Quality of discharge practices and patient understanding at an academic medical center

Elucidating the information exchange during interfacility care transitions: Insights from a Qualitative Study

OBJECTIVE

To explore the perceptions of patients, their caregivers and healthcare professionals associated with the exchange of information during transitioning from two acute care hospitals to one rehabilitation hospital.

DESIGN

An exploratory qualitative study using semi-structured interviews and observation.

PARTICIPANTS AND SETTING

Patients over the age of 65 years admitted to an orthopaedic unit for a non-elective admission, their caregivers and healthcare professionals involved in their care. Participating sites included orthopaedic inpatient units from two acute care teaching hospitals and one orthopaedic unit at a rehabilitation hospital in an urban setting.

FINDINGS

Three distinct themes emerged from participants' narrative of their transitional care experience: (1) having no clue what the care plan is, (2) being told and notified about the plan and (3) experiencing challenges absorbing information. Participating patients and their caregivers reported not being engaged in an active discussion with healthcare professionals about their care transition plan. Several healthcare professionals described withholding information within the plan until they themselves were clear about the transition outcomes.

CONCLUSION

This study highlights the need to increase efforts to ensure that effective information exchanges occur during transition from acute care hospital to rehabilitation settings.

Exploring challenges in the patient's discharge process from the internal medicine service: A qualitative study of patients' and providers' perceptions

In hospital-based medicine units, patients have a wide range of complex medical conditions, requiring timely and accurate communication between multiple interprofessional providers at the time of discharge. Limited work has investigated the challenges in interprofessional collaboration and communication during the patient discharge process. In this study, authors qualitatively assessed the experiences of internal medicine providers and patients about roles, challenges, and potential solutions in the discharge process, with a phenomenological focus on the process of collaboration. Authors conducted interviews with 87 providers and patients-41 providers in eight focus-groups, 39 providers in individual interviews, and seven individual patient interviews. Provider roles included physicians, nurses, therapists, pharmacists, care coordinators, and social workers. Interviews were audio-recorded and transcribed verbatim, followed by iterative review of transcripts using qualitative coding and content analysis. Participants identified several barriers related to interprofessional collaboration during the discharge process, including systems insufficiencies (e.g., medication reconciliation process, staffing challenges); lack of understanding others' roles (e.g., unclear which provider should be completing the discharge summary); information-communication breakdowns (e.g., inaccurate information communicated to the primary medical team); patient issues (e.g., patient preferences misaligned with recommendations); and poor collaboration processes (e.g., lack of structured interprofessional rounds). These results provide context for targeting improvement in interprofessional collaboration in medicine units during patient discharges. Implementing changes in care delivery processes may increase potential for accurate and timely coordination, thereby improving the quality of care transitions.

Knowledge is Power. A quality improvement project to increase patient understanding of their hospital stay

Patients frequently leave hospital uninformed about the details of their hospital stay with studies showing that only 59.9% of patients are able to accurately state their diagnosis and ongoing management after discharge. 1 2 This places patients at a higher risk of complications. Educating patients by providing them with accurate and understandable information enables them to take greater control, potentially reducing readmission rates, and unplanned visits to secondary services whilst providing safer care and improving patient satisfaction. 3 4 We wished to investigate whether through a simple intervention, we could improve the understanding and retention of key pieces of clinical information in those patients recently admitted to hospital. A leaflet was designed to trigger patients to ask questions about key aspects of their stay. This was then given to inpatients who were interviewed two weeks later using telephone follow up to assess their understanding of their hospital admission. Patients were asked about their diagnosis, new medications, likely complications, follow up arrangements and recommended points of contact in case of difficulty. Sequential modifications were made using PDSA cycles to maximise the impact and benefit of the process. Baseline data revealed that only 77% of patients could describe their diagnosis and only 27% of patients knew details about their new medications. After the leaflet intervention these figures improved to 100% and 71% respectively. Too often patients are unaware about what happens to them whilst in hospital and are discharged unsafely and dissatisfied as a result. A simple intervention such as a leaflet prompting patients to ask questions and take responsibility for their health can make a difference in potentially increasing patient understanding and thereby reducing risk.

Patient experience with discharge instructions in postdischarge recovery: a qualitative study

OBJECTIVES

We examined the role of discharge instructions in postoperative recovery for patients undergoing colorectal surgery and report themes related to patient perceptions of discharge instructions and postdischarge experience.

DESIGN

Semistructured interviews were conducted as part of a formative evaluation of a Project Re-Engineered Discharge intervention adapted for surgical patients.

SETTING

Michael E. DeBakey VA Medical Center, a tertiary referral centre in Houston, Texas.

PARTICIPANTS

Twelve patients undergoing elective colorectal surgery. Interviews were conducted at the two-week postoperative appointment.

RESULTS

Participants demonstrated understanding of the content in the discharge instructions. During the interviews, participants reported several positive roles for discharge instructions in their postdischarge care: a sense of security, a reminder of inhospital education, a living document and a source of empowerment. Despite these positive associations, participants reported that the instructions provided insufficient information to promote access to care that effectively addressed acute issues following discharge. Participants noted difficulty reaching providers after discharge, which resulted in the adoption of workarounds to overcome system barriers.

CONCLUSIONS

Despite concerted efforts to provide patient-centred instructions, the discharge instructions did not provide enough context to effectively guide postdischarge interactions with the healthcare system. Insufficient information on how to access and communicate with the most appropriate personnel in the healthcare system is an important barrier to patients receiving high-quality postdischarge care. Tools and strategies from team training programmes, such as team strategies and tools to enhance performance and patient safety, could be adapted to include patients and provide them with structured methods for communicating with healthcare providers post discharge.

SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients' Healthcare from Skilled Nursing Facilities to the Community

We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.

A systematic review on the effect of the organisation of hospital discharge on patient health outcomes

OBJECTIVE

The transition from hospital to home represents a key step in the management of patients and several problems related to this transition may arise, with potential adverse effects on patient health after discharge. The purpose of our study was to explore the association between components of the hospital discharge process including subsequent continuity of care and patient outcomes in the post-discharge period.

DESIGN

Systematic review of observational and interventional studies.

SETTING

We conducted a combined search in the Medline and Web of Science databases. Additional studies were identified by screening the bibliographies of the included studies. The data collection process was conducted using a standardised predefined grid that included quality criteria.

PARTICIPANTS

A standard patient population returning home after hospitalisation.

PRIMARY AND SECONDARY OUTCOMES

Adverse health outcomes occurring after hospital discharge.

RESULTS

In the 20 studies fulfilling our eligibility criteria, the main discharge-process components explored were: discharge summary (n=2), discharge instructions (n=2), drug-related problems at discharge (n=4), transition from hospital to home (n=5) and continuity of care after hospital discharge (n=7). The major subsequent patient health outcomes measured were: rehospitalisations (n=18), emergency department visits (n=8) and mortality (n=5). Eight of the 18 studies exploring rehospitalisations and two of the eight studies examining emergency department visits reported at least one significant association between the discharge process and these outcomes. None of the studies investigating patient mortality reported any significant such associations between the discharge process and these outcomes.

CONCLUSIONS

Irrespective of the component of the discharge process explored, the outcome considered (composite or not), the sample size and the study design, no consistent statistical association between hospital discharge and patient health outcome was identified. This systematic review highlights a wide heterogeneity between studies, especially in terms of the component(s) of the hospital discharge process investigated, study designs, outcomes and follow-up durations.

"That's Where the Arguments Come in": A Qualitative Analysis of Booster Sessions Following a Brief Intervention for Drug Use and Intimate Partner Violence in the Emergency Department

Although booster phone calls have been used to enhance the impact of brief interventions in the emergency department, there has been less number of studies describing the content of these boosters. We conducted a qualitative analysis of booster calls occurring two weeks after an initial Web-based intervention for drug use and intimate partner violence (IPV) among women presenting for emergency care, with the objective of identifying the following: progress toward goals set during the initial emergency department visit, barriers to positive change, and additional resources and services needed in order to inform improvements in future booster sessions. The initial thematic framework was developed by summarizing codes by major themes and subthemes; the study team collaboratively decided on a final thematic framework. Eighteen participants completed the booster call. Most of them described a therapeutic purpose for their drug use. Altering the social milieu was the primary means of drug use change; this seemed to increase isolation of women already in abusive relationships. Women described IPV as interwoven with drug use. Participants identified challenges in attending substance use treatment service and domestic violence agencies. Women with substance use disorders and in abusive relationships face specific barriers to reducing drug use and to seeking help after a brief intervention.

Patient Preferences for Information on Post-Acute Care Services

The purpose of the current study was to explore what hospitalized patients would like to know about post-acute care (PAC) services to ultimately help them make an informed decision when offered PAC options. Thirty hospitalized adults 55 and older in a Northeastern U.S. academic medical center participated in a qualitative descriptive study with conventional content analysis as the analytical technique. Three themes emerged: (a) receiving practical information about the services, (b) understanding "how it relates to me," and (c) having opportunities to understand PAC options. Study findings inform clinicians what information should be included when discussing PAC options with older adults. Improving the quality of discharge planning discussions may better inform patient decision making and, as a result, increase the numbers of patients who accept a plan of care that supports recovery, meets their needs, and results in improved quality of life and fewer readmissions. [Res Gerontol Nurs. 2016; 9(4):175-182.].

Closing the Gap: Supporting Patients' Transition to Self-Management after Hospitalization

Patients going home after a hospitalization face many challenges. This transition period exposes patients to unnecessary risks related to inadequate preparation prior to leaving the hospital, potentially leading to errors and patient harm. Although patients engaging in self-management have better health outcomes and increased self-efficacy, little is known about the processes in place to support and develop these skills for patients leaving the hospital. Through qualitative interviews and observations of 28 patients during and after their hospitalizations, we explore the challenges they face transitioning from hospital care to self-management. We identify three key elements in this process: knowledge, resources, and self-efficacy. We describe how both system and individual factors contribute to breakdowns leading to ineffective patient management. This work expands our understanding of the unique challenges faced by patients during this difficult transition and uncovers important design opportunities for supporting crucial yet unmet patient needs.

Older patients' experiences during care transition

BACKGROUND

A fragmented health care system leads to an increased demand for continuity of care across health care levels. Research indicates age-related differences during care transition, with the oldest patients having experiences and needs that differ from those of other patients. To meet the older patients' needs and preferences during care transition, professionals must understand their experiences.

OBJECTIVE

The purpose of the study was to explore how patients ≥80 years of age experienced the care transition from hospital to municipal health care services.

METHODS

The study has a descriptive, explorative design, using semistructured interviews. Fourteen patients aged ≥80 participated in the study. Qualitative content analysis was used to describe the individuals' experiences during care transition.

RESULTS

Two complementary themes emerged during the analysis: "Participation depends on being invited to plan the care transition" and "Managing continuity of care represents a complex and challenging process".

DISCUSSION

Lack of participation, insufficient information, and vague responsibilities among staff during care transition seemed to limit the continuity of care. The patients are the vulnerable part of the care transition process, although they possess important resources, which illustrate the importance of making their voice heard. Older patients are therefore likely to benefit from more intensive support. A tailored, patient-centered follow-up of each patient is suggested to ensure that patient preferences and continuity of care to adhere to the new situation.

Nurses' communication of pharmacogenetic test results as part of discharge care

As pharmacogenetic (PGx) testing is becoming integrated into routine clinical procedures for admitted hospital patients, consideration is needed as to when test results will be communicated to patients and by whom. Given the implications of PGx test results for current and future care, we propose that if results are not promptly discussed with patients when testing is completed, results should be discussed with patients during discharge care when possible, included in the printed or electronic discharge summary and a copy of the results sent to their primary provider. Nurses play an important role in discharge planning and care by providing patients with the necessary information and support to transfer from the hospital setting to an outpatient setting or to return to home and work. To promote nurses' ability to fulfill the role of communicating PGx test results, revised curricula and interprofessional and clinical decision support are needed.

Patient satisfaction in cardiology after cardiac catheterization : Effects of treatment outcome, visit characteristics, and perception of received care

BACKGROUND

Patient satisfaction is a key indicator for quality of care. However, recent data on determinants of satisfaction in invasive cardiology are lacking. Hence this study was conducted to identify determinants of patient satisfaction after hospitalization for cardiac catheterization.

PATIENTS AND METHODS

Data were obtained from 811 randomly selected patients discharged from ten hospitals responding to a mailed post-visit questionnaire. The satisfaction dimension was measured with a validated 42-item inventory assessing demographic and visit characteristics as well as medical, organizational, and service aspects of received care. Bivariate and multivariate statistical analyses were performed to identify predictors of satisfaction.

RESULTS

Patients were most satisfied with the kindness of medical practitioners and nurses. The lowest ratings were observed for discharge procedures and instructions. Multivariate analysis revealed five predictors of satisfaction: treatment outcome (OR, 2.14), individualized medical care (OR, 1.64), clear reply to patient's inquiries by physicians (OR, 1.63), kindness of nonmedical professionals (OR, 3.01), and room amenities (OR, 2.02). No association between demographic data and overall satisfaction was observed.

CONCLUSION

Five key determinants that can be addressed by health-care providers in order to improve patient satisfaction were identified. Our findings highlight the importance of the communicational behavior of health-care professionals and the transparency of discharge management.

Interdisciplinary Diabetes Care: A New Model for Inpatient Diabetes Education

A patient-centered interdisciplinary diabetes care model was implemented at Vidant Medical Center in Greenville, N.C., a 909-bed tertiary care teaching hospital, for the purpose of providing all patients with diabetes clear and concise instructions on diabetes survival skills. Survival skills education during hospitalization is needed for safe transition to community resources for continued and expanded diabetes self-management education. This article describes the process used to develop, implement, and evaluate the model. This initiative achieved substantial cost savings, with no significant changes in length of stay (LOS) or diabetes readmission rates. This patient-centered model demonstrates how a team of interdisciplinary health care professionals can integrate services in providing care for a large population of patients with chronic disease.

Comparing Patients' Opinions on the Hospital Discharge Process Collected With a Self-Reported Questionnaire Completed Via the Internet or Through a Telephone Survey: An Ancillary Study of the SENTIPAT Randomized Controlled Trial

BACKGROUND

Hospital discharge, a critical stage in the hospital-to-home transition of patient care, is a complex process with potential dysfunctions having an impact on patients' health on their return home. No study has yet reported the feasibility and usefulness of an information system that would directly collect and transmit, via the Internet, volunteer patients' opinions on their satisfaction concerning the organization of hospital discharge.

OBJECTIVE

Our primary objective was to compare patients' opinions on the discharge process collected with 2 different methods: self-questionnaire completed on a dedicated website versus a telephone interview. The secondary goal was to estimate patient satisfaction.

METHODS

We created a questionnaire to examine hospital discharge according to 3 dimensions: discharge logistics organization, preplanned posthospital continuity-of-care organization, and patients' impressions at the time of discharge. A satisfaction score (between 0 and 1) for each of those dimensions and an associated total score were calculated. Taking advantage of the randomized SENTIPAT trial that questioned patients recruited at hospital discharge about the evolution of their health after returning home and randomly assigned them to complete a self-questionnaire directly online or during a telephone interview, we conducted an ancillary study comparing satisfaction with the organization of hospital discharge for these 2 patient groups. The questionnaire was proposed to 1141 patients included in the trial who were hospitalized for ≥2 days, among whom 867 eligible patients had access to the Internet at home and were randomized to the Internet or telephone group.

RESULTS

Of the 1141 patients included, 755 (66.17%) completed the questionnaire. The response rates for the Internet (39.1%, 168/430) and telephone groups (87.2%, 381/437) differed significantly (P<.001), but their total satisfaction scores did not (P=.08) nor did the satisfaction subscores (P=.58 for discharge logistics organization, P=.12 for preplanned posthospital continuity-of-care organization, and P=.35 for patients' impressions at the time of discharge). The total satisfaction score (median 0.83, IQR 0.72-0.92) indicated the patients' high satisfaction.

CONCLUSIONS

The direct transmission of personal health data via the Internet requires patients' active participation and those planning surveys in the domain explored in this study should anticipate a lower response rate than that issued from a similar survey conducted by telephone interviews. Nevertheless, collecting patients' opinions on their hospital discharge via the Internet proved operational; study results indicate that conducting such surveys via the Internet yields similar estimates to those obtained via a telephone survey. The results support the establishment of a permanent dedicated website that could also be used to obtain users' opinions on other aspects of their hospital stay and follow-up.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01769261; http://clinicaltrials.gov/ct2/show/NCT01769261 (Archived by WebCite at http://www.webcitation.org/6ZDF5bdQb).

Location of HIV diagnosis impacts linkage to medical care

: We evaluated 1359 adults newly diagnosed with HIV in Philadelphia in 2010-2011 to determine if diagnosis site (medical clinic, inpatient setting, counseling and testing center (CTC), and correctional facility) impacted time to linkage to care (difference between date of diagnosis and first CD4/viral load). A total of 1093 patients (80%) linked to care: 86% diagnosed in medical clinics, 75% in inpatient settings, 62% in CTCs, and 44% in correctional facilities. Adjusting for other factors, diagnosis in inpatient settings, CTCs, and correctional facilities resulted in a 33% (adjusted hazard ratio = 0.77; 95% confidence interval: 0.64 to 0.92), 46% (0.56; 0.42-0.72), and 75% (0.25; 0.18-0.35) decrease in the probability of linkage compared with medical clinics, respectively.

Development and use of an administrative claims measure for profiling hospital-wide performance on 30-day unplanned readmission

BACKGROUND

Existing publicly reported readmission measures are condition-specific, representing less than 20% of adult hospitalizations. An all-condition measure may better measure quality and promote innovation.

OBJECTIVE

To develop an all-condition, hospital-wide readmission measure.

DESIGN

Measure development study.

SETTING

4821 U.S. hospitals.

PATIENTS

Medicare fee-for-service beneficiaries aged 65 years or older.

MEASUREMENTS

Hospital-level, risk-standardized unplanned readmissions within 30 days of discharge. The measure uses Medicare fee-for-service claims and is a composite of 5 specialty-based, risk-standardized rates for medicine, surgery/gynecology, cardiorespiratory, cardiovascular, and neurology cohorts. The 2007-2008 admissions were randomly split for development and validation. Models were adjusted for age, principal diagnosis, and comorbid conditions. Calibration in Medicare and all-payer data was examined, and hospital rankings in the development and validation samples were compared.

RESULTS

The development data set contained 8 018 949 admissions associated with 1 276 165 unplanned readmissions (15.9%). The median hospital risk-standardized unplanned readmission rate was 15.8 (range, 11.6 to 21.9). The 5 specialty cohort models accurately predicted readmission risk in both Medicare and all-payer data sets for average-risk patients but slightly overestimated readmission risk at the extremes. Overall hospital risk-standardized readmission rates did not differ statistically in the split samples (P = 0.71 for difference in rank), and 76% of hospitals' validation-set rankings were within 2 deciles of the development rank (24% were more than 2 deciles). Of hospitals ranking in the top or bottom deciles, 90% remained within 2 deciles (10% were more than 2 deciles) and 82% remained within 1 decile (18% were more than 1 decile).

LIMITATION

Risk adjustment was limited to that available in claims data.

CONCLUSION

A claims-based, hospital-wide unplanned readmission measure for profiling hospitals produced reasonably consistent results in different data sets and was similarly calibrated in both Medicare and all-payer data.

PRIMARY FUNDING SOURCE

Centers for Medicare & Medicaid Services.

Hospital discharge instructions: comprehension and compliance among older adults

BACKGROUND

Little is known regarding the prevalence or risk factors for non-comprehension and non-compliance with discharge instructions among older adults.

OBJECTIVE

To quantify the prevalence of non-comprehension and non-compliance with discharge instructions and to identify associated patient characteristics.

RESEARCH DESIGN

Prospective cohort study.

SUBJECTS

Four hundred and fifty adults aged ≥ 65 admitted to medical and surgical units of a tertiary care facility and meeting inclusion criteria.

MEASURES

We collected information on demographics, psycho-social factors, discharge diagnoses, and medications using surveys and patient medical records. Domains within discharge instructions included medications, follow-up appointments, diet, and exercise. At 5 days post-discharge, we assessed comprehension by asking patients about their discharge instructions, and compared responses to written instructions from medical charts. We assessed compliance among patients who understood their instructions.

RESULTS

Prevalence of non-comprehension was 5 % for follow-up appointments, 27 % for medications, 48 % for exercise and 50 % for diet recommendations. Age was associated with non-comprehension of medication [odds ratio (OR) 1.07; 95 % confidence interval (CI) 1.04, 1.12] and follow-up appointment (OR 1.08; 95 % CI 1.00, 1.17) instructions. Male sex was associated with non-comprehension of diet instructions (OR 1.91; 95 % CI 1.10, 3.31). Social isolation was associated with non-comprehension of exercise instructions (OR 9.42; 95 % CI 1.50, 59.11) Depression was associated with non-compliance with medication (OR 2.29; 95 % CI 1.02, 5.10) and diet instructions (OR 3.30; 95 % CI 1.24, 8.83).

CONCLUSIONS

Non-comprehension of discharge instructions among older adults is prevalent, multi-factorial, and varies by domain.

Readmissions at a public safety net hospital

Objective

We aimed to determine factors related to avoidability of 30-day readmissions at our public, safety net hospital in the United States (US).

Methods

We prospectively reviewed medical records of adult internal medicine patients with scheduled and unscheduled 30-day readmissions. We also interviewed patients if they were available. An independent panel used pre-specified, objective criteria to adjudicate potential avoidability.

Results

Of 153 readmissions evaluated, 68% were unscheduled. Among these, 67% were unavoidable, primarily due to disease progression and development of new diagnoses. Scheduled readmissions accounted for 32% of readmissions and most (69%) were clinically appropriate and unavoidable. The scheduled but avoidable readmissions (31%) were attributed largely to limited resources in our healthcare system.

Conclusions

Most readmissions at our public, safety net hospital were unavoidable, even among our unscheduled readmissions. Surprisingly, one-third of our overall readmissions were scheduled, the majority reflecting appropriate management strategies designed to reduce unnecessary hospital days. The scheduled but avoidable readmissions were due to constrained access to non-emergent, expensive procedures that are typically not reimbursed given our system’s payor mix, a problem which likely plague other safety net systems. These findings suggest that readmissions do not necessarily reflect inadequate medical care, may reflect resource constraints that are unlikely to be addressable in systems caring for a large burden of uninsured patients, and merit individualized review.

Cardiovascular Admissions, Readmissions, and Transitions of Care

Hospital 30-day readmissions have become a major priority for hospitals. Hospitals face penalties for excessive readmissions for acute myocardial infarction (AMI) and heart failure (HF). Thus, it is important for hospitals to understand the transitions of care that occur for both of these conditions, and what tools are available to guide the processes involved. A multi-disciplinary team including Emergency Medical Service providers, Emergency Medicine providers, cardiologists, hospitalists, pharmacists, nurses, case managers, and outpatient physicians can all be involved in the process of safely transitioning a patient between care settings. Small-scale studies in the geriatric population have shown improved transitions of care and decreased readmissions with these care teams. The emergency department is a key transition point for patients with AMI and HF, yet it is rarely identified and utilized as such in transitions of care interventions. Future research and implementation projects will need to refine and expand the role of the emergency department in the process.

Professionalism and patient education in urologic surgery

Medical professionalism provides the guidelines that govern the patient-physician relationship. This implicit contract requires that patients be informed before making decisions regarding their medical care. Educating patients about diagnostic and treatment decisions is critical to an informed decision-making process. Shared decision-making is a recent paradigm shift in patient education that allows patients to make decisions based both on the counsel of their physicians and according to their own preferences and values. This approach moves away from previous models that focused on physicians or third-party payers as the arbiters of diagnostic and treatment choices. Urologic surgeons have been at the forefront of shared decision-making research and continue to promote this concept in the most recent American Urological Association Guideline on Detection of Prostate Cancer. Unfortunately, the fee-for-service financial structure that predominates in the United States’ health care system provides a disincentive for shared decision-making. By promoting patient volume rather than time spent with patients, this system rewards physicians who spend less time educating patients about diagnostic and treatment options. Therefore, to promote adherence to the educational responsibility inherent in medical professionalism, we recommend physician payment reform that rewards physicians for time spent with patients rather than the volume of patients seen.

Quality collaboratives and campaigns to reduce readmissions: what strategies are hospitals using?

BACKGROUND

Reducing hospital readmissions is a national priority, and many hospitals are participating in quality collaboratives or campaigns.

OBJECTIVE

To describe and compare the current use of hospital strategies to reduce readmissions in 2 prominent quality initiatives-STAAR (State Action on Avoidable Rehospitalization) and H2H (Hospital-to-Home Campaign).

DESIGN

Cross-sectional.

METHODS

Web-based survey of hospitals that had enrolled in H2H or STAAR from May 2009 through June 2010, conducted from November 1, 2010 through June 30, 2011 (n = 599, response rate of 91%). We used standard frequency analysis and multivariable logistic regression to describe differences between STAAR and H2H hospitals.

RESULTS

Many hospitals were not implementing several of the recommended strategies. Although STAAR hospitals tended to be more likely to implement several strategies, differences were attenuated when we adjusted for region and ownership type. In multivariable models, STAAR hospitals compared with H2H hospitals were more likely to ensure outpatient physicians were alerted within 48 hours of patient discharge (63% vs 38%, P < 0.001), and more likely to provide skilled nursing facilities the direct contact number of the inpatient treating physician for patients transferred (53% vs 34%, P = 0.001). H2H hospitals were more likely to assign responsibility for medication reconciliation to nurses usually or always (80% vs 54%, P = 0.001) and more likely to give most or all discharged patients referrals to cardiac rehabilitation services (59% vs 41%, P = 0.001).

CONCLUSIONS

Substantial opportunity for improvement exists for hospitals engaged in STAAR or H2H quality initiatives.