The notion of “reverse innovation”--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries.
BACKGROUND: Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient’s care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in leading these discussions and may lack the necessary skill set. We created an innovative online video curriculum designed to teach these skills. This curriculum was compared to a traditional method of learning from reading the medical literature. METHODS: In this bi-institutional randomized controlled trial at 2 major academic medical centers, 60 anesthesiology trainees were randomized to receive the educational content in 1 of 2 formats: (1) the novel video curriculum (video group) or (2) journal articles (reading group). Thirty residents were assigned to the experimental video curriculum group, and 30 were assigned to the reading group. The content incorporated into the 2 formats focused on general preoperative evaluation of patients and communication strategies pertaining to GOC and CS discussions. Residents in both groups underwent a pre- and postintervention objective structured clinical examination (OSCE) with standardized patients. Both OSCEs were scored using the same 24-point rubric. Score changes between the 2 OSCEs were examined using linear regression, and interrater reliability was assessed using weighted Cohen’s kappa. RESULTS: Residents receiving the video curriculum performed significantly better overall on the OSCE encounter, with a mean score of 4.19 compared to 3.79 in the reading group. The video curriculum group also demonstrated statistically significant increased scores on 8 of 24 rubric categories when compared to the reading group. CONCLUSIONS: Our novel video curriculum led to significant increases in resident performance during simulated GOC discussions and modest increases during CS discussions. Further development and refinement of this curriculum are warranted.
Background Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists. Approach We evaluated all endorsed performance measures in the National Quality Forum (NQF), the clearing house for all federal performance measures, and classified all measures as follows: 1) anesthesia-specific; 2) surgery-specific; 3) jointly attributable; or 4) other. We used NQF-provided descriptors to characterize measures in terms of (1) structure, process, outcome or efficiency; (2) patients; disease and events targeted; (3) procedural specialty; (4) reporting eligibility; (5) measures stewards; and (6) timing in the care stream. National Quality Forum Measures Of the 637 endorsed performance measures, few (6, 1.0%) were anesthesia-specific. An additional 39 measures (6.1%) were surgery-specific, and 67 others (10.5%) were jointly attributable. “Anesthesia-specific” measures addressed preoperative antibiotic timing (n=4), normothermia (n=1), and protocol use for placement of central venous catheter (n=1). Jointly attributable measures included outcome measures (n=49/67, 73.1%) which were weighted towards mortality alone (n=24) and cardiac surgery (n=14). Other jointly attributable measures addressed orthopedic surgery (n=4), general surgical oncologic resections (n=12) or nonspecified surgeries (n=15), but none specifically addressed anesthesia care outside the operating room such as for endoscopy. Only 4 measures were eligible for value-based purchasing. No named anesthesiology professional groups were among measure stewards, but surgical professional groups (n=33/67, 47%) were frequent measure stewards. Summary and Ways Forward Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcomes-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented as well as procedural and sedation care provided in non-operating room settings.
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