Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation

BACKGROUND

The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.

METHODS

MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.

DISCUSSION

A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

Burnout Among Staff in a Home Hospital Pilot

Background

Burnout affects large portions of the healthcare workforce and is associated with increased medical errors, decreased patient experience and adherence, loss of professionalism, and decreased productivity. Little data exists on how novel clinical care settings might impact burnout. We studied the experience and burnout of staff involved in a home hospital pilot, where acutely ill patients were cared for at home as a substitute for traditional hospitalization.

Methods

We analyzed evaluations completed by home hospital staff (physicians, registered nurses, and research assistants) at the conclusion of a 2-month pilot program. Our primary outcome was burnout evaluated by the Mini Z Burnout Survey. Secondary outcomes included overall job satisfaction, work environment, workload, and team evaluation measured on a 5-point Likert scale.

Results

Eight of nine (89%) staff completed evaluations. Seven of eight (88%) staff had no symptoms of burnout; one (13%) was under stress but did not feel burned out. Median overall satisfaction with home hospital was 4.5/5.0 (interquartile range (IQR), 1.0). Most staff (6/8; 75%) “strongly agreed” that their professional values were well-aligned with the program. Three of six (50%) “entirely” or “very much” preferred home hospital to their standard clinical setting. Six of eight (75%) staff felt that their opinions were “entirely” heard; four of eight (50%) felt the team “entirely” valued each of its participants.

Conclusions

Novel clinical care settings like home hospital may lead to low staff burnout, high job satisfaction, and a healthy work environment. Further study is warranted.

Patterns of multimorbidity associated with 30-day readmission: a multinational study

BACKGROUND

Multimorbidity is associated with higher healthcare utilization; however, data exploring its association with readmission are scarce. We aimed to investigate which most important patterns of multimorbidity are associated with 30-day readmission.

METHODS

We used a multinational retrospective cohort of 126,828 medical inpatients with multimorbidity defined as ≥2 chronic diseases. The primary and secondary outcomes were 30-day potentially avoidable readmission (PAR) and 30-day all-cause readmission (ACR), respectively. Only chronic diseases were included in the analyses. We presented the OR for readmission according to the number of diseases or body systems involved, and the combinations of diseases categories with the highest OR for readmission.

RESULTS

Multimorbidity severity, assessed as number of chronic diseases or body systems involved, was strongly associated with PAR, and to a lesser extend with ACR. The strength of association steadily and linearly increased with each additional disease or body system involved. Patients with four body systems involved or nine diseases already had a more than doubled odds for PAR (OR 2.35, 95%CI 2.15-2.57, and OR 2.25, 95%CI 2.05-2.48, respectively). The combinations of diseases categories that were most strongly associated with PAR and ACR were chronic kidney disease with liver disease or chronic ulcer of skin, and hematological malignancy with esophageal disorders or mood disorders, respectively.

CONCLUSIONS

Readmission was associated with the number of chronic diseases or body systems involved and with specific combinations of diseases categories. The number of body systems involved may be a particularly interesting measure of the risk for readmission in multimorbid patients.

Physician Perspectives on Interhospital Transfers

OBJECTIVE

The transfer of patients between acute care hospitals (interhospital transfer [IHT]) is a common but nonstandardized process leading to variable quality and safety. The goal of this study was to survey accepting physicians regarding problems encountered in the transfer process.

METHODS

A cross-sectional survey of residents and inpatient attendings from internal medicine, neurology, and surgery services at a large tertiary care referral hospital was undertaken to identify problematic aspects of the IHT process as perceived by accepting frontline providers. The frequency that specific scenarios were encountered in caring for transferred patients and whether these processes impacted patient safety were determined using 5- and 3-point Likert scales, respectively. The frequency of responses to each question were measured using proportions.

RESULTS

Approximately 51% of the 284 physicians surveyed responded. Pertinent findings included the following: physician subject surveys found that transferred patients sometimes, frequently, or always arrived without requiring specialized care in 56% of responses, arrived with unrealistic expectations of care in 77.2% of responses, arrived more than 24 hours after accepted for transfer in 80.1% of responses, and arrived without necessary transfer records in 86.9% of responses. Most respondents felt that lack of availability of transfer records and the time of day of arrival frequently posed a risk to transferred patients (57.2% and 53.1%, respectively). Response variation was noted between resident and attending physician respondents.

CONCLUSIONS

Expectations of care, delays and timing of transfer, and information exchange at time of transfer were identified as all too common problems in IHT, which creates a risk for patient safety. These areas are important targets for investigation and the development of interventions to improve patient safety.

I-PASS Mentored Implementation Handoff Curriculum: Champion Training Materials

INTRODUCTION

The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. I-PASS champions are a critical part of the implementation and sustainment of this curriculum, and therefore, a rigorous program to support their training is necessary.

METHODS

The I-PASS Handoff champion training materials were created for the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach and adult learning theory. The training includes an overview of I-PASS handoff techniques, an opportunity to practice evaluating handoffs with the I-PASS observation tools using a handoff video vignette, and other key implementation principles.

RESULTS

As part of the SHM I-PASS Mentored Implementation Program, 366 champions were trained at 32 sites across North America and participated in a total of 3,491 handoff observations. A total of 346 champions completed the I-PASS Champion Workshop evaluation form at the end of their training (response rate: 94.5%). After receiving the training, over 90% agreed/strongly agreed that it provided them with knowledge or skills critical to their patient care activities and that they were able to distinguish the difference between high- and poor-quality handoffs, competently use the I-PASS handoff assessment tools, and articulate the importance of handoff observations.

CONCLUSION

The I-PASS champion training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation.

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study

BACKGROUND

Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging.

METHODS

We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression.

RESULTS

Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR.

CONCLUSIONS

Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study.

TRIAL REGISTRATION NUMBER

NCT01337063.

I-PASS Mentored Implementation Handoff Curriculum: Implementation Guide and Resources

Introduction

Communication failures during shift-to-shift handoffs of patient care have been identified as a leading cause of adverse events in health care institutions. The I-PASS Handoff Program is a comprehensive handoff program that has been shown to decrease rates of medical errors and adverse events. As part of the spread and adaptation of this program, a comprehensive implementation guide was created to assist individuals in the implementation process.

Methods

The I-PASS Mentored Implementation Guide grew out of materials created for the original I-PASS Study, Society of Hospital Medicine (SHM) mentored implementation programs, and the experience of members of the I-PASS Study Group. The guide provides a comprehensive framework of all elements required to implement the large-scale I-PASS Handoff Program and contains detailed information on generating institutional support, training activities, a campaign, measuring impact, and sustaining the program.

Results

Thirty-two sites across North America utilized the guide as part of the SHM program. The guide served as a main reference for 477 hours of mentoring phone calls between site leads and their mentors. Postprogram surveys from wave 2 sites revealed that 85% (N = 34) of respondents felt the quality of the guide was very good/excellent. Site leads noted that they referenced the guide most often during the early part of the program and that they referenced the sections on the curriculum and handoff observations most often.

Discussion

The I-PASS Mentored Implementation Guide is an essential resource for those looking to implement the large-scale I-PASS Handoff Program at their institution.

The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial

BACKGROUND

Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up.

KEY RESULTS

Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03).

CONCLUSIONS

Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern.

CLINICAL TRIALS IDENTIFIER

NCT01153451.

Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients

Background

Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame.

Objective

To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability.

Design

Prospective cohort study.

Setting

10 academic medical centers in the United States.

Patients

822 adults readmitted to a general medicine service.

Measurements

For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics.

Results

Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions.

Limitation

Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results.

Conclusion

Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions.

Primary Funding Source

Association of American Medical Colleges.

Interhospital Transfer and Receipt of Specialty Procedures

The practice of transferring patients between acute care hospitals is variable and largely nonstandardized. Although often-cited reasons for transfer include providing patients access to specialty services only available at the receiving institution, little is known about whether and when patients receive such specialty care during the transfer continuum. We performed a retrospective analysis using 2013 100% Master Beneficiary Summary and Inpatient claims files from Centers for Medicare and Medicaid Services. Beneficiaries were included if they were aged =65 years, continuously enrolled in Medicare A and B, with an acute care hospitalization claim, and transferred to another acute care hospital with a primary diagnosis of acute myocardial infarction, gastrointestinal bleed, renal failure, or hip fracture/dislocation. Associated specialty procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) were identified for each diagnosis. We performed descriptive analyses to compare receipt of specialty procedural services between transferring and receiving hospitals, stratified by diagnosis. Across the 19,613 included beneficiaries, receipt of associated specialty procedures was more common at the receiving than the transferring hospital, with the exception of patients with a diagnosis of gastrointestinal bleed. Depending on primary diagnosis, between 32.4% and 89.1% of patients did not receive any associated specialty procedure at the receiving hospital. Our results demonstrate variable receipt of specialty procedural care across the transfer continuum, implying the likelihood of alternate drivers of interhospital transfer other than solely receipt of specialty procedural care.

Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver

A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. The dashboard aligns all care team members, including patients and families, in the safety plan. The screensaver content includes icons that pertain to common geriatric syndromes. In two phases, interviews were conducted with nurses, nursing assistants, patients, and informal caregivers in a large, tertiary care center. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Many themes were identified, ranging from appreciation of the clinical decision support provided by the screensavers to the value of the safety-centric content. Differences emerged stemming from each group of end users' role on the care team. All feedback will inform requirements for improvements to the personalized safety plan screensaver. [Journal of Gerontological Nursing, 43(4), 15-22.].

Rates, Predictors and Variability of Interhospital Transfers: A National Evaluation

IMPORTANCE

Interhospital transfer (IHT) remains a largely unstudied process of care.

OBJECTIVE

To determine the nationwide frequency of, patient and hospital-level predictors of, and hospital variability in IHT.

DESIGN

Cross-sectional study.

SETTING

Centers for Medicare and Medicaid 2013 100% Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

PATIENTS

Beneficiaries ≥65 years and older enrolled in Medicare A and B, with an acute care hospitalization claim in 2013.

EXPOSURES

Patient and hospital characteristics of transferred and nontransferred patients.

MEASUREMENTS

Frequency of interhospital transfers (IHT); adjusted odds of transfer of each patient and each hospital characteristic; and variability in hospital transfer rates.

RESULTS

Of 6.6 million eligible beneficiaries with an acute care hospitalization, 101,507 (1.5%) underwent IHT. Selected characteristics associated with greater adjusted odds of transfer included: patient age 74-85 years (odds ratio [OR], 2.38 compared with 65-74 years; 95% confidence intervals [CI], 2.33-2.43); nonblack race (OR, 1.17; 95% CI, 1.13-1.20); higher comorbidity (OR, 1.37; 95% CI, 1.36-1.37); lower diagnosis-related group-weight (OR, 2.02; 95% CI, 1.95-2.09); fewer recent hospitalizations (OR, 1.87; 95% CI, 1.79-1.95); and hospitalization in the Northeast (OR, 1.40; 95% CI, 1.27-1.55). Higher case mix index of the hospital was associated with a lower adjusted odds of transfer (OR, 0.36; 95% CI, 0.30-0.45). Variability in hospital transfer rates remained significant after adjustment for patient and hospital characteristics (variance 0.28, P = 0.01).

CONCLUSIONS

In this nationally representative evaluation, we found that a sizable number of patients undergo IHT. We identified both expected and unexpected patient and hospital-level predictors of IHT, as well as unexplained variability in hospital transfer rates, suggesting lack of standardization of this complex care transition. Our study highlights further investigative avenues to help guide best practices in IHT. Journal of Hospital Medicine 2017;12:435-442.

The HOSPITAL Score Predicts Potentially Preventable 30-Day Readmissions in Conditions Targeted by the Hospital Readmissions Reduction Program

BACKGROUND/OBJECTIVES

New tools to accurately identify potentially preventable 30-day readmissions are needed. The HOSPITAL score has been internationally validated for medical inpatients, but its performance in select conditions targeted by the Hospital Readmission Reduction Program (HRRP) is unknown.

DESIGN

Retrospective cohort study.

SETTING

Six geographically diverse medical centers.

PARTICIPANTS/EXPOSURES

All consecutive adult medical patients discharged alive in 2011 with 1 of the 4 medical conditions targeted by the HRRP (acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and heart failure) were included. Potentially preventable 30-day readmissions were identified using the SQLape algorithm. The HOSPITAL score was calculated for all patients.

MEASUREMENTS

A multivariable logistic regression model accounting for hospital effects was used to evaluate the accuracy (Brier score), discrimination (c-statistic), and calibration (Pearson goodness-of-fit) of the HOSPITAL score for each 4 medical conditions.

RESULTS

Among the 9181 patients included, the overall 30-day potentially preventable readmission rate was 13.6%. Across all 4 diagnoses, the HOSPITAL score had very good accuracy (Brier score of 0.11), good discrimination (c-statistic of 0.68), and excellent calibration (Hosmer-Lemeshow goodness-of-fit test, P=0.77). Within each diagnosis, performance was similar. In sensitivity analyses, performance was similar for all readmissions (not just potentially preventable) and when restricted to patients age 65 and above.

CONCLUSIONS

The HOSPITAL score identifies a high-risk cohort for potentially preventable readmissions in a variety of practice settings, including conditions targeted by the HRRP. It may be a valuable tool when included in interventions to reduce readmissions within or across these conditions.

Simplification of the HOSPITAL score for predicting 30-day readmissions

OBJECTIVE

The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted.

DESIGN AND SETTING

Retrospective study in 9 large hospitals across 4 countries, from January through December 2011.

PARTICIPANTS

We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility.

MEASUREMENTS

The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) 'discharge from an oncology division' was replaced by 'cancer diagnosis or discharge from an oncology division'; (2) 'any procedure' was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration.

RESULTS

Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2-5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories.

CONCLUSIONS

The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

All Together Now: Impact of a Regionalization and Bedside Rounding Initiative on the Efficiency and Inclusiveness of Clinical Rounds

BACKGROUND

Attending rounds at academic medical centers are often disconnected from patients and team members who are not physicians. Regionalization of care teams may facilitate bedside rounding and more frequent interactions among doctors, nurses, and patients.

OBJECTIVE

We used time-motion analysis to investigate how regionalization of medical teams and encouragement of bedside rounds affect participants on rounds and rounding time.

DESIGN AND SETTING

We used pre-post analysis to study the effects of care redesign on teams' daily rounds on a general medicine service at an academic medical center.

PARTICIPANTS

Four general medical teams were evaluated before the intervention and 5 teams afterward.

INTERVENTIONS

General medical teams were regionalized to specific units, the admitting structure was changed to facilitate regionalization, and teams were encouraged to round bedside.

MEASUREMENTS

Primary outcomes included proportion of time each team member was present on rounds and proportion of bedside rounding time. Secondary outcomes included round duration and non-patient time during rounds.

RESULTS

Proportion of time the nurse was present on rounds increased from 24.1% to 67.8% (P ⟨ 0.001), and proportion of total bedside rounding time increased from 39.9% to 55.8% (P ⟨ 0.001). Mean total rounding time decreased from 3.0 hours to 2.4 hours (P = 0.01), despite a higher patient census.

CONCLUSIONS

Creating regionalized care teams and encouraging interdisciplinary bedside rounds increased the proportion of bedside rounding time and the presence of nurses on rounds while decreasing total rounding time. Journal of Hospital Medicine 2017;12:150-156.

Risk Factors and Patterns of Potentially Avoidable Readmission in Patients With Cancer

Purpose:

Patients with cancer are particularly at risk for readmission within 30-days after discharge. To identify the patients who might benefit from more-intensive discharge interventions, we identified the risk factors associated with 30-day potentially avoidable readmissions.

Methods and Materials:

We included all consecutive discharges from the oncology division of an academic tertiary medical center in Boston, Massachusetts, between July 1, 2009, and June 30, 2010. Potentially avoidable 30-day readmissions to the index hospital and two other hospitals within its network were identified. We performed a multivariable logistic regression in which the final model included variables found in bivariable testing to be significantly associated with the outcome.

Results:

Among the 2,916 patients discharged during the study period, 1,086 (37.3%) were readmitted within 30 days. Of these, 341 (31.4% of all readmissions, 11.7% of all discharges) were identified as potentially avoidable. In the multivariable analysis, the following patient factors were associated with a significantly higher risk of a potentially avoidable readmission: total number of medications at discharge, liver disease, last sodium level, and last hemoglobin level before discharge. In addition, potentially avoidable readmissions occurred significantly earlier than unavoidable readmissions (median, 10 v 13 days; P < .001).

Conclusion:

Almost 40% of patients with cancer had a 30-day readmission, and almost one third of these were deemed potentially avoidable, and several risk factors for this were identified. Interventions at discharge may be prioritized to patients with these risk factors.

Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge

OBJECTIVES

Medication discrepancies at the time of hospital discharge are common and can harm patients. Medication reconciliation by pharmacists has been shown to prevent such discrepancies and the adverse drug events (ADEs) that can result from them. Our objective was to estimate the economic value of nontargeted and targeted medication reconciliation conducted by pharmacists and pharmacy technicians at hospital discharge versus usual care.

STUDY DESIGN

Discrete-event simulation model.

METHODS

We developed a discrete-event simulation model to prospectively model the incidence of drug-related events from a hospital payer's perspective. The model assumptions were based on data published in the peer-reviewed literature. Incidences of medication discrepancies, preventable ADEs, emergency department visits, rehospitalizations, costs, and net benefit were estimated.

RESULTS

The expected total cost of preventable ADEs was estimated to be $472 (95% credible interval [CI], $247-$778) per patient with usual care. Under the base-case assumption that medication reconciliation could reduce medication discrepancies by 52%, the cost of preventable ADEs could be reduced to $266 (95% CI, $150-$423), resulting in a net benefit of $206 (95% CI, $73-$373) per patient, after accounting for intervention costs. A medication reconciliation intervention that reduces medication discrepancies by at least 10% could cover the initial cost of intervention. Targeting medication reconciliation to high-risk individuals would achieve a higher net benefit than a nontargeted intervention only if the sensitivity and specificity of a screening tool were at least 90% and 70%, respectively.

CONCLUSIONS

Our study suggests that implementing a pharmacist-led medication reconciliation intervention at hospital discharge could be cost saving compared with usual care.

How often are hospitalized patients and providers on the same page with regard to the patient's primary recovery goal for hospitalization?

BACKGROUND

To deliver high-quality, patient-centered care during hospitalization, healthcare providers must correctly identify the patient's primary recovery goal.

OBJECTIVE

To determine the degree of concordance between patients and key hospital providers.

DESIGN

A validated questionnaire administered to a random sample of hospitalized patients alongside their nurse and physician provider. Goals included: "be cured," "live longer," "improve/maintain health," "be comfortable," "accomplish a particular life goal," or "other."

SETTING

Major academic hospital in Boston, Massachusetts.

PARTICIPANTS

Adult patients admitted for more than 48 hours from November 2013 to May 2014 were eligible. When a patient was incapacitated, a legal proxy was interviewed. The nurse and physician provider were then interviewed within 24 hours.

MEASUREMENTS

Frequencies of responses for each recovery goal and the rate of concordance among the patient, nurse, and physician provider were measured. The frequency of responses across groups were compared using adjusted χ(2) analyses. Inter-rater agreement was measured using 2-way Kappa tests.

RESULTS

All 3 participants were interviewed in 109 of the 181 (60.2%) patients approached (or with proxy available). Significant differences in selected goals were observed across respondent groups (P < 0.001). Patients frequently chose "be cured" (46.8%). Nurses and physician providers frequently selected "improve or maintain health" (38.5% and 46.8%, respectively). All 3 participants selected the same goal in 22 cases (20.2%). Inter-rater agreement was poor to slight for all pairs (kappa 0.09 [-0.03-0.19], 0.19 [0.08-0.30], and 0.20 [0.08-0.32] for patient-physician, patient-nurse, and nurse-physician, respectively).

CONCLUSIONS

We observed poor to slight concordance among hospitalized patients and key medical team members with regard to the patient's primary recovery goal. Journal of Hospital Medicine 2016;11:615-619. © 2016 Society of Hospital Medicine.

Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services

BACKGROUND

Dispersion of inpatient care teams across different medical units impedes effective team communication, potentially leading to adverse events (AEs).

OBJECTIVE

To regionalize 3 inpatient general medical teams to nursing units and examine the association with communication and preventable AEs.

DESIGN

Pre-post cohort analysis.

SETTING

A 700-bed academic medical center.

PATIENTS

General medicine patients on any of the participating nursing units before and after implementation of regionalized care.

INTERVENTION

Regionalizing 3 general medical physician teams to 3 corresponding nursing units.

MEASUREMENTS

Concordance of patient care plan between nurse and intern, and adjusted odds of preventable AEs.

RESULTS

Of the 414 included nurse and intern paired surveys, there were no significant differences pre- versus postregionalization in total mean concordance scores (0.65 vs 0.67, P = 0.26), but there was significant improvement in agreement on expected discharge date (0.56 vs 0.68, P = 0.003), knowledge of the other provider's name (0.56 vs 0.86,P < 0.001), and daily care plan discussions (0.73 vs 0.88, P < 0.001). Of the 392 reviewed patient medical records, there was no significant difference in the adjusted odds of preventable AEs pre- versus postregionalization (adjusted odds ratio: 1.37, 95% confidence interval: 0.69, 2.69).

CONCLUSIONS

We found that regionalization of care teams improved recognition of care team members, discussion of daily care plan, and agreement on estimated discharge date, but did not significantly improve nurse and physician concordance of the care plan or reduce the odds of preventable AEs. Our findings suggest that regionalization alone may be insufficient to effectively promote communication and lead to patient safety improvements. Journal of Hospital Medicine 2016;11:620-627. © 2016 Society of Hospital Medicine.

Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial

BACKGROUND

Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal.

OBJECTIVE

The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge.

DESIGN

Randomized, controlled trial with concealed allocation and blinded outcome assessors

SETTING

Two tertiary care academic medical centers

PARTICIPANTS

Adults hospitalized with a diagnosis of ACS and/or ADHF.

INTERVENTION

Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge

MAIN MEASURES

The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) are reported.

KEY RESULTS

A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women's Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95% CI 0.78-1.39). There was an interaction of treatment effect by site (p = 0.04 for interaction); VUH aHR = 0.77, 95% CI 0.51-1.15; BWH aHR = 1.44 (95% CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95% CI 0.17-1.00). There was no difference in treatment effect by patient cognition.

CONCLUSION

A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.