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Development and Introduction of Point-of-Care Testing in Mobile Critical Care Units for Improved Patient Safety in Rural Areas. POINT OF CARE 2009. [DOI: 10.1097/poc.0b013e3181b24315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
BACKGROUND Transition of patient care from an inpatient to outpatient setting is a critical aspect of patient care. The objectives of this study were to describe the content and evaluation of the discharge planning curricula (DPC) in internal medicine (IM) residency programs and identify program directors' perceptions of discharge planning education. METHOD A 24-item questionnaire was sent to 387 IM program directors during April 2005. The analysis was conducted using SPSS (version 15). RESULTS A total of 140 program directors (PDs) responded. Formal DPC was offered in 16% (n = 23) of the programs. Hospital resources to coordinate transition of care and communication skills were the main curricular content areas. Seventy-five percent of the PDs agreed that discharge planning should be an important part of the curriculum. More than 50% of the PDs agreed that discharge planning would decrease the re-admission rate, and increase patient satisfaction and referring physician satisfaction. The programs with a DPC had a higher level of agreement that a DPC program would facilitate continuity of care between inpatient and outpatient care (P = 0.027) compared to programs without a DPC. CONCLUSIONS The majority of the PDs agreed that DPC should be an important curricular component, yet only a few programs offered formal discharge planning education. Residency programs need to address this critical aspect of patient care within the core curricula.
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Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, Weiss KB, Williams MV. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med 2009; 24:971-6. [PMID: 19343456 PMCID: PMC2710485 DOI: 10.1007/s11606-009-0969-x] [Citation(s) in RCA: 165] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Revised: 01/21/2009] [Accepted: 03/17/2009] [Indexed: 11/29/2022]
Abstract
The American College of Physicians (ACP), Society of Hospital Medicine (SHM), Society of General Internal Medicine (SGIM), American Geriatric Society (AGS), American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) developed consensus standards to address the quality gaps in the transitions between inpatient and outpatient settings. The following summarized principles were established: 1.) Accountability; 2) Communication; 3.) Timely interchange of information; 4.) Involvement of the patient and family member; 5.) Respect the hub of coordination of care; 6.) All patients and their family/caregivers should have a medical home or coordinating clinician; 7.) At every point of transitions the patient and/or their family/caregivers need to know who is responsible for their care at that point; 9.) National standards; and 10.) Standardized metrics related to these standards in order to lead to quality improvement and accountability. Based on these principles, standards describing necessary components for implementation were developed: coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards, and measurement.
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Affiliation(s)
- Vincenza Snow
- American College of Physicians, 190 N Independence Mall West, Philadelphia, PA, USA.
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Goderis G, Borgermans L, Mathieu C, Van Den Broeke C, Hannes K, Heyrman J, Grol R. Barriers and facilitators to evidence based care of type 2 diabetes patients: experiences of general practitioners participating to a quality improvement program. Implement Sci 2009; 4:41. [PMID: 19624848 PMCID: PMC2719589 DOI: 10.1186/1748-5908-4-41] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 07/22/2009] [Indexed: 11/24/2022] Open
Abstract
Objective To evaluate the barriers and facilitators to high-quality diabetes care as experienced by general practitioners (GPs) who participated in an 18-month quality improvement program (QIP). This QIP was implemented to promote compliance with international guidelines. Methods Twenty out of the 120 participating GPs in the QIP underwent semi-structured interviews that focused on three questions: 'Which changes did you implement or did you observe in the quality of diabetes care during your participation in the QIP?' 'According to your experience, what induced these changes?' and 'What difficulties did you experience in making the changes?' Results Most GPs reported that enhanced knowledge, improved motivation, and a greater sense of responsibility were the key factors that led to greater compliance with diabetes care guidelines and consequent improvements in diabetes care. Other factors were improved communication with patients and consulting specialists and reliance on diabetes nurse educators. Some GPs were reluctant to collaborate with specialists, and especially with diabetes educators and dieticians. Others blamed poor compliance with the guidelines on lack of time. Most interviewees reported that a considerable minority of patients were unwilling to change their lifestyles. Conclusion Qualitative research nested in an experimental trial may clarify the improvements that a QIP may bring about in a general practice, provide insight into GPs' approach to diabetes care and reveal the program's limits. Implementation of a QIP encounters an array of cognitive, motivational, and relational obstacles that are embedded in a patient-healthcare provider relationship.
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Affiliation(s)
- Geert Goderis
- Department of General Practice, Katholieke Universiteit, Leuven, Belgium.
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Goldfield NI, Fuller RL, Averill RF. Paying for Quality and Coordination: Aligning Provider Payments With Global Goals. Am J Med Qual 2009; 24:480-8. [DOI: 10.1177/1062860609341195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bardach NS, Huang J, Brand R, Hsu J. Evolving health information technology and the timely availability of visit diagnoses from ambulatory visits: a natural experiment in an integrated delivery system. BMC Med Inform Decis Mak 2009; 9:35. [PMID: 19615081 PMCID: PMC2731742 DOI: 10.1186/1472-6947-9-35] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Accepted: 07/17/2009] [Indexed: 12/05/2022] Open
Abstract
Background Health information technology (HIT) may improve health care quality and outcomes, in part by making information available in a timelier manner. However, there are few studies documenting the changes in timely availability of data with the use of a sophisticated electronic medical record (EMR), nor a description of how the timely availability of data might differ with different types of EMRs. We hypothesized that timely availability of data would improve with use of increasingly sophisticated forms of HIT. Methods We used an historical observation design (2004–2006) using electronic data from office visits in an integrated delivery system with three types of HIT: Basic, Intermediate, and Advanced. We calculated the monthly percentage of visits using the various types of HIT for entry of visit diagnoses into the delivery system's electronic database, and the time between the visit and the availability of the visit diagnoses in the database. Results In January 2004, when only Basic HIT was available, 10% of office visits had diagnoses entered on the same day as the visit and 90% within a week; 85% of office visits used paper forms for recording visit diagnoses, 16% used Basic at that time. By December 2006, 95% of all office visits had diagnoses available on the same day as the visit, when 98% of office visits used some form of HIT for entry of visit diagnoses (Advanced HIT for 67% of visits). Conclusion Use of HIT systems is associated with dramatic increases in the timely availability of diagnostic information, though the effects may vary by sophistication of HIT system. Timely clinical data are critical for real-time population surveillance, and valuable for routine clinical care.
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Affiliation(s)
- Naomi S Bardach
- Department of General Pediatrics, University of California, San Francisco, 3333 California St, Suite 245, San Francisco, CA 94118, USA.
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Graumlich JF, Novotny NL, Nace GS, Aldag JC. Patient and physician perceptions after software-assisted hospital discharge: cluster randomized trial. J Hosp Med 2009; 4:356-63. [PMID: 19621342 DOI: 10.1002/jhm.565] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hospital discharge software potentially improves communication and clinical outcomes. OBJECTIVE To measure patient and physician perceptions after discharge with computerized physician order entry (CPOE) software. DESIGN Cluster randomized controlled trial. SETTING Tertiary care, teaching hospital in central Illinois. PATIENTS A total of 631 inpatients discharged to home with high risk for readmission. INTERVENTION A total of 70 internal medicine hospital physicians randomly assigned (allocation concealed) to discharge software vs. usual care, handwritten discharge. MEASUREMENTS Discharge perceptions from patients, outpatient primary care physicians, and hospital physicians. RESULTS One week after discharge, 92.4% (583/631) of patients answered interviews. For 78.6% (496/631) of patients, their outpatient physicians returned questionnaires 19 days (median) postdischarge. Generalized estimating equations gave intervention variable coefficients with 95% confidence intervals (CIs). When comparing patients assigned to discharge software vs. usual care, patient mean (standard deviation [SD]) scores for discharge preparedness were higher (17.7 [4.1] vs. 17.2 [4.0]; coefficient = 0.147; 95% CI = 0.005-0.289; P = 0.042), patient scores for satisfaction with medication information were unchanged (12.3 [4.8] vs. 12.1 [4.6]; coefficient = -0.212; 95% CI = -0.937-0.513; P = 0.567), and their outpatient physicians scored higher quality discharge (17.2 [3.8] vs. 16.5 [3.9]; coefficient = 0.133; 95% CI = 0.015-0.251; P = 0.027). Hospital physicians found mean effort to use discharge software was more difficult than the usual care (6.5 [1.9] vs. 7.9 [2.1]; P = 0.011). CONCLUSIONS Discharge software with CPOE caused small improvements in discharge perceptions by patients and their outpatient physicians. These small improvements might balance the difficulty perceived by hospital physicians who used discharge software.
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Affiliation(s)
- James F Graumlich
- Department of Medicine, University of Illinois College of Medicine and OSF-Saint Francis Medical Center, Peoria, Illinois, USA.
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Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, Weiss KB, Williams MV. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med 2009; 4:364-70. [PMID: 19479781 DOI: 10.1002/jhm.510] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies such as the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services, performance measure developers such as the National Committee for Quality Assurance and the American Medical Association Physician Consortium on Performance Improvement, nurse associations such as the Visiting Nurse Associations of America and Home Care and Hospice, pharmacist groups, and patient groups such as the Institute for Family-Centered Care. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document.
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Affiliation(s)
- Vincenza Snow
- American College of Physicians, Philadelphia, Pennsylvania 19106, USA.
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Donohue PK, Hussey-Gardner B, Sulpar LJ, Fox R, Aucott SW. Convalescent care of infants in the neonatal intensive care unit in community hospitals: risk or benefit? Pediatrics 2009; 124:105-11. [PMID: 19564289 DOI: 10.1542/peds.2008-0880] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To compare very low birth weight (VLBW) infants transported to a community hospital (CH) before discharge with infants who received convalescent care in a regional-referral NICU (RR-NICU) on 4 parameters: health indicators at the time of hospital discharge, health care use during the 4 months after discharge to home, parent satisfaction with hospital care, and cost of hospitalization. PATIENTS AND METHODS VLBW infants cared for in 2 RR-NICUs during 2004-2006 were enrolled in the study. One RR-NICU transfers infants to a CH for convalescent care and the other discharges infants directly home. Infants were followed prospectively. Information was gathered from medical charts, parent interviews, and hospital business offices. RESULTS A total of 255 VLBW infants were enrolled in the study, and 148 were transferred to 15 CHs. Nineteen percent of transferred infants were readmitted to a higher level of care before discharge from the hospital. Preventative health measures and screening examinations were more frequently missed, readmission within 2 weeks of discharge from the hospital was more frequent, parents were less satisfied with hospital care, and duration of hospitalization was 12 days longer, although not statistically different, if infants were transferred to a CH for convalescence rather than discharged from the RR-NICU. Total hospital charges did not differ significantly between the groups. CONCLUSION Transfer of infants to a CH from an RR-NICU for convalescent care has become routine but may place infants at risk. Our study indicates room for improvement by both CHs and RR-NICUs in the care of transferred VLBW infants.
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Affiliation(s)
- Pamela K Donohue
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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O'Connor C, Friedrich JO, Scales DC, Adhikari NKJ. The use of wireless e-mail to improve healthcare team communication. J Am Med Inform Assoc 2009; 16:705-13. [PMID: 19567803 DOI: 10.1197/jamia.m2299] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To assess the impact of using wireless e-mail for clinical communication in an intensive care unit (ICU). DESIGN The authors implemented push wireless e-mail over a GSM cellular network in a 26-bed ICU during a 6-month study period. Daytime ICU staff (intensivists, nurses, respiratory therapists, pharmacists, clerical staff, and ICU leadership) used handheld devices (BlackBerry, Research in Motion, Waterloo, ON) without dedicated training. The authors recorded e-mail volume and used standard methods to develop a self-administered survey of ICU staff to measure wireless e-mail impact. MEASUREMENTS The survey assessed perceived impact of wireless e-mail on communication, team relationships, staff satisfaction and patient care. Answers were recorded on a 7-point Likert scale; favorable responses were categorized as Likert responses 5, 6, and 7. RESULTS Staff sent 5.2 (1.9) and received 8.9 (2.1) messages (mean [SD]) per day during 5 months of the 6-month study period; usage decreased after study completion. Most (106/125 [85%]) staff completed the questionnaire. The majority reported that wireless e-mail improved speed (92%) and reliability (92%) of communication, improved coordination of ICU team members (88%), reduced staff frustration (75%), and resulted in faster (90%) and safer (75%) patient care; Likert responses were significantly different from neutral (p < 0.001 for all). Staff infrequently (18%) reported negative effects on communication. There were no reports of radiofrequency interference with medical devices. CONCLUSIONS Interdisciplinary ICU staff perceived wireless e-mail to improve communication, team relationships, staff satisfaction, and patient care. Further research should address the impact of wireless e-mail on efficiency and timeliness of staff workflow and clinical outcomes.
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Affiliation(s)
- Chris O'Connor
- Department of Critical Care Medicine, Room D1.08, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, Canada M4N3M5.
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Beaulieu MD, Samson L, Rocher G, Rioux M, Boucher L, Del Grande C. Investigating the barriers to teaching family physicians' and specialists' collaboration in the training environment: a qualitative study. BMC MEDICAL EDUCATION 2009; 9:31. [PMID: 19500409 PMCID: PMC2701430 DOI: 10.1186/1472-6920-9-31] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 06/07/2009] [Indexed: 05/12/2023]
Abstract
BACKGROUND Collaboration between physicians in different specialties is often taken for granted. However, poor interactions between family physicians and specialists contribute significantly to the observed discontinuity between primary and specialty care. The objective of this study was to explore how collaboration between family physicians and specialists was conceptualised as a competency and experienced in residency training curricula of four faculties of medicine in Canada. METHODS This is a multiple-case study based on Abbott's theory of professions. Programs targeted were family medicine, general psychiatry, radiology, and internal medicine. The content of the programs' objectives was analyzed. Associate deans of postgraduate studies, program directors, educators, and residents were interviewed individually or in focus groups (47 residents and 45 faculty members). RESULTS The training objectives related to family physicians-specialists collaboration were phrased in very general terms and lacked specificity. Obstacles to effective collaboration were aggregated under themes of professional responsibility and questioned expertise. Both trainees and trainers reported increasing distances between specialty and general medicine in three key fields of the professional system: the workplace arena, the training setting, and the production of academic knowledge. CONCLUSION The challenges of developing collaborating skills between generalists and specialist physicians are comparable in many ways to those encountered in inter-professional collaboration and should be given more consideration than they currently receive if we want to improve coordination between primary and specialty care.
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Affiliation(s)
- Marie-Dominique Beaulieu
- Doctor Sadok Besrour Chair in Family Medicine, Department of Family Medicine, Universite de Montreal, Montreal, Canada.
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Brez S, Rowan M, Malcolm J, Izzi S, Maranger J, Liddy C, Keely E, Ooi TC. Transition from specialist to primary diabetes care: a qualitative study of perspectives of primary care physicians. BMC FAMILY PRACTICE 2009; 10:39. [PMID: 19500397 PMCID: PMC2704171 DOI: 10.1186/1471-2296-10-39] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 06/06/2009] [Indexed: 12/13/2022]
Abstract
Background The growing prevalence of diabetes and heightened awareness of the benefits of early and intensive disease management have increased service demands and expectations not only of primary care physicians but also of diabetes specialists. While research has addressed issues related to referral into specialist care, much less has been published about the transition from diabetes specialists back to primary care. Understanding the concerns of family physicians related to discharge of diabetes care from specialist centers can support the development of strategies that facilitate this transition and result in broader access to limited specialist services. This study was undertaken to explore primary care physician (PCP) perspectives and concerns related to reassuming responsibility for diabetes care after referral to a specialized diabetes center. Methods Qualitative data were collected through three focus groups. Sessions were audio-taped and transcribed verbatim. Data were coded and sorted with themes identified using a constant comparison method. The study was undertaken through the regional academic referral center for adult diabetes care in Ottawa, Canada. Participants included 22 primary care physicians representing a variety of referral frequencies, practice types and settings. Results Participants described facilitators and barriers to successful transition of diabetes care at the provider, patient and systems level. Major facilitators included clear communication of a detailed, structured plan of care, ongoing access to specialist services for advice or re-referral, continuing education and mentoring for PCPs. Identified provider barriers were gaps in PCP knowledge and confidence related to diabetes treatment, excessive workload and competing time demands. Systems deterrents included reimbursement policies for health professionals and inadequate funding for diabetes medications and supplies. At the PCP-patient interface, insufficient patient confidence or trust in PCP's ability to manage diabetes, poor motivation and "non-compliance" emerged as potential patient barriers to transition. Incongruence between PCP attitudes and expectations related to diabetes self-management and those of patients who had attended a multidisciplinary specialist center was also observed. Conclusion This study underlines the breadth of PCP concerns related to transition of diabetes care and the importance of this topic to them. While tools that promote timely information flow and care planning are cornerstones to successful transition, and may be sufficient for some practitioners, appropriately resourced decision support and education strategies should also be available to enhance PCP capacity and readiness to resume diabetes care after referral to a specialist center. Characteristics of the patient-care provider relationship that impact discharge were identified and are worthy of further research.
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Affiliation(s)
- Sharon Brez
- Foustanellas Endocrine and Diabetes Centre, The Ottawa Hospital, 4th Floor Riverside Campus, 1967 Riverside Drive, Ottawa Ontario, K1H 7W9, Canada .
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Clancy CM. Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. Am J Med Qual 2009; 24:344-6. [PMID: 19502567 DOI: 10.1177/1062860609338131] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carolyn M Clancy
- Agency for Healthcare Research and Quality, Rockville, Maryland, USA
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Horwitz LI, Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY. Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care. Ann Emerg Med 2009; 53:701-10.e4. [DOI: 10.1016/j.annemergmed.2008.05.007] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2007] [Revised: 04/29/2008] [Accepted: 05/05/2008] [Indexed: 11/30/2022]
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Miller A, Scheinkestel C, Joseph M, Hospital A. Coordination and continuity of intensive care unit patient care. HUMAN FACTORS 2009; 51:354-367. [PMID: 19750797 DOI: 10.1177/0018720809340032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Using Klein's model of team coordination, we explored the null hypothesis that intensive care unit (ICU) care coordination unfolds as a linear sequence. Our intent was to generate hypotheses for further research and to provide interim recommendations for improving care coordination. We also explored factors contributing to care coordination (e.g., role responsibilities, support tools). BACKGROUND Although the body of clinical communications research is considerable, few studies address broader team processes in real-world environments; hence, these processes are not well understood. METHODS All bedside communications for 5 ICU patients were recorded for 5 days per patient and were coded using Klein's model. Markov analysis was used to describe the care coordination process. Multivariate contingency table analysis and standardized parameter estimates described important contributing factors, and support tools were described using descriptive statistics. RESULTS First-, second-, and third-order Markov analyses show that care coordination does not unfold as a linear sequence; however, Markov diagrams suggest some process structure. Standardized parameter estimates of factors contributing to care coordination were calculated from a statistically significant three-way model (chi2[df= 18] = 36.95, p < .005). Role-based differences depend on context, with important differences in contributions to care coordination occurring within rounds. Tools supported only 48% of conversations. CONCLUSION Three alternative research hypotheses were defined with at least a minimal level of support. Testing these hypotheses present substantial theoretical, methodological, and data analysis challenges. APPLICATION Within a research framework, recommendations for change could achieve significant gains for understanding and for reducing breakdowns in care coordination.
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Affiliation(s)
- Anne Miller
- Vanderbilt University Medical Center, Center for Perioperative Research in Quality, 1211 21st Avenue South, Nashville, TN 37212, USA.
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Wood SK, Campbell AK, Marden JD, Schmidtman L, Blundell GH, Sheerin NJ, Davidson PM. Inpatient care to community care: improving clinical handover in the private mental health setting. Med J Aust 2009; 190:S144-9. [DOI: 10.5694/j.1326-5377.2009.tb02623.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2008] [Accepted: 01/18/2009] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | | | | | | | - Patricia M Davidson
- Centre for Cardiovascular and Chronic Care, Curtin University of Technology (Sydney), Sydney, NSW
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Miller A, Scheinkestel C, Limpus A, Joseph M, Karnik A, Venkatesh B. Uni- and interdisciplinary effects on round and handover content in intensive care units. HUMAN FACTORS 2009; 51:339-353. [PMID: 19750796 DOI: 10.1177/0018720809338188] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE The aim of this study was to explore differences in the verbal content of handovers and rounds conducted in uni- and interdisciplinary social contexts. We expected higher proportions of goals to be articulated during interdisciplinary rounds. BACKGROUND Lack of explanatory connections between round improvement initiatives and outcomes suggest insufficient understanding about health care communications, especially the role of social interaction. METHODS The recognition-primed abstract decomposition space (RP-ADS) was used to analyze the information content of nurse handovers and morning rounds in a unidisciplinary- (physicians only) and an interdisciplinary-round intensive care unit (ICU). Data were collected using audio recordings of rounds and handovers for five patients for 5 days each in both ICUs. RESULTS Hierarchical log-linear analyses show strong associations between events (medical rounds vs. nurses' shift handovers), type (uni- vs. interdisciplinary), and focus (levels of the RP-ADS) with highly significant combined two-way and higher-order interactions, LRchi2(df=4) = 30.91, p < .0001. All tests of partial association were also highly significant. Differences among levels of the variables were evaluated using standardized residuals. CONCLUSION Nurses focused on RP-ADS data and intervention levels, whereas physicians focused on diagnoses and expectations. Clinical goals that integrate these orientations emerged to a greater extent in interdisciplinary rounds. In addition, social context of rounds appears to influence nurse handovers. Unidisciplinary ICU nurse handovers consisted of a series of data- and intervention-related observations, whereas ICU nurse handovers in interdisciplinary ICUs tended to integrate data, interventions and clinical goals. APPLICATION These results are relevant to the design and implementation of clinical communication improvement initiatives and support tools.
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Affiliation(s)
- Anne Miller
- Vanderbilt University Medical Center, Center for Perioperative Research in Quality, 1211 21st Avenue South, Nashville, TN 37212, USA.
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Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med 2009; 24:630-5. [PMID: 19291332 PMCID: PMC2669872 DOI: 10.1007/s11606-009-0948-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Revised: 02/11/2009] [Accepted: 02/12/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Failure to reconcile medications across transitions in care is an important source of harm to patients. Little is known about medication discrepancies upon admission to skilled nursing facilities (SNFs). OBJECTIVE To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the SNF setting. DESIGN Cross-sectional study. PARTICIPANTS Patients admitted to SNF for subacute care. MEASUREMENTS Number of medication discrepancies, defined as unexplained differences among documented medication regimens, including the hospital discharge summary, patient care referral form and SNF admission orders. RESULTS Of 2,319 medications reviewed on admission, 495 (21.3%) had a medication discrepancy. At least one medication discrepancy was identified in 142 of 199 (71.4%) SNF admissions. The discharge summary and the patient care referral form did not match in 104 of 199 (52.3%) SNF admissions. Disagreement between the discharge summary and the patient care referral form accounted for 62.0% (n = 307) of all medication discrepancies. Cardiovascular agents, opioid analgesics, neuropsychiatric agents, hypoglycemics, antibiotics, and anticoagulants accounted for over 50% of all discrepant medications. CONCLUSIONS Medication discrepancies occurred in almost three out of four SNF admissions and accounted for one in five medications prescribed on admission. The discharge summary and the patient care referral forms from the discharging institution are often in disagreement. Our study findings underscore the importance of current efforts to improve the quality of inter-institutional communication.
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Affiliation(s)
- Jennifer Tjia
- Division of Geriatric Medicine, University of Massachusetts Medical School, 377 Plantation Street, Suite 315, Biotech Four, Worcester, MA 01605, USA.
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Zsenits B, Polashenski WA, Sterns RH, Brown DR, Moheet A. Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record. J Hosp Med 2009; 4:308-12. [PMID: 19504492 DOI: 10.1002/jhm.401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The nationwide expansion of the hospitalist movement brings rapid change in communication and work processes in many hospitals. While our fast-growing hospitalist program has greatly improved length of stay and quality measures, it has also faced complex operational challenges affecting the whole organization rather than just our division: assigning and tracking hospitalist coverage of admitted patients was one of these challenges. METHODS We integrated a system of algorithms and interface solutions into our hospital's preexisting electronic health records (EHR) program to act as a decision support tool and computerized safety net during admission and patient distribution. Its main structural elements include: (1) algorithms that identify patients for hospitalist coverage and monitor coverage during transitions of care; (2) EHR data fields that enable hospitalists to assign and update each patient's coverage information in real time; and (3) a combination of display solutions to inform users of coverage arrangements and alert for potentially misassigned patients. Our system assists with correct attending selection on admission. It also assures continuity of coverage during transitions within the hospitalist program and across care settings. RESULTS Our enhancements to the EHR received unanimously positive assessment by users and added an important layer of patient safety and organizational efficiency for our hospitalist program. DISCUSSION Adaptations of our tools may provide similar opportunities for improvements in a variety of hospitalist settings; an integrated computerized physician order entry (CPOE) system is not a prerequisite. We demonstrate how the presented innovations can be used to enhance other EHR functions as well.
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Affiliation(s)
- Balazs Zsenits
- Department of Medicine, Rochester General Hospital, Rochester, New York, USA.
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Sharma G, Fletcher KE, Zhang D, Kuo YF, Freeman JL, Goodwin JS. Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults. JAMA 2009; 301:1671-80. [PMID: 19383958 PMCID: PMC2771916 DOI: 10.1001/jama.2009.517] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization. OBJECTIVES To describe continuity of care in older hospitalized patients, change in continuity over time, and factors associated with discontinuity. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of 3,020,770 hospital admissions between 1996 and 2006 using enrollment and claims data for a 5% national sample of Medicare beneficiaries older than 66 years. Data files were constructed to include the patients' demographic and enrollment information (denominator file) and claims for hospital stays (MEDPAR file) and physician services (carrier claims file). Characteristics of the hospitals were included in annual provider of services files. Being seen by a physician was defined as when a physician had submitted a bill for evaluation and management services for that patient. MAIN OUTCOME MEASURES Percentage of patients who during hospitalization were seen by any outpatient physician they had visited in the year before hospitalization (continuity with any outpatient physician) or by their primary care physician (PCP) (continuity with a PCP). RESULTS In 1996, 50.5% (95% confidence interval [CI], 50.3%-50.7%) of hospitalized patients were seen by at least 1 physician that they had visited in an outpatient setting in the prior year, and 44.3% (95% CI, 44.1%-44.6%) of patients with an identifiable PCP were seen by that physician while hospitalized. These percentages decreased to 39.8% (95% CI, 39.6%-40.0%) and 31.9% (95% CI, 31.6%-32.1%), respectively, in 2006. Greater absolute decreases in continuity with any outpatient physician between 1996 and 2006 occurred in patients admitted on weekends (13.9%; 95% CI, 12.9%-14.7%) and those living in large metropolitan areas (11.7%; 95% CI, 11.1%-12.3%) and in New England (16.2%; 95% CI, 14.4%-18.0%). In multivariable multilevel models, increasing involvement of hospitalists was associated with approximately one-third of the decrease in continuity of care between 1996 and 2006. CONCLUSION Between 1996 and 2006, physician continuity from outpatient to inpatient settings decreased in the Medicare population.
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Affiliation(s)
- Gulshan Sharma
- Department of Internal Medicine, University of Texas Medical Branch, 301 University Blvd, JSA-5.112, Galveston, TX 77555-0561, USA.
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Vedel I, De Stampa M, Bergman H, Ankri J, Cassou B, Blanchard F, Lapointe L. Healthcare professionals and managers' participation in developing an intervention: a pre-intervention study in the elderly care context. Implement Sci 2009; 4:21. [PMID: 19383132 PMCID: PMC2678079 DOI: 10.1186/1748-5908-4-21] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 04/21/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In order to increase the chances of success in new interventions in healthcare, it is generally recommended to tailor the intervention to the target setting and the target professionals. Nonetheless, pre-intervention studies are rarely conducted or are very limited in scope. Moreover, little is known about how to integrate the results of a pre-intervention study into an intervention. As part of a project to develop an intervention aimed at improving care for the elderly in France, a pre-intervention study was conducted to systematically gather data on the current practices, issues, and expectations of healthcare professionals and managers in order to determine the defining features of a successful intervention. METHODS A qualitative study was carried out from 2004 to 2006 using a grounded theory approach and involving a purposeful sample of 56 healthcare professionals and managers in Paris, France. Four sources of evidence were used: interviews, focus groups, observation, and documentation. RESULTS The stepwise approach comprised three phases, and each provided specific results. In the first step of the pre-intervention study, we gathered data on practices, perceived issues, and expectations of healthcare professionals and managers. The second step involved holding focus groups in order to define the characteristics of a tailor-made intervention. The third step allowed validation of the findings. Using this approach, we were able to design and develop an intervention in elderly care that met the professionals' and managers' expectations. CONCLUSION This article reports on an in-depth pre-intervention study that led to the design and development of an intervention in partnership with local healthcare professionals and managers. The stepwise approach represents an innovative strategy for developing tailored interventions, particularly in complex domains such as chronic care. It highlights the usefulness of seeking out the insight of healthcare professionalnd managers and emphasizes the need to intervene at different levels. Further research will be needed in order to develop a more thorough understanding of the impacts of such strategies on the final outcomes of intervention implementations.
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Affiliation(s)
- Isabelle Vedel
- Université de Versailles St-Quentin, Laboratoire Santé Vieillissement, AP-HP, Hôpital Sainte Perine, 49 rue Mirabeau 75016 Paris, France.
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O'Leary KJ, Liebovitz DM, Feinglass J, Liss DT, Evans DB, Kulkarni N, Landler MP, Baker DW. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med 2009; 4:219-25. [PMID: 19267397 DOI: 10.1002/jhm.425] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Deficits in information transfer between inpatient and outpatient physicians are common and potentially dangerous. OBJECTIVE To evaluate the effect of a newly-created electronic discharge summary. DESIGN AND PARTICIPANTS Pre-post evaluation of discharge summaries using a survey of outpatient physicians and a medical records review. MEASUREMENTS Outpatient physicians' ratings of satisfaction with discharge summaries before and after implementation of an electronic discharge summary using a 5-point Likert scale (1 = very dissatisfied; 5 = very satisfied). Additionally, 196 randomly selected discharge summaries before and after implementation were rated for timeliness and presence of 16 key content areas by 3 internists. RESULTS Two hundred and twenty-six of 416 (54%) and 256 of 397 (64%) outpatient physicians completed the baseline and postimplementation surveys. Satisfaction with quality and timeliness of discharge summaries improved with the use of the electronic discharge summary (mean quality rating 3.04 versus 3.64; P < 0.001, mean timeliness rating 2.59 versus 3.34; P < 0.001). A higher percentage of electronic discharge summaries were completed within 3 days of discharge as compared with dictated discharge summaries (44.8% versus 74.1%; P < 0.001). Several elements of the discharge summary were present more often with the electronic discharge summary, including discussion of follow-up issues (52.0% versus 75.8%; P = 0.001), pending test results (13.9% versus 46.3%; P < 0.001), and information provided to the patient and/or family (85.1% versus 95.8%; P = 0.01). CONCLUSIONS The use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries.
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Affiliation(s)
- Kevin J O'Leary
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, 259 East Erie Street, Chicago, IL 60611, USA.
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Cowie L, Morgan M, White1 P, Gulliford M. Experience of continuity of care of patients with multiple long-term conditions in England. J Health Serv Res Policy 2009; 14:82-7. [DOI: 10.1258/jhsrp.2009.008111] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives: To examine patients’ experiences of continuity of care in the context of different long-term conditions and models of care, and to explore implications for the future organization care of long-term conditions. Methods: Qualitative semi-structured interviews were carried out with 33 patients recruited from seven general practices in South London. Patients were selected who had one or more of the following long-term conditions: arthritis, coronary heart disease, stroke, hypercholesterolaemia, hypertension, diabetes mellitus or chronic obstructive pulmonary disease. Results: Multiple morbidity was frequent and experiences of continuity were framed within patients’ wider experiences of health care rather than the context of a particular diagnosis. Positive experiences of relational continuity were strongly associated with long-term GP-led or specialist-led care. Management continuity was experienced in the context of shared care in terms of transitions between professionals or organizations. Access and flexibility issues were identified as important barriers or facilitators of continuity. Conclusions: Across a range of long-term conditions, patients’ experiences of health care can be understood in terms of nuanced understandings of relational and management continuity. Continuity experiences, meanings and expectations, as well as barriers and facilitators, are influenced by the model of care rather than type of condition.
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Affiliation(s)
| | | | - Patrick White1
- Department of General Practice, Kings College London, London, UK
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Wong HJ, Caesar M, Bandali S, Agnew J, Abrams H. Electronic inpatient whiteboards: Improving multidisciplinary communication and coordination of care. Int J Med Inform 2009; 78:239-47. [DOI: 10.1016/j.ijmedinf.2008.07.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 06/23/2008] [Accepted: 07/21/2008] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To explore the structure, components, and training goals of pediatric hospitalist fellowship programs in North America. DESIGN We constructed a 17-item structured questionnaire to be administered by phone. Questionnaire items focused on documenting goals, training, requirements, and clinical duties of pediatric hospitalist training programs. From February through June 2007, research staff contacted directors of the programs. Responses were analyzed to determine program characteristics, including goals, formal training requirements, clinical rotations, and participation in hospital administrative activities. RESULTS All 8 training programs completed the survey. There appear to be 2 distinct tracks for pediatric hospitalist training programs: clinical or academic specialization. Currently there are no standards or requirements for fellowship training from an external accrediting body and the curriculum for these programs is likely driven by service requirements and speculation on the needs of a future generation of pediatric hospitalists. The stated goals of the programs were quite similar. Seven reported that the provision of advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration are central goals of their training program. Six reported training in the education of medical students and residents to be a primary goal, while 5 indicated training in health services research as a primary goal. CONCLUSIONS Pediatric hospitalist fellowships are in the very early stages of their development. In time, greater structure across institutions will need to be put in place if they are to succeed in becoming a necessary prerequisite to the practice of hospital medicine.
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Affiliation(s)
- Gary L Freed
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan 48109-0456, USA.
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Roy CL, Kachalia A, Woolf S, Burdick E, Karson A, Gandhi TK. Hospital readmissions: physician awareness and communication practices. J Gen Intern Med 2009; 24:374-80. [PMID: 18982395 PMCID: PMC2642583 DOI: 10.1007/s11606-008-0848-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 09/25/2008] [Accepted: 10/14/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients requiring early hospital readmission may be readmitted to different physicians, potentially without the knowledge of the prior caregivers. This lost opportunity to share information about readmitted patients may be detrimental to quality of care and resident education. OBJECTIVE To measure physician awareness of and communication about readmissions. DESIGN Cross-sectional study. SETTING Two academic medical centers. PARTICIPANTS A total of 432 patients discharged from the general medicine services and readmitted within 14 days. MEASUREMENTS We identified patients discharged from the general medicine services and readmitted within 14 days, excluding patients readmitted to the same physician(s) and planned readmissions. We surveyed discharging and readmitting physicians 48 h after the time of readmission. RESULTS Discharging physician teams were aware of 48.5% (95% CI 41.5%-55.5%) of patient readmissions. Communication between teams occurred on 43.7% (95% CI 37.1%-50.3%). Higher medical complexity was associated with an increased likelihood of physician communication (adjusted OR 1.12, 95% CI 1.06-1.19). When communication occurred, readmitting physicians received information about the discharging team's overall assessment (61.9%, 95% CI 51.9%-71.9%), psychosocial issues (52.6%, 95% CI 42.4%-62.8%), pending tests (34.0%, 95% CI 24.2%-43.8%), and discharge medications (30.9%, 95% CI 21.5%-40.3%). When communication did not occur, most physicians (60.8%, 95% CI 56.7%-64.9%) responded it would have been desirable to communicate. CONCLUSIONS Physicians are frequently unaware of patient readmissions and often do not communicate when readmissions occur. This communication is often desired and frequently results in the exchange of important patient information. Further work is needed to design systems to address this potential discontinuity of care.
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Affiliation(s)
- Christopher L Roy
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Harlan G, Srivastava R, Harrison L, McBride G, Maloney C. Pediatric hospitalists and primary care providers: a communication needs assessment. J Hosp Med 2009; 4:187-93. [PMID: 19263485 PMCID: PMC2918252 DOI: 10.1002/jhm.456] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVE Existing research on hospitalist-primary care provider (PCP) communication focuses mainly on adult hospitalist models with little known about the quality of current pediatric hospitalist-PCP communication. Our objective was to perform a needs assessment by exploring important issues around communication between pediatric hospitalists and PCPs. METHODS Six previously identified issues around hospitalist-PCP communication from the adult hospitalist literature were abstracted and incorporated into an open-ended and closed-ended questionnaire. The questionnaire was pretested, revised, and administered by phone to 10 pediatric hospitalists and 12 pediatric PCPs residing in our 5-state catchment area. Interviews were transcribed and openly coded, and themes compared using qualitative methods. RESULTS The 6 identified issues were: quality of communication, barriers to communication, methods of information sharing, key data element requirements, critical timing, and perceived benefits. Hospitalists and PCPs rated overall quality of communication from "poor" to "very good." Both groups acknowledge that significant barriers to optimal communication currently exist, yet the barriers differ for each group. Hospitalists and PCPs agree on what information is important to transmit (diagnoses, medications, follow-up needs, and pending laboratory test results) and critical times for communication during the hospitalization (at discharge, admission, and during major clinical changes). Both groups also agree that optimal communication could improve many aspects of patient care. CONCLUSIONS Identifying and addressing barriers to these 6 issues may help both hospitalists and PCPs implement targeted interventions aimed at improving communication. Future studies will need to demonstrate the link between improved hospitalist-PCP communication and improved patient care and outcomes.
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Affiliation(s)
- Gregory Harlan
- Division of Pediatric Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah 84113, USA.
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Bell CM, Schnipper JL, Auerbach AD, Kaboli PJ, Wetterneck TB, Gonzales DV, Arora VM, Zhang JX, Meltzer DO. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med 2009; 24:381-6. [PMID: 19101774 PMCID: PMC2642573 DOI: 10.1007/s11606-008-0882-8] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 10/27/2008] [Accepted: 11/10/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes. METHODS We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient's PCP was associated with the 30-day composite outcome. RESULTS A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 - 1.34), the presence of a discharge summary (0.84, 95% CI 0.57-1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73-1.59). CONCLUSION Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample.
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Affiliation(s)
- Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Shadmi E, Zisberg A, Coleman EA. Translation and validation of the Care Transition Measure into Hebrew and Arabic. Int J Qual Health Care 2009; 21:97-102. [PMID: 19196739 DOI: 10.1093/intqhc/mzp004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the validity and reliability of the Hebrew and Arabic translations of the complete and shortened versions of the Care Transition Measure (CTM)-a measure of patients' experience of the transition between hospital and community care. DESIGN Translation of questionnaire's items, evaluation of reliability, construct validity, factor structure and convergent validity. SETTING An oncology center at a tertiary care facility that serves the entire population of the north part of Israel. PARTICIPANTS Patients receiving care at the clinics of an oncology treatment center. Main outcome measure Psychometric properties of both the 15-item (complete) and 3-item (shortened) versions of the CTM in Hebrew and Arabic. Reliability established using internal consistency with Cronbach's-alpha. Exploratory factor analysis conducted using Varimax rotation. Convergent validity determined with Pearson correlation and ANOVA tests. RESULTS Three hundred and eighteen Hebrew- and Arabic-speaking oncology patients completed the questionnaire. Cronbach's-alpha for the questionnaire was 0.94 and 0.90 for the Hebrew and the Arabic versions, respectively. Factor analysis resulted in three factors in each of the translated versions with a cumulative variance of 73.41% and 69.2% in the Hebrew and Arabic versions, respectively. Tests of the convergent validity showed that the measure is correlated with health status and that the shortened and complete versions' ratings are consistent across different patient groups. CONCLUSION The translated Hebrew and Arabic versions of the questionnaire are reliable and valid instruments to assess patients' transitions across settings in diverse populations.
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Affiliation(s)
- Efrat Shadmi
- Faculty of Social Welfare and Health Sciences, Haifa University, Eshkol Tower, Mount Carmel, Haifa, Israel.
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Bishop TF, Kathuria N. Economic and healthcare forces of hospitalist movement. ACTA ACUST UNITED AC 2009; 75:424-9. [PMID: 18828163 DOI: 10.1002/msj.20069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The field of hospital medicine has become a widely accepted model for inpatient care and has grown rapidly in the past ten years. The impetus for growth has largely been pressure to contain costs for inpatient care and improve efficiency in the hospital. Studies have shown that care by hospitalists is generally more cost-effective than care by faculty or private practice physicians without affecting quality. The field faces challenges in continuity of patient care and retention of physicians in the workforce.
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Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, Forsythe SR, O'Donnell JK, Paasche-Orlow MK, Manasseh C, Martin S, Culpepper L. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009; 150:178-87. [PMID: 19189907 PMCID: PMC2738592 DOI: 10.7326/0003-4819-150-3-200902030-00007] [Citation(s) in RCA: 1104] [Impact Index Per Article: 73.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Emergency department visits and rehospitalization are common after hospital discharge. OBJECTIVE To test the effects of an intervention designed to minimize hospital utilization after discharge. DESIGN Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card. SETTING General medical service at an urban, academic, safety-net hospital. PATIENTS 749 English-speaking hospitalized adults (mean age, 49.9 years). INTERVENTION A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment. MEASUREMENTS Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment. RESULTS Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed. LIMITATION This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report. CONCLUSION A package of discharge services reduced hospital utilization within 30 days of discharge. FUNDING Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.
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Affiliation(s)
- Brian W Jack
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts 02118, USA.
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Hebert RS, Schulz R, Copeland VC, Arnold RM. Preparing family caregivers for death and bereavement. Insights from caregivers of terminally ill patients. J Pain Symptom Manage 2009; 37:3-12. [PMID: 18538977 DOI: 10.1016/j.jpainsymman.2007.12.010] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 12/18/2007] [Accepted: 12/28/2007] [Indexed: 11/28/2022]
Abstract
Many family caregivers are unprepared for the death of their loved one and may suffer from worse mental health as a result. We therefore sought to determine the factors that family caregivers believe are important to preparing for death and bereavement. Focus groups and ethnographic interviews were conducted with 33 family caregivers (bereaved or current) of terminally ill patients. The interviews were audiotaped, transcribed, and analyzed using the constant comparative method. Life experiences such as the duration of caregiving/illness, advance care planning, previous experiences with caregiving or death, and medical sophistication all impacted preparedness, or the degree to which a caregiver is ready for the death and bereavement. Regardless of life experiences, however, all caregivers reported medical, practical, psychosocial, and religious/spiritual uncertainty. Because uncertainty was multidimensional, caregivers often needed more than prognostic information in order to prepare. Communication was the primary mechanism used to manage uncertainty. Good communication included clear, reliable information, combined with relationship-centered care from health care providers. Finally, preparedness had cognitive, affective, and behavioral dimensions. To prepare, some caregivers needed information tailored to their uncertainty (cognitive), others needed to "mentally" or "emotionally" prepare (affective), and still others had important tasks to complete (behavioral). In order to better prepare family caregivers for the death of a loved one, health care providers must develop a trusting relationship with caregivers, provide them with reliable information tailored to their uncertainty, and allow time for caregivers to process the information and complete important tasks.
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Affiliation(s)
- Randy S Hebert
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Gandara E, Moniz TT, Ungar J, Lee J, Chan-Macrae M, O'Malley T, Schnipper JL. Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation. Jt Comm J Qual Patient Saf 2008; 34:460-3. [PMID: 18714747 DOI: 10.1016/s1553-7250(08)34057-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Anticoagulation is a commonly prescribed and effective therapy for several medical conditions but requires detailed communication among clinicians to avoid adverse patient outcomes following hospital discharge. METHODS Discharge documentation packets of a sample of patients discharged from all five acute care hospitals of the Partners Healthcare System to 30 subacute facilities in Boston and prescribed anticoagulation for treatment or prophylaxis of thromboembolic disease were evaluated. Required data elements included information on anticoagulation indication, duration, dosing, monitoring, and follow-up. Discharge documentation packets were randomly selected for reviewers at acute sites, whereas reviewers at subacute sites selected which packets to review. RESULTS Of 757 patients prescribed anticoagulation at discharge from March 2005 through June 2007, duration of therapy (for unfractionated or low-molecular-weight heparin [UFH/LMWH]) and recent dosing and monitoring information (for warfarin) were the areas with the biggest deficits. Of the patients prescribed UFH/LMWH or warfarin, 45.4% and 16.4%, respectively, had all the required information in the discharge summary. Patients discharged from community hospitals were more likely to be discharged with all the information needed for the use of warfarin (Odds Ratio [OR], 2.56; 95% confidence interval [CI], 1.20-5.46) or UFH/LMWH (OR, 2.97; 95% CI, 1.98-4.44) than patients discharged from academic medical centers. DISCUSSION Important information to safely prescribe anticoagulation after discharge was often missing from the discharge summaries of patients transferred from acute hospitals to subacute facilities. Future research should focus on developing, implementing, and evaluating quality improvement interventions to address this gap.
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Affiliation(s)
- Esteban Gandara
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, USA.
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van Walraven C, Taljaard M, Bell CM, Etchells E, Zarnke KB, Stiell IG, Forster AJ. Information exchange among physicians caring for the same patient in the community. CMAJ 2008; 179:1013-8. [PMID: 18981442 DOI: 10.1503/cmaj.080430] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The exchange of information is an integral component of continuity of health care and may limit or prevent costly duplication of tests and treatments. This study determined the probability that patient information from previous visits with other physicians was available for a current physician visit. METHODS We conducted a multicentre prospective cohort study including patients discharged from the medical or surgical services of 11 community and academic hospitals in Ontario. Patients included in the study saw at least 2 different physicians during the 6 months after discharge. The primary outcome was whether information from a previous visit with another physician was available at the current visit. We determined the availability of previous information using surveys of or interviews with the physicians seen during current visits. RESULTS A total of 3250 patients, with a total of 39 469 previous-current visit combinations, met the inclusion criteria. Overall, information about the previous visit was available 22.0% of the time. Information was more likely to be available if the current doctor was a family physician (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.54-1.98) or a physician who had treated the patient before the hospital admission (OR 1.33, 95% CI 1.21-1.46). Conversely, information was less likely to be available if the previous doctor was a family physician (OR 0.38, 95% CI 0.32-0.44) or a physician who had treated the patient before the admission (OR 0.72, 95% CI 0.60-0.86). The strongest predictor of information exchange was the current physician having previously received information about the patient from the previous physician (OR 7.72, 95% CI 6.92-8.63). INTERPRETATION Health care information is often not shared among multiple physicians treating the same patient. This situation would be improved if information from family physicians and patients' regular physicians was more systematically available to other physicians.
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Affiliation(s)
- Carl van Walraven
- Clinical Epidemiology Program, Ottawa Health Research Institute, ASB1-003, Ottawa Hospital, Civic Campus, 1053 Carling Ave., Ottawa, ONK1Y4E9.
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1289
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Graumlich JF, Novotny NL, Aldag JC. Brief scale measuring patient preparedness for hospital discharge to home: Psychometric properties. J Hosp Med 2008; 3:446-54. [PMID: 19084894 DOI: 10.1002/jhm.316] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Adverse events occur when patients transition from the hospital to outpatient care. For quality improvement and research purposes, clinicians need appropriate, reliable, and valid survey instruments to measure and improve the discharge processes. OBJECTIVE The object was to describe psychometric properties of the Brief PREPARED (B-PREPARED) instrument to measure preparedness for hospital discharge from the patient's perspective. METHODS The study was a prospective cohort of 460 patient or proxy telephone interviews following hospital discharge home. We administered the Satisfaction with Information about Medicines Scale and the PREPARED instrument 1 week after discharge. PREPARED measured patients' perceptions of quality and outcome of the discharge-planning processes. Four weeks after discharge, interviewers elicited emergency department visits. The main outcome was the B-PREPARED scale value: the sum of scores from 11 items. Internal consistency, construct, and predictive validity were assessed. RESULTS : The mean B-PREPARED scale value was 17.3 +/- 4.2 (SD) with a range of 3 to 22. High scores reflected high preparedness. Principal component analysis identified 3 domains: self-care information, equipment/services, and confidence. The B-PREPARED had acceptable internal consistency (Cronbach's alpha 0.76) and construct validity. The B-PREPARED correlated with medication information satisfaction (P < 0.001). Higher median B-PREPARED scores appropriately discriminated patients with no worry about managing at home from worriers (P < 0.001) and predicted patients without emergency department visits after discharge from those who had visits (P = 0.011). CONCLUSIONS The B-PREPARED scale measured patients' perceptions of their preparedness for hospital discharge home with acceptable internal consistency and construct and predictive validity. Brevity may potentiate use by patients and proxies. Clinicians and researchers may use B-PREPARED to evaluate discharge interventions.
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Affiliation(s)
- James F Graumlich
- Department of Medicine, University of Illinois College of Medicine, 530 NE Glen Oak Avenue, Peoria, IL 61637, USA.
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1290
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Wexler DJ, Nathan DM, Grant RW, Regan S, Van Leuvan AL, Cagliero E. Prevalence of elevated hemoglobin A1c among patients admitted to the hospital without a diagnosis of diabetes. J Clin Endocrinol Metab 2008; 93:4238-44. [PMID: 18697862 PMCID: PMC2582564 DOI: 10.1210/jc.2008-1090] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
CONTEXT One in four hospitalized patients has diagnosed diabetes. The prevalence of unrecognized, or undiagnosed, diabetes among hospitalized patients is not well established. OBJECTIVE Our objective was to determine the prevalence of unrecognized probable diabetes in this patient population determined by elevated hemoglobin A1c (HbA1c) level. DESIGN We conducted a prospective observational cohort trial with retrospective follow-up of patients with elevated HbA1c levels and no diagnosis of diabetes. HbA1c levels were obtained for all patients. SETTING The study was conducted at an acute care general hospital. PATIENTS Patients included 695 adult, nonobstetric patients admitted on 11 d in 2006. MAIN OUTCOME MEASURES Outcome measures included rate of unrecognized probable diabetes, defined as admission HbA1c of more than 6.1% and no diagnosis of diabetes or treatment with antidiabetic medications before or during their admission and rate of unrecognized diabetes 1 yr after discharge. RESULTS Eighteen percent of hospitalized patients had elevated HbA1c levels without a diagnosis of diabetes. Random glucose levels poorly predicted elevated HbA1c levels (area under receiver operating characteristic curve, 0.60). Neither diagnosed diabetes nor HbA1c level was associated with length of stay or costs (P>0.1 for all comparisons). Only 15% of patients with elevated HbA1c levels who continued to receive care within the system studied had diabetes diagnosed in the year after the index admission. CONCLUSIONS Nearly one in five adult patients admitted to a large general hospital had unrecognized probable diabetes, based on elevated HbA1c levels. Random glucose levels during the hospital stay were poorly predictive of this condition. Few hospitalized patients with elevated HbA1c levels were diagnosed within the year after admission.
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Affiliation(s)
- Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, Bulfinch 408, Massachusetts General Hospital, and Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114, USA.
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1291
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Abstract
BACKGROUND Adverse events occur when patients transition from hospital to outpatient care. For quality improvement and research purposes, clinicians need appropriate, reliable, and valid survey instruments to measure and improve discharge processes. OBJECTIVE The objective of this study was to validate the Modified Physician-PREPARED scale to measure qualities of hospital discharge from the outpatient physician perspective. Descriptions include item development and psychometric properties. METHODS The design was a postal survey of outpatient physicians/practitioners who followed 403 patients who were discharged from hospital to home. We mailed questionnaires 10 days after discharge. Questionnaire items assessed perceptions of quality and outcome of discharge planning and communication. Analysis yielded the Modified Physician-PREPARED scale value: the sum of scores from 8 items. Internal consistency and construct validity were assessed. RESULTS Survey response rate was 76%. Mean Modified Physician-PREPARED scale value was 16.6 +/- 4.0 with range 8 to 24. High scores reflected high perceptions of discharge quality. Analysis identified 2 principal components: timeliness of communication, and adequacy of discharge plan/transmission. The scale had acceptable internal consistency (Cronbach's alpha 0.86) and construct validity. When considering the discharge planning and communication for a specific patient, outpatient primary care physicians reported higher scores when they were involved in the discharge planning (P < 0.001) and when they were aware of community support services (P = 0.002). CONCLUSIONS The Modified Physician-PREPARED scale measured outpatient physician perceptions of quality of hospital discharge to home. Clinicians and researchers may find the scale useful to evaluate discharge processes.
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Affiliation(s)
- James F Graumlich
- Department of Medicine, University of Illinois College of Medicine, 530 NE Glen Oak Avenue, Peoria, IL 61637, USA.
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1292
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1293
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Shared care guidelines and protocols in the United kingdom. J Ambul Care Manage 2008; 31:239-43. [PMID: 18574382 DOI: 10.1097/01.jac.0000324669.91153.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The divide between primary and secondary care in the United Kingdom's National Health Service is becoming increasingly blurred, leading to the development of shared care guidelines and protocols. These often contain measurable performance and outcome measures, and aim to encourage joint working between specialists and primary care physicians. Shared care will become an increasingly important part of healthcare in the United Kingdom, supported by information systems that provide patients and professionals with the information they need to optimize the management of patient's health.
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1294
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Factors affecting the offer of pulmonary rehabilitation to patients with chronic obstructive pulmonary disease by primary care professionals: a qualitative study. Prim Health Care Res Dev 2008. [DOI: 10.1017/s1463423608000832] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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1295
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Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc 2008; 56:1946-52. [PMID: 18771457 DOI: 10.1111/j.1532-5415.2008.01916.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Thousands of Americans are injured or die each year from adverse drug reactions, many of which are preventable. The burden of harm conveyed by the use of medications is a significant public health problem, and therefore, improving the medication-use process is a priority. Recent and ongoing efforts to improve the medication-use process have focused primarily on improving medication prescribing, and not much emphasis has been put on improving medication discontinuation. A formalized approach for rationally discontinuing medications is a necessary antecedent to improving medication safety and improving the nation's quality of care. This article proposes a conceptual framework for revising the prescribing stage of the medication-use process to include discontinuing medications. This framework has substantial practice and research implications, especially for the clinical care of older persons, who are particularly susceptible to the adverse effects of medications.
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Affiliation(s)
- Kevin T Bain
- Department of Quality Outcomes, excelleRx Inc, an Omnicare Company, Philadelphia, Pennsylvania 19102, USA.
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1296
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Pham HH, Grossman JM, Cohen G, Bodenheimer T. Hospitalists And Care Transitions: The Divorce Of Inpatient And Outpatient Care. Health Aff (Millwood) 2008; 27:1315-27. [DOI: 10.1377/hlthaff.27.5.1315] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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1297
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O'Malley CW, Emanuele M, Halasyamani L, Amin AN. Bridge over troubled waters: safe and effective transitions of the inpatient with hyperglycemia. J Hosp Med 2008; 3:55-65. [PMID: 18951384 DOI: 10.1002/jhm.355] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Cheryl W O'Malley
- Department of Internal Medicine, Banner Good Samaritan Medical Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona 85006, USA.
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1298
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Vasilevskis EE, Meltzer D, Schnipper J, Kaboli P, Wetterneck T, Gonzales D, Arora V, Zhang J, Auerbach AD. Quality of care for decompensated heart failure: comparable performance between academic hospitalists and non-hospitalists. J Gen Intern Med 2008; 23:1399-406. [PMID: 18592321 PMCID: PMC2517998 DOI: 10.1007/s11606-008-0680-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 02/06/2008] [Accepted: 05/13/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hospitalists improve efficiency, but little information exists regarding whether they impact quality of care. OBJECTIVE To determine hospitalists' effect on the quality of acute congestive heart failure care. DESIGN AND PARTICIPANTS Using data from the Multicenter Hospitalist Study, we retrospectively evaluated quality of care in patients admitted with congestive heart failure who were assigned to hospitalists (n = 120) or non-hospitalists (n = 252) among six academic hospitals. MEASUREMENTS Quality measures included the percentage of patients who had ejection fraction (EF) measurement, received appropriate medications [i.e., angiotensin-converting enzyme inhibitor (ACE-I) or beta-blockers] at discharge, measures of care coordination (e.g., follow-up within 30 days), testing for cardiac ischemia (e.g., cardiac catheterization), as well as hospital length of stay, cost, and combined 30-day readmissions and mortality. RESULTS Compared to non-hospitalist physicians, hospitalists' patients had similar rates of EF measurement (85.3% vs. 87.5%; P = 0.57), ACE-I (91.5% vs. 88.0%; P = 0.52), or beta-blocker (46.9% vs. 42.1%; P = 0.57) prescriptions. Multivariable adjustment did not change these findings. Hospitalists' patients had higher odds of 30-day follow-up (adjusted OR = 1.83, 95% CI, 1.44 - 2.93). There were no significant differences between the groups' frequency of cardiac testing, length of stay, costs, or risk for readmission or death by 30-days. CONCLUSION Academic hospitalists and non-hospitalists provide similar quality of care for heart failure patients, although hospitalists are paying more attention to longitudinal care. Future efforts to improve quality of care in decompensated heart failure may require attention towards system-level factors.
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Affiliation(s)
- Eduard E Vasilevskis
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA 94143, USA.
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1299
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Tripp JS, Narus SP, Magill MK, Huff SM. Evaluating the accuracy of existing EMR data as predictors of follow-up providers. J Am Med Inform Assoc 2008; 15:787-90. [PMID: 18755996 DOI: 10.1197/jamia.m2753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In order to evaluate the accuracy of existing EMR data in predicting follow-up providers, a retrospective analysis was performed on six months of data for inpatient and ED encounters occurring at two hospitals, and on related outpatient data. Sensitivity and Positive Predictive Value (PPV) were calculated for each of eight predictors, to determine their effectiveness in predicting follow-up providers. Our findings indicate that access to longitudinal patient care records can improve prediction of which providers a patient is likely to see post-discharge compared to simply using Primary Care Provider data from admissions records. Of the predictors evaluated, a patient's past appointment history was the best predictor of which providers they would see in the future (PPV = 48% following inpatient visits, 35% following emergency department visits). However, even the best performing predictors failed to predict more than half of the follow-up providers and might generate many "false" alerts.
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Affiliation(s)
- Jacob S Tripp
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT 84112-5750, USA.
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1300
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Menckeberg TT, Bouvy ML, Bracke M, Hugtenburg JG, Lammers JW, Raaijmakers JAM. Patients' understanding of the reasons for starting and discontinuing inhaled corticosteroids. Br J Clin Pharmacol 2008; 66:255-60. [PMID: 18717916 PMCID: PMC2492937 DOI: 10.1111/j.1365-2125.2008.03168.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Accepted: 02/11/2008] [Indexed: 11/27/2022] Open
Abstract
AIM Although early discontinuation of treatment in new users of inhaled corticosteroids (ICS) has been widely discussed, the reasons for stopping have not been investigated in depth. We aimed to describe reasons for discontinuation from a patient's perspective in relation to their experience of symptoms at the time of the investigation. METHODS A cross-sectional study among new users that discontinued ICS use in the Netherlands was performed. Patients were interviewed by telephone, aiming to identify the symptoms for which they were prescribed ICS, the reasons for discontinuing treatment and the respiratory symptoms patients still experienced at the time of the survey. In addition, automated dispensing records of all patients were retrieved. RESULTS From 287 eligible patients, 230 (80.1%) were interviewed. Only 22 patients (9.6%) mentioned asthma as the reason for a first ICS prescription. A decrease in symptoms was the main reason for discontinuation (45%). Thirty patients (13%) reported clinically significant residual symptoms. These patients reported more seasonal variation of symptoms and were more often prescribed short-acting beta(2)-agonists. CONCLUSIONS The majority of patients mentioned a wide range of symptoms and conditions, other than asthma or chronic obstructive pulmonary disease, as the reason for the start of ICS therapy. Most of these conditions may be expected to be of short duration. Not surprisingly a decrease in symptoms was the main, and justifiable, reason for discontinuing ICS. However, a non-negligible proportion of patients reported residual symptoms that suggest the need of continued ICS use. Physicians and pharmacists could cooperate in identifying those patients for which ICS are really indicated and motivate them to continue the use of ICS.
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Affiliation(s)
- Tanja T Menckeberg
- Division of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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