Publications by authors named "Anthony Mazzarelli"

23 Publications

  • Page 1 of 1

Association of Emergency Department Waiting Times With Patient Experience in Admitted and Discharged Patients.

J Patient Exp 2021 28;8:23743735211011404. Epub 2021 Apr 28.

Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA.

Prolonged waiting times are associated with worse patient experience in patients discharged from the emergency department (ED). However, it is unclear which component of the waiting times is most impactful to the patient experience and the impact on hospitalized patients. We performed a retrospective analysis of ED patients between July 2018 and March 30, 2020. In all, 3278 patients were included: 1477 patients were discharged from the ED, and 1680 were admitted. Discharged patients had a longer door-to-first provider and door-to-doctor time, but a shorter doctor-to-disposition, disposition-to-departure, and total ED time when compared to admitted patients. Some, but not all, components of waiting times were significantly higher in patients with suboptimal experience (<100th percentile). Prolonged door-to-doctor time was significantly associated with worse patient experience in discharged patients and in patients with hospital length of stay ≤4 days. Prolonged ED waiting times were significantly associated with worse patient experience in patients who were discharged from the ED and in inpatients with short length of stay. Door-to-doctor time seems to have the highest impact on the patient's experience of these 2 groups.
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http://dx.doi.org/10.1177/23743735211011404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8205338PMC
April 2021

Buprenorphine use and disparities in access among emergency department patients with opioid use disorder: A cross-sectional study.

J Subst Abuse Treat 2021 Apr 20;130:108405. Epub 2021 Apr 20.

Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ 08103, United States of America; Cooper University Hospital, Department of Emergency Medicine, Keleman 152, 1 Cooper Plaza, Camden, NJ 08103, United States of America. Electronic address:

Background: Buprenorphine, a partial mu-opioid agonist and kappa-opioid antagonist, is an approved treatment for opioid use disorder (OUD). Studies demonstrate that buprenorphine decreases cravings for other opioids, effectively ameliorates withdrawal symptoms, and decreases opioid overdose and mortality. However, buprenorphine remains under-utilized. Despite its low potential for misuse, research has reported wide use of non-prescribed buprenorphine, seemingly for its effectiveness in treating withdrawal and helping to maintain sobriety. We designed our study to describe patient experiences with both prescribed and non-prescribed buprenorphine usage and to identify potential disparities in buprenorphine access within a high-risk population of patients with OUD.

Methods: This was a cross-sectional study conducted in the emergency department (ED) of a large inner-city university hospital from January 15, 2015, through April 30, 2018. Patients were eligible to participate in the study if they presented with opioid intoxication or after an opioid overdose and were 18 years of age or older. Research assistants administered surveys after the ED team deemed an eligible patient to be clinically sober.

Results: The study enrolled 423 patients. Most patients in this study were white (59.8%) and male (77.5%), with a mean age of 37.5 years. A majority of patients (58.4%) had Medicaid insurance. Of those, 15.8% had previously been on medication for opioid use disorder (MOUD) with methadone, and 16.3% received outpatient buprenorphine. Most (72.8%, 95% CI 68.6-77.0%) respondents reported having used buprenorphine at one point. Of the participants reporting prior buprenorphine use, 15.5% had either traded, shared, or sold their buprenorphine in the past. Patients who obtained non-prescribed buprenorphine generally purchased it from a dealer, took only 8 mg at a time, and paid $10 per dose. Of those patients with a history of using buprenorphine, only 3.2% reported taking buprenorphine for euphoric effects, though 45.5% of participants declined to provide a specific reason for using the drug. Patients younger than 40 were more likely than those older than 40 to have taken buprenorphine in the past (81% vs 60%, p < 0.001). Further, white patients were more likely than nonwhite patients to have both used (42% vs 31%) and been prescribed buprenorphine (46% vs 25%, p < 0.001).

Discussion: Familiarity with buprenorphine is high among patients with OUD, and our data show that there is a strong demand among these patients for access to legal buprenorphine-based treatment programs. However, a variety of issues hamper access to this medication. Most patients in our study reported having been to an in-patient detox or rehabilitation program, yet only 16% of patients participated in a buprenorphine-based program. Furthermore, less than half of patients surveyed (37%) received a prescription for buprenorphine, and few participants reported taking buprenorphine for euphoric effects. Our findings suggest that a major barrier exists in legally obtaining buprenorphine for treatment of OUD, and that there appear to be racial and other disparities in buprenorphine prescribing, further limiting access to patients. Buprenorphine access needs to be expanded to satisfy the unmet need for appropriate treatment of those struggling with OUD, with particular attention to older and nonwhite patients.
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http://dx.doi.org/10.1016/j.jsat.2021.108405DOI Listing
April 2021

Preconsultation compassion intervention to reduce anxiety among patients referred to a cancer center: protocol for a randomised control trial.

BMJ Open 2021 05 24;11(5):e048201. Epub 2021 May 24.

Department of Emergency Medicine, Cooper University Health Care, Rowan University Cooper Medical School, Camden, New Jersey, USA

Introduction: Patients diagnosed with cancer commonly have a high degree of anxiety during an initial oncology consultation, which may interfere with a patient's ability to retain information required to make informed treatment decisions. A previous study randomised breast cancer survivors (volunteers) to view either (a) a brief video depicting a standard initial consultation from an oncologist or (b) an identical consultation with the addition of compassionate statements from the oncologist, and found the compassionate statements reduced anxiety among the volunteers. However, while compassionate statements reduced anxiety during simulation, it is currently unknown whether watching a video containing compassionate statements from an oncologist prior to an initial oncology consultation will reduce anxiety among patients referred to a cancer centre. The aim of this randomised control trial is to test whether watching a brief video containing compassionate statements from an oncologist, compared with watching a standard introduction video, prior to an initial oncology consultation will reduce the degree of anxiety among patients referred to a cancer centre.

Methods And Analysis: This is a prospective, randomised controlled clinical trial at an academic cancer centre. We will enrol adult patients scheduled for an initial oncology consultation. Subjects will be randomly assigned to receive a standard introduction video or enhanced compassion video for viewing prior to the initial oncology consultation. On arrival to the cancer centre, we will measure anxiety severity using the Hospital Anxiety and Depression Scale (HADS). The HADS has two 7-item subscales (HADS anxiety and HADS depression) and is well-validated among oncology patients. We will use Wilcoxon rank-sum test to test for a difference in the HADS subscales between the two video groups.

Ethics And Dissemination: The Cooper University Hospital Institutional Review Board approved this study. The results from this randomised control trial will be submitted for publication to a peer-reviewed journal.

Trial Registration Number: NCT04503681.
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http://dx.doi.org/10.1136/bmjopen-2020-048201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149444PMC
May 2021

Validation of a 5-Item Tool to Measure Patient Assessment of Clinician Compassion in Hospitals.

J Gen Intern Med 2021 Apr 9. Epub 2021 Apr 9.

Center for Humanism, Cooper Medical School of Rowan University, Camden, NJ, USA.

Background: We previously validated a 5-item compassion measure to assess patient experience of clinician compassion in the outpatient setting. However, currently, there is no validated and feasible method for health care systems to measure patient experience of clinician compassion in the inpatient setting across multiple hospitals.

Objective: To test if the 5-item compassion measure can validly and distinctly measure patient assessment of physician and nurse compassion in the inpatient setting.

Design: Cross-sectional study between July 1 and July 31, 2020, in a US health care network of 91 community hospitals across 16 states consisting of approximately 15,000 beds.

Patients: Adult patients who had an inpatient hospital stay and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Measurements: We adapted the original 5-item compassion measure to be specific for physicians, as well as for nurses. We disseminated both measures with the HCAHPS survey and used confirmatory factor analysis for validity testing. We tested reliability using Cronbach's alpha, as well as convergent validity with patient assessment of physician and nursing communication and overall hospital rating questions from HCAHPS.

Results: We analyzed 4756 patient responses. Confirmatory factor analysis found good fit for two distinct constructs (i.e., physician and nurse compassion). Both measures demonstrated good internal consistency (alpha > 0.90) and good convergent validity but reflected a construct (compassionate care) distinct from what is currently captured in HCAHPS.

Conclusion: We validated two 5-item tools that can distinctly measure patient experience of physician and nurse compassion for use in the inpatient hospital setting in conjunction with HCAHPS.
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http://dx.doi.org/10.1007/s11606-021-06733-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034051PMC
April 2021

Socioeconomic, racial and ethnic differences in patient experience of clinician empathy: Results of a systematic review and meta-analysis.

PLoS One 2021 3;16(3):e0247259. Epub 2021 Mar 3.

Cooper University Health Care, Camden, New Jersey, United States of America.

Introduction: Empathy is essential for high quality health care. Health care disparities may reflect a systemic lack of empathy for disadvantaged people; however, few data exist on disparities in patient experience of empathy during face-to-face health care encounters with individual clinicians. We systematically analyzed the literature to test if socioeconomic status (SES) and race/ethnicity disparities exist in patient-reported experience of clinician empathy.

Methods: Using a published protocol, we searched Ovid MEDLINE, PubMed, CINAHL, EMBASE, CENTRAL and PsychINFO for studies using the Consultation and Relational Empathy (CARE) Measure, which to date is the most commonly used and well-validated methodology for measuring clinician empathy from the patient perspective. We included studies containing CARE Measure data stratified by SES and/or race/ethnicity. We contacted authors to request stratified data, when necessary. We performed quantitative meta-analyses using random effects models to test for empathy differences by SES and race/ethnicity.

Results: Eighteen studies (n = 9,708 patients) were included. We found that, compared to patients whose SES was not low, low SES patients experienced lower empathy from clinicians (mean difference = -0.87 [95% confidence interval -1.72 to -0.02]). Compared to white patients, empathy scores were numerically lower for patients of multiple race/ethnicity groups (Black/African American, Asian, Native American, and all non-whites combined) but none of these differences reached statistical significance.

Conclusion: These data suggest an empathy gap may exist for patients with low SES. More research is needed to further test for SES and race/ethnicity disparities in clinician empathy and help promote health care equity.

Trial Registration: Registration (PROSPERO): CRD42019142809.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247259PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928470PMC
March 2021

Racial and socioeconomic disparities in patient experience of clinician empathy: a protocol for systematic review and meta-analysis.

BMJ Open 2020 06 28;10(6):e034247. Epub 2020 Jun 28.

Departments of Medicine and Emergency Medicine, Cooper University Health Care, Camden, New Jersey, USA.

Introduction: Clinician empathy is a vital component of high-quality healthcare. Healthcare disparities may reflect a societal lack of empathy for disadvantaged persons in general, and recent research suggests that socioeconomic disparities exist in patient satisfaction with clinicians. However, it is currently unclear if there are disparities in patient experience of empathy from clinicians. Our objective is to systematically analyse the scientific literature to test the hypothesis that racial and socioeconomic status (SES) disparities exist in patient-reported experience of clinician empathy.

Methods And Analysis: In accordance with published methodological guidelines for conducting a systematic review, we will analyse studies reporting patient assessment of clinician empathy using the Consultation and Relational Empathy (CARE) measure, which to date is the most commonly used and well-validated methodology in clinical research for measuring clinician empathy from the patient's perspective. We will use a standardised data collection template and assess study quality (risk of bias) using the Newcastle-Ottawa Scale. We will abstract data for the CARE measure stratified by race and SES, and we will contact the corresponding authors to obtain stratified data by race/SES if not reported in the original manuscript. Where appropriate, we will pool the data and perform quantitative meta-analysis to test if non-white (compared to white) patients and low SES (compared to high SES) patients report lower scores for clinician empathy.

Ethics And Dissemination: No individual patient-level data will be collected and thus the proposed systematic review does not require ethical approval. This systematic review will test if racial and SES differences exist in patient experience of clinician empathy, and will inform future research to help promote healthcare equity.

Prospero Registration Number: CRD42019142809.
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http://dx.doi.org/10.1136/bmjopen-2019-034247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322320PMC
June 2020

Income Disparities and Nonresponse Bias in Surveys of Patient Experience.

J Gen Intern Med 2020 07 31;35(7):2217-2218. Epub 2020 Jan 31.

Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, USA.

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http://dx.doi.org/10.1007/s11606-020-05677-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351907PMC
July 2020

Validation of a 5-item tool to measure patient assessment of clinician compassion in the emergency department.

BMC Emerg Med 2019 11 4;19(1):63. Epub 2019 Nov 4.

Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, New Jersey, 08103, USA.

Background: To test if the 5-item compassion measure (a tool previously validated in the outpatient setting to measure patient assessment of clinician compassion) is a valid and reliable tool to quantify a distinct construct (i.e. clinical compassion) among patients evaluated in the emergency department (ED).

Methods: Cross-sectional study conducted in three academic emergency departments in the U.S. between November 2018 and April 2019. We enrolled adult patients who were evaluated in the EDs of the participating institutions and administered the 5-item compassion measure after completion of care in the ED. Validity testing was performed using confirmatory factor analysis. Cronbach's alpha was used to test reliability. Convergent validity with patient assessment of overall satisfaction questions was tested using Spearman correlation coefficients and we tested if the 5-item compassion measure assessed a construct distinct from overall patient satisfaction using confirmatory factor analysis.

Results: We analyzed 866 patient responses. Confirmatory factor analysis found all five items loaded well on a single construct and our model was found to have good fit. Reliability was excellent (Cronbach's alpha = 0.93) among the entire cohort. These results remained consistent on sub-analyses stratified by individual institutions. The 5-item compassion measure had moderate correlation with overall patient satisfaction (r = 0.66) and patient recommendation of the ED to friends and family (r = 0.57), but reflected a patient experience domain (i.e. compassionate care) distinctly different from patient satisfaction.

Conclusions: The 5-item compassion measure is a valid and reliable tool to measure patient assessment of clinical compassion in the ED.
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http://dx.doi.org/10.1186/s12873-019-0279-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827199PMC
November 2019

Development and Validation of a Tool to Measure Patient Assessment of Clinical Compassion.

JAMA Netw Open 2019 05 3;2(5):e193976. Epub 2019 May 3.

Center for Humanism, Cooper Medical School of Rowan University, Camden, New Jersey.

Importance: Clinician compassion is a vital element of health care quality. Currently, there appears to be no validated and feasible method for health care organizations to measure patient assessment of clinician compassion on a large scale.

Objective: To develop and validate a tool for measuring patient assessment of clinician compassion that can be used in conjunction with the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey.

Design, Setting, And Participants: This prospective cohort study took place from June 1 to August 30, 2018, at a US academic health care system among a pilot cohort consisting of 3325 adult patients and a validation cohort consisting of 3483 adult patients, both of whom had an outpatient clinic visit and completed the CG-CAHPS survey.

Main Outcomes And Measurements: After a comprehensive literature review, 12 candidate survey items were developed. Face and construct validity were performed. Candidate items were disseminated to patients in conjunction with the CG-CAHPS survey in a series of 2 studies: (1) exploratory factor analysis in one cohort to determine the factor structure and the most parsimonious set of items; and (2) validity testing in a second cohort using confirmatory factor analysis. Reliability was tested using Cronbach α. Convergent validity was tested with patient assessment of clinician communication and overall satisfaction questions from CG-CAHPS survey.

Results: Overall, 6493 patient responses were analyzed. The mean (SD) age was 60 (15) years, 4239 patients (65.3%) were women, and 5079 (78.2%) were white. Exploratory factor analyses identified a 5-item compassion measure to be the most parsimonious. Confirmatory factor analyses found good fit. The compassion measure demonstrated good internal consistency (α = 0.94) and convergent validity (clinician communication: ρ = 0.44; overall satisfaction: ρ = 0.52) but reflected a patient experience domain (compassionate care) distinct from what is currently captured in the CG-CAHPS survey.

Conclusions And Relevance: A simple 5-item tool to measure patient assessment of clinician compassion was developed and validated for use in conjunction with CG-CAHPS survey.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.3976DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537812PMC
May 2019

Elective Naloxone-Induced Opioid Withdrawal for Rapid Initiation of Medication-Assisted Treatment of Opioid Use Disorder.

Ann Emerg Med 2019 09 14;74(3):430-432. Epub 2019 Feb 14.

Cooper University Hospital Emergency Department, Camden, NJ.

We present a case of elective naloxone-induced opioid withdrawal followed by buprenorphine rescue to initiate opioid use disorder treatment in the emergency department. This strategy may represent a safe alternative to prescribing buprenorphine for outpatient initiation, a method that puts the patient at risk for complications of unmonitored opioid withdrawal, including relapse. After confirmation that the naloxone-induced withdrawal was adequately treated with buprenorphine, the patient was discharged with prescribed buprenorphine to follow up in an addiction medicine clinic, where he was treated 2 days later.
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http://dx.doi.org/10.1016/j.annemergmed.2019.01.006DOI Listing
September 2019

Early Interventions for the Prevention of Posttraumatic Stress Symptoms in Survivors of Critical Illness: A Qualitative Systematic Review.

Crit Care Med 2018 08;46(8):1328-1333

The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ.

Objectives: Posttraumatic stress disorder among survivors of critical illness is of public health importance, as it is common and reduces patient quality of life. The objective of this systematic review was to collate the world's literature on interventions aimed at preventing posttraumatic stress disorder among survivors of critical illness.

Data Sources: We performed a search of CENTRAL, MEDLINE, EMBASE, CINAHL, and clinical trials registry platforms, with no restriction to language using a comprehensive strategy.

Study Selection: Study inclusion criteria were as follows: 1) adult human subjects, 2) patients treated in an ICU setting, 3) intervention arm aimed at reducing posttraumatic stress disorder symptoms, 4) use of a control arm, and 5) an outcome measure assessing development of acute stress or posttraumatic stress disorder symptoms.

Data Extraction: We performed a qualitative analysis to collate and summarize effects of identified interventions according to the recommended methodology from the Cochrane Handbook.

Data Synthesis: Seventeen studies met all inclusion and no exclusion criteria. There was heterogeneity in interventions and outcome measures used. All studies had some concern for risk of bias as per the Cochrane tool for assessing risk of bias. In eight of 12 studies (67%) testing early interventions (i.e., initiated in the ICU course) and one of five studies (20%) testing delayed interventions following ICU discharge, posttraumatic stress disorder symptoms were decreased among the intervention group compared with controls.

Conclusions: Despite a paucity of high-quality clinical investigations, the preponderance of evidence to date suggests that 1) posttraumatic stress disorder among survivors of critical illness may be preventable and 2) early interventions may be the most effective.
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http://dx.doi.org/10.1097/CCM.0000000000003222DOI Listing
August 2018

Compassionomics: Hypothesis and experimental approach.

Med Hypotheses 2017 Sep 12;107:92-97. Epub 2017 Aug 12.

Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, USA.

Recent reports indicate that healthcare is experiencing a compassion crisis - an absence of (or inconsistency in) compassionate patient care. It is currently unclear if, or to what extent, this exerts significant effects on health and healthcare. Experimental data are few, and this represents a critical knowledge gap for all health sciences. We hypothesize that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout). Compassionomics is the branch of knowledge and scientific study of the effects of compassionate healthcare, and herein we describe a framework for hypothesis testing. If the hypotheses are confirmed, compassionate healthcare can be established in the domain of evidence-based medicine.
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http://dx.doi.org/10.1016/j.mehy.2017.08.015DOI Listing
September 2017

Early interventions for the prevention of post-traumatic stress symptoms in survivors of critical illness: protocol for a systematic review.

BMJ Open 2017 Sep 1;7(9):e018270. Epub 2017 Sep 1.

Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey, USA.

Introduction: Post-traumatic stress disorder (PTSD) is being increasingly reported among survivors of critical illness and injury. Previous work has demonstrated that PTSD reduces patient quality of life and ability to return to work, as well as increases healthcare costs. As such, identifying interventions aimed at preventing the development of critical illness-related PTSD could have an important public health impact. The objective of this systematic review is to collate the world's literature on early interventions aimed at preventing PTSD among survivors of critical illness.

Methods And Analysis: We will perform a qualitative systematic review of human clinical trials of interventions aimed at preventing or reducing critical illness-related PTSD symptoms. We will methodically search CENTRAL, MEDLINE, Embase and CINAHL. We will also search websites containing details on clinical trials registration (National Library of Medicine's ClinicalTrials.gov and the WHO's International Clinical Trials Registry Platform), as well as screen reference lists of the articles we select for inclusion to identify additional studies for potential inclusion. Two authors will independently review all search results. After identification and inclusion of articles, we will use a standardised form for data extraction. We will use tables to describe the study type, populations, interventions tested and timing of interventions, outcome measures and effects of interventions on outcome measures compared with control groups. This review will be completed between 1 August 2017 and 31 August 2017.

Ethics And Dissemination: The proposed systematic review will not collect individual patient level data and does not require ethical approval. Results of this study will contribute to the understanding of critical illness-related PTSD and help prompt future research aimed at further developing interventions to prevent PTSD symptoms in survivors of critical illness.

Prospero Registration Number: This systematic review is registered in the PROSPERO international prospective register of systematic reviews (registration number CRD42017069672).
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http://dx.doi.org/10.1136/bmjopen-2017-018270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588947PMC
September 2017

Association Between Medicare Star Ratings for Patient Experience and Medicare Spending per Beneficiary for US Hospitals.

J Patient Exp 2017 Mar 12;4(1):17-21. Epub 2017 Jan 12.

Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, USA.

Objective: To test the association between patient experience and Centers for Medicare and Medicaid Services (CMS) spending at the hospital level.

Methods: Using CMS Hospital Compare data set, we analyzed 2014 data for CMS patient experience star ratings and the hospital Medicare Spending per Beneficiary (MSPB) Measure, which assesses price-standardized, risk-adjusted payments for services provided to Medicare beneficiaries for an episode of care from 3 days before hospital admission to 30 days following discharge. We tested the association using linear regression, adjusting for complexity of care using hospital Case Mix Index (CMI) and for socioeconomic status of the hospital patient population using Disproportionate Share Hospital (DSH) status.

Results: The MSPB decreased with increasing hospital patient experience ratings. After adjustment for CMI and DSH, better hospital patient experience was associated with lower spending per episode (5.6% decrease from the lowest to highest patient experience star rating).

Conclusion: We found that better hospital patient experience was associated with lower health-care spending. Further research is needed to define what specific elements and phases of the episode of care are driving the association.
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http://dx.doi.org/10.1177/2374373516685938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513662PMC
March 2017

A critical review of patient safety indicators attributed to trauma surgeons.

Injury 2017 Sep 1;48(9):1994-1998. Epub 2017 Apr 1.

Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States. Electronic address:

Background: The Agency for Health Care Research and Quality (AHRQ) developed patient safety indicators (PSIs) to identify events with a high likelihood of representing medical error. The purpose of this study was to validate PSIs attributed to trauma surgeons and compare validated PSIs to performance improvement (PI) and morbidity and mortality (M&M) data. We hypothesized that PSIs are not an indicator of quality of care in trauma.

Methods: PSI's attributed to trauma surgeons (n=9) at our institution were reviewed (Jan-Dec 2015). An initial review was conducted to ensure they met inclusion and exclusion criteria (valid). "Valid" PSIs were distributed to the trauma division for secondary review.

Results: 48 PSIs were identified (17.2 per 1000 cases) during the study period. 19 were false positives yielding a positive predictive value of 60% (95% CI 45-74%). False positive PSIs were the result of coding error (78%), present on admission status (17%) and documentation error (5%). Valid PSIs (n=29) were further analyzed. The most common were post-op PE/DVT (n=14), failure to rescue (n=6) and accidental puncture/laceration (n=3). 60% of patients with a post-op PE/DVT were started on chemoprophylaxis on admission and 40% had significant intracranial hemorrhage; all were deemed non-preventable through trauma PI. All deaths considered failure to rescue were classified as expected mortalities during M&M review. Although not clinically significant, all cases of accidental puncture/laceration (10% of valid PSIs) represented opportunities for improvement.

Conclusion: Overall, PSIs have low validity and do not reflect quality of care in trauma.
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http://dx.doi.org/10.1016/j.injury.2017.03.051DOI Listing
September 2017

Web Exclusives. Annals Story Slam - Humanism in Medical Education.

Ann Intern Med 2017 04;166(7):SS1

From Cooper University Hospital, Camden, New Jersey.

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http://dx.doi.org/10.7326/W17-0038DOI Listing
April 2017

Lean Six Sigma to Reduce Intensive Care Unit Length of Stay and Costs in Prolonged Mechanical Ventilation.

J Healthc Qual 2018 Jan/Feb;40(1):36-43

Objective: Patients with prolonged mechanical ventilation (PMV) represent important "outliers" of hospital length of stay (LOS) and costs (∼$26 billion annually in the United States). We tested the hypothesis that a Lean Six Sigma (LSS) approach for process improvement could reduce hospital LOS and the associated costs of care for patients with PMV.

Design: Before-and-after cohort study.

Setting: Multidisciplinary intensive care unit (ICU) in an academic medical center.

Patients: Adult patients admitted to the ICU and treated with PMV, as defined by diagnosis-related group (DRG).

Methods: We implemented a clinical redesign intervention based on LSS principles. We identified eight distinct processes in preparing patients with PMV for post-acute care. Our clinical redesign included reengineering daily patient care rounds ("Lean ICU rounds") to reduce variation and waste in these processes. We compared hospital LOS and direct cost per case in patients with PMV before (2013) and after (2014) our LSS intervention.

Results: Among 259 patients with PMV (131 preintervention; 128 postintervention), median hospital LOS decreased by 24% during the intervention period (29 vs. 22 days, p < .001). Accordingly, median hospital direct cost per case decreased by 27% ($66,335 vs. $48,370, p < .001).

Conclusion: We found that a LSS-based clinical redesign reduced hospital LOS and the costs of care for patients with PMV.
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http://dx.doi.org/10.1097/JHQ.0000000000000075DOI Listing
September 2019

Patient Experience and Health Care Quality.

JAMA Intern Med 2016 10;176(10):1575

Cooper University Health Care, Camden, New Jersey2Cooper Medical School of Rowan University, Camden, New Jersey.

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http://dx.doi.org/10.1001/jamainternmed.2016.5435DOI Listing
October 2016

Refractory Ventricular Fibrillation Successfully Cardioverted With Dual Sequential Defibrillation.

J Emerg Med 2016 Sep 28;51(3):e37-40. Epub 2016 Jun 28.

Department of Emergency Medicine, Cooper University Hospital, Camden, New Jersey.

Background: Current guidelines for the treatment of adult patients in cardiac arrest are supplied by the American Heart Association through basic life support and advanced cardiovascular life support (ACLS) provider courses. When treatments defined by the ACLS guidelines are unsuccessful in terminating a lethal dysrhythmia, the use of alternative strategies may prove useful. In this case, two defibrillators were used to deliver a greater than normal energy waveform over an extended time interval to return a patient to a normal sinus rhythm.

Case Report: A 56-year-old woman presented to the emergency department with complaints of chest pain, nausea, and vomiting. The patient's initial work-up, including an electrocardiogram and cardiac troponin, did not show evidence of acute ischemia, and she was admitted to the observation unit for further evaluation. While in the emergency department, the patient developed ventricular fibrillation, and ACLS was initiated. After four unsuccessful defibrillation attempts, a second defibrillator was placed on the patient, and the two were activated almost simultaneously. The patient had immediate return of spontaneous circulation, underwent cardiac catheterization, and was discharged home 1 week later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case shows that dual sequential defibrillation may be a successful method for terminating refractory ventricular fibrillation. Further investigation on cardiac resuscitation should be conducted to standardize the dual sequential defibrillation delivery procedure. Until such guidelines are established, physicians should take this treatment into consideration when standard ACLS measures have failed to successfully terminate refractory ventricular fibrillation.
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http://dx.doi.org/10.1016/j.jemermed.2016.05.024DOI Listing
September 2016

Lost in translation: Focused documentation improvement benefits trauma surgeons.

Injury 2016 Sep 24;47(9):1919-23. Epub 2016 Apr 24.

Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States. Electronic address:

Introduction: There is a translational gap between physicians who document in the medical record and coders, who ultimately determine which codes are submitted. This gap exists because physicians are never formally educated about documentation strategies despite the fact that the quality of physician documentation directly affects revenue, outcomes and public profiling. We evaluated the effect of a formal model of focused documentation improvement (FDI) on the trauma/critical care division. We hypothesized that FDI would improve physician documentation, resulting in revenue recovery and a shift in the case mix index (CMI) to more accurately reflect the clinical complexity of trauma patients.

Methods: FDI is defined as targeted physician education followed by concurrent inpatient chart review for documentation improvement opportunities by a clinical documentation specialist (CDS). All trauma surgeons (n=9) at our Level 1 trauma center first completed three hours of mandatory training on documentation improvement. A CDS was subsequently assigned to the trauma service. They reviewed the charts of Medicare patients (n=776) from January-December 2014 to identify opportunities for documentation improvement, participated in ICU rounds and provided ongoing education. Requests to clarify documentation (queries) were posted in the electronic medical record (EMR) and physicians were required to respond within 48h. Data was collected on physician response rate, CMI and revenue recovery.

Results: 411 of 776 (57%) charts were reviewed. Opportunities for FDI were identified in 177 (43%) cases. The physician response rate to queries was 100%. The CMI for reviewed cases increased (1.80 (SD 0.15) vs. 2.11 (SD 0.19); p<0.001) after FDI. Overall revenue recovery was $1,132,581 with an average of $154,092 in revenue recovery/clinical full time equivalent. The total cost for administration of FDI was $353,265 resulting in a 220% return on investment (ROI).

Conclusion: FDI is an effective strategy to engage physicians in documentation improvement. It provides an infrastructure to assist physicians and yields a significant ROI.
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http://dx.doi.org/10.1016/j.injury.2016.04.035DOI Listing
September 2016

Association Between Medicare Summary Star Ratings for Patient Experience and Clinical Outcomes in US Hospitals.

J Patient Exp 2016 Mar 7;3(1):6-9. Epub 2016 Apr 7.

Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA.

Objective: In 2015, the Centers for Medicare and Medicaid Services (CMS) released new summary star ratings for US hospitals based on patient experience. We aimed to test the association between CMS patient experience star ratings and clinical outcomes.

Methods: We analyzed risk-adjusted data for more than 3000 US hospitals from CMS Hospital Compare using linear regression.

Results: We found that better patient experience was associated with favorable clinical outcomes. Specifically, a higher number of stars for patient experience had a statistically significant association with lower rates of many in-hospital complications. A higher patient experience star rating also had a statistically significant association with lower rates of unplanned readmissions to the hospital within 30 days.

Conclusion: Better patient experience according to the CMS star ratings is associated with favorable clinical outcomes. These results support the inclusion of patient experience data in the framework of how hospitals are paid for services.
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http://dx.doi.org/10.1177/2374373516636681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513621PMC
March 2016

Purchase and use patterns of heroin users at an inner-city emergency department.

J Emerg Med 2012 Jan 30;42(1):93-9. Epub 2010 Aug 30.

Department of Emergency Medicine, University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School and Cooper University Hospital, Camden, New Jersey 08103, USA.

Background: Many consider heroin abuse a problem of the inner city, but suburban patients may also be at risk.

Objective: To characterize the demographics and purchase/use patterns of heroin users in an inner-city emergency department (ED).

Methods: The study was conducted in one of the most impoverished and crime-ridden cities in the United States. Demographics and substance use habits of ED patients were prospectively collected. Patients who were<18 years of age, cognitively impaired, or did not speak English were excluded. Participants were further categorized as homeless, inner-city, and suburban residents.

Results: Of 3947 participants, 608 (15%) used an illicit substance in the past year, with marijuana (9%) and cocaine (6%) the most commonly used. Heroin ranked third, used by 180 (5%) participants, with 61% male, 31% black, and 20% Hispanic. There were 64 homeless, 60 suburban, and 56 inner-city heroin users. The most common route of use was injection (68%), with the highest rate in the homeless (84%). The majority of homeless and inner-city users bought (73%, both groups) and used (homeless 74%, inner city 88%) in the inner city. Of suburban users, 58% purchased and 61% used heroin in the inner city. Prescription narcotic use was more common in homeless (20%) and suburban (23%) heroin users than in inner-city users (9%) (p<0.001).

Conclusions: Heroin is the third most commonly used illicit substance by ED patients, and a significant amount of inner-city purchase and use activity is conducted by suburban heroin users.
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http://dx.doi.org/10.1016/j.jemermed.2010.06.006DOI Listing
January 2012

Draw the line.

Pharos Alpha Omega Alpha Honor Med Soc 2003 ;66(2):32-4

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August 2003
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