Designing and Implementation of a Digitalized Intersectoral Discharge Management System and Its Effect on Readmissions: Mixed Methods Approach

BACKGROUND

Digital transformation offers new opportunities to improve the exchange of information between different health care providers, including inpatient, outpatient and care facilities. As information is especially at risk of being lost when a patient is discharged from a hospital, digital transformation offers great opportunities to improve intersectoral discharge management. However, most strategies for improvement have focused on structures within the hospital.

OBJECTIVE

This study aims to evaluate the implementation of a digitalized discharge management system, the project "Optimizing instersectoral discharge management" (SEKMA, derived from the German Sektorübergreifende Optimierung des Entlassmanagements), and its impact on the readmission rate.

METHODS

A mixed methods design was used to evaluate the implementation of a digitalized discharge management system and its impact on the readmission rate. After the implementation, the congruence between the planned (logic model) and the actual intervention was evaluated using a fidelity analysis. Finally, bivariate and multivariate analyses were used to evaluate the effectiveness of the implementation on the readmission rate. For this purpose, a difference-in-difference approach was adopted based on routine data of hospital admissions between April 2019 and August 2019 and between April 2022 and August 2022. The department of vascular surgery served as the intervention group, in which the optimized discharge management was implemented in April 2022. The departments of internal medicine and cardiology formed the control group.

RESULTS

Overall, 26 interviews were conducted, and we explored 21 determinants, which can be categorized into 3 groups: "optimization potential," "barriers," and "enablers." On the basis of these results, 19 strategies were developed to address the determinants, including a lack of networking among health care providers, digital information transmission, and user-unfriendliness. On the basis of these strategies, which were prioritized by 11 hospital physicians, a logic model was formulated. Of the 19 strategies, 7 (37%; eg, electronic discharge letter, providing mobile devices to the hospital's social service, and generating individual medication plans in the format of the national medication plan) have been implemented in SEKMA. A survey on the fidelity of the application of the implemented strategies showed that 3 of these strategies were not yet widely applied. No significant effect of SEKMA on readmissions was observed in the routine data of 14,854 hospital admissions (P=.20).

CONCLUSIONS

This study demonstrates the potential of optimizing intersectoral collaboration for patient care. Although a significant effect of SEKMA on readmissions has not yet been observed, creating a digital ecosystem that connects different health care providers seems to be a promising approach to ensure secure and fast networking of the sectors. The described intersectoral optimization of discharge management provides a structured template for the implementation of a similar local digital care networking infrastructure in other care regions in Germany and other countries with a similarly fragmented health care system.

A222 BILIARY ATRESIA IN BRITISH COLUMBIA: THE ROLE OF REFERRAL AGE AND DIAGNOSITIC EVALUATION ON OUTCOME

Background

Biliary atresia (BA), a newborn liver disease, is the leading cause of cirrhosis and liver-related death in children and the most common indication for pediatric liver transplantation (LT). The current standard of BA care is sequential surgery with an initial Kasai hepatoportoenterostomy (KP), followed by LT for those who progress to liver failure. Survival with native liver (SNL) correlates to infant age at KP with best outcome at early KP at <30 days of age. Novel screening tests and diagnostic algorithms have been proposed, however the variability of clinical presentation and lack of a diagnostic test challenge early diagnosis and timely KP.

Aims

To assess age at BA presentation and subsequent investigations to the timing of KP and outcome.

Methods

A retrospective study of all BA cases referred to BC Children’s Hospital January 1, 2000-December 31, 2018. Data collection included age at referral, clinical presentation, laboratory and imaging studies, age at KP and LT. SNL and overall survival rates were determined. Descriptive statistics and data analyses using SSPS were applied.

Results

In this 19-year study, there were 48 cases (58% female) of BA in BC (1:17,000 live births). KP was performed in 41 patients and 7 had primary LT. Following the initial KP, 23 cases had LT. Median age at presentation decreased from 55 to 42 days after introduction of the BC BA stool card screening program in 2014. The Median (IQR) age at KP was 62 days (48–87). Median delay from the age at first encounter to the KP was 10 days (4–21); early referral (youngest 3^rd of cohort) had a mean delay to KP of 25 days (15–40) compared with the late group (oldest 3^rd of cohort) with median delay to KP of 5 days (1–8). There were 2.4 and 1.4 investigations/patient before undergoing KP in the youngest and oldest age at presentation cohorts. HIDA scan was done in 41% and 19% of the youngest and oldest presentation cohorts respectively. Median LT age was 9.6 months (8-13months). Median age at KP for patients who received LT was 77 days (53–92), compared to 52 days (41–79) in those without LT (p=0.08). All KPs were completed by 7 surgeons, each completing 1- 10 KPs. Overall patient survival and SNL were 98% and 37.5%.

Conclusions

In this cohort, SNL rates were below SNL rates in other national studies. SNL rates were higher in patients who underwent KP at a younger age, and early findings from a provincial screening program show a shift in age at presentation, potentially owing in part to increased community awareness of BA. A diagnostic algorithm that accounts for age at presentation is needed achieve timely KP.

Funding Agencies

None

A59 SEVERE CHEMOTHERAPY-INDUCED SECRETORY DIARRHEA

Background

Diarrhea is one of the most common side effects of chemotherapy, estimated to occur in up to 40% of all patients undergoing cancer therapy. Non-complicated chemotherapy-induced diarrhea (CID) can be managed with loperamide, whereas complicated CID should be treated with continuous infusion of octreotide. Octreotide is usually effective within 48hs of administration. Options for patients that do not respond to loperamide or octreotide include atropine, oral budesonide and cholestyramine.

Aims

To describe the case of an 18 yo girl with acute myeloid leukemia (AML) who developed severe secretory diarrhea during her treatment course.

Methods

Retrospective case report.

Results

The patient was initially treated with Cytarabine, Daunorubicin and Etoposide, and on her third cycle, Gemtuzumab was added. Four weeks later she presented with watery diarrhea up to 6 L/day. She continued with high output despite no oral intake, which was consistent with secretory diarrhea. Infectious workup was negative, and she received Loperamide. Her output decreased to 1 L for 2 days but then increased again to 6 L. She deteriorated and loperamide was switched to octreotide 0.8mcg/Kg/h. The dose was increased to 1.2mcg/Kg/h and she presented blood in the stools. Her stool output was still 4 L/day and octreotide was stopped after one week. Flex sigmoidoscopy showed proctocolitis with friability. Biopsy showed architectural distortion with loss of the superficial epithelium. She was emotionally distressed due to many days of no oral intake, hence Pediasure peptide was introduced, with no changes in the output. Rice was introduced but her diarrhea worsened, and oral intake was stopped again. Four weeks after the onset of diarrhea, her stool output was still above 2 L/day, and cholestyramine 4g once daily was started. Four days later her output decreased and diet was slowly introduced. Two weeks later she had a normal stool output. Cholestyramine was stopped and she was discharged home.

Finding the culprit for this case is a challenge, but important to avoid this drug in the future as prior history of CID is a risk factor for a new-onset. Gemtuzumab is a relatively new anti-CD33 antibody used in AML, and results from a meta-analysis showed that adding it to induction chemotherapy may increase the incidence of diarrhea. Her diarrhea started four weeks after the dose of Gemtuzumab, and we believe this new agent might have played an important role in her case. To our knowledge, there are no cases in the literature associating Gemtzumab with such prolonged and severe diarrhea.

Conclusions

This was a challenging case of CID that did not respond to Loperamide or octreotide and caused a lot of emotional distress for the patient and her providers. Since she responded well to cholestyramine, we recommend its use when the loperamide and octreotide have failed, or in addition to octreotide in severe cases.

Funding Agencies

None

Thrombosen im Kindesalter

Thrombosen im Kindesalter sind häufiger als bisher vermutet. Eine 1990 durchgeführte grob orientierende Umfrage in den Kinderkliniken der BRD (ohne ehemalige DDR) ergab für die vorangegangenen 12 Monate etwa 200 Thrombosen, davon ca. zwei Drittel venöse, ca. ein Drittel arterielle und disseminierte.

Thrombosen bei Säuglingen und Kindern weisen folgende Besonderheiten auf: Erstmanifestation von hereditären Thrombophilien, wie z.B. der Purpura fulminans beim homozygoten Protein-C- und Protein-S-Mangel; Thrombophilie bei pädiatrischen Krankheitsbildern, wie kongenitale zyanotische Herzfehler, Kawasaki-Syndrom, hämolytisch-urämisches Syndrom ; unterschiedliche Erscheinungsformen, z.B. beim systemischen Lupus erythematodes des Erwachsenen vorwiegend Thrombosen, beim Kind dagegen vorwiegend Blutungen; keine arteriosklerotischen Gefäßveränderungen, dafür aber erhöhte Gefäßpermeabilität bei Frühgeborenen; der Pädiater muß mit den altersspezifischen Normalwerten von antithrombotischen Faktoren, die besonders beim Neugeborenen erheblich von der Erwachsenennorm abweichen, vertraut sein, und er muß mit geringen Blutmengen zur Diagnosestellung und Verlaufskontrolle auskommen.

Building a Privacy, Ethics, and Data Access Framework for Real World Computerised Medical Record System Data: A Delphi Study. Contribution of the Primary Health Care Informatics Working Group

BACKGROUND

Privacy, ethics, and data access issues pose significant challenges to the timely delivery of health research. Whilst the fundamental drivers to ensure that data access is ethical and satisfies privacy requirements are similar, they are often dealt with in varying ways by different approval processes.

OBJECTIVE

To achieve a consensus across an international panel of health care and informatics professionals on an integrated set of privacy and ethics principles that could accelerate health data access in data-driven health research projects.

METHOD

A three-round consensus development process was used. In round one, we developed a baseline framework for privacy, ethics, and data access based on a review of existing literature in the health, informatics, and policy domains. This was further developed using a two-round Delphi consensus building process involving 20 experts who were members of the International Medical Informatics Association (IMIA) and European Federation of Medical Informatics (EFMI) Primary Health Care Informatics Working Groups. To achieve consensus we required an extended Delphi process.

RESULTS

The first round involved feedback on and development of the baseline framework. This consisted of four components: (1) ethical principles, (2) ethical guidance questions, (3) privacy and data access principles, and (4) privacy and data access guidance questions. Round two developed consensus in key areas of the revised framework, allowing the building of a newly, more detailed and descriptive framework. In the final round panel experts expressed their opinions, either as agreements or disagreements, on the ethics and privacy statements of the framework finding some of the previous round disagreements to be surprising in view of established ethical principles.

CONCLUSION

This study develops a framework for an integrated approach to ethics and privacy. Privacy breech risk should not be considered in isolation but instead balanced by potential ethical benefit.

Evidence for the role of microRNA 374b in acquired cisplatin resistance in pancreatic cancer cells

Recent evidence has implicated microRNAs (miRNAs) as potentially significant players in the acquisition of cancer-drug resistance in pancreatic and other cancers. To evaluate the potential contribution of miRNAs in acquired resistance to cisplatin in pancreatic cancer, we compared levels of more than 2000 human miRNAs in a cisplatin-resistant cell line (BxPC3-R) derived from parental (BxPC3) cells by step-wise exposure to increasing concentrations of the drug over more than 20 passages. The acquired drug resistance was accompanied by significant changes in the expression of 57 miRNAs, of which 23 were downregulated and 34 were upregulated. Employing a hidden Markov model (HMM) algorithm, we identified downregulation of miR-374b as likely being directly involved in acquisition of the drug-resistant phenotype. Consistent with this prediction, ectopic overexpression of miR-374b in the resistant BxPC3-R cells restored cisplatin sensitivity to levels approaching those displayed by the BxPC3 parental cells. The results are consistent with a growing body of evidence implicating miRNAs in acquired cancer-drug resistance and with the potential therapeutic value of these small regulatory RNAs in blocking and/or reversing the process.

Anoctamin 6 is localized in the primary cilium of renal tubular cells and is involved in apoptosis-dependent cyst lumen formation

Primary cilia are antenna-like structures projected from the apical surface of various mammalian cells including renal tubular cells. Functional or structural defects of the cilium lead to systemic disorders comprising polycystic kidneys as a key feature. Here we show that anoctamin 6 (ANO6), a member of the anoctamin chloride channel family, is localized in the primary cilium of renal epithelial cells in vitro and in vivo. ANO6 was not essential for cilia formation and had no effect on in vitro cyst expansion. However, knockdown of ANO6 impaired cyst lumen formation of MDCK cells in three-dimensional culture. In the absence of ANO6, apoptosis was reduced and epithelial cells were incompletely removed from the center of cell aggregates, which form in the early phase of cystogenesis. In line with these data, we show that ANO6 is highly expressed in apoptotic cyst epithelial cells of human polycystic kidneys. These data identify ANO6 as a cilium-associated protein and suggest its functional relevance in cyst formation.

Divergent effects of the 'biased' 5-HT1 A receptor agonists F15599 and F13714 in a novel object pattern separation task

BACKGROUND AND PURPOSE

Pattern separation, that is, the formation of distinct representations from similar inputs, is an important hippocampal process implicated in cognitive domains like episodic memory. A deficit in pattern separation could lead to memory impairments in several psychiatric and neurological disorders. Hence, mechanisms by which pattern separation can be increased are of potential therapeutic interest.

EXPERIMENTAL APPROACH

5-HT1A receptors are involved in spatial memory. Herein we tested the 'biased' 5-HT1A receptor agonists F15599, which preferentially activates post-synaptic heteroreceptors, and F13714, which preferentially activates raphe-located autoreceptors, in rats in a novel spatial task assessing pattern separation, the object pattern separation (OPS) task.

KEY RESULTS

The acetylcholinesterase inhibitor donepezil, which served as a positive control, significantly improved spatial pattern separation at a dose of 1 mg·kg(-1) , p.o. F15599 increased pattern separation at 0.04 mg·kg(-1) , i.p., while F13714 decreased pattern separation at 0.0025 mg·kg(-1) , i.p. The selective 5-HT1A receptor antagonist WAY-100635 (0.63 mg·kg(-1) , s.c.) counteracted the effects of both agonists. These data suggest that acute preferential activation of post-synaptic 5-HT1A heteroreceptors improves spatial pattern separation, whereas acute preferential activation of raphe-located 5-HT1A autoreceptors impairs performance.

CONCLUSIONS AND IMPLICATIONS

We successfully established and validated a novel, simple and robust OPS task and observed a diverging profile of response with 'biased' 5-HT1A receptor agonists based on their targeting of receptors in distinct brain regions. Our data suggest that the post-synaptic 5-HT1A receptor consists of a potential novel molecular target to improve pattern separation performance.

Computerized provider order entry reduces length of stay in a community hospital

OBJECTIVE

Does computerized provider order entry (CPOE) improve clinical, cost, and efficiency outcomes as quantified in shortened hospital length of stay (LOS)? Most prior studies were done in university settings with home-grown electronic records, and are now 20 years old. This study asked whether CPOE exerts a downward force on LOS in the current era of HITECH incentives, using a vendor product in a community hospital.

METHODS

The methodology retrospectively evaluated correlation between CPOE and LOS on a perpatient, per-visit basis over 22 consecutive quarters, organized by discipline. All orders from all areas were eligible, except verbals, and medication orders in the emergency department which were not available via CPOE. These results were compared with quarterly case mix indices organized by discipline. Correlational and regression analyses were cross-checked to ensure validity of R-square coefficients, and data were smoothed for ease of display. Standard models were used to calculate the inflection point.

RESULTS

Gains in CPOE adoption occurred iteratively house-wide, and in each discipline. LOS decreased in a sigmoid shaped curve. The inflection point shows that once CPOE adoption approaches 60%, further lowering of LOS accelerates. Overall there was a 20.2% reduction in LOS correlated with adoption of CPOE. Case mix index increased during the study period showing that reductions in LOS occurred despite increased patient complexity and resource utilization.

CONCLUSIONS

There was a 20.2% reduction in LOS correlated with rising adoption of CPOE. CPOE contributes to improved clinical, cost, and efficiency outcomes as quantified in reduced LOS, over and above other processes introduced to lower LOS. CPOE enabled a reduction in LOS despite an increase in the case mix index during the time frame of this study.

Calcium-activated and apoptotic phospholipid scrambling induced by Ano6 can occur independently of Ano6 ion currents

Immune cells and platelets maintain plasma membrane phospholipid asymmetry. Upon activation, this asymmetry is disrupted by phospholipid scrambling (PS), which is a major step during activation of immune cells, hemostasis and apoptosis. Anoctamin 6 (Ano6; TMEM16F) causes chloride (Cl(-)) and cation currents and is required for Ca(2+)-dependent PS. It is defective in blood cells from patients with Scott syndrome, a rare bleeding disorder. We examined if Cl(-) currents and PS are related, whether both processes are Ca(2+) dependent, and whether Ca(2+)-independent scrambling during intrinsic and extrinsic apoptosis is controlled by Ano6. Ca(2+) increase by ionomycin activated Ano6 Cl(-) currents and PS in normal lymphocytes, but not in B-lymphocytes from two different patients with Scott syndrome. Fas ligand (FasL) did not increase intracellular Ca(2+), but activated Cl(-) currents in normal but not in Scott lymphocytes. Whole-cell currents were inhibited by Cl(-) channel blockers and by siRNA knockdown of Ano6. In contrast, intrinsic mitochondrial apoptosis by ABT-737 did not induce Cl(-) currents in lymphocytes. PS was not inhibited by blockers of Ano6 or removal of Cl(-) ions. Remarkably, Ca(2+)-independent scrambling due to extrinsic (FasL) or intrinsic (ABT-737) apoptosis was unchanged in Scott cells. We conclude that: (i) Ano6 Cl(-) currents are activated by increase in cytosolic Ca(2+), or Ca(2+) independent by stimulation of Fas receptors; (ii) Ca(2+)-dependent PS induced by Ano6 does not require Cl(-) currents; (iii) Ca(2+)-independent PS does not require Ano6; (iv) Ano6 is necessary for Ca(2+)-dependent PS, but not by increasing intracellular Ca(2+).

CYBA C242T polymorphism is associated with obesity and diabetes mellitus in Brazilian hypertensive patients

AIMS

The CYBA C242T polymorphism has been associated with cardiovascular phenotypes such as hypertension and atherosclerosis, but available data are conflicting. This report investigated the impact of this variant on hypertension and metabolic determinants of cardiovascular risk in a large Brazilian sample.

METHODS

We cross-sectionally evaluated 1856 subjects (826 normotensive subjects and 1030 hypertensive patients) by clinical history, anthropometry, laboratory analysis and genotyping of the CYBA C242T polymorphism.

RESULTS

Genotype frequencies in the whole population were consistent with the Hardy-Weinberg equilibrium and genotype distributions were not different between hypertensive and normotensive subjects. Hypertensive patients with the CC genotype presented lower fasting plasma glucose levels (5.9 ± 0.1 vs. 6.2 ± 0.1 mmol/l, P = 0.020) and waist circumference (94.5 ± 0.6 vs. 96.3 ± 0.6 cm, P = 0.028) than CT + TT ones. Similarly, the prevalence of diabetes mellitus and obesity was also lower in hypertensive patients carrying the CC genotype (16% vs. 21%, P = 0.041; 36% vs. 43%, P = 0.029, respectively). In addition, multiple and logistic regression analysis demonstrated that the CYBA C242T polymorphism was associated with glucose levels, waist circumference, obesity and diabetes mellitus in hypertensive patients independently of potential confounders. Conversely, in normotensive subjects, no significant difference in studied variables was detected between the genotype groups.

CONCLUSIONS

These data suggest that the T allele of the CYBA C242T polymorphism may be used as a marker for adverse metabolic features in Brazilian subjects with systemic hypertension.

Hip circumference is associated with high density lipoprotein cholesterol response following statin therapy in hypertensive subjects

AIM

This report investigated the relationship between anthropometric measurements of body fat distribution and lipid response to statins in hypercholesterolemic hypertensive patients.

METHODS

We prospectively examined 129 subjects who used either simvastatin 20 mg/day (no.=83) or atorvastatin 10 mg/day (no.=46) for 3 months. Anthropometry included evaluation of body mass index, waist and hip circumferences, and waist-to-hip-ratio.

RESULTS

Significant decreases in LDL (p<0.001), total cholesterol (p<0.001), and triglycerides (p=0.04) levels were detected after 3 months of therapy in the whole sample. At baseline, only an inverse correlation between waist circumference and HDLcholesterol levels was detected (r=-0.18; p=0.04). Conversely, a direct relationship between hip circumference and HDLcholesterol response to statins was found in the whole sample (r=0.24; p=0.006), while no other anthropometric measurement displayed significant correlation with lipid changes. The association between HDL-cholesterol response and hip circumference was further confirmed by stepwise regression analysis adjusted for baseline HDL-cholesterol levels, metabolic syndrome, body mass index, and waist circumference.

CONCLUSIONS

Hip circumference, a surrogate marker of peripheral adiposity, is associated with HDL-cholesterol changes following statin therapy in hypertensive patients.

The effect of gluteus medius training on hip kinematics in a runner with iliotibial band syndrome

Iliotibial  band  syndrome  (ITBS)  is  a  common  clinical  presentation in  runners.  There  are  several  hypotheses  to  explain  this  condition  including  faulty  control of the hip joint in the frontal plane during the stance phase of running. It is postulated that improving activity in the gluteus medius muscle may assist in produc-ing  more  appropriate  stabilization and  therefore  reduce  the  stress  on  the  Iliotibial band  (ITB).  This  single  case  study  provides  an  interesting  clinical  scenario  where a single-subject with ITBS was measured for hip kinematics during running, before and after a trial period of classic gluteus medius exercises. The biomechanical data show an initial (pre-intervention) increase in adduction position during the stance phase of running on the affected side (in contrast to the unaffected side). This was measured using a Moven motion analysis suit. After the trial intervention period, the relative position of the affected hip had reduced in adduction at both heel strike and at 30° knee flexion. This study provides support  for the theory that hip control in the frontal plane may be a contributing factor in ITBS. Clinicians are encouraged to monitor hip control as well as ITBS symptoms when they utilise this gluteus medius protocol. Further research to establish whether change in pelvic control results in decrease in ITBS symptoms is warranted.