Public Reporting of Cost and Quality Information in Orthopaedics

Background  

Public reporting of patient health outcomes offers the potential to incentivize quality improvement by fostering increased accountability among providers. Voluntary reporting of risk-adjusted outcomes in cardiac surgery, for example, is viewed as a “watershed event” in healthcare accountability. However, public reporting of outcomes, cost, and quality information in orthopaedic surgery remains limited by comparison, attributable in part to the lack of standard assessment methods and metrics, provider fear of inadequate adjustment of health outcomes for patient characteristics (risk adjustment), and historically weak market demand for this type of information.     

Pesticide mixtures, endocrine disruption, and amphibian declines: are we underestimating the impact?

Amphibian populations are declining globally at an alarming rate. Pesticides are among a number of proposed causes for these declines. Although a sizable database examining effects of pesticides on amphibians exists, the vast majority of these studies focus on toxicological effects (lethality, external malformations, etc.) at relatively high doses (parts per million). Very few studies focus on effects such as endocrine disruption at low concentrations. Further, most studies examine exposures to single chemicals only. The present study examined nine pesticides (four herbicides, two fungicides, and three insecticides) used on cornfields in the midwestern United States. Effects of each pesticide alone (0.1 ppb) or in combination were examined. In addition, we also examined atrazine and S-metolachlor combined (0.1 or 10 ppb each) and the commercial formulation Bicep II Magnum, which contains both of these herbicides. These two pesticides were examined in combination because they are persistent throughout the year in the wild. We examined larval growth and development, sex differentiation, and immune function in leopard frogs (Rana pipiens). In a follow-up study, we also examined the effects of the nine-compound mixture on plasma corticosterone levels in male African clawed frogs (Xenopus laevis). Although some of the pesticides individually inhibited larval growth and development, the pesticide mixtures had much greater effects. Larval growth and development were retarded, but most significantly, pesticide mixtures negated or reversed the typically positive correlation between time to metamorphosis and size at metamorphosis observed in controls: exposed larvae that took longer to metamorphose were smaller than their counterparts that metamorphosed earlier. The nine-pesticide mixture also induced damage to the thymus, resulting in immunosuppression and contraction of flavobacterial meningitis. The study in X. laevis revealed that these adverse effects may be due to an increase in plasma levels of the stress hormone corticosterone. Although it cannot be determined whether all the pesticides in the mixture contribute to these adverse effects or whether some pesticides are effectors, some are enhancers, and some are neutral, the present study revealed that estimating ecological risk and the impact of pesticides on amphibians using studies that examine only single pesticides at high concentrations may lead to gross underestimations of the role of pesticides in amphibian declines.     

Interprofessional teamwork in decentralized child welfare in The Netherlands: A comparison between the cities of Amsterdam and Utrecht

The recent transformation of child welfare in the Netherlands has improved opportunities for interprofessional working. We compared two models of teamworking within newly established interprofessional teams in the cities of Amsterdam and Utrecht, conducting a secondary analysis of semi-structured interviews collected through three broader research projects. Respondents include seventeen interprofessional team members (six from Utrecht, eleven from Amsterdam), representing a variety of teams across city, as well as two policymakers from Utrecht and one from Amsterdam. Team members were approached using convenience sampling, policymakers were purposively recruited. In different rounds of open and focused coding, we found that differences in team organization between the two cities have led to differences in the quality of interprofessional teamworking. Teamworking is best developed in Utrecht partly because team members are recruited and employed by a single organization. This has enabled a more careful process of selection and team composition than in Amsterdam, where a delegation approach entailed fragmentation as well as the risk of divided loyalty between team and mother organization. In addition, while the development of interprofessional teamwork in Utrecht is served by certain structures, teams in Amsterdam have suffered from an imbalance between freedom and structure, causing insecurity amongst staff and reduced chances of interprofessional integration. Despite the apparent success of the Utrecht model of interprofessional teamworking, interprofessional collaboration across team boundaries might suffer from the fact that teams in Utrecht, unlike in Amsterdam, do not comprise representatives of relevant partner organizations.     

Spontaneous retroperitoneal hematoma induced by vitamin K antagonist therapy: A case report

Vitamin K antagonists (VKA) are recommended in patients with mechanical heart valves. Major bleeding events remain the most life-threatening complication of this therapy and sometimes it can occur in unusual anatomic areas. Spontaneous retroperitoneal hematoma is one of the rare complications of anticoagulation therapy, which needs to be recognized early and managed promptly. Here, we report a case of a 40-year-old woman with mechanical heart valve treated with acenocoumarol, who was admitted to the emergency department with abdominal pain and whose investigations came back in favor of a massive retroperitoneal hematoma. The patient was successfully treated through conservative management resulting in a good outcome. Clinicians should be careful when prescribing VKA and should always think of retroperitoneal bleeding in the event of abdominal pain or a sudden decrease in the hemoglobin levels of anticoagulated patients.