his help extracting the data used in the analyses.

Corresponding author: Walter Matthew Drymalski, PhD; [email protected]

Disclosures: None reported.

From Milwaukee County Behavioral Health Services, Milwaukee, WI.

Abstract

Objectives: The goal of this study was to determine whether a single-item quality of life (QOL) measure could serve as a useful population health–level metric within the Quadruple Aim framework in a publicly funded behavioral health system.

Design: This was a retrospective, cross-sectional study that examined the correlation between the single-item QOL measure and several other key measures of the social determinants of health and a composite measure of acute service utilization for all patients receiving mental health and substance use services in a community behavioral health system.

Methods: Data were collected for 4488 patients who had at least 1 assessment between October 1, 2020, and September 30, 2021. Data on social determinants of health were obtained through patient self-report; acute service use data were obtained from electronic health records.

Results: Statistical analyses revealed results in the expected direction for all relationships tested. Patients with higher QOL were more likely to report “Good” or better self-rated physical health, be employed, have a private residence, and report recent positive social interactions, and were less likely to have received acute services in the previous 90 days.

Conclusion: A single-item QOL measure shows promise as a general, minimally burdensome whole-system metric that can function as a target for population health management efforts in a large behavioral health system. Future research should explore whether this QOL measure is sensitive to change over time and examine its temporal relationship with other key outcome metrics.

Keywords: Quadruple Aim, single-item measures, social determinants of health, acute service utilization metrics.

The Triple Aim for health care—improving the individual experience of care, increasing the health of populations, and reducing the costs of care—was first proposed in 2008.¹ More recently, some have advocated for an expanded focus to include a fourth aim: the quality of staff work life.² Since this seminal paper was published, many health care systems have endeavored to adopt and implement the Quadruple Aim^3,4; however, the concepts representing each of the aims are not universally defined,³ nor are the measures needed to populate the Quadruple Aim always available within the health system in question.⁵

Although several assessment models and frameworks that provide guidance to stakeholders have been developed,^6,7 it is ultimately up to organizations themselves to determine which measures they should deploy to best represent the different quadrants of the Quadruple Aim.⁶ Evidence suggests, however, that quality measurement, and the administrative time required to conduct it, can be both financially and emotionally burdensome to providers and health systems.^8-10 Thus, it is incumbent on organizations to select a set of measures that are not only meaningful but as parsimonious as possible.^6,11,12

Quality of life (QOL) is a potential candidate to assess the aim of population health. Brief health-related QOL questions have long been used in epidemiological surveys, such as the Behavioral Risk Factor Surveillance System survey.¹³ Such questions are also a key component of community health frameworks, such as the County Health Rankings developed by the University of Wisconsin Population Health Institute.¹⁴ Furthermore, Humana recently revealed that increasing the number of physical and mental health “Healthy Days” (which are among the Centers for Disease Control and Prevention’s Health-Related Quality of Life questions¹⁵) among the members enrolled in their insurance plan would become a major goal for the organization.^16,17 Many of these measures, while brief, focus on QOL as a function of health, often as a self-rated construct (from “Poor” to “Excellent”) or in the form of days of poor physical or mental health in the past 30 days,¹⁵ rather than evaluating QOL itself; however, several authors have pointed out that health status and QOL are related but distinct concepts.^18,19

Brief single-item assessments focused specifically on QOL have been developed and implemented within nonclinical²⁰ and clinical populations, including individuals with cancer,²¹ adults with disabilities,²² individuals with cystic fibrosis,²³ and children with epilepsy.²⁴ Despite the long history of QOL assessment in behavioral health treatment,²⁵ single-item measures have not been widely implemented in this population.

Milwaukee County Behavioral Health Services (BHS), a publicly funded, county-based behavioral health care system in Milwaukee, Wisconsin, provides inpatient and ambulatory treatment, psychiatric emergency care, withdrawal management, care management, crisis services, and other support services to individuals in Milwaukee County. In 2018 the community services arm of BHS began implementing a single QOL question from the World Health Organization’s WHOQOL-BREF²⁶: On a 5-point rating scale of “Very Poor” to “Very Good,” “How would you rate your overall quality of life right now?” Previous research by Atroszko and colleagues,²⁰ which used a similar approach with the same item from the WHOQOL-BREF, reported correlations in the expected direction of the single-item QOL measure with perceived stress, depression, anxiety, loneliness, and daily hours of sleep. This study’s sample, however, comprised opportunistically recruited college students, not a clinical population. Further, the researchers did not examine the relationship of QOL with acute service utilization or other measures of the social determinants of health, such as housing, employment, or social connectedness.

The following study was designed to extend these results by focusing on a clinical population—individuals with mental health or substance use issues—being served in a large, publicly funded behavioral health system in Milwaukee, Wisconsin. The objective of this study was to determine whether a single-item QOL measure could be used as a brief, parsimonious measure of overall population health by examining its relationship with other key outcome measures for patients receiving services from BHS. This study was reviewed and approved by BHS’s Institutional Review Board.

Methods

All patients engaged in nonacute community services are offered a standardized assessment that includes, among other measures, items related to QOL, housing status, employment status, self-rated physical health, and social connectedness. This assessment is administered at intake, discharge, and every 6 months while patients are enrolled in services. Patients who received at least 1 assessment between October 1, 2020, and September 30, 2021, were included in the analyses. Patients receiving crisis, inpatient, or withdrawal management services alone (ie, did not receive any other community-based services) were not offered the standard assessment and thus were not included in the analyses. If patients had more than 1 assessment during this time period, QOL data from the last assessment were used. Data on housing (private residence status, defined as adults living alone or with others without supervision in a house or apartment), employment status, self-rated physical health, and social connectedness (measured by asking people whether they have had positive interactions with family or friends in the past 30 days) were extracted from the same timepoint as well.

Also included in the analyses were rates of acute service utilization, in which any patient with at least 1 visit to BHS’s psychiatric emergency department, withdrawal management facility, or psychiatric inpatient facility in the 90 days prior to the date of the assessment received a code of “Yes,” and any patient who did not receive any of these services received a code of “No.” Chi-square analyses were conducted to determine the relationship between QOL rankings (“Very Poor,” “Poor,” “Neither Good nor Poor,” “Good,” and “Very Good”) and housing, employment, self-rated physical health, social connectedness, and 90-day acute service use. All acute service utilization data were obtained from BHS’s electronic health records system. All data used in the study were stored on a secure, password-protected server. All analyses were conducted with SPSS software (SPSS 28; IBM).

Results

Data were available for 4488 patients who received an assessment between October 1, 2020, and September 30, 2021 (total numbers per item vary because some items had missing data; see supplementary eTables 1-3 for sample size per item). Demographics of the patient sample are listed in Table 1; the demographics of the patients who were missing data for specific outcomes are presented in eTables 1-3.

Statistical analyses revealed results in the expected direction for all relationships tested (Table 2). As patients’ self-reported QOL improved, so did the likelihood of higher rates of self-reported “Good” or better physical health, which was 576% higher among individuals who reported “Very Good” QOL relative to those who reported “Very Poor” QOL. Similarly, when compared with individuals with “Very Poor” QOL, individuals who reported “Very Good” QOL were 21.91% more likely to report having a private residence, 126.7% more likely to report being employed, and 29.17% more likely to report having had positive social interactions with family and friends in the past 30 days. There was an inverse relationship between QOL and the likelihood that a patient had received at least 1 admission for an acute service in the previous 90 days, such that patients who reported “Very Good” QOL were 86.34% less likely to have had an admission compared to patients with “Very Poor” QOL (2.8% vs 20.5%, respectively). The relationships among the criterion variables used in this study are presented in Table 3.

Discussion

The results of this preliminary analysis suggest that self-rated QOL is related to key health, social determinants of health, and acute service utilization metrics. These data are important for several reasons. First, because QOL is a diagnostically agnostic measure, it is a cross-cutting measure to use with clinically diverse populations receiving an array of different services. Second, at 1 item, the QOL measure is extremely brief and therefore minimally onerous to implement for both patients and administratively overburdened providers. Third, its correlation with other key metrics suggests that it can function as a broad population health measure for health care organizations because individuals with higher QOL will also likely have better outcomes in other key areas. This suggests that it has the potential to broadly represent the overall status of a population of patients, thus functioning as a type of “whole system” measure, which the Institute for Healthcare Improvement describes as “a small set of measures that reflect a health system’s overall performance on core dimensions of quality guided by the Triple Aim.”⁷ These whole system measures can help focus an organization’s strategic initiatives and efforts on the issues that matter most to the patients and community it serves.

The relationship of QOL to acute service utilization deserves special mention. As an administrative measure, utilization is not susceptible to the same response bias as the other self-reported variables. Furthermore, acute services are costly to health systems, and hospital readmissions are associated with payment reductions in the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program for hospitals that fail to meet certain performance targets.²⁷ Thus, because of its alignment with federal mandates, improved QOL (and potentially concomitant decreases in acute service use) may have significant financial implications for health systems as well.

This study was limited by several factors. First, it was focused on a population receiving publicly funded behavioral health services with strict eligibility requirements, one of which stipulated that individuals must be at 200% or less of the Federal Poverty Level; therefore, the results might not be applicable to health systems with a more clinically or socioeconomically diverse patient population. Second, because these data are cross-sectional, it was not possible to determine whether QOL improved over time or whether changes in QOL covaried longitudinally with the other metrics under observation. For example, if patients’ QOL improved from the first to last assessment, did their employment or residential status improve as well, or were these patients more likely to be employed at their first assessment? Furthermore, if there was covariance, did changes in employment, housing status, and so on precede changes in QOL or vice versa? Multiple longitudinal observations would help to address these questions and will be the focus of future analyses.

Conclusion

This preliminary study suggests that a single-item QOL measure may be a valuable population health–level metric for health systems. It requires little administrative effort on the part of either the clinician or patient. It is also agnostic with regard to clinical issue or treatment approach and can therefore admit of a range of diagnoses or patient-specific, idiosyncratic recovery goals. It is correlated with other key health, social determinants of health, and acute service utilization indicators and can therefore serve as a “whole system” measure because of its ability to broadly represent improvements in an entire population. Furthermore, QOL is patient-centered in that data are obtained through patient self-report, which is a high priority for CMS and other health care organizations.²⁸ In summary, a single-item QOL measure holds promise for health care organizations looking to implement the Quadruple Aim and assess the health of the populations they serve in a manner that is simple, efficient, and patient-centered.

Acknowledgments: The author thanks Jennifer Wittwer for her thoughtful comments on the initial draft of this manuscript and Gary Kraft for his help extracting the data used in the analyses.

Corresponding author: Walter Matthew Drymalski, PhD; [email protected]

Disclosures: None reported.

From Milwaukee County Behavioral Health Services, Milwaukee, WI.

Abstract

Objectives: The goal of this study was to determine whether a single-item quality of life (QOL) measure could serve as a useful population health–level metric within the Quadruple Aim framework in a publicly funded behavioral health system.

Design: This was a retrospective, cross-sectional study that examined the correlation between the single-item QOL measure and several other key measures of the social determinants of health and a composite measure of acute service utilization for all patients receiving mental health and substance use services in a community behavioral health system.

Methods: Data were collected for 4488 patients who had at least 1 assessment between October 1, 2020, and September 30, 2021. Data on social determinants of health were obtained through patient self-report; acute service use data were obtained from electronic health records.

Results: Statistical analyses revealed results in the expected direction for all relationships tested. Patients with higher QOL were more likely to report “Good” or better self-rated physical health, be employed, have a private residence, and report recent positive social interactions, and were less likely to have received acute services in the previous 90 days.

Conclusion: A single-item QOL measure shows promise as a general, minimally burdensome whole-system metric that can function as a target for population health management efforts in a large behavioral health system. Future research should explore whether this QOL measure is sensitive to change over time and examine its temporal relationship with other key outcome metrics.

Keywords: Quadruple Aim, single-item measures, social determinants of health, acute service utilization metrics.

The Triple Aim for health care—improving the individual experience of care, increasing the health of populations, and reducing the costs of care—was first proposed in 2008.¹ More recently, some have advocated for an expanded focus to include a fourth aim: the quality of staff work life.² Since this seminal paper was published, many health care systems have endeavored to adopt and implement the Quadruple Aim^3,4; however, the concepts representing each of the aims are not universally defined,³ nor are the measures needed to populate the Quadruple Aim always available within the health system in question.⁵

Although several assessment models and frameworks that provide guidance to stakeholders have been developed,^6,7 it is ultimately up to organizations themselves to determine which measures they should deploy to best represent the different quadrants of the Quadruple Aim.⁶ Evidence suggests, however, that quality measurement, and the administrative time required to conduct it, can be both financially and emotionally burdensome to providers and health systems.^8-10 Thus, it is incumbent on organizations to select a set of measures that are not only meaningful but as parsimonious as possible.^6,11,12

Quality of life (QOL) is a potential candidate to assess the aim of population health. Brief health-related QOL questions have long been used in epidemiological surveys, such as the Behavioral Risk Factor Surveillance System survey.¹³ Such questions are also a key component of community health frameworks, such as the County Health Rankings developed by the University of Wisconsin Population Health Institute.¹⁴ Furthermore, Humana recently revealed that increasing the number of physical and mental health “Healthy Days” (which are among the Centers for Disease Control and Prevention’s Health-Related Quality of Life questions¹⁵) among the members enrolled in their insurance plan would become a major goal for the organization.^16,17 Many of these measures, while brief, focus on QOL as a function of health, often as a self-rated construct (from “Poor” to “Excellent”) or in the form of days of poor physical or mental health in the past 30 days,¹⁵ rather than evaluating QOL itself; however, several authors have pointed out that health status and QOL are related but distinct concepts.^18,19

Brief single-item assessments focused specifically on QOL have been developed and implemented within nonclinical²⁰ and clinical populations, including individuals with cancer,²¹ adults with disabilities,²² individuals with cystic fibrosis,²³ and children with epilepsy.²⁴ Despite the long history of QOL assessment in behavioral health treatment,²⁵ single-item measures have not been widely implemented in this population.

Milwaukee County Behavioral Health Services (BHS), a publicly funded, county-based behavioral health care system in Milwaukee, Wisconsin, provides inpatient and ambulatory treatment, psychiatric emergency care, withdrawal management, care management, crisis services, and other support services to individuals in Milwaukee County. In 2018 the community services arm of BHS began implementing a single QOL question from the World Health Organization’s WHOQOL-BREF²⁶: On a 5-point rating scale of “Very Poor” to “Very Good,” “How would you rate your overall quality of life right now?” Previous research by Atroszko and colleagues,²⁰ which used a similar approach with the same item from the WHOQOL-BREF, reported correlations in the expected direction of the single-item QOL measure with perceived stress, depression, anxiety, loneliness, and daily hours of sleep. This study’s sample, however, comprised opportunistically recruited college students, not a clinical population. Further, the researchers did not examine the relationship of QOL with acute service utilization or other measures of the social determinants of health, such as housing, employment, or social connectedness.

The following study was designed to extend these results by focusing on a clinical population—individuals with mental health or substance use issues—being served in a large, publicly funded behavioral health system in Milwaukee, Wisconsin. The objective of this study was to determine whether a single-item QOL measure could be used as a brief, parsimonious measure of overall population health by examining its relationship with other key outcome measures for patients receiving services from BHS. This study was reviewed and approved by BHS’s Institutional Review Board.

Methods

All patients engaged in nonacute community services are offered a standardized assessment that includes, among other measures, items related to QOL, housing status, employment status, self-rated physical health, and social connectedness. This assessment is administered at intake, discharge, and every 6 months while patients are enrolled in services. Patients who received at least 1 assessment between October 1, 2020, and September 30, 2021, were included in the analyses. Patients receiving crisis, inpatient, or withdrawal management services alone (ie, did not receive any other community-based services) were not offered the standard assessment and thus were not included in the analyses. If patients had more than 1 assessment during this time period, QOL data from the last assessment were used. Data on housing (private residence status, defined as adults living alone or with others without supervision in a house or apartment), employment status, self-rated physical health, and social connectedness (measured by asking people whether they have had positive interactions with family or friends in the past 30 days) were extracted from the same timepoint as well.

Also included in the analyses were rates of acute service utilization, in which any patient with at least 1 visit to BHS’s psychiatric emergency department, withdrawal management facility, or psychiatric inpatient facility in the 90 days prior to the date of the assessment received a code of “Yes,” and any patient who did not receive any of these services received a code of “No.” Chi-square analyses were conducted to determine the relationship between QOL rankings (“Very Poor,” “Poor,” “Neither Good nor Poor,” “Good,” and “Very Good”) and housing, employment, self-rated physical health, social connectedness, and 90-day acute service use. All acute service utilization data were obtained from BHS’s electronic health records system. All data used in the study were stored on a secure, password-protected server. All analyses were conducted with SPSS software (SPSS 28; IBM).

Results

Data were available for 4488 patients who received an assessment between October 1, 2020, and September 30, 2021 (total numbers per item vary because some items had missing data; see supplementary eTables 1-3 for sample size per item). Demographics of the patient sample are listed in Table 1; the demographics of the patients who were missing data for specific outcomes are presented in eTables 1-3.

Statistical analyses revealed results in the expected direction for all relationships tested (Table 2). As patients’ self-reported QOL improved, so did the likelihood of higher rates of self-reported “Good” or better physical health, which was 576% higher among individuals who reported “Very Good” QOL relative to those who reported “Very Poor” QOL. Similarly, when compared with individuals with “Very Poor” QOL, individuals who reported “Very Good” QOL were 21.91% more likely to report having a private residence, 126.7% more likely to report being employed, and 29.17% more likely to report having had positive social interactions with family and friends in the past 30 days. There was an inverse relationship between QOL and the likelihood that a patient had received at least 1 admission for an acute service in the previous 90 days, such that patients who reported “Very Good” QOL were 86.34% less likely to have had an admission compared to patients with “Very Poor” QOL (2.8% vs 20.5%, respectively). The relationships among the criterion variables used in this study are presented in Table 3.

Discussion

The results of this preliminary analysis suggest that self-rated QOL is related to key health, social determinants of health, and acute service utilization metrics. These data are important for several reasons. First, because QOL is a diagnostically agnostic measure, it is a cross-cutting measure to use with clinically diverse populations receiving an array of different services. Second, at 1 item, the QOL measure is extremely brief and therefore minimally onerous to implement for both patients and administratively overburdened providers. Third, its correlation with other key metrics suggests that it can function as a broad population health measure for health care organizations because individuals with higher QOL will also likely have better outcomes in other key areas. This suggests that it has the potential to broadly represent the overall status of a population of patients, thus functioning as a type of “whole system” measure, which the Institute for Healthcare Improvement describes as “a small set of measures that reflect a health system’s overall performance on core dimensions of quality guided by the Triple Aim.”⁷ These whole system measures can help focus an organization’s strategic initiatives and efforts on the issues that matter most to the patients and community it serves.

The relationship of QOL to acute service utilization deserves special mention. As an administrative measure, utilization is not susceptible to the same response bias as the other self-reported variables. Furthermore, acute services are costly to health systems, and hospital readmissions are associated with payment reductions in the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program for hospitals that fail to meet certain performance targets.²⁷ Thus, because of its alignment with federal mandates, improved QOL (and potentially concomitant decreases in acute service use) may have significant financial implications for health systems as well.

This study was limited by several factors. First, it was focused on a population receiving publicly funded behavioral health services with strict eligibility requirements, one of which stipulated that individuals must be at 200% or less of the Federal Poverty Level; therefore, the results might not be applicable to health systems with a more clinically or socioeconomically diverse patient population. Second, because these data are cross-sectional, it was not possible to determine whether QOL improved over time or whether changes in QOL covaried longitudinally with the other metrics under observation. For example, if patients’ QOL improved from the first to last assessment, did their employment or residential status improve as well, or were these patients more likely to be employed at their first assessment? Furthermore, if there was covariance, did changes in employment, housing status, and so on precede changes in QOL or vice versa? Multiple longitudinal observations would help to address these questions and will be the focus of future analyses.

Conclusion

This preliminary study suggests that a single-item QOL measure may be a valuable population health–level metric for health systems. It requires little administrative effort on the part of either the clinician or patient. It is also agnostic with regard to clinical issue or treatment approach and can therefore admit of a range of diagnoses or patient-specific, idiosyncratic recovery goals. It is correlated with other key health, social determinants of health, and acute service utilization indicators and can therefore serve as a “whole system” measure because of its ability to broadly represent improvements in an entire population. Furthermore, QOL is patient-centered in that data are obtained through patient self-report, which is a high priority for CMS and other health care organizations.²⁸ In summary, a single-item QOL measure holds promise for health care organizations looking to implement the Quadruple Aim and assess the health of the populations they serve in a manner that is simple, efficient, and patient-centered.

Acknowledgments: The author thanks Jennifer Wittwer for her thoughtful comments on the initial draft of this manuscript and Gary Kraft for his help extracting the data used in the analyses.

Corresponding author: Walter Matthew Drymalski, PhD; [email protected]

Disclosures: None reported.

From the Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (Stefan W. Koester, Puja Jagasia, and Drs. Liles, Dambrino IV, Feldman, and Chambless), and the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN (Drs. Mathews and Tiwari).

ABSTRACT

Background: The COVID-19 pandemic has had broad effects on surgical care, including operating room (OR) staffing, personal protective equipment (PPE) utilization, and newly implemented anti-infective measures. Our aim was to assess neurosurgery OR efficiency before the COVID-19 pandemic, during peak COVID-19, and during current times.

Methods: Institutional perioperative databases at a single, high-volume neurosurgical center were queried for operations performed from December 2019 until October 2021. March 12, 2020, the day that the state of Tennessee declared a state of emergency, was chosen as the onset of the COVID-19 pandemic. The 90-day periods before and after this day were used to define the pre-COVID-19, peak-COVID-19, and post-peak restrictions time periods for comparative analysis. Outcomes included delay in first-start and OR turnover time between neurosurgical cases. Preset threshold times were used in analyses to adjust for normal leniency in OR scheduling (15 minutes for first start and 90 minutes for turnover). Univariate analysis used Wilcoxon rank-sum test for continuous outcomes, while chi-square test and Fisher’s exact test were used for categorical comparisons. Significance was defined as P < .05.

Results: First-start time was analyzed in 426 pre-COVID-19, 357 peak-restrictions, and 2304 post-peak-restrictions cases. The unadjusted mean delay length was found to be significantly different between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes, 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004). The adjusted average delay length and proportion of cases delayed beyond the 15-minute threshold were not significantly different. The proportion of cases that started early, as well as significantly early past a 15-minute threshold, have not been impacted. There was no significant change in turnover time during peak restrictions relative to the pre-COVID-19 period (88 [100] minutes vs 85 [95] minutes), and turnover time has since remained unchanged (83 [87] minutes).

Conclusion: Our center was able to maintain OR efficiency before, during, and after peak restrictions even while instituting advanced infection-control strategies. While there were significant changes, delays were relatively small in magnitude.

Keywords: operating room timing, hospital efficiency, socioeconomics, pandemic.

The COVID-19 pandemic has led to major changes in patient care both from a surgical perspective and in regard to inpatient hospital course. Safety protocols nationwide have been implemented to protect both patients and providers. Some elements of surgical care have drastically changed, including operating room (OR) staffing, personal protective equipment (PPE) utilization, and increased sterilization measures. Furloughs, layoffs, and reassignments due to the focus on nonelective and COVID-19–related cases challenged OR staffing and efficiency. Operating room staff with COVID-19 exposures or COVID-19 infections also caused last-minute changes in staffing. All of these scenarios can cause issues due to actual understaffing or due to staff members being pushed into highly specialized areas, such as neurosurgery, in which they have very little experience. A further obstacle to OR efficiency included policy changes involving PPE utilization, sterilization measures, and supply chain shortages of necessary resources such as PPE.

Neurosurgery in particular has been susceptible to COVID-19–related system-wide changes given operator proximity to the patient’s respiratory passages, frequency of emergent cases, and varying anesthetic needs, as well as the high level of specialization needed to perform neurosurgical care. Previous studies have shown a change in the makeup of neurosurgical patients seeking care, as well as in the acuity of neurological consult of these patients.¹ A study in orthopedic surgery by Andreata et al demonstrated worsened OR efficiency, with significantly increased first-start and turnover times.² In the COVID-19 era, OR quality and safety are crucially important to both patients and providers. Providing this safe and effective care in an efficient manner is important for optimal neurosurgical management in the long term.³ Moreover, the financial burden of implementing new protocols and standards can be compounded by additional financial losses due to reduced OR efficiency.

Methods

To analyze the effect of COVID-19 on neurosurgical OR efficiency, institutional perioperative databases at a single high-volume center were queried for operations performed from December 2019 until October 2021. March 12, 2020, was chosen as the onset of COVID-19 for analytic purposes, as this was the date when the state of Tennessee declared a state of emergency. The 90-day periods before and after this date were used for comparative analysis for pre-COVID-19, peak COVID-19, and post-peak-restrictions time periods. The peak COVID-19 period was defined as the 90-day period following the initial onset of COVID-19 and the surge of cases. For comparison purposes, post-peak COVID-19 was defined as the months following the first peak until October 2021 (approximately 17 months). COVID-19 burden was determined using a COVID-19 single-institution census of confirmed cases by polymerase chain reaction (PCR) for which the average number of cases of COVID-19 during a given month was determined. This number is a scaled trend, and a true number of COVID-19 cases in our hospital was not reported.

Neurosurgical and neuroendovascular cases were included in the analysis. Outcomes included delay in first-start and OR turnover time between neurosurgical cases, defined as the time from the patient leaving the room until the next patient entered the room. Preset threshold times were used in analyses to adjust for normal leniency in OR scheduling (15 minutes for first start and 90 minutes for turnover, which is a standard for our single-institution perioperative center). Statistical analyses, including data aggregation, were performed using R, version 4.0.1 (R Foundation for Statistical Computing). Patients’ demographic and clinical characteristics were analyzed using an independent 2-sample t-test for interval variables and a chi-square test for categorical variables. Significance was defined as P < .05.

Results

First-Start Time

First-start time was analyzed in 426 pre-COVID-19, 357 peak-COVID-19, and 2304 post-peak-COVID-19 cases. The unadjusted mean delay length was significantly different between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes, 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004) (Table 1).

The adjusted average delay length and proportion of cases delayed beyond the 15-minute threshold were not significantly different, but they have been slightly higher since the onset of COVID-19. The proportion of cases that have started early, as well as significantly early past a 15-minute threshold, have also trended down since the onset of the COVID-19 pandemic, but this difference was again not significant. The temporal relationship of first-start delay, both unadjusted and adjusted, from December 2019 to October 2021 is shown in Figure 1. The trend of increasing delay is loosely associated with the COVID-19 burden experienced by our hospital. The start of COVID-19 as well as both COVID-19 peaks have been associated with increased delays in our hospital.

Turnover Time

Turnover time was assessed in 437 pre-COVID-19, 278 peak-restrictions, and 2411 post-peak-restrictions cases. Turnover time during peak restrictions was not significantly different from pre-COVID-19 (88 [100] vs 85 [95]) and has since remained relatively unchanged (83 [87], P = .78). A similar trend held for comparisons of proportion of cases with turnover time past 90 minutes and average times past the 90-minute threshold (Table 2). The temporal relationship between COVID-19 burden and turnover time, both unadjusted and adjusted, from December 2019 to October 2021 is shown in Figure 2. Both figures demonstrate a slight initial increase in turnover time delay at the start of COVID-19, which stabilized with little variation thereafter.

We analyzed the OR efficiency metrics of first-start and turnover time during the 90-day period before COVID-19 (pre-COVID-19), the 90 days following Tennessee declaring a state of emergency (peak COVID-19), and the time following this period (post-COVID-19) for all neurosurgical and neuroendovascular cases at Vanderbilt University Medical Center (VUMC). We found a significant difference in unadjusted mean delay length in first-start time between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes for pre-COVID-19, peak-COVID-19, and post-COVID-19: 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004). No significant increase in turnover time between cases was found between these 3 time periods. Based on metrics from first-start delay and turnover time, our center was able to maintain OR efficiency before, during, and after peak COVID-19.

After the Centers for Disease Control and Prevention released guidelines recommending deferring elective procedures to conserve beds and PPE, VUMC made the decision to suspend all elective surgical procedures from March 18 to April 24, 2020. Prior research conducted during the COVID-19 pandemic has demonstrated more than 400 types of surgical procedures with negatively impacted outcomes when compared to surgical outcomes from the same time frame in 2018 and 2019.⁴ For more than 20 of these types of procedures, there was a significant association between procedure delay and adverse patient outcomes.⁴ Testing protocols for patients prior to surgery varied throughout the pandemic based on vaccination status and type of procedure. Before vaccines became widely available, all patients were required to obtain a PCR SARS-CoV-2 test within 48 to 72 hours of the scheduled procedure. If the patient’s procedure was urgent and testing was not feasible, the patient was treated as a SARS-CoV-2–positive patient, which required all health care workers involved in the case to wear gowns, gloves, surgical masks, and eye protection. Testing patients preoperatively likely helped to maintain OR efficiency since not all patients received test results prior to the scheduled procedure, leading to cancellations of cases and therefore more staff available for fewer cases.

After vaccines became widely available to the public, testing requirements for patients preoperatively were relaxed, and only patients who were not fully vaccinated or severely immunocompromised were required to test prior to procedures. However, approximately 40% of the population in Tennessee was fully vaccinated in 2021, which reflects the patient population of VUMC.⁵ This means that many patients who received care at VUMC were still tested prior to procedures.

Adopting adequate safety protocols was found to be key for OR efficiency during the COVID-19 pandemic since performing surgery increased the risk of infection for each health care worker in the OR.⁶ VUMC protocols identified procedures that required enhanced safety measures to prevent infection of health care workers and avoid staffing shortages, which would decrease OR efficiency. Protocols mandated that only anesthesia team members were allowed to be in the OR during intubation and extubation of patients, which could be one factor leading to increased delays and decreased efficiency for some institutions. Methods for neurosurgeons to decrease risk of infection in the OR include postponing all nonurgent cases, reappraising the necessity for general anesthesia and endotracheal intubation, considering alternative surgical approaches that avoid the respiratory tract, and limiting the use of aerosol-generating instruments.^7,8 VUMC’s success in implementing these protocols likely explains why our center was able to maintain OR efficiency throughout the COVID-19 pandemic.

A study conducted by Andreata et al showed a significantly increased mean first-case delay and a nonsignificant increased turnover time in orthopedic surgeries in Northern Italy when comparing surgeries performed during the COVID-19 pandemic to those performed prior to COVID-19.² Other studies have indicated a similar trend in decreased OR efficiency during COVID-19 in other areas around the world.^9,10 These findings are not consistent with our own findings for neurosurgical and neuroendovascular surgeries at VUMC, and any change at our institution was relatively immaterial. Factors that threatened to change OR efficiency—but did not result in meaningful changes in our institutional experience—include delays due to pending COVID-19 test results, safety procedures such as PPE donning, and planning difficulties to ensure the existence of teams with non-overlapping providers in the case of a surgeon being infected.^2,11-13

Globally, many surgery centers halted all elective surgeries during the initial COVID-19 spike to prevent a PPE shortage and mitigate risk of infection of patients and health care workers.^8,12,14 However, there is no centralized definition of which neurosurgical procedures are elective, so that decision was made on a surgeon or center level, which could lead to variability in efficiency trends.¹⁴ One study on neurosurgical procedures during COVID-19 found a 30% decline in all cases and a 23% decline in emergent procedures, showing that the decrease in volume was not only due to cancellation of elective procedures.¹⁵ This decrease in elective and emergent surgeries created a backlog of surgeries as well as a loss in health care revenue, and caused many patients to go without adequate health care.¹⁰ Looking forward, it is imperative that surgical centers study trends in OR efficiency from COVID-19 and learn how to better maintain OR efficiency during future pandemic conditions to prevent a backlog of cases, loss of health care revenue, and decreased health care access.

Limitations

Our data are from a single center and therefore may not be representative of experiences of other hospitals due to different populations and different impacts from COVID-19. However, given our center’s high volume and diverse patient population, we believe our analysis highlights important trends in neurosurgery practice. Notably, data for patient and OR timing are digitally generated and are entered manually by nurses in the electronic medical record, making it prone to errors and variability. This is in our experience, and if any error is present, we believe it is minimal.

Conclusion

The COVID-19 pandemic has had far-reaching effects on health care worldwide, including neurosurgical care. OR efficiency across the United States generally worsened given the stresses of supply chain issues, staffing shortages, and cancellations. At our institution, we were able to maintain OR efficiency during the known COVID-19 peaks until October 2021. Continually functional neurosurgical ORs are important in preventing delays in care and maintaining a steady revenue in order for hospitals and other health care entities to remain solvent. Further study of OR efficiency is needed for health care systems to prepare for future pandemics and other resource-straining events in order to provide optimal patient care.

Corresponding author: Campbell Liles, MD, Vanderbilt University Medical Center, Department of Neurological Surgery, 1161 21st Ave. South, T4224 Medical Center North, Nashville, TN 37232-2380; [email protected]

Disclosures: None reported.

From the Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (Stefan W. Koester, Puja Jagasia, and Drs. Liles, Dambrino IV, Feldman, and Chambless), and the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN (Drs. Mathews and Tiwari).

ABSTRACT

Background: The COVID-19 pandemic has had broad effects on surgical care, including operating room (OR) staffing, personal protective equipment (PPE) utilization, and newly implemented anti-infective measures. Our aim was to assess neurosurgery OR efficiency before the COVID-19 pandemic, during peak COVID-19, and during current times.

Methods: Institutional perioperative databases at a single, high-volume neurosurgical center were queried for operations performed from December 2019 until October 2021. March 12, 2020, the day that the state of Tennessee declared a state of emergency, was chosen as the onset of the COVID-19 pandemic. The 90-day periods before and after this day were used to define the pre-COVID-19, peak-COVID-19, and post-peak restrictions time periods for comparative analysis. Outcomes included delay in first-start and OR turnover time between neurosurgical cases. Preset threshold times were used in analyses to adjust for normal leniency in OR scheduling (15 minutes for first start and 90 minutes for turnover). Univariate analysis used Wilcoxon rank-sum test for continuous outcomes, while chi-square test and Fisher’s exact test were used for categorical comparisons. Significance was defined as P < .05.

Results: First-start time was analyzed in 426 pre-COVID-19, 357 peak-restrictions, and 2304 post-peak-restrictions cases. The unadjusted mean delay length was found to be significantly different between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes, 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004). The adjusted average delay length and proportion of cases delayed beyond the 15-minute threshold were not significantly different. The proportion of cases that started early, as well as significantly early past a 15-minute threshold, have not been impacted. There was no significant change in turnover time during peak restrictions relative to the pre-COVID-19 period (88 [100] minutes vs 85 [95] minutes), and turnover time has since remained unchanged (83 [87] minutes).

Conclusion: Our center was able to maintain OR efficiency before, during, and after peak restrictions even while instituting advanced infection-control strategies. While there were significant changes, delays were relatively small in magnitude.

Keywords: operating room timing, hospital efficiency, socioeconomics, pandemic.

The COVID-19 pandemic has led to major changes in patient care both from a surgical perspective and in regard to inpatient hospital course. Safety protocols nationwide have been implemented to protect both patients and providers. Some elements of surgical care have drastically changed, including operating room (OR) staffing, personal protective equipment (PPE) utilization, and increased sterilization measures. Furloughs, layoffs, and reassignments due to the focus on nonelective and COVID-19–related cases challenged OR staffing and efficiency. Operating room staff with COVID-19 exposures or COVID-19 infections also caused last-minute changes in staffing. All of these scenarios can cause issues due to actual understaffing or due to staff members being pushed into highly specialized areas, such as neurosurgery, in which they have very little experience. A further obstacle to OR efficiency included policy changes involving PPE utilization, sterilization measures, and supply chain shortages of necessary resources such as PPE.

Neurosurgery in particular has been susceptible to COVID-19–related system-wide changes given operator proximity to the patient’s respiratory passages, frequency of emergent cases, and varying anesthetic needs, as well as the high level of specialization needed to perform neurosurgical care. Previous studies have shown a change in the makeup of neurosurgical patients seeking care, as well as in the acuity of neurological consult of these patients.¹ A study in orthopedic surgery by Andreata et al demonstrated worsened OR efficiency, with significantly increased first-start and turnover times.² In the COVID-19 era, OR quality and safety are crucially important to both patients and providers. Providing this safe and effective care in an efficient manner is important for optimal neurosurgical management in the long term.³ Moreover, the financial burden of implementing new protocols and standards can be compounded by additional financial losses due to reduced OR efficiency.

Methods

To analyze the effect of COVID-19 on neurosurgical OR efficiency, institutional perioperative databases at a single high-volume center were queried for operations performed from December 2019 until October 2021. March 12, 2020, was chosen as the onset of COVID-19 for analytic purposes, as this was the date when the state of Tennessee declared a state of emergency. The 90-day periods before and after this date were used for comparative analysis for pre-COVID-19, peak COVID-19, and post-peak-restrictions time periods. The peak COVID-19 period was defined as the 90-day period following the initial onset of COVID-19 and the surge of cases. For comparison purposes, post-peak COVID-19 was defined as the months following the first peak until October 2021 (approximately 17 months). COVID-19 burden was determined using a COVID-19 single-institution census of confirmed cases by polymerase chain reaction (PCR) for which the average number of cases of COVID-19 during a given month was determined. This number is a scaled trend, and a true number of COVID-19 cases in our hospital was not reported.

Neurosurgical and neuroendovascular cases were included in the analysis. Outcomes included delay in first-start and OR turnover time between neurosurgical cases, defined as the time from the patient leaving the room until the next patient entered the room. Preset threshold times were used in analyses to adjust for normal leniency in OR scheduling (15 minutes for first start and 90 minutes for turnover, which is a standard for our single-institution perioperative center). Statistical analyses, including data aggregation, were performed using R, version 4.0.1 (R Foundation for Statistical Computing). Patients’ demographic and clinical characteristics were analyzed using an independent 2-sample t-test for interval variables and a chi-square test for categorical variables. Significance was defined as P < .05.

Results

First-Start Time

First-start time was analyzed in 426 pre-COVID-19, 357 peak-COVID-19, and 2304 post-peak-COVID-19 cases. The unadjusted mean delay length was significantly different between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes, 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004) (Table 1).

The adjusted average delay length and proportion of cases delayed beyond the 15-minute threshold were not significantly different, but they have been slightly higher since the onset of COVID-19. The proportion of cases that have started early, as well as significantly early past a 15-minute threshold, have also trended down since the onset of the COVID-19 pandemic, but this difference was again not significant. The temporal relationship of first-start delay, both unadjusted and adjusted, from December 2019 to October 2021 is shown in Figure 1. The trend of increasing delay is loosely associated with the COVID-19 burden experienced by our hospital. The start of COVID-19 as well as both COVID-19 peaks have been associated with increased delays in our hospital.

Turnover Time

Turnover time was assessed in 437 pre-COVID-19, 278 peak-restrictions, and 2411 post-peak-restrictions cases. Turnover time during peak restrictions was not significantly different from pre-COVID-19 (88 [100] vs 85 [95]) and has since remained relatively unchanged (83 [87], P = .78). A similar trend held for comparisons of proportion of cases with turnover time past 90 minutes and average times past the 90-minute threshold (Table 2). The temporal relationship between COVID-19 burden and turnover time, both unadjusted and adjusted, from December 2019 to October 2021 is shown in Figure 2. Both figures demonstrate a slight initial increase in turnover time delay at the start of COVID-19, which stabilized with little variation thereafter.

We analyzed the OR efficiency metrics of first-start and turnover time during the 90-day period before COVID-19 (pre-COVID-19), the 90 days following Tennessee declaring a state of emergency (peak COVID-19), and the time following this period (post-COVID-19) for all neurosurgical and neuroendovascular cases at Vanderbilt University Medical Center (VUMC). We found a significant difference in unadjusted mean delay length in first-start time between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes for pre-COVID-19, peak-COVID-19, and post-COVID-19: 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004). No significant increase in turnover time between cases was found between these 3 time periods. Based on metrics from first-start delay and turnover time, our center was able to maintain OR efficiency before, during, and after peak COVID-19.

After the Centers for Disease Control and Prevention released guidelines recommending deferring elective procedures to conserve beds and PPE, VUMC made the decision to suspend all elective surgical procedures from March 18 to April 24, 2020. Prior research conducted during the COVID-19 pandemic has demonstrated more than 400 types of surgical procedures with negatively impacted outcomes when compared to surgical outcomes from the same time frame in 2018 and 2019.⁴ For more than 20 of these types of procedures, there was a significant association between procedure delay and adverse patient outcomes.⁴ Testing protocols for patients prior to surgery varied throughout the pandemic based on vaccination status and type of procedure. Before vaccines became widely available, all patients were required to obtain a PCR SARS-CoV-2 test within 48 to 72 hours of the scheduled procedure. If the patient’s procedure was urgent and testing was not feasible, the patient was treated as a SARS-CoV-2–positive patient, which required all health care workers involved in the case to wear gowns, gloves, surgical masks, and eye protection. Testing patients preoperatively likely helped to maintain OR efficiency since not all patients received test results prior to the scheduled procedure, leading to cancellations of cases and therefore more staff available for fewer cases.

After vaccines became widely available to the public, testing requirements for patients preoperatively were relaxed, and only patients who were not fully vaccinated or severely immunocompromised were required to test prior to procedures. However, approximately 40% of the population in Tennessee was fully vaccinated in 2021, which reflects the patient population of VUMC.⁵ This means that many patients who received care at VUMC were still tested prior to procedures.

Adopting adequate safety protocols was found to be key for OR efficiency during the COVID-19 pandemic since performing surgery increased the risk of infection for each health care worker in the OR.⁶ VUMC protocols identified procedures that required enhanced safety measures to prevent infection of health care workers and avoid staffing shortages, which would decrease OR efficiency. Protocols mandated that only anesthesia team members were allowed to be in the OR during intubation and extubation of patients, which could be one factor leading to increased delays and decreased efficiency for some institutions. Methods for neurosurgeons to decrease risk of infection in the OR include postponing all nonurgent cases, reappraising the necessity for general anesthesia and endotracheal intubation, considering alternative surgical approaches that avoid the respiratory tract, and limiting the use of aerosol-generating instruments.^7,8 VUMC’s success in implementing these protocols likely explains why our center was able to maintain OR efficiency throughout the COVID-19 pandemic.

A study conducted by Andreata et al showed a significantly increased mean first-case delay and a nonsignificant increased turnover time in orthopedic surgeries in Northern Italy when comparing surgeries performed during the COVID-19 pandemic to those performed prior to COVID-19.² Other studies have indicated a similar trend in decreased OR efficiency during COVID-19 in other areas around the world.^9,10 These findings are not consistent with our own findings for neurosurgical and neuroendovascular surgeries at VUMC, and any change at our institution was relatively immaterial. Factors that threatened to change OR efficiency—but did not result in meaningful changes in our institutional experience—include delays due to pending COVID-19 test results, safety procedures such as PPE donning, and planning difficulties to ensure the existence of teams with non-overlapping providers in the case of a surgeon being infected.^2,11-13

Globally, many surgery centers halted all elective surgeries during the initial COVID-19 spike to prevent a PPE shortage and mitigate risk of infection of patients and health care workers.^8,12,14 However, there is no centralized definition of which neurosurgical procedures are elective, so that decision was made on a surgeon or center level, which could lead to variability in efficiency trends.¹⁴ One study on neurosurgical procedures during COVID-19 found a 30% decline in all cases and a 23% decline in emergent procedures, showing that the decrease in volume was not only due to cancellation of elective procedures.¹⁵ This decrease in elective and emergent surgeries created a backlog of surgeries as well as a loss in health care revenue, and caused many patients to go without adequate health care.¹⁰ Looking forward, it is imperative that surgical centers study trends in OR efficiency from COVID-19 and learn how to better maintain OR efficiency during future pandemic conditions to prevent a backlog of cases, loss of health care revenue, and decreased health care access.

Limitations

Our data are from a single center and therefore may not be representative of experiences of other hospitals due to different populations and different impacts from COVID-19. However, given our center’s high volume and diverse patient population, we believe our analysis highlights important trends in neurosurgery practice. Notably, data for patient and OR timing are digitally generated and are entered manually by nurses in the electronic medical record, making it prone to errors and variability. This is in our experience, and if any error is present, we believe it is minimal.

Conclusion

The COVID-19 pandemic has had far-reaching effects on health care worldwide, including neurosurgical care. OR efficiency across the United States generally worsened given the stresses of supply chain issues, staffing shortages, and cancellations. At our institution, we were able to maintain OR efficiency during the known COVID-19 peaks until October 2021. Continually functional neurosurgical ORs are important in preventing delays in care and maintaining a steady revenue in order for hospitals and other health care entities to remain solvent. Further study of OR efficiency is needed for health care systems to prepare for future pandemics and other resource-straining events in order to provide optimal patient care.

Corresponding author: Campbell Liles, MD, Vanderbilt University Medical Center, Department of Neurological Surgery, 1161 21st Ave. South, T4224 Medical Center North, Nashville, TN 37232-2380; [email protected]

Disclosures: None reported.

From the Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (Stefan W. Koester, Puja Jagasia, and Drs. Liles, Dambrino IV, Feldman, and Chambless), and the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN (Drs. Mathews and Tiwari).

ABSTRACT

Background: The COVID-19 pandemic has had broad effects on surgical care, including operating room (OR) staffing, personal protective equipment (PPE) utilization, and newly implemented anti-infective measures. Our aim was to assess neurosurgery OR efficiency before the COVID-19 pandemic, during peak COVID-19, and during current times.

Methods: Institutional perioperative databases at a single, high-volume neurosurgical center were queried for operations performed from December 2019 until October 2021. March 12, 2020, the day that the state of Tennessee declared a state of emergency, was chosen as the onset of the COVID-19 pandemic. The 90-day periods before and after this day were used to define the pre-COVID-19, peak-COVID-19, and post-peak restrictions time periods for comparative analysis. Outcomes included delay in first-start and OR turnover time between neurosurgical cases. Preset threshold times were used in analyses to adjust for normal leniency in OR scheduling (15 minutes for first start and 90 minutes for turnover). Univariate analysis used Wilcoxon rank-sum test for continuous outcomes, while chi-square test and Fisher’s exact test were used for categorical comparisons. Significance was defined as P < .05.

Results: First-start time was analyzed in 426 pre-COVID-19, 357 peak-restrictions, and 2304 post-peak-restrictions cases. The unadjusted mean delay length was found to be significantly different between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes, 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004). The adjusted average delay length and proportion of cases delayed beyond the 15-minute threshold were not significantly different. The proportion of cases that started early, as well as significantly early past a 15-minute threshold, have not been impacted. There was no significant change in turnover time during peak restrictions relative to the pre-COVID-19 period (88 [100] minutes vs 85 [95] minutes), and turnover time has since remained unchanged (83 [87] minutes).

Conclusion: Our center was able to maintain OR efficiency before, during, and after peak restrictions even while instituting advanced infection-control strategies. While there were significant changes, delays were relatively small in magnitude.

Keywords: operating room timing, hospital efficiency, socioeconomics, pandemic.

The COVID-19 pandemic has led to major changes in patient care both from a surgical perspective and in regard to inpatient hospital course. Safety protocols nationwide have been implemented to protect both patients and providers. Some elements of surgical care have drastically changed, including operating room (OR) staffing, personal protective equipment (PPE) utilization, and increased sterilization measures. Furloughs, layoffs, and reassignments due to the focus on nonelective and COVID-19–related cases challenged OR staffing and efficiency. Operating room staff with COVID-19 exposures or COVID-19 infections also caused last-minute changes in staffing. All of these scenarios can cause issues due to actual understaffing or due to staff members being pushed into highly specialized areas, such as neurosurgery, in which they have very little experience. A further obstacle to OR efficiency included policy changes involving PPE utilization, sterilization measures, and supply chain shortages of necessary resources such as PPE.

Neurosurgery in particular has been susceptible to COVID-19–related system-wide changes given operator proximity to the patient’s respiratory passages, frequency of emergent cases, and varying anesthetic needs, as well as the high level of specialization needed to perform neurosurgical care. Previous studies have shown a change in the makeup of neurosurgical patients seeking care, as well as in the acuity of neurological consult of these patients.¹ A study in orthopedic surgery by Andreata et al demonstrated worsened OR efficiency, with significantly increased first-start and turnover times.² In the COVID-19 era, OR quality and safety are crucially important to both patients and providers. Providing this safe and effective care in an efficient manner is important for optimal neurosurgical management in the long term.³ Moreover, the financial burden of implementing new protocols and standards can be compounded by additional financial losses due to reduced OR efficiency.

Methods

To analyze the effect of COVID-19 on neurosurgical OR efficiency, institutional perioperative databases at a single high-volume center were queried for operations performed from December 2019 until October 2021. March 12, 2020, was chosen as the onset of COVID-19 for analytic purposes, as this was the date when the state of Tennessee declared a state of emergency. The 90-day periods before and after this date were used for comparative analysis for pre-COVID-19, peak COVID-19, and post-peak-restrictions time periods. The peak COVID-19 period was defined as the 90-day period following the initial onset of COVID-19 and the surge of cases. For comparison purposes, post-peak COVID-19 was defined as the months following the first peak until October 2021 (approximately 17 months). COVID-19 burden was determined using a COVID-19 single-institution census of confirmed cases by polymerase chain reaction (PCR) for which the average number of cases of COVID-19 during a given month was determined. This number is a scaled trend, and a true number of COVID-19 cases in our hospital was not reported.

Neurosurgical and neuroendovascular cases were included in the analysis. Outcomes included delay in first-start and OR turnover time between neurosurgical cases, defined as the time from the patient leaving the room until the next patient entered the room. Preset threshold times were used in analyses to adjust for normal leniency in OR scheduling (15 minutes for first start and 90 minutes for turnover, which is a standard for our single-institution perioperative center). Statistical analyses, including data aggregation, were performed using R, version 4.0.1 (R Foundation for Statistical Computing). Patients’ demographic and clinical characteristics were analyzed using an independent 2-sample t-test for interval variables and a chi-square test for categorical variables. Significance was defined as P < .05.

Results

First-Start Time

First-start time was analyzed in 426 pre-COVID-19, 357 peak-COVID-19, and 2304 post-peak-COVID-19 cases. The unadjusted mean delay length was significantly different between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes, 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004) (Table 1).

The adjusted average delay length and proportion of cases delayed beyond the 15-minute threshold were not significantly different, but they have been slightly higher since the onset of COVID-19. The proportion of cases that have started early, as well as significantly early past a 15-minute threshold, have also trended down since the onset of the COVID-19 pandemic, but this difference was again not significant. The temporal relationship of first-start delay, both unadjusted and adjusted, from December 2019 to October 2021 is shown in Figure 1. The trend of increasing delay is loosely associated with the COVID-19 burden experienced by our hospital. The start of COVID-19 as well as both COVID-19 peaks have been associated with increased delays in our hospital.

Turnover Time

Turnover time was assessed in 437 pre-COVID-19, 278 peak-restrictions, and 2411 post-peak-restrictions cases. Turnover time during peak restrictions was not significantly different from pre-COVID-19 (88 [100] vs 85 [95]) and has since remained relatively unchanged (83 [87], P = .78). A similar trend held for comparisons of proportion of cases with turnover time past 90 minutes and average times past the 90-minute threshold (Table 2). The temporal relationship between COVID-19 burden and turnover time, both unadjusted and adjusted, from December 2019 to October 2021 is shown in Figure 2. Both figures demonstrate a slight initial increase in turnover time delay at the start of COVID-19, which stabilized with little variation thereafter.

We analyzed the OR efficiency metrics of first-start and turnover time during the 90-day period before COVID-19 (pre-COVID-19), the 90 days following Tennessee declaring a state of emergency (peak COVID-19), and the time following this period (post-COVID-19) for all neurosurgical and neuroendovascular cases at Vanderbilt University Medical Center (VUMC). We found a significant difference in unadjusted mean delay length in first-start time between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes for pre-COVID-19, peak-COVID-19, and post-COVID-19: 6 [18] vs 10 [21] vs 8 [20], respectively; P = .004). No significant increase in turnover time between cases was found between these 3 time periods. Based on metrics from first-start delay and turnover time, our center was able to maintain OR efficiency before, during, and after peak COVID-19.

After the Centers for Disease Control and Prevention released guidelines recommending deferring elective procedures to conserve beds and PPE, VUMC made the decision to suspend all elective surgical procedures from March 18 to April 24, 2020. Prior research conducted during the COVID-19 pandemic has demonstrated more than 400 types of surgical procedures with negatively impacted outcomes when compared to surgical outcomes from the same time frame in 2018 and 2019.⁴ For more than 20 of these types of procedures, there was a significant association between procedure delay and adverse patient outcomes.⁴ Testing protocols for patients prior to surgery varied throughout the pandemic based on vaccination status and type of procedure. Before vaccines became widely available, all patients were required to obtain a PCR SARS-CoV-2 test within 48 to 72 hours of the scheduled procedure. If the patient’s procedure was urgent and testing was not feasible, the patient was treated as a SARS-CoV-2–positive patient, which required all health care workers involved in the case to wear gowns, gloves, surgical masks, and eye protection. Testing patients preoperatively likely helped to maintain OR efficiency since not all patients received test results prior to the scheduled procedure, leading to cancellations of cases and therefore more staff available for fewer cases.

After vaccines became widely available to the public, testing requirements for patients preoperatively were relaxed, and only patients who were not fully vaccinated or severely immunocompromised were required to test prior to procedures. However, approximately 40% of the population in Tennessee was fully vaccinated in 2021, which reflects the patient population of VUMC.⁵ This means that many patients who received care at VUMC were still tested prior to procedures.

Adopting adequate safety protocols was found to be key for OR efficiency during the COVID-19 pandemic since performing surgery increased the risk of infection for each health care worker in the OR.⁶ VUMC protocols identified procedures that required enhanced safety measures to prevent infection of health care workers and avoid staffing shortages, which would decrease OR efficiency. Protocols mandated that only anesthesia team members were allowed to be in the OR during intubation and extubation of patients, which could be one factor leading to increased delays and decreased efficiency for some institutions. Methods for neurosurgeons to decrease risk of infection in the OR include postponing all nonurgent cases, reappraising the necessity for general anesthesia and endotracheal intubation, considering alternative surgical approaches that avoid the respiratory tract, and limiting the use of aerosol-generating instruments.^7,8 VUMC’s success in implementing these protocols likely explains why our center was able to maintain OR efficiency throughout the COVID-19 pandemic.

A study conducted by Andreata et al showed a significantly increased mean first-case delay and a nonsignificant increased turnover time in orthopedic surgeries in Northern Italy when comparing surgeries performed during the COVID-19 pandemic to those performed prior to COVID-19.² Other studies have indicated a similar trend in decreased OR efficiency during COVID-19 in other areas around the world.^9,10 These findings are not consistent with our own findings for neurosurgical and neuroendovascular surgeries at VUMC, and any change at our institution was relatively immaterial. Factors that threatened to change OR efficiency—but did not result in meaningful changes in our institutional experience—include delays due to pending COVID-19 test results, safety procedures such as PPE donning, and planning difficulties to ensure the existence of teams with non-overlapping providers in the case of a surgeon being infected.^2,11-13

Globally, many surgery centers halted all elective surgeries during the initial COVID-19 spike to prevent a PPE shortage and mitigate risk of infection of patients and health care workers.^8,12,14 However, there is no centralized definition of which neurosurgical procedures are elective, so that decision was made on a surgeon or center level, which could lead to variability in efficiency trends.¹⁴ One study on neurosurgical procedures during COVID-19 found a 30% decline in all cases and a 23% decline in emergent procedures, showing that the decrease in volume was not only due to cancellation of elective procedures.¹⁵ This decrease in elective and emergent surgeries created a backlog of surgeries as well as a loss in health care revenue, and caused many patients to go without adequate health care.¹⁰ Looking forward, it is imperative that surgical centers study trends in OR efficiency from COVID-19 and learn how to better maintain OR efficiency during future pandemic conditions to prevent a backlog of cases, loss of health care revenue, and decreased health care access.

Limitations

Our data are from a single center and therefore may not be representative of experiences of other hospitals due to different populations and different impacts from COVID-19. However, given our center’s high volume and diverse patient population, we believe our analysis highlights important trends in neurosurgery practice. Notably, data for patient and OR timing are digitally generated and are entered manually by nurses in the electronic medical record, making it prone to errors and variability. This is in our experience, and if any error is present, we believe it is minimal.

Conclusion

The COVID-19 pandemic has had far-reaching effects on health care worldwide, including neurosurgical care. OR efficiency across the United States generally worsened given the stresses of supply chain issues, staffing shortages, and cancellations. At our institution, we were able to maintain OR efficiency during the known COVID-19 peaks until October 2021. Continually functional neurosurgical ORs are important in preventing delays in care and maintaining a steady revenue in order for hospitals and other health care entities to remain solvent. Further study of OR efficiency is needed for health care systems to prepare for future pandemics and other resource-straining events in order to provide optimal patient care.

Corresponding author: Campbell Liles, MD, Vanderbilt University Medical Center, Department of Neurological Surgery, 1161 21st Ave. South, T4224 Medical Center North, Nashville, TN 37232-2380; [email protected]

Disclosures: None reported.

From the Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA.

Clinical inertia is defined as the failure of clinicians to initiate or escalate guideline-directed medical therapy to achieve treatment goals for well-defined clinical conditions.^1,2 Evidence-based guidelines recommend optimal disease management with readily available medical therapies throughout the phases of clinical care. Unfortunately, the care provided to individual patients undergoes multiple modifications throughout the disease course, resulting in divergent pathways, significant deviations from treatment guidelines, and failure of “safeguard” checkpoints to reinstate, initiate, optimize, or stop treatments. Clinical inertia generally describes rigidity or resistance to change around implementing evidence-based guidelines. Furthermore, this term describes treatment behavior on the part of an individual clinician, not organizational inertia, which generally encompasses both internal (immediate clinical practice settings) and external factors (national and international guidelines and recommendations), eventually leading to resistance to optimizing disease treatment and therapeutic regimens. Individual clinicians’ clinical inertia in the form of resistance to guideline implementation and evidence-based principles can be one factor that drives organizational inertia. In turn, such individual behavior can be dictated by personal beliefs, knowledge, interpretation, skills, management principles, and biases. The terms therapeutic inertia or clinical inertia should not be confused with nonadherence from the patient’s standpoint when the clinician follows the best practice guidelines.³

Clinical inertia has been described in several clinical domains, including diabetes,^4,5 hypertension,^6,7 heart failure,⁸ depression,⁹ pulmonary medicine,¹⁰ and complex disease management.¹¹ Clinicians can set suboptimal treatment goals due to specific beliefs and attitudes around optimal therapeutic goals. For example, when treating a patient with a chronic disease that is presently stable, a clinician could elect to initiate suboptimal treatment, as escalation of treatment might not be the priority in stable disease; they also may have concerns about overtreatment. Other factors that can contribute to clinical inertia (ie, undertreatment in the presence of indications for treatment) include those related to the patient, the clinical setting, and the organization, along with the importance of individualizing therapies in specific patients. Organizational inertia is the initial global resistance by the system to implementation, which can slow the dissemination and adaptation of best practices but eventually declines over time. Individual clinical inertia, on the other hand, will likely persist after the system-level rollout of guideline-based approaches.

The trajectory of dissemination, implementation, and adaptation of innovations and best practices is illustrated in the Figure. When the guidelines and medical societies endorse the adaptation of innovations or practice change after the benefits of such innovations/change have been established by the regulatory bodies, uptake can be hindered by both organizational and clinical inertia. Overcoming inertia to system-level changes requires addressing individual clinicians, along with practice and organizational factors, in order to ensure systematic adaptations. From the clinicians’ view, training and cognitive interventions to improve the adaptation and coping skills can improve understanding of treatment options through standardized educational and behavioral modification tools, direct and indirect feedback around performance, and decision support through a continuous improvement approach on both individual and system levels.

Addressing inertia in clinical practice requires a deep understanding of the individual and organizational elements that foster resistance to adapting best practice models. Research that explores tools and approaches to overcome inertia in managing complex diseases is a key step in advancing clinical innovation and disseminating best practices.

Corresponding author: Ebrahim Barkoudah, MD, MPH; [email protected]

Disclosures: None reported.

From the Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA.

Clinical inertia is defined as the failure of clinicians to initiate or escalate guideline-directed medical therapy to achieve treatment goals for well-defined clinical conditions.^1,2 Evidence-based guidelines recommend optimal disease management with readily available medical therapies throughout the phases of clinical care. Unfortunately, the care provided to individual patients undergoes multiple modifications throughout the disease course, resulting in divergent pathways, significant deviations from treatment guidelines, and failure of “safeguard” checkpoints to reinstate, initiate, optimize, or stop treatments. Clinical inertia generally describes rigidity or resistance to change around implementing evidence-based guidelines. Furthermore, this term describes treatment behavior on the part of an individual clinician, not organizational inertia, which generally encompasses both internal (immediate clinical practice settings) and external factors (national and international guidelines and recommendations), eventually leading to resistance to optimizing disease treatment and therapeutic regimens. Individual clinicians’ clinical inertia in the form of resistance to guideline implementation and evidence-based principles can be one factor that drives organizational inertia. In turn, such individual behavior can be dictated by personal beliefs, knowledge, interpretation, skills, management principles, and biases. The terms therapeutic inertia or clinical inertia should not be confused with nonadherence from the patient’s standpoint when the clinician follows the best practice guidelines.³

Clinical inertia has been described in several clinical domains, including diabetes,^4,5 hypertension,^6,7 heart failure,⁸ depression,⁹ pulmonary medicine,¹⁰ and complex disease management.¹¹ Clinicians can set suboptimal treatment goals due to specific beliefs and attitudes around optimal therapeutic goals. For example, when treating a patient with a chronic disease that is presently stable, a clinician could elect to initiate suboptimal treatment, as escalation of treatment might not be the priority in stable disease; they also may have concerns about overtreatment. Other factors that can contribute to clinical inertia (ie, undertreatment in the presence of indications for treatment) include those related to the patient, the clinical setting, and the organization, along with the importance of individualizing therapies in specific patients. Organizational inertia is the initial global resistance by the system to implementation, which can slow the dissemination and adaptation of best practices but eventually declines over time. Individual clinical inertia, on the other hand, will likely persist after the system-level rollout of guideline-based approaches.

The trajectory of dissemination, implementation, and adaptation of innovations and best practices is illustrated in the Figure. When the guidelines and medical societies endorse the adaptation of innovations or practice change after the benefits of such innovations/change have been established by the regulatory bodies, uptake can be hindered by both organizational and clinical inertia. Overcoming inertia to system-level changes requires addressing individual clinicians, along with practice and organizational factors, in order to ensure systematic adaptations. From the clinicians’ view, training and cognitive interventions to improve the adaptation and coping skills can improve understanding of treatment options through standardized educational and behavioral modification tools, direct and indirect feedback around performance, and decision support through a continuous improvement approach on both individual and system levels.

Addressing inertia in clinical practice requires a deep understanding of the individual and organizational elements that foster resistance to adapting best practice models. Research that explores tools and approaches to overcome inertia in managing complex diseases is a key step in advancing clinical innovation and disseminating best practices.

Corresponding author: Ebrahim Barkoudah, MD, MPH; [email protected]

Disclosures: None reported.

From the Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA.

Clinical inertia is defined as the failure of clinicians to initiate or escalate guideline-directed medical therapy to achieve treatment goals for well-defined clinical conditions.^1,2 Evidence-based guidelines recommend optimal disease management with readily available medical therapies throughout the phases of clinical care. Unfortunately, the care provided to individual patients undergoes multiple modifications throughout the disease course, resulting in divergent pathways, significant deviations from treatment guidelines, and failure of “safeguard” checkpoints to reinstate, initiate, optimize, or stop treatments. Clinical inertia generally describes rigidity or resistance to change around implementing evidence-based guidelines. Furthermore, this term describes treatment behavior on the part of an individual clinician, not organizational inertia, which generally encompasses both internal (immediate clinical practice settings) and external factors (national and international guidelines and recommendations), eventually leading to resistance to optimizing disease treatment and therapeutic regimens. Individual clinicians’ clinical inertia in the form of resistance to guideline implementation and evidence-based principles can be one factor that drives organizational inertia. In turn, such individual behavior can be dictated by personal beliefs, knowledge, interpretation, skills, management principles, and biases. The terms therapeutic inertia or clinical inertia should not be confused with nonadherence from the patient’s standpoint when the clinician follows the best practice guidelines.³

Clinical inertia has been described in several clinical domains, including diabetes,^4,5 hypertension,^6,7 heart failure,⁸ depression,⁹ pulmonary medicine,¹⁰ and complex disease management.¹¹ Clinicians can set suboptimal treatment goals due to specific beliefs and attitudes around optimal therapeutic goals. For example, when treating a patient with a chronic disease that is presently stable, a clinician could elect to initiate suboptimal treatment, as escalation of treatment might not be the priority in stable disease; they also may have concerns about overtreatment. Other factors that can contribute to clinical inertia (ie, undertreatment in the presence of indications for treatment) include those related to the patient, the clinical setting, and the organization, along with the importance of individualizing therapies in specific patients. Organizational inertia is the initial global resistance by the system to implementation, which can slow the dissemination and adaptation of best practices but eventually declines over time. Individual clinical inertia, on the other hand, will likely persist after the system-level rollout of guideline-based approaches.

The trajectory of dissemination, implementation, and adaptation of innovations and best practices is illustrated in the Figure. When the guidelines and medical societies endorse the adaptation of innovations or practice change after the benefits of such innovations/change have been established by the regulatory bodies, uptake can be hindered by both organizational and clinical inertia. Overcoming inertia to system-level changes requires addressing individual clinicians, along with practice and organizational factors, in order to ensure systematic adaptations. From the clinicians’ view, training and cognitive interventions to improve the adaptation and coping skills can improve understanding of treatment options through standardized educational and behavioral modification tools, direct and indirect feedback around performance, and decision support through a continuous improvement approach on both individual and system levels.

Addressing inertia in clinical practice requires a deep understanding of the individual and organizational elements that foster resistance to adapting best practice models. Research that explores tools and approaches to overcome inertia in managing complex diseases is a key step in advancing clinical innovation and disseminating best practices.

Corresponding author: Ebrahim Barkoudah, MD, MPH; [email protected]

Disclosures: None reported.

Emergencies happen anywhere, anytime – and sometimes physicians find themselves in situations where they are the only ones who can help. “Is There a Doctor in the House?” is a new series telling these stories.

When the plane crashed, I was asleep. I had arrived the evening before with my wife and three sons at a house on Kezar Lake on the Maine–New Hampshire border. We were going to spend a week there with my wife’s four brothers and their families. I was woken by people screaming my name. I jumped out of bed and ran downstairs. My kids had been watching a float plane circling and gliding along the lake. It had crashed into the water and flipped upside down. My oldest brother-in-law jumped into his ski boat and we sped out to the scene.

All we can see are the plane’s pontoons. The rest is underwater. A woman has already surfaced, screaming. I dive in.

I find the woman’s husband and 3-year-old son struggling to get free from the plane through the smashed windshield. They manage to get to the surface. The pilot is dead, impaled through the chest by the left wing strut.

The big problem: A little girl, whom I would learn later is named Lauren, remained trapped. The water is murky but I can see her, a 5- or 6-year-old girl with this long hair, strapped in upside down and unconscious.

The mom and I dive down over and over, pulling and ripping at the door. We cannot get it open. Finally, I’m able to bend the door open enough where I can reach in, but I can’t undo the seatbelt. In my mind, I’m debating, should I try and go through the front windshield? I’m getting really tired, I can tell there’s fuel in the water, and I don’t want to drown in the plane. So I pop up to the surface and yell, “Does anyone have a knife?”

My brother-in-law shoots back to shore in the boat, screaming, “Get a knife!” My niece gets in the boat with one. I’m standing on the pontoon, and my niece is in the front of the boat calling, “Uncle Todd! Uncle Todd!” and she throws the knife. It goes way over my head. I can’t even jump for it, it’s so high.

I have to get the knife. So, I dive into the water to try and find it. Somehow, the black knife has landed on the white wing, 4 or 5 feet under the water. Pure luck. It could have sunk down a hundred feet into the lake. I grab the knife and hand it to the mom, Beth. She’s able to cut the seatbelt, and we both pull Lauren to the surface.

I lay her out on the pontoon. She has no pulse and her pupils are fixed and dilated. Her mom is yelling, “She’s dead, isn’t she?” I start CPR. My skin and eyes are burning from the airplane fuel in the water. I get her breathing, and her heart comes back very quickly. Lauren starts to vomit and I’m trying to keep her airway clear. She’s breathing spontaneously and she has a pulse, so I decide it’s time to move her to shore.

We pull the boat up to the dock and Lauren’s now having anoxic seizures. Her brain has been without oxygen, and now she’s getting perfused again. We get her to shore and lay her on the lawn. I’m still doing mouth-to-mouth, but she’s seizing like crazy, and I don’t have any way to control that. Beth is crying and wants to hold her daughter gently while I’m working.

Someone had called 911, and finally this dude shows up with an ambulance, and it’s like something out of World War II. All he has is an oxygen tank, but the mask is old and cracked. It’s too big for Lauren, but it sort of fits me, so I’m sucking in oxygen and blowing it into the girl’s mouth. I’m doing whatever I can, but I don’t have an IV to start. I have no fluids. I got nothing.

As it happens, I’d done my emergency medicine training at Maine Medical Center, so I tell someone to call them and get a Life Flight chopper. We have to drive somewhere where the chopper can land, so we take the ambulance to the parking lot of the closest store called the Wicked Good Store. That’s a common thing in Maine. Everything is “wicked good.”

The whole town is there by that point. The chopper arrives. The ambulance doors pop open and a woman says, “Todd?” And I say, “Heather?”

Heather is an emergency flight nurse whom I’d trained with many years ago. There’s immediate trust. She has all the right equipment. We put in breathing tubes and IVs. We stop Lauren from seizing. The kid is soon stable.

There is only one extra seat in the chopper, so I tell Beth to go. They take off.

Suddenly, I begin to doubt my decision. Lauren had been underwater for 15 minutes at minimum. I know how long that is. Did I do the right thing? Did I resuscitate a brain-dead child? I didn’t think about it at the time, but if that patient had come to me in the emergency department, I’m honestly not sure what I would have done.

So, I go home. And I don’t get a call. The FAA and sheriff arrive to take statements from us. I don’t hear from anyone.

The next day I start calling. No one will tell me anything, so I finally get to one of the pediatric ICU attendings who had trained me. He says Lauren literally woke up and said, “I have to go pee.” And that was it. She was 100% normal. I couldn’t believe it.

Here’s a theory: In kids, there’s something called the glottic reflex. I think her glottic reflex went off as soon as she hit the water, which basically closed her airway. So when she passed out, she could never get enough water in her lungs and still had enough air in there to keep her alive. Later, I got a call from her uncle. He could barely get the words out because he was in tears. He said Lauren was doing beautifully.  

Three days later, I drove to Lauren’s house with my wife and kids. I had her read to me. I watched her play on the jungle gym for motor function. All sorts of stuff. She was totally normal.

Beth told us that the night before the accident, her mother had given the women in her family what she called a “miracle bracelet,” a bracelet that is supposed to give you one miracle in your life. Beth said she had the bracelet on her wrist the day of the accident, and now it’s gone. “Saving Lauren’s life was my miracle,” she said.

Funny thing: For 20 years, I ran all the EMS, police, fire, ambulance, in Boulder, Colo., where I live. I wrote all the protocols, and I would never advise any of my paramedics to dive into jet fuel to save someone. That was risky. But at the time, it was totally automatic. I think it taught me not to give up in certain situations, because you really don’t know.

Dr. Dorfman is an emergency medicine physician in Boulder, Colo., and medical director at Cedalion Health.
 

A version of this article first appeared on Medscape.com.

Emergencies happen anywhere, anytime – and sometimes physicians find themselves in situations where they are the only ones who can help. “Is There a Doctor in the House?” is a new series telling these stories.

When the plane crashed, I was asleep. I had arrived the evening before with my wife and three sons at a house on Kezar Lake on the Maine–New Hampshire border. We were going to spend a week there with my wife’s four brothers and their families. I was woken by people screaming my name. I jumped out of bed and ran downstairs. My kids had been watching a float plane circling and gliding along the lake. It had crashed into the water and flipped upside down. My oldest brother-in-law jumped into his ski boat and we sped out to the scene.

All we can see are the plane’s pontoons. The rest is underwater. A woman has already surfaced, screaming. I dive in.

I find the woman’s husband and 3-year-old son struggling to get free from the plane through the smashed windshield. They manage to get to the surface. The pilot is dead, impaled through the chest by the left wing strut.

The big problem: A little girl, whom I would learn later is named Lauren, remained trapped. The water is murky but I can see her, a 5- or 6-year-old girl with this long hair, strapped in upside down and unconscious.

The mom and I dive down over and over, pulling and ripping at the door. We cannot get it open. Finally, I’m able to bend the door open enough where I can reach in, but I can’t undo the seatbelt. In my mind, I’m debating, should I try and go through the front windshield? I’m getting really tired, I can tell there’s fuel in the water, and I don’t want to drown in the plane. So I pop up to the surface and yell, “Does anyone have a knife?”

My brother-in-law shoots back to shore in the boat, screaming, “Get a knife!” My niece gets in the boat with one. I’m standing on the pontoon, and my niece is in the front of the boat calling, “Uncle Todd! Uncle Todd!” and she throws the knife. It goes way over my head. I can’t even jump for it, it’s so high.

I have to get the knife. So, I dive into the water to try and find it. Somehow, the black knife has landed on the white wing, 4 or 5 feet under the water. Pure luck. It could have sunk down a hundred feet into the lake. I grab the knife and hand it to the mom, Beth. She’s able to cut the seatbelt, and we both pull Lauren to the surface.

I lay her out on the pontoon. She has no pulse and her pupils are fixed and dilated. Her mom is yelling, “She’s dead, isn’t she?” I start CPR. My skin and eyes are burning from the airplane fuel in the water. I get her breathing, and her heart comes back very quickly. Lauren starts to vomit and I’m trying to keep her airway clear. She’s breathing spontaneously and she has a pulse, so I decide it’s time to move her to shore.

We pull the boat up to the dock and Lauren’s now having anoxic seizures. Her brain has been without oxygen, and now she’s getting perfused again. We get her to shore and lay her on the lawn. I’m still doing mouth-to-mouth, but she’s seizing like crazy, and I don’t have any way to control that. Beth is crying and wants to hold her daughter gently while I’m working.

Someone had called 911, and finally this dude shows up with an ambulance, and it’s like something out of World War II. All he has is an oxygen tank, but the mask is old and cracked. It’s too big for Lauren, but it sort of fits me, so I’m sucking in oxygen and blowing it into the girl’s mouth. I’m doing whatever I can, but I don’t have an IV to start. I have no fluids. I got nothing.

As it happens, I’d done my emergency medicine training at Maine Medical Center, so I tell someone to call them and get a Life Flight chopper. We have to drive somewhere where the chopper can land, so we take the ambulance to the parking lot of the closest store called the Wicked Good Store. That’s a common thing in Maine. Everything is “wicked good.”

The whole town is there by that point. The chopper arrives. The ambulance doors pop open and a woman says, “Todd?” And I say, “Heather?”

Heather is an emergency flight nurse whom I’d trained with many years ago. There’s immediate trust. She has all the right equipment. We put in breathing tubes and IVs. We stop Lauren from seizing. The kid is soon stable.

There is only one extra seat in the chopper, so I tell Beth to go. They take off.

Suddenly, I begin to doubt my decision. Lauren had been underwater for 15 minutes at minimum. I know how long that is. Did I do the right thing? Did I resuscitate a brain-dead child? I didn’t think about it at the time, but if that patient had come to me in the emergency department, I’m honestly not sure what I would have done.

So, I go home. And I don’t get a call. The FAA and sheriff arrive to take statements from us. I don’t hear from anyone.

The next day I start calling. No one will tell me anything, so I finally get to one of the pediatric ICU attendings who had trained me. He says Lauren literally woke up and said, “I have to go pee.” And that was it. She was 100% normal. I couldn’t believe it.

Here’s a theory: In kids, there’s something called the glottic reflex. I think her glottic reflex went off as soon as she hit the water, which basically closed her airway. So when she passed out, she could never get enough water in her lungs and still had enough air in there to keep her alive. Later, I got a call from her uncle. He could barely get the words out because he was in tears. He said Lauren was doing beautifully.  

Three days later, I drove to Lauren’s house with my wife and kids. I had her read to me. I watched her play on the jungle gym for motor function. All sorts of stuff. She was totally normal.

Beth told us that the night before the accident, her mother had given the women in her family what she called a “miracle bracelet,” a bracelet that is supposed to give you one miracle in your life. Beth said she had the bracelet on her wrist the day of the accident, and now it’s gone. “Saving Lauren’s life was my miracle,” she said.

Funny thing: For 20 years, I ran all the EMS, police, fire, ambulance, in Boulder, Colo., where I live. I wrote all the protocols, and I would never advise any of my paramedics to dive into jet fuel to save someone. That was risky. But at the time, it was totally automatic. I think it taught me not to give up in certain situations, because you really don’t know.

Dr. Dorfman is an emergency medicine physician in Boulder, Colo., and medical director at Cedalion Health.
 

A version of this article first appeared on Medscape.com.

Emergencies happen anywhere, anytime – and sometimes physicians find themselves in situations where they are the only ones who can help. “Is There a Doctor in the House?” is a new series telling these stories.

When the plane crashed, I was asleep. I had arrived the evening before with my wife and three sons at a house on Kezar Lake on the Maine–New Hampshire border. We were going to spend a week there with my wife’s four brothers and their families. I was woken by people screaming my name. I jumped out of bed and ran downstairs. My kids had been watching a float plane circling and gliding along the lake. It had crashed into the water and flipped upside down. My oldest brother-in-law jumped into his ski boat and we sped out to the scene.

All we can see are the plane’s pontoons. The rest is underwater. A woman has already surfaced, screaming. I dive in.

I find the woman’s husband and 3-year-old son struggling to get free from the plane through the smashed windshield. They manage to get to the surface. The pilot is dead, impaled through the chest by the left wing strut.

The big problem: A little girl, whom I would learn later is named Lauren, remained trapped. The water is murky but I can see her, a 5- or 6-year-old girl with this long hair, strapped in upside down and unconscious.

The mom and I dive down over and over, pulling and ripping at the door. We cannot get it open. Finally, I’m able to bend the door open enough where I can reach in, but I can’t undo the seatbelt. In my mind, I’m debating, should I try and go through the front windshield? I’m getting really tired, I can tell there’s fuel in the water, and I don’t want to drown in the plane. So I pop up to the surface and yell, “Does anyone have a knife?”

My brother-in-law shoots back to shore in the boat, screaming, “Get a knife!” My niece gets in the boat with one. I’m standing on the pontoon, and my niece is in the front of the boat calling, “Uncle Todd! Uncle Todd!” and she throws the knife. It goes way over my head. I can’t even jump for it, it’s so high.

I have to get the knife. So, I dive into the water to try and find it. Somehow, the black knife has landed on the white wing, 4 or 5 feet under the water. Pure luck. It could have sunk down a hundred feet into the lake. I grab the knife and hand it to the mom, Beth. She’s able to cut the seatbelt, and we both pull Lauren to the surface.

I lay her out on the pontoon. She has no pulse and her pupils are fixed and dilated. Her mom is yelling, “She’s dead, isn’t she?” I start CPR. My skin and eyes are burning from the airplane fuel in the water. I get her breathing, and her heart comes back very quickly. Lauren starts to vomit and I’m trying to keep her airway clear. She’s breathing spontaneously and she has a pulse, so I decide it’s time to move her to shore.

We pull the boat up to the dock and Lauren’s now having anoxic seizures. Her brain has been without oxygen, and now she’s getting perfused again. We get her to shore and lay her on the lawn. I’m still doing mouth-to-mouth, but she’s seizing like crazy, and I don’t have any way to control that. Beth is crying and wants to hold her daughter gently while I’m working.

Someone had called 911, and finally this dude shows up with an ambulance, and it’s like something out of World War II. All he has is an oxygen tank, but the mask is old and cracked. It’s too big for Lauren, but it sort of fits me, so I’m sucking in oxygen and blowing it into the girl’s mouth. I’m doing whatever I can, but I don’t have an IV to start. I have no fluids. I got nothing.

As it happens, I’d done my emergency medicine training at Maine Medical Center, so I tell someone to call them and get a Life Flight chopper. We have to drive somewhere where the chopper can land, so we take the ambulance to the parking lot of the closest store called the Wicked Good Store. That’s a common thing in Maine. Everything is “wicked good.”

The whole town is there by that point. The chopper arrives. The ambulance doors pop open and a woman says, “Todd?” And I say, “Heather?”

Heather is an emergency flight nurse whom I’d trained with many years ago. There’s immediate trust. She has all the right equipment. We put in breathing tubes and IVs. We stop Lauren from seizing. The kid is soon stable.

There is only one extra seat in the chopper, so I tell Beth to go. They take off.

Suddenly, I begin to doubt my decision. Lauren had been underwater for 15 minutes at minimum. I know how long that is. Did I do the right thing? Did I resuscitate a brain-dead child? I didn’t think about it at the time, but if that patient had come to me in the emergency department, I’m honestly not sure what I would have done.

So, I go home. And I don’t get a call. The FAA and sheriff arrive to take statements from us. I don’t hear from anyone.

The next day I start calling. No one will tell me anything, so I finally get to one of the pediatric ICU attendings who had trained me. He says Lauren literally woke up and said, “I have to go pee.” And that was it. She was 100% normal. I couldn’t believe it.

Here’s a theory: In kids, there’s something called the glottic reflex. I think her glottic reflex went off as soon as she hit the water, which basically closed her airway. So when she passed out, she could never get enough water in her lungs and still had enough air in there to keep her alive. Later, I got a call from her uncle. He could barely get the words out because he was in tears. He said Lauren was doing beautifully.  

Three days later, I drove to Lauren’s house with my wife and kids. I had her read to me. I watched her play on the jungle gym for motor function. All sorts of stuff. She was totally normal.

Beth told us that the night before the accident, her mother had given the women in her family what she called a “miracle bracelet,” a bracelet that is supposed to give you one miracle in your life. Beth said she had the bracelet on her wrist the day of the accident, and now it’s gone. “Saving Lauren’s life was my miracle,” she said.

Funny thing: For 20 years, I ran all the EMS, police, fire, ambulance, in Boulder, Colo., where I live. I wrote all the protocols, and I would never advise any of my paramedics to dive into jet fuel to save someone. That was risky. But at the time, it was totally automatic. I think it taught me not to give up in certain situations, because you really don’t know.

Dr. Dorfman is an emergency medicine physician in Boulder, Colo., and medical director at Cedalion Health.
 

A version of this article first appeared on Medscape.com.

In most cases, passengers on an airline flight are representative of the general population, which means that anyone could have an emergency at any time.

A study published in the New England Journal of Medicine in 2013 showed that a medical emergency occurred in 1 per 604 flights, as determined on the basis of in-flight medical emergencies that resulted in calls to a physician-directed medical communications center, said Amy Faith Ho, MD, MPH of Integrative Emergency Services, Dallas–Fort Worth, in a presentation at the annual meeting of the American College of Emergency Physicians.

The study authors reviewed records of 11,920 in-flight medical emergencies between Jan. 1, 2008, and Oct. 31, 2010. The data showed that physician passengers provided medical assistance in nearly half of in-flight emergencies (48.1%) and that flights were diverted because of the emergency in 7.3% of cases.

The majority of the in-flight emergencies involved syncope or presyncope (37.4% of cases), followed by respiratory symptoms (12.1%) and nausea or vomiting (9.5%), according to the study.

The in-flight medical bag

Tools in a physician’s in-flight toolbox start with the first-aid kit. Airplanes also have an emergency medical kit (EMK), an oxygen tank, and an AED.

The minimum EMK contents are mandated by the Federal Aviation Administration, said Dr. Ho. The standard equipment includes a stethoscope, a sphygmomanometer, and three sizes of oropharyngeal airways. Other items include self-inflating manual resuscitation devices and CPR masks in thee sizes, alcohol sponges, gloves, adhesive tape, scissors, a tourniquet, as well as saline solution, needles, syringes, and an intravenous administration set consisting of tubing and two Y connectors.

An EMK also should contain the following medications: nonnarcotic analgesic tablets, antihistamine tablets, an injectable antihistamine, atropine, aspirin tablets, a bronchodilator, and epinephrine (both 1:1000; 1 injectable cc and 1:10,000; two injectable cc). Nitroglycerin tablets and 5 cc of 20 mg/mL injectable cardiac lidocaine are part of the mandated kit as well, according to Dr. Ho.

Some airlines carry additional supplies on all their flights, said Dr. Ho. Notably, American Airlines and British Airways carry EpiPens for adults and children, as well as opioid reversal medication (naloxone) and glucose for managing low blood sugar. American Airlines and Delta stock antiemetics, and Delta also carries naloxone. British Airways is unique in stocking additional cardiac medications, both oral and injectable.
 

How to handle an in-flight emergency

Physicians should always carry a copy of their medical license when traveling for documentation by the airline if they assist in a medical emergency during a flight, Dr. Ho emphasized. “Staff” personnel should be used. These include the flight attendants, medical ground control, and other passengers who might have useful skills, such as nursing, the ability to perform CPR, or therapy/counseling to calm a frightened patient. If needed, “crowdsource additional supplies from passengers,” such as a glucometer or pulse oximeter.

Legal lessons

Physicians are not obligated to assist during an in-flight medical emergency, said Dr. Ho. Legal jurisdiction can vary. In the United States, a bystander who assists in an emergency is generally protected by Good Samaritan laws; for international airlines, the laws may vary; those where the airline is based usually apply.

The Aviation Medical Assistance Act, passed in 1998, protects individuals from being sued for negligence while providing medical assistance, “unless the individual, while rendering such assistance, is guilty of gross negligence of willful misconduct,” Dr. Ho noted. The Aviation Medical Assistance Act also protects the airline itself “if the carrier in good faith believes that the passenger is a medically qualified individual.”

Dr. Ho disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In most cases, passengers on an airline flight are representative of the general population, which means that anyone could have an emergency at any time.

A study published in the New England Journal of Medicine in 2013 showed that a medical emergency occurred in 1 per 604 flights, as determined on the basis of in-flight medical emergencies that resulted in calls to a physician-directed medical communications center, said Amy Faith Ho, MD, MPH of Integrative Emergency Services, Dallas–Fort Worth, in a presentation at the annual meeting of the American College of Emergency Physicians.

The study authors reviewed records of 11,920 in-flight medical emergencies between Jan. 1, 2008, and Oct. 31, 2010. The data showed that physician passengers provided medical assistance in nearly half of in-flight emergencies (48.1%) and that flights were diverted because of the emergency in 7.3% of cases.

The majority of the in-flight emergencies involved syncope or presyncope (37.4% of cases), followed by respiratory symptoms (12.1%) and nausea or vomiting (9.5%), according to the study.

The in-flight medical bag

Tools in a physician’s in-flight toolbox start with the first-aid kit. Airplanes also have an emergency medical kit (EMK), an oxygen tank, and an AED.

The minimum EMK contents are mandated by the Federal Aviation Administration, said Dr. Ho. The standard equipment includes a stethoscope, a sphygmomanometer, and three sizes of oropharyngeal airways. Other items include self-inflating manual resuscitation devices and CPR masks in thee sizes, alcohol sponges, gloves, adhesive tape, scissors, a tourniquet, as well as saline solution, needles, syringes, and an intravenous administration set consisting of tubing and two Y connectors.

An EMK also should contain the following medications: nonnarcotic analgesic tablets, antihistamine tablets, an injectable antihistamine, atropine, aspirin tablets, a bronchodilator, and epinephrine (both 1:1000; 1 injectable cc and 1:10,000; two injectable cc). Nitroglycerin tablets and 5 cc of 20 mg/mL injectable cardiac lidocaine are part of the mandated kit as well, according to Dr. Ho.

Some airlines carry additional supplies on all their flights, said Dr. Ho. Notably, American Airlines and British Airways carry EpiPens for adults and children, as well as opioid reversal medication (naloxone) and glucose for managing low blood sugar. American Airlines and Delta stock antiemetics, and Delta also carries naloxone. British Airways is unique in stocking additional cardiac medications, both oral and injectable.
 

How to handle an in-flight emergency

Physicians should always carry a copy of their medical license when traveling for documentation by the airline if they assist in a medical emergency during a flight, Dr. Ho emphasized. “Staff” personnel should be used. These include the flight attendants, medical ground control, and other passengers who might have useful skills, such as nursing, the ability to perform CPR, or therapy/counseling to calm a frightened patient. If needed, “crowdsource additional supplies from passengers,” such as a glucometer or pulse oximeter.

Legal lessons

Physicians are not obligated to assist during an in-flight medical emergency, said Dr. Ho. Legal jurisdiction can vary. In the United States, a bystander who assists in an emergency is generally protected by Good Samaritan laws; for international airlines, the laws may vary; those where the airline is based usually apply.

The Aviation Medical Assistance Act, passed in 1998, protects individuals from being sued for negligence while providing medical assistance, “unless the individual, while rendering such assistance, is guilty of gross negligence of willful misconduct,” Dr. Ho noted. The Aviation Medical Assistance Act also protects the airline itself “if the carrier in good faith believes that the passenger is a medically qualified individual.”

Dr. Ho disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In most cases, passengers on an airline flight are representative of the general population, which means that anyone could have an emergency at any time.

A study published in the New England Journal of Medicine in 2013 showed that a medical emergency occurred in 1 per 604 flights, as determined on the basis of in-flight medical emergencies that resulted in calls to a physician-directed medical communications center, said Amy Faith Ho, MD, MPH of Integrative Emergency Services, Dallas–Fort Worth, in a presentation at the annual meeting of the American College of Emergency Physicians.

The study authors reviewed records of 11,920 in-flight medical emergencies between Jan. 1, 2008, and Oct. 31, 2010. The data showed that physician passengers provided medical assistance in nearly half of in-flight emergencies (48.1%) and that flights were diverted because of the emergency in 7.3% of cases.

The majority of the in-flight emergencies involved syncope or presyncope (37.4% of cases), followed by respiratory symptoms (12.1%) and nausea or vomiting (9.5%), according to the study.

The in-flight medical bag

Tools in a physician’s in-flight toolbox start with the first-aid kit. Airplanes also have an emergency medical kit (EMK), an oxygen tank, and an AED.

The minimum EMK contents are mandated by the Federal Aviation Administration, said Dr. Ho. The standard equipment includes a stethoscope, a sphygmomanometer, and three sizes of oropharyngeal airways. Other items include self-inflating manual resuscitation devices and CPR masks in thee sizes, alcohol sponges, gloves, adhesive tape, scissors, a tourniquet, as well as saline solution, needles, syringes, and an intravenous administration set consisting of tubing and two Y connectors.

An EMK also should contain the following medications: nonnarcotic analgesic tablets, antihistamine tablets, an injectable antihistamine, atropine, aspirin tablets, a bronchodilator, and epinephrine (both 1:1000; 1 injectable cc and 1:10,000; two injectable cc). Nitroglycerin tablets and 5 cc of 20 mg/mL injectable cardiac lidocaine are part of the mandated kit as well, according to Dr. Ho.

Some airlines carry additional supplies on all their flights, said Dr. Ho. Notably, American Airlines and British Airways carry EpiPens for adults and children, as well as opioid reversal medication (naloxone) and glucose for managing low blood sugar. American Airlines and Delta stock antiemetics, and Delta also carries naloxone. British Airways is unique in stocking additional cardiac medications, both oral and injectable.
 

How to handle an in-flight emergency

Physicians should always carry a copy of their medical license when traveling for documentation by the airline if they assist in a medical emergency during a flight, Dr. Ho emphasized. “Staff” personnel should be used. These include the flight attendants, medical ground control, and other passengers who might have useful skills, such as nursing, the ability to perform CPR, or therapy/counseling to calm a frightened patient. If needed, “crowdsource additional supplies from passengers,” such as a glucometer or pulse oximeter.

Legal lessons

Physicians are not obligated to assist during an in-flight medical emergency, said Dr. Ho. Legal jurisdiction can vary. In the United States, a bystander who assists in an emergency is generally protected by Good Samaritan laws; for international airlines, the laws may vary; those where the airline is based usually apply.

The Aviation Medical Assistance Act, passed in 1998, protects individuals from being sued for negligence while providing medical assistance, “unless the individual, while rendering such assistance, is guilty of gross negligence of willful misconduct,” Dr. Ho noted. The Aviation Medical Assistance Act also protects the airline itself “if the carrier in good faith believes that the passenger is a medically qualified individual.”

Dr. Ho disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

There has been a steady decline in Medicare reimbursement for common gastrointestinal (GI) services and patient office visits over the past 15 years, which could have a direct impact on patients.

“When Medicare reimbursements decrease, health outcomes, health care access, and patient satisfaction may be affected, particularly in light of high inflation and increased costs due to staffing shortages, increased staffing salaries, and additional equipment necessary for COVID-19 safety,” researchers wrote in The American Journal of Gastroenterology.

Samir A. Shah, MD, of Brown University, Providence, R.I., and colleagues evaluated trends from 2007 to 2022 in Medicare reimbursement for the top 10 common GI procedures.

These procedures, which included colonoscopies, endoscopies, and gastrostomy tube placement, were identified through a joint list published by the American College of Gastroenterology, the American Society of Gastrointestinal Endoscopy, and the American Gastroenterological Association (AGA).

From 2007 to 2022, unadjusted and adjusted reimbursement for GI procedures declined by 7% and 33%, respectively, on average.

The adjusted change in physician reimbursement ranged from a decrease of roughly 29% for esophagus endoscopy to 38% for colonoscopy and biopsy, the study team found.

They found that the decline in reimbursement of GI procedures was significantly larger after 2015 (P < .001).

From 2007 to 2014, the mean decrease in physician reimbursement for GI services was 6.7%, and the annual growth rate in reimbursement was –1.0%.

In comparison, from 2015 to 2022, the mean decrease in physician reimbursement was 28.2%, and the mean annual growth rate in reimbursement was –4.7%.

To examine trends in reimbursement for office and inpatient visits from 2007 to 2022, the researchers identified the top five current procedural terminology (CPT) codes from outpatient office and inpatient consult visits provided to Medicare Part B beneficiaries by gastroenterologists.

In contrast to the reimbursement trends for GI procedures, the unadjusted physician reimbursement for inpatient and outpatient visits showed an average increase of 32%.

However, after adjustment for inflation, physician reimbursement for patient visits showed an average decline of 4.9%.

Overall, reimbursement for outpatient visits increased by 4.3%, while reimbursement for inpatient visits decreased by 18.8%.

Dr. Shah and colleagues said their findings are important, given that Medicare patients make up a substantial and growing proportion of patients with GI problems and because fewer than 1% of gastroenterologists have opted out of Medicare.

They noted that the trends in GI reimbursement they observed mirror trends in other specialties, which have also noted a decrease in adjusted reimbursement for care.

Physicians are once again facing cuts of at least 4.5% on Jan. 1, 2023, unless Congress acts. AGA and the entire medical community continue to call on Congress to make statutory changes to the Medicare payment system to address these payment challenges. Specifically, AGA and the physician community have recommended that payment rates include an inflationary adjustment similar to what other providers, such as hospitals, nursing homes, and ambulatory surgery centers, receive to account for practice, equipment, labor, and other costs associated with running a clinical practice.

AGA continues to urge physicians to write federal lawmakers to educate Congress about the detrimental effects of payment cuts, noting that the cuts, when coupled with rising inflation, increased administrative burdens, and staffing shortages, will negatively impact patients’ access to care.

The study had no financial support. The authors have disclosed no relevant financial relationships.

--From Staff Reports

There has been a steady decline in Medicare reimbursement for common gastrointestinal (GI) services and patient office visits over the past 15 years, which could have a direct impact on patients.

“When Medicare reimbursements decrease, health outcomes, health care access, and patient satisfaction may be affected, particularly in light of high inflation and increased costs due to staffing shortages, increased staffing salaries, and additional equipment necessary for COVID-19 safety,” researchers wrote in The American Journal of Gastroenterology.

Samir A. Shah, MD, of Brown University, Providence, R.I., and colleagues evaluated trends from 2007 to 2022 in Medicare reimbursement for the top 10 common GI procedures.

These procedures, which included colonoscopies, endoscopies, and gastrostomy tube placement, were identified through a joint list published by the American College of Gastroenterology, the American Society of Gastrointestinal Endoscopy, and the American Gastroenterological Association (AGA).

From 2007 to 2022, unadjusted and adjusted reimbursement for GI procedures declined by 7% and 33%, respectively, on average.

The adjusted change in physician reimbursement ranged from a decrease of roughly 29% for esophagus endoscopy to 38% for colonoscopy and biopsy, the study team found.

They found that the decline in reimbursement of GI procedures was significantly larger after 2015 (P < .001).

From 2007 to 2014, the mean decrease in physician reimbursement for GI services was 6.7%, and the annual growth rate in reimbursement was –1.0%.

In comparison, from 2015 to 2022, the mean decrease in physician reimbursement was 28.2%, and the mean annual growth rate in reimbursement was –4.7%.

To examine trends in reimbursement for office and inpatient visits from 2007 to 2022, the researchers identified the top five current procedural terminology (CPT) codes from outpatient office and inpatient consult visits provided to Medicare Part B beneficiaries by gastroenterologists.

In contrast to the reimbursement trends for GI procedures, the unadjusted physician reimbursement for inpatient and outpatient visits showed an average increase of 32%.

However, after adjustment for inflation, physician reimbursement for patient visits showed an average decline of 4.9%.

Overall, reimbursement for outpatient visits increased by 4.3%, while reimbursement for inpatient visits decreased by 18.8%.

Dr. Shah and colleagues said their findings are important, given that Medicare patients make up a substantial and growing proportion of patients with GI problems and because fewer than 1% of gastroenterologists have opted out of Medicare.

They noted that the trends in GI reimbursement they observed mirror trends in other specialties, which have also noted a decrease in adjusted reimbursement for care.

Physicians are once again facing cuts of at least 4.5% on Jan. 1, 2023, unless Congress acts. AGA and the entire medical community continue to call on Congress to make statutory changes to the Medicare payment system to address these payment challenges. Specifically, AGA and the physician community have recommended that payment rates include an inflationary adjustment similar to what other providers, such as hospitals, nursing homes, and ambulatory surgery centers, receive to account for practice, equipment, labor, and other costs associated with running a clinical practice.

AGA continues to urge physicians to write federal lawmakers to educate Congress about the detrimental effects of payment cuts, noting that the cuts, when coupled with rising inflation, increased administrative burdens, and staffing shortages, will negatively impact patients’ access to care.

The study had no financial support. The authors have disclosed no relevant financial relationships.

--From Staff Reports

There has been a steady decline in Medicare reimbursement for common gastrointestinal (GI) services and patient office visits over the past 15 years, which could have a direct impact on patients.

“When Medicare reimbursements decrease, health outcomes, health care access, and patient satisfaction may be affected, particularly in light of high inflation and increased costs due to staffing shortages, increased staffing salaries, and additional equipment necessary for COVID-19 safety,” researchers wrote in The American Journal of Gastroenterology.

Samir A. Shah, MD, of Brown University, Providence, R.I., and colleagues evaluated trends from 2007 to 2022 in Medicare reimbursement for the top 10 common GI procedures.

These procedures, which included colonoscopies, endoscopies, and gastrostomy tube placement, were identified through a joint list published by the American College of Gastroenterology, the American Society of Gastrointestinal Endoscopy, and the American Gastroenterological Association (AGA).

From 2007 to 2022, unadjusted and adjusted reimbursement for GI procedures declined by 7% and 33%, respectively, on average.

The adjusted change in physician reimbursement ranged from a decrease of roughly 29% for esophagus endoscopy to 38% for colonoscopy and biopsy, the study team found.

They found that the decline in reimbursement of GI procedures was significantly larger after 2015 (P < .001).

From 2007 to 2014, the mean decrease in physician reimbursement for GI services was 6.7%, and the annual growth rate in reimbursement was –1.0%.

In comparison, from 2015 to 2022, the mean decrease in physician reimbursement was 28.2%, and the mean annual growth rate in reimbursement was –4.7%.

To examine trends in reimbursement for office and inpatient visits from 2007 to 2022, the researchers identified the top five current procedural terminology (CPT) codes from outpatient office and inpatient consult visits provided to Medicare Part B beneficiaries by gastroenterologists.

In contrast to the reimbursement trends for GI procedures, the unadjusted physician reimbursement for inpatient and outpatient visits showed an average increase of 32%.

However, after adjustment for inflation, physician reimbursement for patient visits showed an average decline of 4.9%.

Overall, reimbursement for outpatient visits increased by 4.3%, while reimbursement for inpatient visits decreased by 18.8%.

Dr. Shah and colleagues said their findings are important, given that Medicare patients make up a substantial and growing proportion of patients with GI problems and because fewer than 1% of gastroenterologists have opted out of Medicare.

They noted that the trends in GI reimbursement they observed mirror trends in other specialties, which have also noted a decrease in adjusted reimbursement for care.

Physicians are once again facing cuts of at least 4.5% on Jan. 1, 2023, unless Congress acts. AGA and the entire medical community continue to call on Congress to make statutory changes to the Medicare payment system to address these payment challenges. Specifically, AGA and the physician community have recommended that payment rates include an inflationary adjustment similar to what other providers, such as hospitals, nursing homes, and ambulatory surgery centers, receive to account for practice, equipment, labor, and other costs associated with running a clinical practice.

AGA continues to urge physicians to write federal lawmakers to educate Congress about the detrimental effects of payment cuts, noting that the cuts, when coupled with rising inflation, increased administrative burdens, and staffing shortages, will negatively impact patients’ access to care.

The study had no financial support. The authors have disclosed no relevant financial relationships.

--From Staff Reports