No abstract

Background: Despite increasing interest in total joint arthroplasty registries, evidence of the impact of physician-level performance on the value of care provided to patients undergoing hip and knee arthroplasty is lacking. The purpose of this study was to examine the effectiveness of an unblinded orthopaedic surgeon-specific value scorecard in improving patient outcomes and reducing hospital costs. Methods: We retrospectively analyzed patient outcomes and hospital costs associated with total joint arthroplasties before and 9 months after the introduction of a Surgeon Value Scorecard at an urban tertiary care center. From August 2016 to May 2017, orthopaedic surgeons received an unblinded monthly Surgeon Value Scorecard summarizing a rolling 6-month view of results by surgeon for patients attributed to Diagnosis Related Group 470 (major lower-extremity arthroplasty without comorbidity or complication). Prior to implementation, surgeons were educated on the scorecard and participated in the development of a document outlining the definition and calculation of included metrics. Scorecard metrics were grouped into 5 categories: patient demographic characteristics, patient outcomes (for example, length of stay, discharge disposition, readmissions), patient experience, financial, and operational (for example, operative times). Financial (cost) measures and patient outcomes were selected as the key performance indicators analyzed in this study. Continuous variables were analyzed using the t test when a normal distribution was assumed and using Mann-Whitney tests when a non-normal distribution was assumed. Categorical variables were compared using chi-square tests. Significance was defined as p < 0.05. Results: After 9 months of unblinded Surgeon Value Scorecard distribution, the mean total costs for total joint arthroplasties decreased by 8.7%, from $17,996 to $16,426 (p < 0.001). The mean total direct variable costs decreased by 17.1% from $10,945 to $9,070 (p < 0.001), and implant costs decreased by 5.3% (p < 0.001). Length of stay also decreased by 0.2 day to 1.7 days (p < 0.001), and, although there was improvement in the home-discharge rate, 30-day readmission rate, and 90-day readmission rate, the differences were not significant (p > 0.05). Conclusions: The implementation of a surgeon-specific value scorecard for lower-extremity joint arthroplasties was associated with reduced total and direct variable hospital costs, reduced implant costs, decreased variation in costs, and reduced postoperative length of stay, without compromising clinical outcomes. Clinical Relevance: Sharing unblinded clinical and financial outcomes with surgeons may promote a culture of shared accountability and may empower surgeons to improve value-based decision-making in care delivery.

Aflatoxins are highly carcinogenic secondary metabolites that can contaminate approximately 25% of crops and that cause or exacerbate multiple adverse health conditions, especially in Sub-Saharan Africa and South and Southeast Asia. Regulation and decontamination of aflatoxins in high exposure areas is lacking. Biological detoxification methods are promising because they are assumed to be cheaper and more environmentally friendly compared to chemical alternatives. White-rot fungi produce non-specific enzymes that are known to degrade aflatoxin in in situ and ex situ experiments. The aims of this study were to (1) decontaminate aflatoxin B1 (AFB1) in naturally contaminated maize with the edible, white-rot fungus Pleurotus ostreatus (oyster mushroom) using a solid-state fermentation system that followed standard cultivation techniques, and to (2) and to assess the risk of mutagenicity in the resulting breakdown products and mushrooms. Vegetative growth and yield characteristics of P. ostreatus were not inhibited by the presence of AFB1. AFB1 was degraded by up to 94% by the Blue strain. No aflatoxin could be detected in P. ostreatus mushrooms produced from AFB1-contaminated maize. Moreover, the mutagenicity of breakdown products from the maize substrate, and reversion of breakdown products to the parent compound, were minimal. These results suggest that P. ostreatus significantly degrades AFB1 in naturally contaminated maize under standard cultivation techniques to levels that are acceptable for some livestock fodder, and that using P. ostreatus to bioconvert crops into mushrooms can reduce AFB1-related losses.