Publications by authors named "Natalie B Riblet"

26 Publications

  • Page 1 of 1

Irregular hospital discharge from acute inpatient and residential mental health treatment settings in a large integrated healthcare system.

Gen Hosp Psychiatry 2021 Jun 26;72:7-14. Epub 2021 Jun 26.

Veterans Affairs Medical Center, 215 North Main Street, White River Junction, VT 05009, USA; Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA; National Center for PTSD, 215 North Main Street, White River Junction, VT 05009, USA. Electronic address:

Objective: Irregular discharge is a concern among mental health populations and associated with poor outcomes. Little is known about the relationship between irregular discharge and treatment setting. Because care processes differ between acute inpatient and residential settings, it is important to evaluate irregular discharge in these settings.

Method: A retrospective study was conducted in patients with mental health conditions admitted to acute inpatient or residential mental health settings in the Department of Veterans Affairs, 2003-2019. Logistic regression and multivariate Cox proportional hazards were used to evaluate factors associated with irregular discharge risk in the first 90- days of admission.

Results: Among 1.8 million discharges, 7.4% had an irregular discharge within 90- days of admission. Younger age was a central predictor of risk. Irregular discharge rates were four-fold higher in residential versus acute settings. When accounting for length of stay (LOS) across settings, there was a modest higher risk of irregular discharge from acute versus residential settings (HR = 1.06, 95% Confidence Interval 1.04-1.07).

Conclusions: Patients are at high risk for irregular discharge from acute and residential settings when they are young. LOS is an important determinant of irregular discharge risk.. Interventions are needed to address drivers of irregular discharge.
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http://dx.doi.org/10.1016/j.genhosppsych.2021.06.009DOI Listing
June 2021

Irregular hospital discharge from acute inpatient and residential mental health treatment settings in a large integrated healthcare system.

Gen Hosp Psychiatry 2021 Jun 26;72:7-14. Epub 2021 Jun 26.

Veterans Affairs Medical Center, 215 North Main Street, White River Junction, VT 05009, USA; Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA; National Center for PTSD, 215 North Main Street, White River Junction, VT 05009, USA. Electronic address:

Objective: Irregular discharge is a concern among mental health populations and associated with poor outcomes. Little is known about the relationship between irregular discharge and treatment setting. Because care processes differ between acute inpatient and residential settings, it is important to evaluate irregular discharge in these settings.

Method: A retrospective study was conducted in patients with mental health conditions admitted to acute inpatient or residential mental health settings in the Department of Veterans Affairs, 2003-2019. Logistic regression and multivariate Cox proportional hazards were used to evaluate factors associated with irregular discharge risk in the first 90- days of admission.

Results: Among 1.8 million discharges, 7.4% had an irregular discharge within 90- days of admission. Younger age was a central predictor of risk. Irregular discharge rates were four-fold higher in residential versus acute settings. When accounting for length of stay (LOS) across settings, there was a modest higher risk of irregular discharge from acute versus residential settings (HR = 1.06, 95% Confidence Interval 1.04-1.07).

Conclusions: Patients are at high risk for irregular discharge from acute and residential settings when they are young. LOS is an important determinant of irregular discharge risk.. Interventions are needed to address drivers of irregular discharge.
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http://dx.doi.org/10.1016/j.genhosppsych.2021.06.009DOI Listing
June 2021

Small Area Analysis of Veterans Affairs Mental Health Services Data.

Psychiatr Serv 2021 Apr 3;72(4):384-390. Epub 2021 Feb 3.

Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont.

Objective: To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment.

Methods: MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period.

Results: A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles.

Conclusions: MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.
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http://dx.doi.org/10.1176/appi.ps.202000130DOI Listing
April 2021

Longitudinal Examination of COVID-19 Public Health Measures on Mental Health for Rural Patients With Serious Mental Illness.

Mil Med 2020 Dec 30. Epub 2020 Dec 30.

Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA.

Introduction: There is emerging evidence to support that the COVID-19 pandemic and related public health measures may be associated with negative mental health sequelae. Rural populations in particular may fair worse because they share many unique characteristics that may put them at higher risk for adverse outcomes with the pandemic. Yet, rural populations may also be more resilient due to increased sense of community. Little is known about the impact of the pandemic on the mental health and well-being of a rural population pre- and post-pandemic, especially those with serious mental illness.

Material And Methods: We conducted a longitudinal, mixed-methods study with assessments preceding the pandemic (between October 2019 and March 2020) and during the stay-at-home orders (between April 23, 2020, and May 4, 2020). Changes in hopelessness, suicidal ideation, connectedness, and treatment engagement were assessed using a repeated-measures ANOVA or Friedman test.

Results: Among 17 eligible participants, 11 people were interviewed. Overall, there were no notable changes in any symptom scale in the first 3-5 months before the pandemic or during the stay-at-home orders. The few patients who reported worse symptoms were significantly older (mean age: 71.7 years, SD: 4.0). Most patients denied disruptions to treatment, and some perceived telepsychiatry as beneficial.

Conclusions: Rural patients with serious mental illness may be fairly resilient in the face of the COVID-19 pandemic when they have access to treatment and supports. Longer-term outcomes are needed in rural patients with serious mental illness to better understand the impact of the pandemic on this population.
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http://dx.doi.org/10.1093/milmed/usaa559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798823PMC
December 2020

Longitudinal Examination of COVID-19 Public Health Measures on Mental Health for Rural Patients With Serious Mental Illness.

Mil Med 2020 Dec 30. Epub 2020 Dec 30.

Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA.

Introduction: There is emerging evidence to support that the COVID-19 pandemic and related public health measures may be associated with negative mental health sequelae. Rural populations in particular may fair worse because they share many unique characteristics that may put them at higher risk for adverse outcomes with the pandemic. Yet, rural populations may also be more resilient due to increased sense of community. Little is known about the impact of the pandemic on the mental health and well-being of a rural population pre- and post-pandemic, especially those with serious mental illness.

Material And Methods: We conducted a longitudinal, mixed-methods study with assessments preceding the pandemic (between October 2019 and March 2020) and during the stay-at-home orders (between April 23, 2020, and May 4, 2020). Changes in hopelessness, suicidal ideation, connectedness, and treatment engagement were assessed using a repeated-measures ANOVA or Friedman test.

Results: Among 17 eligible participants, 11 people were interviewed. Overall, there were no notable changes in any symptom scale in the first 3-5 months before the pandemic or during the stay-at-home orders. The few patients who reported worse symptoms were significantly older (mean age: 71.7 years, SD: 4.0). Most patients denied disruptions to treatment, and some perceived telepsychiatry as beneficial.

Conclusions: Rural patients with serious mental illness may be fairly resilient in the face of the COVID-19 pandemic when they have access to treatment and supports. Longer-term outcomes are needed in rural patients with serious mental illness to better understand the impact of the pandemic on this population.
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http://dx.doi.org/10.1093/milmed/usaa559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798823PMC
December 2020

An analysis of the relationship between chronic obstructive pulmonary disease, smoking and depression in an integrated healthcare system.

Gen Hosp Psychiatry 2020 May - Jun;64:72-79. Epub 2020 Apr 4.

Veterans Affairs Medical Center, White River Junction, VT, USA; National Center for PTSD, White River Junction, VT, USA; Geisel School of Medicine at Dartmouth College, Hanover, NH, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA. Electronic address:

Objective: Chronic Obstructive Pulmonary Disease (COPD) and smoking are highly associated with depression and hypoxia. There is limited knowledge about whether hypoxic conditions interact to cause depression.

Method: A population-based cohort study was conducted using the Veterans Affairs (VA) Corporate Data Warehouse. Patients must have accessed any healthcare at a VA facility between 2004 and 2014 and had a negative depression screen (Patient Health Questionnaire-2 (PHQ-2) score ≤ 2). Patients with COPD or a positive depression screen (PHQ-2 score: 3+) during or prior to the year with a negative depression screen were excluded. Logistic regression with annual observations was used to evaluate depression incidence based on COPD and smoking status. Models were adjusted for demographics and other comorbid conditions. A probability scale was used to examine interactions between COPD and smoking.

Results: A total of 3,284,496 patients were included. Patients with COPD and current smokers were at increased risk for developing depression. There were minimal interaction effects between COPD and smoking. The odds of developing depression in a year varied from 1.4% among never smokers without COPD to 2.9.% among current smokers with COPD.

Conclusion: Smoking and COPD are independent risk factors for depression and interact to cause depression. Further research is needed to confirm whether hypoxia contributes to this association.
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http://dx.doi.org/10.1016/j.genhosppsych.2020.03.007DOI Listing
May 2021

A systematic review and meta-analysis of long-term reintervention after endovascular abdominal aortic aneurysm repair.

J Vasc Surg 2020 09 6;72(3):1122-1131. Epub 2020 Apr 6.

Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH.

Objective: Patients who undergo endovascular aneurysm repair (EVAR) often require reintervention after the index repair. The long-term rate of reintervention and how this has changed with newer device technology are poorly understood. Therefore, we performed a systematic review and meta-analysis of the available literature to determine long-term freedom from reintervention after EVAR and the change in reintervention rates over time.

Methods: We performed a systematic review of MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials and observational studies that documented the rate of reintervention after EVAR. We performed a meta-analysis of Kaplan-Meier freedom from reintervention at each year after EVAR. We used linear regression to evaluate change in reintervention rate over time with newer device technology.

Results: We included a total of 30 studies (randomized trials, n = 3; observational studies, n = 27) comprising 32,126 patients in this review and meta-analysis. Studies ranged in the implantation date of the EVAR device from 1996 to 2014. The probability of freedom from reintervention was 81% (95% confidence interval [CI], 77%-85%) at 5 years, 70% (95% CI, 65%-76%) at 10 years, and 64% (95% CI, 46%-79%) at 14 years. Linear regression demonstrated an improvement in freedom from reintervention when results were stratified by the year of device implantation. At 1 year, estimated freedom from reintervention improved from 90% in 1998 to 94% in 2008 (n = 26 studies; R = 0.11; P = .10). At three years, estimated freedom from reintervention improved from 77% in 1998 to 90% in 2008 (n = 26 studies; R = 0.27; P = .006). At 5 years, estimated freedom from reintervention improved from 68% in 1998 to 81% in 2008 (n = 22 studies; R =0.12; P = .12). At 7 years, estimated freedom from reintervention improved from 51% in 1998 to 86% in 2011 (n = 22 studies; R = 0.40; P = .015).

Conclusions: EVAR patients remain at risk for reintervention indefinitely, and therefore lifelong surveillance is imperative. Encouragingly, reintervention rates have improved over time, with newer devices exhibiting lower rates. Reintervention rate remains an important metric for new devices and registries.
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http://dx.doi.org/10.1016/j.jvs.2020.02.030DOI Listing
September 2020

Associations between Medication Assisted Therapy Services Delivery and Mortality in a National Cohort of Veterans with Posttraumatic Stress Disorder and Opioid Use Disorder.

J Dual Diagn 2020 Apr-Jun;16(2):228-238. Epub 2019 Dec 18.

Department of Mental Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.

Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years ( = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.
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http://dx.doi.org/10.1080/15504263.2019.1701218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192001PMC
May 2021

Associations between Medication Assisted Therapy Services Delivery and Mortality in a National Cohort of Veterans with Posttraumatic Stress Disorder and Opioid Use Disorder.

J Dual Diagn 2020 Apr-Jun;16(2):228-238. Epub 2019 Dec 18.

Department of Mental Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.

Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years ( = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.
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http://dx.doi.org/10.1080/15504263.2019.1701218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192001PMC
May 2021

Associations between Medication Assisted Therapy Services Delivery and Mortality in a National Cohort of Veterans with Posttraumatic Stress Disorder and Opioid Use Disorder.

J Dual Diagn 2020 Apr-Jun;16(2):228-238. Epub 2019 Dec 18.

Department of Mental Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.

Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years ( = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.
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http://dx.doi.org/10.1080/15504263.2019.1701218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192001PMC
May 2021

Causes of Excess Mortality in Veterans Treated for Posttraumatic Stress Disorder.

Am J Prev Med 2019 08 24;57(2):145-152. Epub 2019 Jun 24.

Veterans Affairs Medical Center, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine, Hanover, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; National Center for Posttraumatic Stress Disorder, White River Junction, Vermont.

Introduction: Published research indicates that posttraumatic stress disorder (PTSD) is associated with increased mortality. However, causes of death among treatment-seeking patients with PTSD remain poorly characterized. The study objective was to describe causes of death among Veterans with PTSD to inform preventive interventions for this treatment population.

Methods: A retrospective cohort study was conducted for all Veterans who initiated PTSD treatment at any Department of Veterans Affairs Medical Center from fiscal year 2008 to 2013. The primary outcome was mortality within the first year after treatment initiation. In 2018, collected data were analyzed to determine leading causes of death. For the top ten causes, standardized mortality ratios (SMRs) were calculated from age- and sex-matched mortality tables of the U.S. general population.

Results: A total of 491,040 Veterans were identified who initiated PTSD treatment. Mean age was 48.5 (±16.0) years, 90.7% were male, and 63.5% were of white race. In the year following treatment initiation, 1.1% (5,215/491,040) died. All-cause mortality was significantly higher for Veterans with PTSD compared with the U.S. population (SMR=1.05, 95% CI=1.02, 1.08, p<0.001). Veterans with PTSD had a significant increase in mortality from suicide (SMR=2.52, 95% CI=2.24, 2.82, p<0.001), accidental injury (SMR=1.99, 95% CI=1.83, 2.16, p<0.001), and viral hepatitis (SMR=2.26, 95% CI=1.68, 2.93, p<0.001) versus the U.S.

Population: Of those dying from accidental injury, more than half died of poisoning (52.3%, 325/622).

Conclusions: Veterans with PTSD have an elevated risk of death from suicide, accidental injury, and viral hepatitis. Preventive interventions should target these important causes of death.
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http://dx.doi.org/10.1016/j.amepre.2019.03.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6642830PMC
August 2019

The Durability of Active Surveillance in Patients with Asymptomatic Kidney Stones: A Systematic Review.

J Endourol 2019 07 7;33(7):598-605. Epub 2019 Jun 7.

1 The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.

The natural progression of asymptomatic kidney stones remains unclear. Such knowledge may promote value-aligned care for patients and reduce potentially unnecessary procedures. We sought to evaluate the natural history of asymptomatic kidney stones in adults undergoing active surveillance. Using themes of "Kidney Stone" and "Active Surveillance," we performed a systematic review by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, Cumulative Index to Nursing and Allied Health Literature, BIOSIS, Scopus, and Web of Science from inception through October 2017-in addition to ClinicalTrials.gov, American Urological Association Annual Meeting abstracts (2014-2017), Google Scholar, and references of included studies and prior reviews. Two blinded reviewers independently extracted data and assessed methodological quality. We qualitatively summarized rates of surgical intervention (primary outcome), spontaneous stone passage, symptom development, and stone growth. We assessed the relationship between surveillance duration and rate of surgical intervention with Pearson's correlation coefficient. Of 7034 unique records, 13 studies met final eligibility criteria. There was substantial variation in reported rates of surgical intervention from 6/85 (7.1%) to 80/301 (26.6%), spontaneous stone passage from 1/32 (3.1%) to 101/347 (29.1%), symptom development from 7/96 (7.3%) to 231/300 (77.0%), and stone growth from 5/96 (5.2%) to 33/50 (66.0%). Mean surveillance duration spanned from 11.3 to 80 months (range 2-180 months). Longer mean duration of surveillance did not correlate with an increase in surgical intervention rate across studies ( = 13,  = 0.01,  = 0.98), and this finding persisted when restricting analysis to observational studies ( = 9,  = 0.12,  = 0.76). Active surveillance appears to be a durable strategy for a majority of patients with asymptomatic kidney stones, as there was no increase in failure of watchful waiting despite increasing duration of surveillance. Higher quality studies are needed to ascertain which patients may benefit most from active surveillance.
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http://dx.doi.org/10.1089/end.2018.0695DOI Listing
July 2019

The Durability of Active Surveillance in Patients with Asymptomatic Kidney Stones: A Systematic Review.

J Endourol 2019 07 7;33(7):598-605. Epub 2019 Jun 7.

1 The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.

The natural progression of asymptomatic kidney stones remains unclear. Such knowledge may promote value-aligned care for patients and reduce potentially unnecessary procedures. We sought to evaluate the natural history of asymptomatic kidney stones in adults undergoing active surveillance. Using themes of "Kidney Stone" and "Active Surveillance," we performed a systematic review by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, Cumulative Index to Nursing and Allied Health Literature, BIOSIS, Scopus, and Web of Science from inception through October 2017-in addition to ClinicalTrials.gov, American Urological Association Annual Meeting abstracts (2014-2017), Google Scholar, and references of included studies and prior reviews. Two blinded reviewers independently extracted data and assessed methodological quality. We qualitatively summarized rates of surgical intervention (primary outcome), spontaneous stone passage, symptom development, and stone growth. We assessed the relationship between surveillance duration and rate of surgical intervention with Pearson's correlation coefficient. Of 7034 unique records, 13 studies met final eligibility criteria. There was substantial variation in reported rates of surgical intervention from 6/85 (7.1%) to 80/301 (26.6%), spontaneous stone passage from 1/32 (3.1%) to 101/347 (29.1%), symptom development from 7/96 (7.3%) to 231/300 (77.0%), and stone growth from 5/96 (5.2%) to 33/50 (66.0%). Mean surveillance duration spanned from 11.3 to 80 months (range 2-180 months). Longer mean duration of surveillance did not correlate with an increase in surgical intervention rate across studies ( = 13,  = 0.01,  = 0.98), and this finding persisted when restricting analysis to observational studies ( = 9,  = 0.12,  = 0.76). Active surveillance appears to be a durable strategy for a majority of patients with asymptomatic kidney stones, as there was no increase in failure of watchful waiting despite increasing duration of surveillance. Higher quality studies are needed to ascertain which patients may benefit most from active surveillance.
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http://dx.doi.org/10.1089/end.2018.0695DOI Listing
July 2019

The Durability of Active Surveillance in Patients with Asymptomatic Kidney Stones: A Systematic Review.

J Endourol 2019 07 7;33(7):598-605. Epub 2019 Jun 7.

1 The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.

The natural progression of asymptomatic kidney stones remains unclear. Such knowledge may promote value-aligned care for patients and reduce potentially unnecessary procedures. We sought to evaluate the natural history of asymptomatic kidney stones in adults undergoing active surveillance. Using themes of "Kidney Stone" and "Active Surveillance," we performed a systematic review by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, Cumulative Index to Nursing and Allied Health Literature, BIOSIS, Scopus, and Web of Science from inception through October 2017-in addition to ClinicalTrials.gov, American Urological Association Annual Meeting abstracts (2014-2017), Google Scholar, and references of included studies and prior reviews. Two blinded reviewers independently extracted data and assessed methodological quality. We qualitatively summarized rates of surgical intervention (primary outcome), spontaneous stone passage, symptom development, and stone growth. We assessed the relationship between surveillance duration and rate of surgical intervention with Pearson's correlation coefficient. Of 7034 unique records, 13 studies met final eligibility criteria. There was substantial variation in reported rates of surgical intervention from 6/85 (7.1%) to 80/301 (26.6%), spontaneous stone passage from 1/32 (3.1%) to 101/347 (29.1%), symptom development from 7/96 (7.3%) to 231/300 (77.0%), and stone growth from 5/96 (5.2%) to 33/50 (66.0%). Mean surveillance duration spanned from 11.3 to 80 months (range 2-180 months). Longer mean duration of surveillance did not correlate with an increase in surgical intervention rate across studies ( = 13,  = 0.01,  = 0.98), and this finding persisted when restricting analysis to observational studies ( = 9,  = 0.12,  = 0.76). Active surveillance appears to be a durable strategy for a majority of patients with asymptomatic kidney stones, as there was no increase in failure of watchful waiting despite increasing duration of surveillance. Higher quality studies are needed to ascertain which patients may benefit most from active surveillance.
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http://dx.doi.org/10.1089/end.2018.0695DOI Listing
July 2019

The effect of preoperative penicillin allergy testing on perioperative non-beta-lactam antibiotic use: A systematic review and meta-analysis.

Allergy Asthma Proc 2018 Nov;39(6):420-429

From Education Division, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.

The majority of patients for elective surgery and with a history of penicillin allergy are placed on alternative prophylactic antibiotic therapies, which have been associated with the emergence of multidrug-resistant pathogens and increased morbidity and mortality rates. However, self-reporting of penicillin allergy alone may overestimate the prevalence of penicillin allergy in the population. To assess the effects of preoperative antibiotic allergy testing protocols in reducing the use of non-beta-lactam antibiotics. We searched medical literature data bases through July of 2018. Two reviewers independently extracted data from published studies and assessed the risk of bias in cohort studies by using the Newcastle-Ottawa Scale. We collected information related to study design, methodology, demographics, interventions, and outcomes. We pooled odds ratios for the rate of prescribing non-beta-lactam antibiotics by using a fixed-effects model. Of 905 citations screened for eligibility, nine studies met inclusion criteria for qualitative analysis. Studies reported that the rates of non-beta-lactam use after preoperative skin testing ranged from 6 to 30%. In addition, four of the nine studies had sufficient control data to be included in a meta-analysis. These four studies found that preoperative testing protocols significantly decreased the rates of prescribing non-beta-lactam antibiotics compared with usual care (odds ratio 3.64 [95% confidence interval, 2.67-4.98]; < 0.0001). Seven studies reported on adverse drug reactions after preoperative skin testing and found that the rate of such reactions was rare. Preoperative antibiotic allergy testing protocols seemed to be a safe and effective tool in reducing the use of non-beta-lactam antibiotics during surgery.
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http://dx.doi.org/10.2500/aap.2018.39.4178DOI Listing
November 2018

Use of Iterative Cycles in Quality Improvement Projects in Imaging: A Systematic Review.

J Am Coll Radiol 2018 Nov 1;15(11):1587-1602. Epub 2018 Sep 1.

Department of Radiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.

Purpose: Studies suggest that quality improvement (QI) projects in health care lack scientific rigor, but the actual frequency of use of proven scientific QI methodology is unknown. The purposes of this study are to (1) conduct a systematic review of QI projects in radiology journals on the frequency of use of iterative cycles, a marker of proven QI methodology, and (2) assess association of the use of iterative cycles with characteristics of these projects.

Materials And Methods: We searched English-language radiology journals on MEDLINE between 2008 and 2015 for published QI studies. Three reviewers appraised studies and extracted data. Use of iterative cycles was identified, and results were summarized qualitatively. χ Analysis evaluated associations of iterative cycles with other data elements.

Results: Of 3,134 potentially eligible citations, 44 studies met inclusion criteria. Only 46% of these used iterative cycles to refine intervention. Use of iterative cycles were associated with projects designed to improve process, QI expert support, reporting of unintended effect of intervention, and explicitly stated use of iterative cycles. General lack of scientific rigor was represented by failure to report baseline data (9%), describe unintended effects (66%), and discuss limitations (36%).

Conclusions: Our systematic review found fewer than half of the QI projects in radiology journals used iterative cycles to refine intervention, a scientific strategy central to many proven improvement methodologies. Use of iterative approach was associated with projects designed to improve processes, QI expert support, report of unintended effect, and explicitly stated use of iterative cycles.
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http://dx.doi.org/10.1016/j.jacr.2018.06.007DOI Listing
November 2018

Electronic Medical Record Reporting Enhances Proactive Psychiatric Consultation.

Psychosomatics 2018 11 17;59(6):561-566. Epub 2018 May 17.

Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, NH.

Background: Numerous studies have demonstrated that psychiatric and substance use issues in general hospital inpatients result in increased length of stay and associated costs. Additional studies have demonstrated that proactive consultation models in psychiatry can effectively address these problems. Selecting patients for proactive interventions is less well studied.

Objective: We sought to develop an automated, electronic medical record-based screening tool to select patients who might benefit from proactive psychiatric consultation.

Methods: An automated daily report was developed using information stored in electronic medical record and billing systems. Discrete data fields populating the report included diagnoses, orders, and nursing care plans.

Results: Over a 9-month period, the report identified 2177 patients (19% of the total nonpsychiatric adult admissions) as potentially benefitting from proactive psychiatric interventions. Of these, 367 were confirmed as likely to benefit from intervention; 139 (38%) were randomized to the proactive psychiatric consultation group. Of those patients randomized to "treatment as usual," a subset later required psychiatric consultation, which was requested an average of 4 days after the time they were flagged by the report.

Conclusions: The use of an electronic medical record-based automated report is feasible to select patients for proactive psychiatric interventions on admission and throughout the hospital stay. Early identification of patients may decrease length of stay and improve patient outcomes.
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http://dx.doi.org/10.1016/j.psym.2018.05.002DOI Listing
November 2018

Postoperative prophylactic antibiotics for facial fractures: A systematic review and meta-analysis.

Laryngoscope 2019 01 14;129(1):82-95. Epub 2018 May 14.

Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.

Objective: Perioperative antibiotic prophylaxis in patients undergoing surgery for maxillofacial fractures is standard practice. However, the use of postoperative antibiotic prophylaxis remains controversial. This systematic review and meta-analysis sought to evaluate the effect of postoperative antibiotic therapy on the incidence of surgical site infection (SSI) in patients with maxillofacial fractures.

Methods: MEDLINE, Embase, and the Cochrane Library were searched from inception through October 2017. Randomized controlled trials (RCTs) and cohort studies evaluating the efficacy of pre-, peri-, and postoperative antibiotic prophylaxis in preventing SSI in maxillofacial fractures were included. Data were extracted from studies using a standardized data collection form, with two reviewers independently performing extraction and quality assessment for each study. Risk ratios (RRs) for SSI were pooled using a random-effects model.

Results: Among 2,150 potentially eligible citations, 13 studies met inclusion criteria and provided data to be included in a meta-analysis. The addition of postoperative antibiotic prophylaxis to a standard preoperative and/or perioperative antibiotic regimen showed no significant difference in the risk of SSI (RR = 1.11 [95% CI: 0.86-1.44], P > .1). There were also no differences in the risk of SSI when restricting the analysis to mandibular fractures (eight studies, RR = 1.22 [95% CI: 0.92-1.62]) or open surgical techniques (eight studies, RR = 1.02 [95% CI: 0.62-1.67]). A sensitivity analysis did not find any significant differences in risk when restricting to RCTs (seven trials, RR = 1.00 [95% CI: 0.61-1.67]) or cohort studies (six studies, RR = 1.21 [95% CI: 0.89-1.63]).

Conclusions: Our findings, along with the available evidence, does not support the routine use of postoperative antibiotic prophylaxis in patients with maxillofacial fractures. Avoiding the unnecessary use of antibiotic therapy in the postoperative period could have important implications for healthcare costs and patient outcomes. Laryngoscope, 129:82-95, 2019.
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http://dx.doi.org/10.1002/lary.27210DOI Listing
January 2019

Authors' reply.

Br J Psychiatry 2017 12;211(6):396-397

Natalie B. V. Riblet, Brian Shiner, Veterans Affairs Medical Center, white River Junction, Vermont, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire; Bradley V. Watts, Veterans Affairs Medical Center, white River Junction, Vermont, and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA. Email:

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http://dx.doi.org/10.1192/bjp.211.6.396aDOI Listing
December 2017

Response to: "Aspirin Therapy on Blood Transfusion in Noncardiac Surgery: Evidence From Quality Effect Model".

Ann Surg 2018 08;268(2):e33

VA Outcomes Group, Veterans Health Administration, White River Junction, VT; VA Quality Scholars, Veterans Health, Administration, White River Junction, VT The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

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http://dx.doi.org/10.1097/SLA.0000000000002453DOI Listing
August 2018

A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery.

Ann Surg 2018 Jan;267(1):1-10

Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Objective: The aim of this study was to determine the bleeding risks associated with single (aspirin) and dual (aspirin + clopidogrel) antiplatelet therapy (DAPT) versus placebo or no treatment in adults undergoing noncardiac surgery.

Summary Of Background Data: The impact of antiplatelet therapy on bleeding during noncardiac surgery remains controversial. A meta-analysis was performed to examine the risk associated with single and DAPT.

Methods: A systematic review of antiplatelet therapy, noncardiac surgery, and perioperative bleeding was performed. Peer-reviewed sources and meeting abstracts from relevant societies were queried. Studies without a control group, or those that only examined patients with coronary stents, were excluded. Primary endpoints were transfusion and reintervention for bleeding.

Results: Of 11,592 references, 46 studies met inclusion criteria. In a meta-analysis of >30,000 patients, the relative risk (RR) of transfusion versus control was 1.14 [95% confidence interval (CI) 1.03-1.26, P = 0.009] for aspirin, and 1.33 (1.15-1.55, P = 0.001) for DAPT. Clopidogrel had an elevated risk, but data were too heterogeneous to analyze. The RR of bleeding requiring reintervention was not significantly higher for any agent compared to control [RR 0.96 (0.76-1.22, P = 0.76) for aspirin, 1.84 (0.87-3.87, P = 0.11) for clopidogrel, and 1.51 (0.92-2.49, P = 0.1) for DAPT]. Subanalysis of thoracic and abdominal procedures was similar. There was no difference in RR for myocardial infarction [1.06 (0.79-1.43)], stroke [0.97 (0.71-1.33)], or mortality [0.97 (0.87-1.1)].

Conclusions: Antiplatelet therapy at the time of noncardiac surgery confers minimal bleeding risk with no difference in thrombotic complications. In many cases, it is safe to continue antiplatelet therapy in patients with important indications for their use.
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http://dx.doi.org/10.1097/SLA.0000000000002279DOI Listing
January 2018

A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery.

Ann Surg 2018 Jan;267(1):1-10

Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Objective: The aim of this study was to determine the bleeding risks associated with single (aspirin) and dual (aspirin + clopidogrel) antiplatelet therapy (DAPT) versus placebo or no treatment in adults undergoing noncardiac surgery.

Summary Of Background Data: The impact of antiplatelet therapy on bleeding during noncardiac surgery remains controversial. A meta-analysis was performed to examine the risk associated with single and DAPT.

Methods: A systematic review of antiplatelet therapy, noncardiac surgery, and perioperative bleeding was performed. Peer-reviewed sources and meeting abstracts from relevant societies were queried. Studies without a control group, or those that only examined patients with coronary stents, were excluded. Primary endpoints were transfusion and reintervention for bleeding.

Results: Of 11,592 references, 46 studies met inclusion criteria. In a meta-analysis of >30,000 patients, the relative risk (RR) of transfusion versus control was 1.14 [95% confidence interval (CI) 1.03-1.26, P = 0.009] for aspirin, and 1.33 (1.15-1.55, P = 0.001) for DAPT. Clopidogrel had an elevated risk, but data were too heterogeneous to analyze. The RR of bleeding requiring reintervention was not significantly higher for any agent compared to control [RR 0.96 (0.76-1.22, P = 0.76) for aspirin, 1.84 (0.87-3.87, P = 0.11) for clopidogrel, and 1.51 (0.92-2.49, P = 0.1) for DAPT]. Subanalysis of thoracic and abdominal procedures was similar. There was no difference in RR for myocardial infarction [1.06 (0.79-1.43)], stroke [0.97 (0.71-1.33)], or mortality [0.97 (0.87-1.1)].

Conclusions: Antiplatelet therapy at the time of noncardiac surgery confers minimal bleeding risk with no difference in thrombotic complications. In many cases, it is safe to continue antiplatelet therapy in patients with important indications for their use.
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http://dx.doi.org/10.1097/SLA.0000000000002279DOI Listing
January 2018

A clinical care pathway to improve the acute care of patients with glioma.

Neurooncol Pract 2016 Sep 23;3(3):145-153. Epub 2015 Oct 23.

Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756 (E.M.S., J.A.S., L.R., K.T., M.D., J.H., L.P.M., T.J.C., L.J., N.L.K., S.R., D.N., C.E.F.); Norris Cotton Cancer Center, 1 Medical Center Drive, Lebanon, NH 03756 (M.D., J.S., L.R., L.M., L.J., S.R., D.N., C.F.); Geisel School of Medicine at Dartmouth, 1 Rope Ferry Drive, Hanover, NH 03755 (N.B.V.R., L.R., C.F.); VA Medical Center, 215 North Main Street, White River Junction VT 05009 (N.B.V.R.).

Background: Patients with glioma are at increased risk for tumor-related and treatment-related complications. Few guidelines exist to manage complications through supportive care. Our prior work suggests that a clinical care pathway can improve the care of patients with glioma.

Methods: We designed a quality improvement (QI) project to address the acute care needs of patients with gliomas. We formed a multidisciplinary team and selected 20 best-practice measures from the literature. Using a plan-do-study-act framework, we brainstormed and implemented various improvement strategies starting in October 2013. Statistical process control charts were used to assess progress.

Results: Retrospective data were available for 12 best practice measures. The baseline population consisted of 98 patients with glioma. Record review suggested wide variation in performance, with compliance ranging from 30% to 100%. The team hypothesized that lack of process standardization may contribute to less-than-ideal performance. After implementing improvement strategies, we reviewed the records of 63 consecutive patients with glioma. The proportion of patients meeting criteria for 12 practice measures modestly improved (65% pre-QI; 76% post-QI, > .1). Unexpectedly, a higher proportion of patients were readmitted within 30 days of hospital discharge (pre-QI: 10%; post-QI: 17%, > .1). Barriers to pathway development included difficulties with transforming manual measures into electronic data sets.

Conclusions: Creating evidence-based clinical care pathways for addressing the acute care needs of patients with glioma is feasible and important. There are many challenges, however, to developing sustainable systems for measuring and reporting performance outcomes overtime.
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http://dx.doi.org/10.1093/nop/npv050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668280PMC
September 2016

Transitioning to Academic Quality-Improvement Work Within the Field of Oncology: Opportunities and Challenges.

J Oncol Pract 2016 10;12(10):855-858

Veterans Affairs Medical Center, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover; and The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.

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http://dx.doi.org/10.1200/JOP.2016.013193DOI Listing
October 2016

Association between serum thyroid-stimulating hormone levels and serum lipids in children and adolescents: a population-based study of german youth.

J Clin Endocrinol Metab 2015 May 17;100(5):2090-7. Epub 2015 Mar 17.

Institute for Community Medicine (T.W., T.I., H.V.), University of Greifswald, 17487 Greifswald, Germany; Robert Koch Institute (M.T.), 13353 Berlin, Germany; and Veterans Affairs Medical Center (N.B.V.R.), White River Junction, Vermont 05009.

Context: No studies have examined the association between TSH and lipid profiles of healthy children and adolescents in the general population.

Objective: The objective was to investigate the association between TSH and lipid profiles.

Design: We used a population-based cross-sectional study design and analyzed our results using multivariable regression models.

Setting: The study was conducted in Germany.

Participants: We analyzed data from 6622 children (ages 3-10 y) and 6134 adolescents (ages 11-17 y) drawn from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS).

Intervention: Not applicable.

Main Outcome Measures: Blood samples were collected, and serum TSH levels were measured using the electrochemiluminescence method. High and low serum TSH levels were defined according to age-specific reference limits for the assay. Total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride levels were determined with enzymatic color analyses.

Results: We found a significant positive association between TSH and all non-HDL parameters (total cholesterol, LDL-C, and triglycerides) in children (β = 0.90, 95% confidence interval [CI], 0.53-1.27; β = 0.78, 95% CI, 0.44-1.13; and β = 0.90, 95% CI, 0.52-1.27, respectively) and in adolescents (β = 0.90, 95% CI, 0.47-1.32; β = 0.67, 95% CI, 0.29-1.05; and β = 0.92, 95% CI, 0.49-1.35, respectively) (P < .05). Using stratified models, we found that this relationship was particularly present in overweight/obese children. Furthermore, high TSH levels in children were significantly associated with non-HDL parameters.

Conclusions: Higher TSH levels are associated with less favorable lipid levels in children. Longitudinal studies are needed to clarify whether the association between TSH and lipid parameters in children and adolescents is a temporary phenomenon or is sustained into adulthood.
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http://dx.doi.org/10.1210/jc.2014-4466DOI Listing
May 2015

Improving the quality of care for patients diagnosed with glioma during the perioperative period.

J Oncol Pract 2014 Nov 7;10(6):365-70. Epub 2014 Oct 7.

Dartmouth-Hitchcock Medical Center; Norris Cotton Cancer Center; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon; and Geisel School of Medicine, Hanover, NH

Purpose: Although there is agreement on the oncologic management of patients with glioma, few guidelines exist to standardize other aspects of care, including supportive care.

Methods: A quality improvement (QI) project was chartered to improve the care provided to patients with glioma. A multidisciplinary team was convened and identified 10 best-practice measures. Using a plan-do-study-act framework, the team brainstormed and implemented various improvement interventions between June 2011 and October 2012. Statistical process control charts were used to evaluate progress. A dashboard of quality measures was generated to allow for ongoing measurement and reporting.

Results: The retrospective assessment phase consisted of 43 patients with diagnosis of glioma. A manual medical record review for these patients showed that compliance with 10 best-practice measures ranged from 23% to 100%. Several factors contributed to less-than-ideal process performance, including poor communication among disciplines and lack of familiarity with the larger system of care. After implementing improvement interventions, performance was measured in 96 consecutive patients with glioma. The proportion of patients who met criteria for 10 practice measures significantly improved (pre-QI work, 63%; post-QI work, 85%; P = .003). The largest improvement was observed in the measure assessing for preoperative notification of the neuro-oncology program (pre-QI work, 39%; post-QI work, 97%; P < .001).

Conclusion: QI principles were used by a multidisciplinary team to improve the quality of care for patients with glioma during the perioperative period. Leadership involvement, ongoing dialogue across departments, and reporting of system performance were important for sustaining process improvements.
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http://dx.doi.org/10.1200/JOP.2014.001556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706136PMC
November 2014
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