Browsing by Subject "Practice guidelines"

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    Hospital Volume Predicts Guideline Concordant Care in Stage III Esophageal Cancer
    (Elsevier, 2022) Adhia, Akash H.; Feinglass, Joseph M.; Schlick, Cary Jo R.; Merkow, Ryan P.; Bilimoria, Karl Y.; Odell, David D.; Surgery, School of Medicine
    Background: Esophageal cancer is a deadly disease requiring multidisciplinary coordination of care and surgical proficiency for adequate treatment. We hypothesize that quality of care is varied nationally. Methods: From published guidelines, we developed quality measures for management of stage III esophageal cancer: utilization of neoadjuvant therapy, surgical sampling of at least 15 lymph nodes, resection within 60 days of chemotherapy or radiation, and completeness of resection. Measure adherence was examined across 1345 hospitals participating in the National Cancer Database from 2004 to 2016. We examined the association of volume, program accreditation, safety net status, geographic region, and patient travel distance on adequate adherence (≥85% of patients are adherent) using logistic regression modeling. Results: The rate of adequate adherence was worst in nodal staging (12.6%) and highest for utilization of neoadjuvant therapy (84.8%). Academic programs had the highest rate of adequate adherence for induction therapy (77.2%; P < .001), timing of surgery (56.6%; P < .001), and completeness of resection (78.5%; P < .001) but the lowest for nodal staging (4.4%; P = .018). For every additional esophagectomy performed per year, the odds of adequate adherence increased for induction therapy (odds ratio [OR]. 1.16; 95% confidence interval [CI], 1.06-1.27) and completeness of resection (OR, 1.15; 95% CI, 1.06-1.25) but decreased for nodal staging (OR, 0.76; 95% CI, 0.65-0.89). Conclusions: Care provided at higher volume and academic facilities was more likely to be guideline concordant in some areas but not in others. Understanding the processes that support the delivery of guideline concordant care may provide valuable opportunities for improvement.
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    Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations
    (Wolters Kluwer, 2023) Chesnut, Randall M.; Aguilera, Sergio; Buki, Andras; Bulger, Eileen M.; Citerio, Giuseppe; Cooper, D. Jamie; Diaz Arrastia, Ramon; Diringer, Michael; Figaji, Anthony; Gao, Guoyi; Geocadin, Romergryko G.; Ghajar, Jamshid; Harris, Odette; Hawryluk, Gregory W. J.; Hoffer, Alan; Hutchinson, Peter; Joseph, Mathew; Kitagawa, Ryan; Manley, Geoffrey; Mayer, Stephan; Menon, David K.; Meyfroidt, Geert; Michael, Daniel B.; Oddo, Mauro; Okonkwo, David O.; Patel, Mayur B.; Robertson, Claudia; Rosenfeld, Jeffrey V.; Rubiano, Andres M.; Sahuquillo, Juain; Servadei, Franco; Shutter, Lori; Stein, Deborah M.; Stocchetti, Nino; Taccone, Fabio Silvio; Timmons, Shelly D.; Tsai, Eve C.; Ullman, Jamie S.; Videtta, Walter; Wright, David W.; Zammit, Christopher; Neurological Surgery, School of Medicine
    Background: Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. Objective: To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. Methods: We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. Results: Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. Conclusion: Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.