The Impact of Performance Enhancement on Value of Care in Hospitals

Hospitals are facing big challenges: decreasing reimbursements are going alongside increasing costs and the necessity of investments. At the same time occurring, excellent quality of care, and high-patient satisfaction have to be assured. The dilemma of providing both with decreasing rather than increasing resources cannot be solved only by striving for economies of scale, but by optimizing supply chain management, or reduction of overhead. Possible effects of these measures most often are already exhausted and seldom have a positive impact on the quality of care or patient satisfaction. Management is tempted to use its best-known instruments to reduce costs, while medical staff's focus is on quality of care and often battle against management as a perceived enemy. The solution to this dilemma lies in focusing on medical core processes that are directly linked to patients' treatments and, thereby improving all the parameters of Michael Porter's value equation: costs, outcome, and patient satisfaction. This approach of performance enhancement presumes understanding, acceptance, and constructive collaboration of two usually separated worlds: The medical-scientific world involved in patient care and the financial world of management. In this article, the authors explain performance enhancement for optimized delivery of care and how the dilemma mentioned above can be solved. The authors explain how performance enhancement can be achieved in daily clinical practice, which kind of obstacles have to be overcome, which changes are necessary within a hospital, how medical staff can be motivated, and how the value of care equation can be influenced.

A Single Center's Clinical Experience With Ergonomix Breast Implants

Background This retrospective study reports on the early experience of a private surgical center with Motiva Ergonomix SilkSurface SikSurface breast implants. Objectives to examine the incidence of complications and satisfaction levels in women who received primary and revision breast augmentation or augmentation-mastopexy with this device. Methods 356 consecutive patients received Motiva Ergonomix breast implants from April 2014 to October 2018 by 3 different surgeons and were followed-up for a minimum of 12 months. Complications were assessed by measuring the rate of rupture, capsular contracture, malposition, late seroma, double capsule, reoperation, symmastia, ptosis, extrusion, and infection. Satisfaction with aesthetic results was assessed by both surgeon and patient, using the Likert scale. Results Only six major complications were observed in these 356 patients (712 implants). One unilateral implant ptosis (“bottoming out”) at 12 months (0.14 %) and 2 capsular contractures (0.28 %), one at 14 months and the other at 2 years. At all time-points, 98% of the patients were “extremely satisfied or very satisfied” with the aesthetic results and surgeons categorized the outcomes as “very important or important improvement” in 96% of the cases. Conclusions Motiva Ergonomix SilkSurface devices provided high patient satisfaction up to more than 5 years postoperatively with very few complications. These data are consistent with other reports in the literature. The observed favorable outcomes might be attributed, at least in part, to Motiva Ergonomix’s bio-engineered “cell-friendly” surface.

A study to evaluate the efficacy and safety of intradermal and intralesional Purified Protein Derivative (PPD) for treatment of common warts in children

: Viral warts are common dermatological diseases with wide range of treatment modalities. Utilization of various vaccines and skin test antigens has broadened the horizon of available immunotherapeutic agents for the treatment of warts. In this study, we compared efficacy and safety of intradermal and intralesional purified protein derivative (PPD) for treating common warts in children. Toevaluate efficacy and safety of intradermal and intralesional PPD in treatment of common warts in children.: 180 children (aged 5-15 years) with common warts were randomly divided to receive intradermal (n=90) PPD 10 TU/0.1 ml at middle third of right forearm or intralesional PPD (n=90) 0.1 ml in the largest wart once in 2-weeks till there is complete clearance or maximum of five injections whichever is earlier. Patients were followed at 4 week after last injection for assessment of response, adverse effects, and recurrence of common warts. : Complete, partial clearance and no response in 51.2%, 45.3% and 2.3% children was observed in intradermal group as compared to 54.2%, 42.5% and 1.1% response in intralesional group respectively. Recurrence of warts was observed in 1.2% and 2.2% children in intradermal and intralesional group respectively. Pain was the most common adverse effect in both groups followed by erythema lasting for 2-3 days not warranting for discontinuation of treatment in any patient.: Overall 96.5% and 96.7% patients in both intradermal and intralesional group responded to treatment respectively. We conclude that immunotherapy with PPD appears safe, effective, and acceptable treatment modality for common warts in children. Although intralesional group showed slightly higher efficacy for warts (0.2%), intradermal PPD has advantage of less pain, high patient satisfaction, less spillage of injection material onto surroundings and better compliance over intralesional group and hence can be considered as valuable first line treatment in children in resource poor developing countries.

Complex wound care by a nurse practitioner in primary care: a quality improvement evaluation on healing rates, costs and patient satisfaction

Complex wounds are a major burden for healthcare professionals. Patients with complex wounds are often referred to hospitals or wound expertise centres. Complex wound care could be organised in primary care, but very little published evidence for this is available. In this study, members of a primary healthcare organisation were interviewed to ascertain how the wound care was organised. Patient characteristics and data regarding wound care, healing rates and costs were collected from medical records. Patients filled in a questionnaire concerning accessibility, communication, medical counselling and the overall experience of their treatment. This study followed 25 patients with a total of 42 wounds. Some 82% of the wounds were healed within a mean treatment duration of 9.7 weeks. Mean treatment costs were calculated at €155 (£130) for healed patients. Patients were generally very satisfied with their treatment, illustrated by an overall 8.7 out of 10 scoring on an amended survey based on the Consumer Quality Index. Treating complex wounds in primary care seemed adequate, with high patient satisfaction and tolerable costs.

Single-Shot Sub-Dissociative Dose Ketofol versus Ketamine Alone for Emergency Department Procedural Sedation and Analgesia in Adult

When compared with Ketamine alone for PSA in ED settings, the Ketofol with rapid onset of action, faster recovery time, cardio respiratory stability, less adverse events, and high patient satisfaction level make it a better option.

Wide-Awake Brachioplasty: A Safe and Effective Technique for Local Anesthesia

Brachioplasty is a popular body contouring surgery which treats upper arm deformity related to both aging and massive weight loss. Demand for brachioplasty is growing, as the volume of bariatric surgery performed in the United States has doubled in the last decade.1 Local anesthesia offers multiple benefits for both patients and providers: it avoids anesthetic risks and anesthesia costs, decreases operating room time, and facilitates a more rapid recovery for patients. Brachioplasty is typically performed under general anesthesia or moderate sedation; this study details a successful technique to perform brachioplasty under wide-awake local anesthesia with high patient satisfaction and an excellent safety profile.

Intralesional Bleomycin for Treatment of a Recalcitrant Wart in an Immunocompromised Patient: A Safe, Effective, and Underutilized Therapy

Injectable bleomycin is infrequently used for recalcitrant warts despite its efficacy, acceptable safety profile, and high patient satisfaction compared to other treatment modalities. We present an immunocompromised patient with a large recalcitrant wart successfully treated with intralesional bleomycin to provide greater clinical exposure, training, and practice with intralesional bleomycin.

SP5.1.8 Long term outcomes of laparoscopic magnetic sphincter augmentation for gastro-oesophageal reflux disease: High patient satisfaction with low dysphagia rates

Aims Laparoscopic magnetic sphincter augmentation (MSA) or LINX® procedure is gaining popularity as a treatment for gastro-oesophageal reflux disease. We looked at the long-term outcomes of this procedure with regards to its efficacy, in particular studying the dysphagia rate in relation to the LINX® device size. Methods Postal questionnaires were sent to all patients who underwent MSA procedure between 2012-2019 at a single institution. Patients were asked to quantify, as a percentage, their symptom resolution, proton pump inhibitor (PPI) intake and side effects. Results 124 patients (male:female ratio was 45:55) underwent MSA procedure, with 82 responding to the questionnaire. Patients' age range was 18-71 years (median 49). Over 90% of patients reported improvements in reflux symptoms with 75% reporting complete resolution. 67% of patients no longer required PPI medication, whilst 21% of patients had >50% reduction in their medication. Post-operative dysphagia occurred in 59% of patients at 3 months, which decreased to 16% at 1 year. There was no significant difference in size of LINX® device used between patients with dysphagia at ≥ 1 year versus those without dysphagia at ≥ 1 year (p = 0.554). In total 3 patients (2%) required explantation of the LINX® device. Overall 86% of patients rated their outcomes as satisfactory or very satisfactory. Conclusions Our 7 years of experience with laparoscopic MSA has demonstrated that this procedure is safe with high patient satisfaction rates. Dysphagia, although common in the early post-operative period, usually resolves within 3-6 months and is unrelated to LINX® device size.

Subcutaneous Endoscopy in Plastic and Reconstructive Surgery

Background Scar visibility is a major deterrent to patients seeking reconstructive surgery. Endoscopic surgery can address a wide range of problems, from minimizing or concealing scars to improving access and outcomes in certain situations. This case series includes a wide range of reconstructive surgery problems addressed by subcutaneous endoscopic surgery. Having one or more trained assistants is a major deterrent to the performance of endoscopic surgery by the lone practitioner. The single (or two-port technique for muscle harvest) used in most cases simplifies subcutaneous endoscopic surgery. Methods A single-port endoscopy technique, with a 4-mm, 30-degree side viewing telescope and sheath, optical camera and cold light source, was used. Case records were reviewed for access incisions, procedure abandonment, postoperative pain, complications, and patient satisfaction. Results A total of 53 endoscopic surgical episodes between 2003 and 2013 were reviewed. Using a single port, most cases were done successfully. The access site was changed peroperatively in one case. Complications included transient nerve palsy in one case, which recovered completely. There was minimal intraoperative bleeding. Postoperative pain was low except in one case and managed with minimal analgesia. Patient satisfaction was high in all cases. Conclusions Subsurface endoscopy done on a wide range of reconstructive surgery procedures and resulted in minimal scars and high patient satisfaction.