University of Pennsylvania Health System

Low volume has been recognized as a problem when benchmarking hospitals due to outcome rate instability. We asked if low-volume hospital outcomes, using matching to control for many clinical and sociodemographic characteristics, would expose quality problems not observed with CMS methods. Matched cohort study. Grades derive from mortality differences between all patients at the low-volume hospital and their matched controls. Medicare patients admitted with Acute Myocardial Infarction, Heart Failure and Pneumonia in 78 low-volume Pennsylvania acute care hospitals (combined condition volume=75≤N≤750 for the 3y, 2017-2019), using Medicare's Virtual Research Data Center. Thirty-day mortality. Using matching, 10 of 78 reportable low-volume hospitals had significantly higher mortality versus matched typical controls and 16 low-volume hospitals displayed significantly higher mortality versus well-resourced controls. In contrast, Medicare reported that only 3 of these same 78 hospitals had significantly higher mortality than "the national rate" on AMI, HF, or pneumonia. We find that some low-volume hospitals performed well. Other low-volume hospitals had significantly worse outcomes than both well-resourced and typical hospitals; and some displayed significantly worse mortality compared with well-resourced controls but did not reach significant differences from typical controls. In short, performing "no different from the national rate," as is almost always reported for low-volume hospitals when using CMS methods, does not imply a low-volume hospital has acceptable outcomes. Reports based on matching can expose low-volume hospital quality problems not apparent using standard methods. Low-volume hospitals have more quality problems than generally reported.

To evaluate whether preoperative intravenous tranexamic acid (TXA) reduces postoperative blood transfusion rates in geriatric patients undergoing operative treatment for hip fracture. Design: Prospective, double-blinded, randomized controlled trial terminated early after interim futility analysis. Single-center Level I trauma center. Patients aged ≥65 years who underwent operative treatment for femoral neck (AO/OTA 31-B), intertrochanteric region (AO/OTA 31-A), or subtrochanteric (AO/OTA 32-A/B/C) fractures between June 2019 and June 2022 were included. Procedures included arthroplasty (hemiarthroplasty or total hip arthroplasty), and internal fixation (ORIF) with intramedullary nailing or sliding hip screw fixation. Exclusion criteria were recent thromboembolic events, cancer, hypercoagulable disorders, or TXA allergy. The primary outcome was postoperative transfusion. Secondary outcomes included hospital length of stay (HLOS), 30-day readmission, and 90-day complications and mortality. Statistical comparisons were performed using odds ratios, chi-squared, and t-tests, with significance thresholds adjusted by O'Brien-Fleming criteria. 283 patients were analyzed (TXA: 146 (mean age 84 (range 65-100), 71.9% female; Placebo: 137 (mean age 83.1 (range 65-100), 77.2% female). Baseline characteristics, including BMI and procedure type, were comparable (all p> 0.05). 229 patients (80.9%) required no postoperative transfusion (TXA 81%; Placebo: 81%, p=0.97). No significant differences were observed in 30-day readmission (p = 0.729), 90-day complications (p = 0.183), HLOS (p = 0.783), or 90-day mortality (p = 0.655). Subgroup analysis revealed higher transfusion rates in ORIF versus arthroplasty (ORIF 25%, Arthroplasty 8%, p < 0.05), though no difference between TXA and placebo within subgroups (p=0.38). Preoperative TXA was not associated with reduced transfusion requirements in geriatric hip fracture surgery. No significant differences were observed in complications, mortality, or hospital stay. Surgical procedure may influence transfusion risk more than TXA use. Level I.

Efficient distribution of scarce critical care resources is essential to save the most lives in times of crisis. Evidence-based practices and processes enhance clinical decision-making. The objective of these guidelines was to develop evidence-based, rather than expert-based, recommendations for triaging critically ill patients eligible for ICU admission during times of crisis-level shortages in ICU capacity. The American College of Critical Care Medicine Board convened a 21-member multidisciplinary panel, comprising doctors in medicine, nursing, and law; advanced practice providers; respiratory therapists; ethicists; and patient/family representatives. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including task force selection and voting. The panel members identified and formulated five fundamental Patient, Intervention, Comparator, and Outcomes questions. The panel conducted a systematic review for each question to identify the best available evidence, analyzed the evidence, and assessed the certainty of the evidence using the GRADE methodology. The GRADE evidence-to-decision framework was used to formulate the recommendations. Good practice statements were included to provide additional guidance. The panel generated one conditional recommendation and five no recommendation statements. Crisis-level shortages significantly disrupt patient care. Despite the role of triage in minimizing adverse outcomes, there is a lack of evidence, as opposed to expert opinion, to guide practice recommendations in the critical clinical scenarios considered by the panel.

Background:Brentuximab vedotin (BV) and polatuzumab vedotin (PV), CD30-specific and CD79b-specific monoclonal antibody conjugates, respectively, are used in the treatment of hematologic cancers. Both have been observed to cause gastrointestinal adverse events (GI AEs).Objectives:We aimed to assess the clinical characteristics, disease course, treatment, and outcomes of patients who developed GI AEs following treatment with BV or PV.Design:We retrospectively identified 879 adult cancer patients who received BV or PV therapy between March 1, 2016, and March 31, 2023, at our tertiary cancer center. Patients with alternate diagnoses were excluded.Methods:Clinical characteristics, management, and outcomes of GI AEs were retrospectively evaluated and statistically analyzed.Results:Sixty-four patients were included, and the median duration from therapy initiation to GI AE onset was 37 days. GI AEs occurred in the lower gastrointestinal tract (78%), upper gastrointestinal tract (45%), hepatobiliary system (11%), and pancreatic system (4.3%). Common symptoms were diarrhea (77%), nausea (61%), and abdominal pain (52%). Some patients had Common Terminology Criteria for Adverse Events grade ⩾3 toxicity (19% with diarrhea and 2.7% with colitis symptoms). Most patients (81%) received supportive care alone, and three received corticosteroids. Most patients (93%) achieved symptom resolution following treatment. Symptoms recurred in 37% of patients, and 41% of patients stopped BV/PV therapy due to GI AE.Conclusion:GI AEs following the use of targeted antibody–drug conjugates can involve various gastrointestinal systems. In our patient cohort who received BV or PV, GI AEs were typically low grade and managed with supportive care or corticosteroids. Nonetheless, some patients experienced high-grade AEs or symptom recurrence and stopped BV/PV therapy. Future studies may provide clarification and guide clinical practice.

For women in the United States desiring implant-based breast reconstruction, the maximum volume of commercially available silicone breast implants has, to date, been 800cc. We evaluated the safety of MENTOR® larger-size MemoryGel® Ultra-High Profile breast implants (≥930cc) in women undergoing postmastectomy breast reconstruction. This 10-year, multicenter, open-label, prospective, investigational study assessed the safety and effectiveness of larger-volume implants in women undergoing postmastectomy 2-stage primary or revision reconstruction. Three-year Kaplan-Meier curves and multivariable Cox regression analyzed the association between patient and treatment characteristics and surgical outcomes. Breast-Q was used to assess effectiveness at 3 years. Four hundred women were enrolled (225 primary, 175 revision reconstruction). Mean body mass index (BMI) was 35.8 kg/m2; 81% had a BMI ≥30 kg/m2. At 3 years, the cumulative incidence of postoperative complications (excluding rupture) was 63.0% (95% confidence interval [CI], 58.1-67.9). The reoperation rate was 24.5% (95% CI, 20.4-29.1), and the explantation rate was 15.8% (95% CI, 23.5-19.9). Independent predictors of complications included radiation and a history of smoking. There were no significant associations between postoperative complications and implant volume ≥1135cc or <1135cc. Breast-Q scores at Year 3 showed significant improvements from baseline in satisfaction with breasts, psychosocial well-being, sexual well-being, and physical well-being (all P<0.0001). The mean score for satisfaction with outcome was 79.9. These 3-year results demonstrate that larger-volume silicone breast implants represent a safe and effective option for patients with larger breasts who are requesting postmastectomy implant-based reconstruction.ClinicalTrials.gov Identifier: NCT02724371.

The HIMSS Nursing Innovation Advisory workgroup, formed in 2023, set out to address critical challenges in health care technology, including a lack of artificial intelligence literacy and accessible innovation resources for clinicians, aligning with national nursing and HIMSS strategic visions. This paper describes the development and evaluation of tools designed to improve AI readiness among nurses and informaticists, with a focus on identifying barriers in transitioning from informatics education to practice. An AI toolkit and innovation resources were developed by the workgroup and presented at an interactive Fishbowl session during HIMSS 2025. This is a descriptive report of an educational activity conducted at a professional conference where authors and presenters utilized discussion and poll questions to gauge perceived barriers in transitioning from informatics education to clinical practice and the usefulness of the tools. Out of 67 responses, 52% identified informatics competency as the primary gap in transitioning from education to practice. The session was well-received, with over 80% of attendees finding the content "very helpful" or "somewhat helpful," highlighting the value of the resources. These findings emphasize the need to update informatics curricula to better prepare graduates with essential digital and data literacy skills. The positive reception of the AI toolkit highlights its potential to bridge the gap between academic preparation and practical application, fostering the ethical integration of AI in health care. Continued learning, early adoption of innovations, advocating for change, and ensuring ethical AI practices are crucial next steps for clinicians and health care leaders.