Toward Spanning the Quality Chasm: An Examination of Team Functioning Measures

Objective

To examine the effect of 5 measures of team functioning on patient outcomes.

Design

Observational, exploratory, measurement. Team functioning surveys and patient outcomes collected 1 year apart in a clinical trial were analyzed. The findings are discussed in context of the domains of team functioning, team effectiveness, and quality improvement.

Setting

27 Veterans Affairs medical centers.

Participants

Staff (t1: N=356; t2: N=273) on inpatient teams and patients (t1: N=4266; t2: N=3213) treated by the teams.

Interventions

Not applicable.

Main Outcome Measures

Five measures of team functioning (Physician Engagement, Shared Leadership, Supervisor Team Support, Teamness, and Team Effectiveness scales) and 3 measures of patient outcomes (functional improvement, discharge destination, and length of stay) were assessed at 2 time points with hierarchical generalized linear models to evaluate the association between team functioning measures and changes in patient outcomes.

Results

Associations (P<.05) between team functioning measures and patient outcomes were found for 3 of the 15 analyses over the study period. Higher Physician Engagement scale score was associated with lower length of stay (P=.017), and increased scores on Teamness and Team Effectiveness scales correlated with higher rates of community discharge (P=.044 and .049, respectively).

Conclusions

This exploratory analysis revealed trends that team functioning corresponds with patient outcomes in clinically relevant patterns. An increase in community discharge and a decrease in length of stay were associated with higher scores of team functioning. Here, we find evidence that modifiable attributes of team functioning have a measurable effect on patient outcomes. Such findings are promising and support the need for further research on team effectiveness.     

Definition of a third VLR gene in hagfish

Jawless vertebrates (cyclostomes) have an alternative adaptive immune system in which lymphocytes somatically diversify their variable lymphocyte receptors (VLR) through recombinatorial use of leucine-rich repeat cassettes during VLR gene assembly. Three types of these anticipatory receptors in lampreys (VLRA, VLRB, and VLRC) are expressed by separate lymphocyte lineages. However, only two VLR genes (VLRA and VLRB) have been found in hagfish. Here we have identified a third hagfish VLR, which undergoes somatic assembly to generate sufficient diversity to encode a large repertoire of anticipatory receptors. Sequence analysis, structural comparison, and phylogenetic analysis indicate that the unique hagfish VLR is the counterpart of lamprey VLRA and the previously identified hagfish “VLRA” is the lamprey VLRC counterpart. The demonstration of three orthologous VLR genes in both lampreys and hagfish suggests that this anticipatory receptor system evolved in a common ancestor of the two cyclostome lineages around 480 Mya.Phylogenetic studies of immunity indicate the emergence of two types of recombinatorial adaptive immune systems (AISs) in vertebrates (1, 2). All of the extant jawed vertebrates generate a vast repertoire of Ig-domain–based T- and B-cell antigen receptors primarily by the recombinatorial assembly of Ig V-(D)-J gene segments and somatic hypermutation (3). The extant jawless vertebrates, lampreys and hagfish, instead have an alternative AIS that is based on variable lymphocyte receptors (VLRs), the diversity of which is generated through recombinatorial use of leucine-rich repeat (LRR) cassettes (4–6). The germ-line VLR genes are incomplete in that they only contain coding sequences for the leader sequence, incomplete amino- and carboxyl-terminal LRR subunits (LRRNT and LRRCT) and the stalk region (4, 7, 8). However, each germ-line VLR gene is flanked by hundreds of different LRR-encoding sequences, which can be used as templates to add LRR sequences during the assembly of a mature VLR gene (4, 8–11). This gene conversion-like process is postulated to involve the activation-induced cytidine deaminase (AID) orthologs, cytidine deaminases 1 and 2 (CDA1 and CDA2) (8, 12). The combinatorial VLR assembly can generate a vast repertoire of anticipatory receptors comparable in diversity to the repertoire of Ig-domain–based antigen receptors in jawed vertebrates (8, 9).Three VLR genes have been identified in lampreys (VLRA, VLRB, and VLRC), but only two (VLRA and VLRB) have been identified so far in hagfish (4, 7, 8, 13). Lamprey VLRB-expressing cells can respond to immunization by undergoing lymphoblastoid transformation, clonal expansion, and secretion of their antigen-specific VLRB antibodies (9, 14). VLRA- and VLRC-bearing cells also proliferate in response to antigen stimulation, but do not differentiate into antibody secreting cells; instead they maintain cell surface expression of their receptors, while increasing the expression of proinflammatory cytokines, macrophage migration inhibitory factor (MIF), and interleukin-17 (IL-17) (12). CDA1-expressing progenitors assemble their VLRA and VLRC genes to become VLRA⁺ and VLRC⁺ lymphocytes in a thymus-equivalent region of the gills termed the thymoid (15, 16). Conversely, VLRB assembly coincides with CDA2 expression during VLRB⁺ lymphocyte development in hematopoietic tissues (15). The T- and B-like characteristics of the lamprey lymphocytes imply that jawless vertebrates have humoral and cellular arms of adaptive immunity comparable to those of jawed vertebrates.In the present study, we sought to determine whether or not hagfish have a third VLR gene. In comparing the sequences of the two known hagfish VLRs with those of the three lamprey VLRs, we noticed that the highly variable inserts in the LRRCT module of the currently designated hagfish “VLRA” are more similar to those of lamprey VLRC than to those of lamprey VLRA (13, 17, 18). This led us to hypothesize that a third hagfish VLR, if present, would be the true counterpart of lamprey VLRA. Through a similarity search against the hagfish database, we identified a fragment of a potential third VLR gene, which was in turn used to clone and sequence a previously uncharacterized VLR gene. Here, we report the characterization of this third VLR type in pacific hagfish (Eptatretus stoutii) and its phylogenetic and structural relationship with previously identified VLRs. Our findings suggest a modified nomenclature for the hagfish VLRs.     

Immediate Open Repair vs Surveillance in Patients with Small Abdominal Aortic Aneurysms: Survival Differences by Aneurysm Size

ObjectiveTo assess whether survival differences exist between patients undergoing immediate open repair vs surveillance with selective repair for 4.0- to 5.4-cm abdominal aortic aneurysms (AAAs) and whether these differences vary by diameter, within sexes, or overall.Patients and MethodsThe study cohort included 2226 patients randomized to immediate repair or surveillance for the UK Small Aneurysm Trial (September 1, 1991, through July 31, 1998; follow-up, 2.6-6.9 years) or the Aneurysm Detection and Management trial (August 1, 1992, through July 31, 2000; follow-up, 3.5-8.0 years). Survival differences were assessed with proportional hazard models, adjusted for a comprehensive array of clinical and nonclinical risk factors. Interaction between treatment and AAA size was added to the model to assess whether the effect of immediate open repair vs surveillance varied by AAA size.ResultsThe adjusted analysis revealed no statistically significant survival difference between immediate open repair and surveillance patients (hazard ratio [HR], 0.99; 95% CI, 0.83-1.18; mean follow-up time, 1921 days for both study groups). This lack of treatment effect persisted when men (HR, 1.01; 95% CI, 0.84-1.21) and women (HR, 0.96; 95% CI, 0.49-1.86) were examined separately and did not vary by AAA size (P=.39 for the entire cohort and P=.24 for women).ConclusionImmediate open repair offered no significant survival benefit, even in patients with the largest AAAs and highest risk of rupture. Because recent trials failed to find a survival benefit of immediate endovascular repair over surveillance for small asymptomatic AAAs, our findings suggest that the gray area of first-line management for these patients should be resolved in favor of surveillance.     

Effect of panel composition on physician ratings of appropriateness of abdominal aortic aneurysm surgery: elucidating differences between multispecialty panel results and specialty society recommendations

OBJECTIVE: To investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies. DATA SOURCES/STUDY SETTING: We examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery. STUDY DESIGN: The panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels' rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. PRINCIPAL FINDINGS: Of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons' rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties. CONCLUSIONS: statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies.     

Impact of Prostate-specific Antigen (PSA) Screening Trials and Revised PSA Screening Guidelines on Rates of Prostate Biopsy and Postbiopsy Complications

Background

Prostate biopsy and postbiopsy complications represent important risks of prostate-specific antigen (PSA) screening. Although landmark randomized trials and updated guidelines have challenged routine PSA screening, it is unclear whether these publications have affected rates of biopsy or postbiopsy complications.

Mycophenolate mofetil in pediatric renal transplantation

The use of mycophenolate mofetil (MMF) in adult renal transplantation has been associated with significantly decreased incidence of acute rejection. However, limited data are available for children after renal transplantation. A total of 67 patients undergoing renal transplantation at the University of Alabama at Birmingham, AL, USA and Children's Hospital of Boston, MA, USA were enrolled into the Cooperative Clinical Trials in Pediatric Transplantation randomized controlled trial of induction with OKT3 vs. i.v. cyclosporin A (CsA) at the time of transplantation. The first 31 patients entered were begun on azathioprine (AZA), 2 mg/kg on the first post-operative day. The subsequent 36 patients were begun on MMF, 1000 mg/m2/d. Other maintenance immunosuppression included oral CsA and Prednisone. Biopsy confirmation was obtained for all suspected rejection episodes. Glomerular filtration rate (GFR) was calculated using the Schwartz formula. Data were analyzed using Kaplan Meier survival curves and compared using log-rank tests. At the time of analysis, 52 patients (mean age 10.1 +/- 5 yr) had completed at least 12 months and 15 others had completed at least 6 months of follow-up post-transplantation. Of these, there were 39 male/28 female; 48 white/15 black/4 other; 49 living donor/18 cadaver donor. There were no significant differences in the incidence of rejection episodes, number of rejection episodes, the GFR at 6 and 12 months, allograft, or patient survival between patients receiving MMF vs. AZA. We could demonstrate no significant differences in these outcomes based on sex, race or induction therapy, leading to the conclusion that pediatric patients treated under a consistent protocol in two institutions have no improvement in short-term allograft outcome with the addition of MMF therapy.