Time Required for Planned and Unplanned Episodes of Care in Septic and Aseptic Hip and Knee Revision Surgery

Background: Surgical reimbursement rates are established by the Centers for Medicare and Medicaid Services (CMS). Studies have indicated that revision hip (rTHA) and knee (rTKA) arthroplasties require significantly more work effort, but are reimbursed less than primary procedures. This study quantified planned and unplanned work performed for revision surgeries by the surgeon and/or the surgeon’s team during the episode of care “reimbursement window.” Quantification of time was performed separately for aseptic and septic (two-stage) revisions and compared to allowed reimbursement amounts. Methods: All unilateral rTHA and rTKA procedures performed over a 10-year period by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. Impromptu patient inquiries and treatments after discharge, but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient. Results: Calculations demonstrated average per patient work for aseptic rTKA exceeded the reimbursable amount by 31 minutes. Calculated average minutes of work per patient required for aseptic rTHA fell within the number of minutes approved for reimbursement. Average per patient work for septic rTKA and rTHA exceeded the reimbursable amounts by 331 and 166 minutes, respectively, equating to 2.8 to 5.5 hours of uncompensated time. Conclusion: Revision hip and knee procedures are substantially more complex than primary procedures, with many surgeons referring patients to out-of-network care. Financially dis-incentivizing surgeons to care for these patients reduces patient access to care when high quality care is needed the most, especially infection cases susceptible to high sepsis and mortality rates. Study findings will be applied to advocacy efforts for appropriate legislative reform.

Who Is Doing What in Home Care Services?

(1) Background: This paper investigates the distribution of work hours by activity, for the main staff categories in home care services in three rural Norwegian municipalities. In Norway these categories are registered nurses, assistant nurses and assistant health workers. (2) Methods: The three categories of home care staff recorded 20,964 eligible observations over 8 weeks. We identified 19 activities, which were recorded. The majority of staff used a smartphone application for the time measuring, while some staff used a manual form for reporting purposes. (3) Results: The registered nurses (RNs) spent 32% of their time on direct patient work, while driving accounted for 18%. Direct patient work and driving accounted for the majority of activities performed by assistant nurses (48% and 29%, respectively) and assistant health workers (70% and 17%, respectively). (4) Conclusions: The demand for home care services is increasing in terms of both size and complexity. Simultaneously, there is a growing shortage of skilled staff. RNs is the group with the least face-to-face time with patients. To meet the patients’ needs, it is necessary to discuss and modify existing home care service systems in order to use resources appropriately and effectively.

“It Is a Full-time Job to Be Ill”: Patient Work Involved in Attending Formal Diabetes Care Among Socially Vulnerable Danish Type 2 Diabetes Patients

Previous research has shown social inequality in type 2 diabetes prevalence and that socially vulnerable type 2 diabetes patients benefit less than average from health services. Based on ethnographic fieldwork carried out between February 2017 and March 2018 in a Danish specialized outpatient clinic, this article focuses on patient work among socially vulnerable type 2 diabetes patients. Through attending to the border zone between formal health care and self-care, we show that patients do a lot of work requiring skills, resources, and initiative, to access and benefit from formal care. This work is complex and implicit in the organization of care. Patients’ social situations, especially their employment situation, complicate getting patient work done. Attending to patient work and implicit tasks in care organization may help us to see how social inequality in type 2 diabetes outcomes develops, and may be combated.

Summarised, verified and accessible: improving clinical information management for potential haematopoietic stem cell transplantation patients

The Welsh Transplantation and Immunogenetics Laboratory (WTAIL) is responsible for managing patient work-up for haematopoietic stem cell transplantation (HSCT), the only potentially curative option for many haematological and non-haematological conditions. Work-up requires regular communication between WTAIL and the transplanting clinicians, facilitated by weekly multidisciplinary team (MDT) meetings, to agree decisions and proceed through each work-up stage. Effective communication and minimising error are critical, as transplanting cells from a suboptimal donor could have severe or fatal consequences for the patient. We reviewed our HSCT patient management and identified issues including staff dissatisfaction with the inefficiency of the current (paper-based) system and concern about the potential for incidents caused by errors in manual transcription of patient information and tracking clinical decisions. Another driver for change was the COVID-19 pandemic, which prevented the usual face-to-face MDT meetings in which staff would show clinicians the paper records and reports; the shift to online MDT required new ways of sharing data. In this project we developed a new central reference point for our patient management data along with electronic patient summary sheets, designed with an eye to improving safety and efficiency. Over several improvement cycles we tested and refined the summary sheets with staff and clinicians and experimented with videoconferencing to facilitate data sharing. We conducted interviews with staff from which we concluded that the new process successfully reduced transcription and duplication and improved communication with the clinicians during the pandemic. Despite an increase in workload due to build-up of active patient work-up cases during the pandemic, staff reported that the new summaries enabled them to cope well. A key initiative was creation of a ‘Task and Finish’ group that helped establish continual improvement culture and identified additional areas for improvement which have been followed up in further improvement projects.

Identifying Tools and Technology Barriers to In-Home Care for Children with Medical Complexity

Family caregivers use tools and technology to provide care for children with medical complexity (CMC) in the home. It is unclear what barriers families experience when using the tools and technology integral to the care and wellbeing of CMC. Our objective was to identify the barriers family caregivers experience in using tools and technology to provide care to CMC in the home. We used contextual inquiry to interview 30 caregivers in their homes and analyzed our data using a deductive content analysis informed by the patient work system (PWS) model and an inductive content analysis to identify emergent barriers. Through these combined analyses, we identified four categories of barriers families experienced using tools and technology to care for CMC: 1) Access and Cost; 2) Usability, which includes the subcategories Functionality, Tool design, Ease of use, and Reliability; 3) Short-term tool impact; and 4) Long-term tool impact. Our results point to the need for further interventions to reduce or mitigate tools and technology barriers to the in-home care for CMC.

Just a leader? Leadership work challenges and identity contradiction experienced by Finnish physician leaders

PurposeThis study seeks to improve the understanding of physician leaders' leadership work challenges.Design/methodology/approachThe subjects of the empirical study were physician leaders (n = 23) in the largest central hospital in Finland.FindingsA total of five largely identity-related, partially paradoxical dilemmas appeared regarding why working as “just a leader” is challenging for physician leaders. First, the dilemma of identity ambiguity between being a physician and a leader. Second, the dilemma of balancing the expected commitment to clinical patient work by various stakeholders and that of physician leadership work. Third, the dilemma of being able to compensate for leadership skill shortcomings by excelling in clinical skills, encouraging physician leaders to commit to patient work. Fourth, the dilemma of “medic discourse”, that is, downplaying leadership work as “non-patient work”, making it inferior to patient work. Fifth, the dilemma of a perceived ethical obligation to commit to patient work even if the physician leadership work would be a full-time job. The first two issues support the findings of earlier research, while the remaining three emerging from the authors’ analysis are novel.Practical implicationsThe authors list some of the practical implications that follow from this study and which could help solve some of the challenges.Originality/valueThis study explores physician leaders' leadership work challenges using authentic physician leader data in a context where no prior empirical research has been carried out.

Personal Health Information Management Among Older Adults: Scoping Review

Background Older adults face growing health care needs and could potentially benefit from personal health information management (PHIM) and PHIM technology. To ensure effective PHIM and to provide supportive tools, it is crucial to investigate the needs, challenges, processes, and tools used by this subpopulation. The literature on PHIM by older adults, however, remains scattered and has not provided a clear picture of what we know about the elements that play a role in older adults’ PHIM. Objective The goal of our review was to provide a comprehensive overview of extant knowledge on PHIM by older adults, establish the status quo of research on this topic, and identify research gaps. Methods We carried out a scoping review of the literature from 1998 to 2020, which followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) framework. First, we executed a broad and structured search. We then carried out a qualitative analysis of papers pertinent to the topic taking into consideration the five elements of the patient work system as follows: (1) personal-level factors, (2) PHIM tasks, (3) tools used, (4) physical settings of PHIM activities, and (5) socio-organizational aspects. Results The review included 22 studies. Consolidated empirical evidence was related to all elements of the patient work system. Multiple personal factors affected PHIM. Various types of personal health information were managed (clinical, patient-generated, and general) and tools were used (electronic, paper-based, and others). Older adults’ PHIM was intertwined with their surroundings, and various individuals participated. The largest body of evidence concerned personal factors, while findings regarding the physical environment of PHIM were scarce. Most research has thus far examined older adults as a single group, and scant attention has been paid to age subgroups. Conclusions Opportunities for further PHIM studies remain across all elements of the patient work system in terms of empirical, design science, or review work.

Need for Assessment of MDS Paper I Examination at the End of the First Year of MDS: A Survey

Introduction: Pursuant to the notification published by Dental Council of India, dated May 17, 2018, no. DE-14-MDS-2018/2131, the committee amended the regulation on postgraduate (PG) Masters of Dental Surgery (MDS) students and made provision of giving MDS paper I at the end of the first year. Assessment of this survey will provide clear information between the responses of PG students and teachers. The focus of this article is to report and discuss the characteristics of new learning process. Material Method: A total of 150 sample sizes and 50 PG teachers were included. Questions were generated using Google Form to gain access and establish rapport with participants and to obtain open, honest understanding of the participants’ “learning experience.” The link was sent to the participants, using emails or WhatsApp number. Result: The analysis of survey data was carried out using Likert scale. The comparison of mean scores was carried out using unpaired t-test. Figures 1 to 10 provide responses of participants. Conclusion: Postgraduate students and PG guides are neutral toward the initial protocol of examination. The participants have a positive attitude toward new framework. But curriculum activities such as library dissertation (LD), dissertation selection, and patient work get disturbed somewhere. It might take time for both students and guides to get familiar with the new framework.