101
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Abstract
Aim: The aim of this literature review was to review and discuss the differences between men and women with heart failure with regard to epidemiology, aetiology, diagnostics, prognosis, pharmacological and non-pharmacological treatment, and the impact of heart failure on psychosocial factors and healthcare utilisation. Method: Two primary health care resources, MEDLINE and CINAHL, were selected to review the current literature. In MEDLINE, 234 abstracts dealing with heart failure and gender/sex were found and in CINAHL, 20 abstracts. Conclusion: Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. The extent of sex differences in treatment, hospital cost and quality of care can partly be explained by age differences. The life situations for men and women with heart failure are different. Physical and social restrictions affecting daily life activities are experienced as most bothersome for men, whereas restrictions affecting the possibility to support family and friends are most difficult to accept for women. Women with heart failure ascribe more positive meanings to their illness. Despite this, women seem to experience a lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care.
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Affiliation(s)
- Anna Strömberg
- Department of Cardiology, Heart Centre, Linköping University Hospital, S-581 85 Linköping, Sweden.
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102
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Wan H, Zhang L, Witz S, Musselman KJ, Yi F, Mullen CJ, Benneyan JC, Zayas-Castro JL, Rico F, Cure LN, Martinez DA. A literature review of preventable hospital readmissions: Preceding the Readmissions Reduction Act. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/19488300.2016.1226210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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103
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Self-reflection as a Tool to Increase Hospitalist Participation in Readmission Quality Improvement. Qual Manag Health Care 2016; 25:219-224. [PMID: 27749719 DOI: 10.1097/qmh.0000000000000111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Reducing 30-day readmissions is a national priority. Although multipronged programs have been shown to reduce readmissions, the role of the individual hospitalist physician in reducing readmissions is not clear. OBJECTIVES We evaluated the effect of physicians' self-review of their own readmission cases on the 30-day readmission rate. METHODS Over a 1-year period, hospitalists were sent their individual readmission rates and cases on a weekly basis. They reviewed their cases and completed a data abstraction tool. In addition, a facilitator led small group discussion about common causes of readmission and ways to prevent such readmissions. RESULTS Our preintervention readmission rate was 16.16% and postintervention was 14.99% (P = .76). Among hospitalists on duty, nearly all participated in scheduled facilitated discussions. Self-review was completed in 67% of the cases. CONCLUSIONS A facilitated reflective practice intervention increased hospitalist participation and awareness in the mission to reduce readmissions and this intervention resulted in a nonsignificant trend in readmission reduction.
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104
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Akbar S, Khimani R, Naz H, Sohani K. ISQUA16-3152COORDINATING CARE ACROSS THE CONTINUUM BY MANAGING POST DISCHARGE TRANSITIONS AT HOME. Int J Qual Health Care 2016. [DOI: 10.1093/intqhc/mzw104.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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105
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Rubin DJ, Handorf EA, Golden SH, Nelson DB, McDonnell ME, Zhao H. DEVELOPMENT AND VALIDATION OF A NOVEL TOOL TO PREDICT HOSPITAL READMISSION RISK AMONG PATIENTS WITH DIABETES. Endocr Pract 2016; 22:1204-1215. [PMID: 27732098 PMCID: PMC5104276 DOI: 10.4158/e161391.or] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To develop and validate a tool to predict the risk of all-cause readmission within 30 days (30-d readmission) among hospitalized patients with diabetes. METHODS A cohort of 44,203 discharges was retrospectively selected from the electronic records of adult patients with diabetes hospitalized at an urban academic medical center. Discharges of 60% of the patients (n = 26,402) were randomly selected as a training sample to develop the index. The remaining 40% (n = 17,801) were selected as a validation sample. Multivariable logistic regression with generalized estimating equations was used to develop the Diabetes Early Readmission Risk Indicator (DERRI™). RESULTS Ten statistically significant predictors were identified: employment status; living within 5 miles of the hospital; preadmission insulin use; burden of macrovascular diabetes complications; admission serum hematocrit, creatinine, and sodium; having a hospital discharge within 90 days before admission; most recent discharge status up to 1 year before admission; and a diagnosis of anemia. Discrimination of the model was acceptable (C statistic 0.70), and calibration was good. Characteristics of the validation and training samples were similar. Performance of the DERRI™ in the validation sample was essentially unchanged (C statistic 0.69). Mean predicted 30-d readmission risks were also similar between the training and validation samples (39.3% and 38.7% in the highest quintiles). CONCLUSION The DERRI™ was found to be a valid tool to predict all-cause 30-d readmission risk of individual patients with diabetes. The identification of high-risk patients may encourage the use of interventions targeting those at greatest risk, potentially leading to better outcomes and lower healthcare costs. ABBREVIATIONS DERRI™ = Diabetes Early Readmission Risk Indicator ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification GEE = generalized estimating equations ROC = receiver operating characteristic.
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Affiliation(s)
- Daniel J. Rubin
- Lewis Katz School of Medicine at Temple University, Section of
Endocrinology, Diabetes, and Metabolism, Philadelphia, Pennsylvania
| | - Elizabeth A. Handorf
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center,
Temple University Health System, Philadelphia, Pennsylvania
| | - Sherita Hill Golden
- Division of Endocrinology and Metabolism and the Welch Center for
Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of
Medicine, Baltimore, Maryland
| | - Deborah B. Nelson
- Department of Epidemiology and Biostatistics, College of Public
Health, Temple University, Philadelphia, Pennsylvania
| | - Marie E. McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and
Women’s Hospital, Harvard Medical School, Cambridge, Massachusetts
| | - Huaqing Zhao
- Temple Clinical Research Institute, Lewis Katz School of Medicine at
Temple University, Philadelphia, Pennsylvania
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106
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Rubin DJ. TRANSITIONING PATIENTS WITH DIABETES OUT OF EMERGENCY DEPARTMENTS: A PATH TOWARDS BETTER OUTCOMES AND LOWER COSTS? Endocr Pract 2016; 22:1245-1247. [PMID: 27631843 DOI: 10.4158/ep161482.co] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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107
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Tanguturi VK, Temin E, Yeh RW, Thompson RW, Rao SK, Mallick A, Cavallo E, Ferris TG, Wasfy JH. Clinical Interventions to Reduce Preventable Hospital Readmission After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2016; 9:600-4. [DOI: 10.1161/circoutcomes.116.003086] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hospital readmissions are common and costly and, in some cases, may be related to problems with care processes. We sought to reduce readmissions after percutaneous coronary intervention (PCI) in a large tertiary care facility through programs to target vulnerabilities predischarge, after discharge, and during re-presentation to the emergency department. During initial hospitalization, we assessed patients’ readmission risk with a validated risk score and used a discharge checklist to ensure access to appropriate medications and close follow-up for high-risk patients. We also developed patient education videos about chest discomfort and heart failure. After discharge, we established a new follow-up clinic with cardiology fellows. A computerized system was developed to automatically notify cardiologists when patients presented to the emergency department within 30 days of PCI to enhance patient access to cardiology care in the emergency department. Early cardiologist assessment and assistance with triage was encouraged, and the emergency department used a risk stratification algorithm derived from a local database of patients to triage patients presenting with chest discomfort after PCI. We tracked the number of patients readmitted after PCI to our hospital. With our interventions, from 2011 to 2015, the index hospital readmission rate has declined from 9.6% to 5.3%. This program could provide tangible structural changes that can be implemented in other healthcare centers, both reducing the cost of care and improving the quality of care for patients with PCI.
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Affiliation(s)
- Varsha K. Tanguturi
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Elizabeth Temin
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Robert W. Yeh
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Ryan W. Thompson
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Sandhya K. Rao
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Aditi Mallick
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Elena Cavallo
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Timothy G. Ferris
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
| | - Jason H. Wasfy
- From the Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (V.K.T.); Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (E.T.); Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.); Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.T., A.M.); and Massachusetts
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108
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Jayakody A, Bryant J, Carey M, Hobden B, Dodd N, Sanson-Fisher R. Effectiveness of interventions utilising telephone follow up in reducing hospital readmission within 30 days for individuals with chronic disease: a systematic review. BMC Health Serv Res 2016; 16:403. [PMID: 27538884 PMCID: PMC4990979 DOI: 10.1186/s12913-016-1650-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/10/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Rates of readmission to hospital within 30 days are highest amongst those with chronic diseases. Effective interventions to reduce unplanned readmissions are needed. Providing support to patients with chronic disease via telephone may help prevent unnecessary readmission. This systematic review aimed to determine the methodological quality and effectiveness of interventions utilising telephone follow up (TFU) alone or in combination with other components in reducing readmission within 30 days amongst patients with cardiovascular disease, chronic respiratory disease and diabetes. METHODS A systematic search of MEDLINE, the Cochrane Library and EMBASE were conducted for articles published from database inception to 19(th) May 2015. Interventions which included TFU alone, or in combination with other components, amongst patients with chronic disease, reported 30 day readmission outcomes and met Effective Practice and Organisation of Care design criteria were included. The titles and abstracts of all identified articles were initially assessed for relevance and rejected on initial screening by one author. Full text articles were assessed against inclusion criteria by two authors with discrepancies resolved through discussion. RESULTS Ten studies were identified, of which five were effective in reducing readmissions within 30 days. Overall, the methodological quality of included studies was poor. All identified studies combined TFU with other intervention components. Interventions that were effective included three studies which provided TFU in addition to pre-discharge support; and two studies which provided TFU with both pre- and post-discharge support which included education, discharge planning, physical therapy and dietary consults, medication assessment, home visits and a resident curriculum. There was no evidence that TFU and telemedicine or TFU and post-discharge interventions was effective, however, only one to two studies examined each of these types of interventions. CONCLUSIONS Evidence is inconclusive for the effectiveness of interventions utilising TFU alone or in combination with other components in reducing readmissions within 30 days in patients with chronic disease. High methodological quality studies examining the effectiveness of TFU in a standardised way are needed. There is also potential importance in focusing interventions on enhancing provider skills in patient education, transitional care and conducting TFU.
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Affiliation(s)
- Amanda Jayakody
- Health Behaviour Research Group, Priority Research Centre for Health Behaviour, University of Newcastle, HMRI Building, Callaghan, NSW 2308 Australia
| | - Jamie Bryant
- Health Behaviour Research Group, Priority Research Centre for Health Behaviour, University of Newcastle, HMRI Building, Callaghan, NSW 2308 Australia
| | - Mariko Carey
- Health Behaviour Research Group, Priority Research Centre for Health Behaviour, University of Newcastle, HMRI Building, Callaghan, NSW 2308 Australia
| | - Breanne Hobden
- Health Behaviour Research Group, Priority Research Centre for Health Behaviour, University of Newcastle, HMRI Building, Callaghan, NSW 2308 Australia
| | - Natalie Dodd
- Health Behaviour Research Group, Priority Research Centre for Health Behaviour, University of Newcastle, HMRI Building, Callaghan, NSW 2308 Australia
| | - Robert Sanson-Fisher
- Health Behaviour Research Group, Priority Research Centre for Health Behaviour, University of Newcastle, HMRI Building, Callaghan, NSW 2308 Australia
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109
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Abstract
The study estimates the rate and cost of preventable readmissions within 6 months after a first preventable admission, by age-group, and by payer and race within age-group. The descriptive results are contrasted with several hypotheses. The hospital discharge data are for residents of New York, Pennsylvania, Tennessee, and Wisconsin in 1999, from files of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. About 19 percent of persons with an initial preventable admission had at least one preventable readmission rate within 6 months. Hospital cost for preventable readmissions during 6 months was about $730 million. There were substantial differences in readmission rates by payer group and by race. Some evidence suggests that preventable readmissions may partly reflect complexity of underlying problems. Interventions to reduce cost might focus on identifying high-risk patients before discharge and devising new approaches to follow-up.
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Affiliation(s)
- Bernard Friedman
- Agency for Healthcare Research and Quality, Rockville, MD 20850, USA.
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110
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George PP, Heng BH, Lim TK, Abisheganaden J, Ng AWK, Verma A, Lim FS. Evaluation of a disease management program for COPD using propensity matched control group. J Thorac Dis 2016; 8:1661-71. [PMID: 27499955 DOI: 10.21037/jtd.2016.06.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Disease management programs (DMPs) have proliferated recently as a means of improving the quality and efficiency of care for patients with chronic illness. These programs include education about disease, optimization of evidence-based medications, information and support from case managers, and institution of self-management principles. Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in Singapore and worldwide. DMP aims to reduce mortality, hospitalizations, and average length of stay in such patients. This study assesses the outcomes of the DMP, comparing the propensity score matched DMP patients with controls. METHODS DMP patients were compared with the controls, who were COPD patients fulfilling the DMP's inclusion criteria but not included in the program. Control patients were identified from Operations Data Store (ODS) database. The outcomes of interest were average length of stay, number of days admitted to hospital per 100 person days, readmission, and mortality rates per person year. The risk of death and readmission was estimated using Cox, and competing risk regression respectively. Propensity score was estimated to identify the predictors of DMP enrolment. DMP patients and controls were matched on their propensity score. RESULTS There were 170 matched DMP patients and control patients having 287 and 207 hospitalizations respectively. Program patient had lower mortality than the controls (0.12 vs. 0.27 per person year); cumulative 1-year survival was 91% among program patient and 76% among the control patients. Readmission, and hospital days per 100 person-days was higher for the program patients (0.36 vs. 0.17 per person year), and (2.19 vs. 1.88 per person year) respectively. CONCLUSIONS Participation in "DMP" was associated with lower all-cause mortality when compared to the controls. This survival gain in the program patients was paradoxically associated with an increase in readmission rate and total hospital days.
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Affiliation(s)
- Pradeep Paul George
- Health Services & Outcomes Research (HSOR), National Healthcare Group HQ, Singapore
| | - Bee Hoon Heng
- Health Services & Outcomes Research (HSOR), National Healthcare Group HQ, Singapore
| | - Tow Keang Lim
- Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore
| | - John Abisheganaden
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Alan Wei Keong Ng
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Akash Verma
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
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111
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Liu MH, Wang CH, Chiou AF, Yang NI, Kuo LT. Factors Associated With Inadequate Effectiveness of a Multidisciplinary Disease Management Program in Heart Failure Patients Stratified by Galectin 3 Level. Biol Res Nurs 2016; 19:77-86. [PMID: 27443525 DOI: 10.1177/1099800416659743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study investigated whether multidisciplinary disease management programs (MDPs) exert the same effects in heart failure (HF) patients across risk levels stratified by galectin-3 (Gal-3) level and what factors are associated with inadequate effectiveness of MDP. METHODS We used a longitudinal follow-up design based on a previous randomized trial. A total of 355 stabilized hospitalized HF patients were enrolled. The effects of MDP on death and HF-related rehospitalization were analyzed according to Gal-3 levels. RESULTS During the 4-year follow-up, Gal-3 levels predicted mortality and composite events ( p < .001). Multivariable analysis demonstrated the event-lowering effect of MDP (hazard ratio [HR] = 0.49, p = .001 for death and HR = 0.50, p < .001 for composite events). However, the effect of MDP was inadequate for those with high Gal-3 levels (≥17.9 ng/ml), whose 4-year composite event rate was 43% in the MDP arm. Further analysis showed that, in patients with Gal-3 ≥ 17.9 ng/ml, the independent factors associated with a high composite event rate were no MDP, older age, worse New York Heart Association functional class, no angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use, higher predischarge natriuretic peptide levels, and wider QRS complexes. CONCLUSIONS The effectiveness of MDP for HF patients at high risk was inadequate. Our findings identified the characteristics of these MDP nonresponders. Better integration of advanced care plans based on strategies guided by Gal-3 level is needed to improve care quality.
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Affiliation(s)
- Min-Hui Liu
- 1 Division of Cardiology, Department of Internal Medicine, Heart Failure Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.,2 Chang Gung University College of Medicine, Taoyuan, Taiwan.,3 Department of Nursing, National Yang-Ming University, Taipei, Taiwan
| | - Chao-Hung Wang
- 1 Division of Cardiology, Department of Internal Medicine, Heart Failure Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.,2 Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ai-Fu Chiou
- 3 Department of Nursing, National Yang-Ming University, Taipei, Taiwan
| | - Ning-I Yang
- 1 Division of Cardiology, Department of Internal Medicine, Heart Failure Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.,2 Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Li-Tang Kuo
- 1 Division of Cardiology, Department of Internal Medicine, Heart Failure Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.,2 Chang Gung University College of Medicine, Taoyuan, Taiwan
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112
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Abstract
PURPOSE OF REVIEW This article examines factors associated with readmission for chronic obstructive pulmonary disease and interventions that may decrease readmissions. RECENT FINDINGS The literature on this topic is relatively sparse. Drug therapy revolves around appropriate use of bronchodilators, antibiotics, and steroids. Patient education and participation and a multidisciplinary approach to the transition out of hospital can lead to decreased rehospitalizations. Patients who cannot participate in self-care may do better in skilled nursing facilities. SUMMARY We must optimize in-hospital care and see that patients receive a continuum of care upon discharge. We must also recognize that some patients have received optimal care and yet continue to suffer with end-stage disease on an ongoing basis; palliative medications such as long-acting narcotics and end-of-life discussions need to be considered in patients unable to survive for long outside of hospital.
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113
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Nguyen OK, Makam AN, Clark C, Zhang S, Xie B, Velasco F, Amarasingham R, Halm EA. Predicting all-cause readmissions using electronic health record data from the entire hospitalization: Model development and comparison. J Hosp Med 2016; 11:473-80. [PMID: 26929062 PMCID: PMC5365027 DOI: 10.1002/jhm.2568] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/15/2016] [Accepted: 01/28/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Incorporating clinical information from the full hospital course may improve prediction of 30-day readmissions. OBJECTIVE To develop an all-cause readmissions risk-prediction model incorporating electronic health record (EHR) data from the full hospital stay, and to compare "full-stay" model performance to a "first day" and 2 other validated models, LACE (includes Length of stay, Acute [nonelective] admission status, Charlson Comorbidity Index, and Emergency department visits in the past year), and HOSPITAL (includes Hemoglobin at discharge, discharge from Oncology service, Sodium level at discharge, Procedure during index hospitalization, Index hospitalization Type [nonelective], number of Admissions in the past year, and Length of stay). DESIGN Observational cohort study. SUBJECTS All medicine discharges between November 2009 and October 2010 from 6 hospitals in North Texas, including safety net, teaching, and nonteaching sites. MEASURES Thirty-day nonelective readmissions were ascertained from 75 regional hospitals. RESULTS Among 32,922 admissions (validation = 16,430), 12.7% were readmitted. In addition to many first-day factors, we identified hospital-acquired Clostridium difficile infection (adjusted odds ratio [AOR]: 2.03, 95% confidence interval [CI]: 1.18-3.48), vital sign instability on discharge (AOR: 1.25, 95% CI: 1.15-1.36), hyponatremia on discharge (AOR: 1.34, 95% CI: 1.18-1.51), and length of stay (AOR: 1.06, 95% CI: 1.04-1.07) as significant predictors. The full-stay model had better discrimination than other models though the improvement was modest (C statistic 0.69 vs 0.64-0.67). It was also modestly better in identifying patients at highest risk for readmission (likelihood ratio +2.4 vs. 1.8-2.1) and in reclassifying individuals (net reclassification index 0.02-0.06). CONCLUSIONS Incorporating clinically granular EHR data from the full hospital stay modestly improves prediction of 30-day readmissions. Given limited improvement in prediction despite incorporation of data on hospital complications, clinical instabilities, and trajectory, our findings suggest that many factors influencing readmissions remain unaccounted for. Further improvements in readmission models will likely require accounting for psychosocial and behavioral factors not currently captured by EHRs. Journal of Hospital Medicine 2016;11:473-480. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Oanh Kieu Nguyen
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Anil N Makam
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | | | - Song Zhang
- Division of Biostatistics, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Bin Xie
- Parkland Center for Clinical Innovation (PCCI), Dallas, Texas
| | | | - Ruben Amarasingham
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
- Parkland Center for Clinical Innovation (PCCI), Dallas, Texas
| | - Ethan A Halm
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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114
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Wakefield BJ, Holman JE. Functional Trajectories Associated With Hospitalization in Older Adults. West J Nurs Res 2016; 29:161-77; discussion 178-82. [PMID: 17337620 DOI: 10.1177/0193945906293809] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
For older adults, acute-care hospital stays can result in functional decline that leads to increased risk of hospitalization, nursing home admission, or mortality. This study describes functional trajectories in hospitalized older adults and identifies risk factors associated with those trajectories. Respondents ( N = 45) exhibited five of six possible functional trajectory patterns. The largest change in functional status was a decline in activities of daily living (ADL) from baseline at 2 weeks before admission to the time of admission; ADL did not return to baseline during the first 4 days in the hospital. Depression scores were significantly higher in respondents who reported experiencing ADL decline before admission. Respondents whose ADL scores declined during hospitalization (regardless of baseline status) were more likely than others to die within 3 months of discharge. Functional trajectory in hospitalized elderly patients is an important and underappreciated prognostic concept requiring further attention.
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Affiliation(s)
- Bonnie J Wakefield
- Harry S. Truman Memorial Veterans Hospital, Health Services Research and Development, Columbia, USA
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115
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Impact of the Hospital to Home Initiative on Readmissions in the VA Health Care System. Qual Manag Health Care 2016; 25:129-33. [DOI: 10.1097/qmh.0000000000000105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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116
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Griffin A, Skinner A, Thornhill J, Weinberger M. Patient Portals: Who uses them? What features do they use? And do they reduce hospital readmissions? Appl Clin Inform 2016; 7:489-501. [PMID: 27437056 DOI: 10.4338/aci-2016-01-ra-0003] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 03/28/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patient portals have demonstrated numerous benefits including improved patient-provider communication, patient satisfaction with care, and patient engagement. Recent literature has begun to illustrate how patients use selected portal features and an association between portal usage and improved clinical outcomes. OBJECTIVES This study sought to: (1) identify patient characteristics associated with the use of a patient portal; (2) determine the frequency with which common patient portal features are used; and (3) examine whether the level of patient portal use (non-users, light users, active users) is associated with 30-day hospital readmission. METHODS My UNC Chart is the patient portal for the UNC Health Care System. We identified adults discharged from three UNC Health Care hospitals with acute myocardial infarction, congestive heart failure, or pneumonia and classified them as active, light, or non-users of My UNC Chart. Multivariable analyses were conducted to compare across user groups; logistic regression was used to predict whether patient portal use was associated with 30-day readmission. RESULTS Of 2,975 eligible patients, 83.4% were non-users; 8.6% were light users; and 8.0% were active users of My UNC Chart. The messaging feature was used most often. For patients who were active users, the odds of being readmitted within 30 days was 66% greater than patients who were non-users (p<0.05). There was no difference in 30-day readmission between non-users and light users. CONCLUSIONS The vast majority of patients who were given an access code for My UNC Chart did not use it within 30 days of discharge. Of those who used the portal, active users had a higher odds of being readmitted within 30 days. Health care systems should consider strategies to: (1) increase overall use of patient portals and (2) target patients with the highest comorbidity scores to reduce hospital readmissions.
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Affiliation(s)
- Ashley Griffin
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill , 135 Dauer Drive, Chapel Hill, NC 27599
| | - Asheley Skinner
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill , 135 Dauer Drive, Chapel Hill, NC 27599
| | - Jonathan Thornhill
- Learning and Diffusion Group, Center for Medicare and Medicaid Innovation , 7500 Security Boulevard, Baltimore, MD 21244
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599; Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham NC 27705
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Whellan DJ, Stebbins A, Hernandez AF, Ezekowitz JA, McMurray JJ, Mather PJ, Hasselblad V, O'Connor CM. Dichotomous Relationship Between Age and 30-Day Death or Rehospitalization in Heart Failure Patients Admitted With Acute Decompensated Heart Failure: Results From the ASCEND-HF Trial. J Card Fail 2016; 22:409-16. [DOI: 10.1016/j.cardfail.2016.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 01/13/2016] [Accepted: 02/29/2016] [Indexed: 01/28/2023]
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Perrier L, Adhihetty C, Soobiah C. Examining semantics in interprofessional research: A bibliometric study. J Interprof Care 2016; 30:269-77. [DOI: 10.3109/13561820.2016.1142430] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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O'Toole TP, Johnson EE, Aiello R, Kane V, Pape L. Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration's "Homeless Patient Aligned Care Team" Program. Prev Chronic Dis 2016; 13:E44. [PMID: 27032987 PMCID: PMC4825747 DOI: 10.5888/pcd13.150567] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. METHODS We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. RESULTS More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. CONCLUSION Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.
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Affiliation(s)
- Thomas P O'Toole
- National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02909.
| | - Erin E Johnson
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
| | - Riccardo Aiello
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
| | - Vincent Kane
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island and Lebanon VA Medical Center, Lebanon, Pennsylvania
| | - Lisa Pape
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
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Ishani A, Christopher J, Palmer D, Otterness S, Clothier B, Nugent S, Nelson D, Rosenberg ME. Telehealth by an Interprofessional Team in Patients With CKD: A Randomized Controlled Trial. Am J Kidney Dis 2016; 68:41-9. [PMID: 26947216 DOI: 10.1053/j.ajkd.2016.01.018] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/14/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Telehealth and interprofessional case management are newer strategies of care within chronic disease management. We investigated whether an interprofessional team using telehealth was a feasible care delivery strategy and whether this strategy could affect health outcomes in patients with chronic kidney disease (CKD). STUDY DESIGN Randomized clinical trial. SETTING & PARTICIPANTS Minneapolis Veterans Affairs Health Care System (VAHCS), St. Cloud VAHCS, and affiliated clinics March 2012 to November 2013 in patients with CKD (estimated glomerular filtration rate < 60mL/min/1.73m(2)). INTERVENTIONS Patients were randomly assigned to receive an intervention (n=451) consisting of care by an interprofessional team (nephrologist, nurse practitioner, nurses, clinical pharmacy specialist, psychologist, social worker, and dietician) using a telehealth device (touch screen computer with peripherals) or to usual care (n=150). OUTCOMES The primary end point was a composite of death, hospitalization, emergency department visits, or admission to skilled nursing facilities, compared to usual care. RESULTS Baseline characteristics of the overall study group: mean age, 75.1±8.1 (SD) years; men, 98.5%; white, 97.3%; and mean estimated glomerular filtration rate, 37±9mL/min/1.73m(2). Telehealth and interprofessional care were successfully implemented with meaningful engagement with the care system. One year after randomization, 208 (46.2%) patients in the intervention group versus 70 (46.7%) in the usual-care group had the primary composite outcome (HR, 0.98; 95% CI, 0.75-1.29; P=0.9). There was no difference between groups for any component of the primary outcome: all-cause mortality (HR, 1.46; 95% CI, 0.42-5.11), hospitalization (HR, 1.15; 95% CI, 0.80-1.63), emergency department visits (HR, 0.92; 95% CI, 0.68-1.24), or nursing home admission (HR, 3.07; 95% CI, 0.71-13.24). LIMITATIONS Older population, mostly men, potentially underpowered/wide CIs. CONCLUSIONS Telehealth by an interprofessional team is a feasible care delivery strategy in patients with CKD. There was no statistically significant evidence of superiority of this intervention on health outcomes compared to usual care.
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Affiliation(s)
- Areef Ishani
- Section of Renal Diseases and Hypertension, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN; Division of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, MN.
| | - Juleen Christopher
- Section of Renal Diseases and Hypertension, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Deirdre Palmer
- Section of Renal Diseases and Hypertension, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Sara Otterness
- Section of Renal Diseases and Hypertension, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Barbara Clothier
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - David Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Mark E Rosenberg
- Division of Renal Diseases and Hypertension, University of Minnesota Medical School, Minneapolis, MN
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Duggan EW, Klopman MA, Berry AJ, Umpierrez G. The Emory University Perioperative Algorithm for the Management of Hyperglycemia and Diabetes in Non-cardiac Surgery Patients. Curr Diab Rep 2016; 16:34. [PMID: 26971119 DOI: 10.1007/s11892-016-0720-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hyperglycemia is a frequent manifestation of critical and surgical illness, resulting from the acute metabolic and hormonal changes associated with the response to injury and stress (Umpierrez and Kitabchi, Curr Opin Endocrinol. 11:75-81, 2004; McCowen et al., Crit Care Clin. 17(1):107-24, 2001). The exact prevalence of hospital hyperglycemia is not known, but observational studies have reported a prevalence of hyperglycemia ranging from 32 to 60 % in community hospitals (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Cook et al., J Hosp Med. 4(9):E7-14, 2009; Farrokhi et al., Best Pract Res Clin Endocrinol Metab. 25(5):813-24, 2011), and 80 % of patients after cardiac surgery (Schmeltz et al., Diabetes Care 30(4):823-8, 2007; van den Berghe et al., N Engl J Med. 345(19):1359-67, 2001). Retrospective and randomized controlled trials in surgical populations have reported that hyperglycemia and diabetes are associated with increased length of stay, hospital complications, resource utilization, and mortality (Frisch et al., Diabetes Care 33(8):1783-8, 2010; Kwon et al., Ann Surg. 257(1):8-14, 2013; Bower et al., Surgery 147(5):670-5, 2010; Noordzij et al., Eur J Endocrinol. 156(1):137-42, 2007; Mraovic et al., J Arthroplasty 25(1):64-70, 2010). Substantial evidence indicates that correction of hyperglycemia reduces complications in critically ill, as well as in general surgery patients (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Clement et al., Diabetes Care 27(2):553-97, 2004; Pomposelli et al., JPEN J Parented Enteral Nutr. 22(2):77-81, 1998). This manuscript reviews the pathophysiology of stress hyperglycemia during anesthesia and the perioperative period. We provide a practical outline for the diagnosis and management of preoperative, intraoperative, and postoperative care of patients with diabetes and hyperglycemia.
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Affiliation(s)
| | - Matthew A Klopman
- Department of Anesthesiology, Emory University Hospital, Atlanta, USA
| | - Arnold J Berry
- Department of Anesthesiology, Emory University Hospital, Atlanta, USA
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Davies ML, Goffman RM, May JH, Monte RJ, Rodriguez KL, Tjader YC, Vargas DL. Large-Scale No-Show Patterns and Distributions for Clinic Operational Research. Healthcare (Basel) 2016; 4:healthcare4010015. [PMID: 27417603 PMCID: PMC4934549 DOI: 10.3390/healthcare4010015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/22/2016] [Accepted: 02/02/2016] [Indexed: 11/16/2022] Open
Abstract
Patient no-shows for scheduled primary care appointments are common. Unused appointment slots reduce patient quality of care, access to services and provider productivity while increasing loss to follow-up and medical costs. This paper describes patterns of no-show variation by patient age, gender, appointment age, and type of appointment request for six individual service lines in the United States Veterans Health Administration (VHA). This retrospective observational descriptive project examined 25,050,479 VHA appointments contained in individual-level records for eight years (FY07-FY14) for 555,183 patients. Multifactor analysis of variance (ANOVA) was performed, with no-show rate as the dependent variable, and gender, age group, appointment age, new patient status, and service line as factors. The analyses revealed that males had higher no-show rates than females to age 65, at which point males and females exhibited similar rates. The average no-show rates decreased with age until 75-79, whereupon rates increased. As appointment age increased, males and new patients had increasing no-show rates. Younger patients are especially prone to no-show as appointment age increases. These findings provide novel information to healthcare practitioners and management scientists to more accurately characterize no-show and attendance rates and the impact of certain patient factors. Future general population data could determine whether findings from VHA data generalize to others.
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Affiliation(s)
- Michael L Davies
- Access and Clinic Administration Program (ACAP), U.S. Department of Veterans Affairs, Washington, DC 57741, USA.
| | - Rachel M Goffman
- Veterans Engineering Resource Center, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
| | - Jerrold H May
- Joseph M. Katz Graduate School of Business, University of Pittsburgh, Pittsburgh, PA 15260, USA.
| | - Robert J Monte
- Veterans Engineering Resource Center, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
| | - Keri L Rodriguez
- Veterans Engineering Resource Center, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA.
| | - Youxu C Tjader
- Joseph M. Katz Graduate School of Business, University of Pittsburgh, Pittsburgh, PA 15260, USA.
| | - Dominic L Vargas
- Joseph M. Katz Graduate School of Business, University of Pittsburgh, Pittsburgh, PA 15260, USA.
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Nuti SV, Qin L, Rumsfeld JS, Ross JS, Masoudi FA, Normand SLT, Murugiah K, Bernheim SM, Suter LG, Krumholz HM. Association of Admission to Veterans Affairs Hospitals vs Non-Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia. JAMA 2016; 315:582-92. [PMID: 26864412 PMCID: PMC5459395 DOI: 10.1001/jama.2016.0278] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
IMPORTANCE Little contemporary information is available about comparative performance between Veterans Affairs (VA) and non-VA hospitals, particularly related to mortality and readmission rates, 2 important outcomes of care. OBJECTIVE To assess and compare mortality and readmission rates among men in VA and non-VA hospitals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis involving male Medicare fee-for-service beneficiaries aged 65 years or older hospitalized between 2010 and 2013 in VA and non-VA acute care hospitals for acute myocardial infarction (AMI), heart failure (HF), or pneumonia using the Medicare Standard Analytic Files and Enrollment Database together with VA administrative claims data. To avoid confounding geographic effects with health care system effects, we studied VA and non-VA hospitals within the same metropolitan statistical area (MSA). EXPOSURES Hospitalization in a VA or non-VA hospital in MSAs that contained at least 1 VA and non-VA hospital. MAIN OUTCOMES AND MEASURES For each condition, 30-day risk-standardized mortality rates and risk-standardized readmission rates for VA and non-VA hospitals. Mean aggregated within-MSA differences in mortality and readmission rates were also assessed. RESULTS We studied 104 VA and 1513 non-VA hospitals, with each condition-outcome analysis cohort for VA and non-VA hospitals containing at least 7900 patients (men; ≥65 years), in 92 MSAs. Mortality rates were lower in VA hospitals than non-VA hospitals for AMI (13.5% vs 13.7%, P = .02; -0.2 percentage-point difference) and HF (11.4% vs 11.9%, P = .008; -0.5 percentage-point difference), but higher for pneumonia (12.6% vs 12.2%, P = .045; 0.4 percentage-point difference). In contrast, readmission rates were higher in VA hospitals for all 3 conditions (AMI, 17.8% vs 17.2%, 0.6 percentage-point difference; HF, 24.7% vs 23.5%, 1.2 percentage-point difference; pneumonia, 19.4% vs 18.7%, 0.7 percentage-point difference, all P < .001). In within-MSA comparisons, VA hospitals had lower mortality rates for AMI (percentage-point difference, -0.22; 95% CI, -0.40 to -0.04) and HF (-0.63; 95% CI, -0.95 to -0.31), and mortality rates for pneumonia were not significantly different (-0.03; 95% CI, -0.46 to 0.40); however, VA hospitals had higher readmission rates for AMI (0.62; 95% CI, 0.48 to 0.75), HF (0.97; 95% CI, 0.59 to 1.34), or pneumonia (0.66; 95% CI, 0.41 to 0.91). CONCLUSIONS AND RELEVANCE Among older men with AMI, HF, or pneumonia, hospitalization at VA hospitals, compared with hospitalization at non-VA hospitals, was associated with lower 30-day risk-standardized all-cause mortality rates for AMI and HF, and higher 30-day risk-standardized all-cause readmission rates for all 3 conditions, both nationally and within similar geographic areas, although absolute differences between these outcomes at VA and non-VA hospitals were small.
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Affiliation(s)
- Sudhakar V Nuti
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Li Qin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut2Section of Cardiovascular Medicine, the Robert Wood Johnson Foundation Clinical Scholars Program, the Section of General Internal Medicine, and Section of Rheumat
| | | | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut2Section of Cardiovascular Medicine, the Robert Wood Johnson Foundation Clinical Scholars Program, the Section of General Internal Medicine, and Section of Rheumat
| | - Frederick A Masoudi
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts7Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Karthik Murugiah
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Susannah M Bernheim
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Lisa G Suter
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut2Section of Cardiovascular Medicine, the Robert Wood Johnson Foundation Clinical Scholars Program, the Section of General Internal Medicine, and Section of Rheumat
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut2Section of Cardiovascular Medicine, the Robert Wood Johnson Foundation Clinical Scholars Program, the Section of General Internal Medicine, and Section of Rheumat
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Sahota O, Pulikottil-Jacob R, Marshall F, Montgomery A, Tan W, Sach T, Logan P, Kendrick D, Watson A, Walker M, Waring J. Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundOlder people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater.ObjectiveTo compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years.MethodsA pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients.ResultsIn total, 250 participants were randomised (n = 125 CIRACT service,n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services.ConclusionsThe CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team.Trial registrationCurrent Controlled Trials ISRCTN94393315.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Opinder Sahota
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Fiona Marshall
- University of Nottingham Business School, Nottingham, UK
| | - Alan Montgomery
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Wei Tan
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Tracey Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Pip Logan
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Denise Kendrick
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Alison Watson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Justin Waring
- University of Nottingham Business School, Nottingham, UK
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Abstract
BACKGROUND Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review. OBJECTIVES To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov). SELECTION CRITERIA Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text. MAIN RESULTS We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials). AUTHORS' CONCLUSIONS A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.
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Affiliation(s)
| | - Natasha A Lannin
- Alfred HealthOccupational TherapyThe Alfred55 Commercial RoadPrahranVictoriaAustralia3004
| | - Lindy M Clemson
- University of SydneyFaculty of Health SciencesJ005, East St. LidcombeLidcombeNSWAustralia1825
| | - Ian D Cameron
- Kolling Institute, Northern Sydney Local Health DistrictJohn Walsh Centre for Rehabilitation ResearchSt LeonardsNSWAustralia2065
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthOxfordUK
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Faucher J, Rosedahl J, Finnie D, Glasgow A, Takahashi P. Patient quality of life in the Mayo Clinic Care Transitions program: a survey study. Patient Prefer Adherence 2016; 10:1679-85. [PMID: 27621601 PMCID: PMC5012838 DOI: 10.2147/ppa.s109157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Transitional care programs are common interventions aimed at reducing medical complications and associated readmissions for patients recently discharged from the hospital. While organizations strive to reduce readmissions, another important related metric is patient quality of life (QoL). AIMS To compare the relationship between QoL in patients enrolled in the Mayo Clinic Care Transitions (MCCT) program versus usual care, and to determine if QoL changed in MCCT participants between baseline and 1-year follow-up. METHODS A baseline survey was mailed to MCCT enrollees in March 2013. Those who completed a baseline survey were sent a follow-up survey 1 year later. A cross-sectional survey of usual care participants was mailed in November 2013. We included in our analysis 199 participants (83 in the MCCT and 116 in usual care) aged over 60 years with multiple comorbidities and receiving primary care. Primary outcomes were self-rated QoL; secondary outcomes included self-reported general, physical, and mental health. Intra- and intergroup comparisons of patients were evaluated using Pearson's chi-squared analysis. RESULTS MCCT participants had more comorbidities and higher elder risk assessment scores than those receiving usual care. At baseline, 74% of MCCT participants reported responses of good-to-excellent QoL compared to 64% after 1 year (P=0.16). Between MCCT and usual care, there was no significant difference in self-reported QoL (P=0.21). Between baseline and follow-up in MCCT patients, and compared to usual care, there were no significant differences in self-reported general, physical, or mental health. CONCLUSION We detected no difference over time in QoL between MCCT patients and those receiving usual care, and a nonsignificant QoL decline in MCCT participants after 1 year. Progression of chronic disease may overwhelm any QoL improvement attributable to the MCCT intervention. The MCCT interventions may blunt expected declines in QoL, producing concordant responses among sicker MCCT patients and healthier usual care participants.
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Affiliation(s)
| | - Jordan Rosedahl
- Division of Biomedical Statistics and Informatics, Department of Health Science Research, Mayo Clinic
| | - Dawn Finnie
- Center for the Science of Health Care Delivery
| | - Amy Glasgow
- Center for the Science of Health Care Delivery
| | - Paul Takahashi
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Correspondence: Paul Takahashi, Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA, Tel +1 507 284 2511, Fax +1 507 266 0036, Email
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Lewis Hunter AE, Spatz ES, Bernstein SL, Rosenthal MS. Factors Influencing Hospital Admission of Non-critically Ill Patients Presenting to the Emergency Department: a Cross-sectional Study. J Gen Intern Med 2016; 31:37-44. [PMID: 26084975 PMCID: PMC4700015 DOI: 10.1007/s11606-015-3438-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 04/03/2015] [Accepted: 05/29/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about the factors that influence physicians' admission decisions, especially among lower acuity patients. For the purpose of our study, non-medical refers to all of the factors-other than the patient's clinical condition-that could potentially influence admission decisions. OBJECTIVE To describe the influence of non-medical factors on physicians' decisions to admit non-critically ill patients presenting to the ED. DESIGN Cross-sectional study of hospital admissions at a single academic medical center. PARTICIPANTS Non-critically ill adult patients admitted to the hospital (n = 297) and the admitting emergency medicine physicians (n = 34). MAIN MEASURES A patient survey assessed non-medical factors, including primary care access and utilization. A physician survey assessed clinical and non-medical factors influencing the decision to admit. Based on physician responses, admissions were characterized as "strongly acuity-driven," "moderately acuity-driven," or "weakly acuity-driven." Among these admission types, we compared length of stay, cost, and readmission within 30 days to the hospital or ED. KEY RESULTS Based on the admitting physician's assessment, we categorized the motivation for admission as strongly acuity-driven in 185 (62 %) admissions, moderately acuity-driven in 92 (31 %), and weakly acuity-driven in 20 (7 %). Per the physician surveys, 51 % of hospitalizations were strongly or moderately influenced by one or more non-medical factors, including lack of information about baseline conditions (23 %); inadequate access to outpatient specialty care (14 %); need for a diagnostic testing or procedure (12 %); a recent ED visit (11 %); and inadequate access to primary care (10 %). Compared with strongly-acuity driven admissions, admissions that were moderately or weakly acuity-driven were shorter and less costly but were associated with similar rates of ED (35 %) and hospital (27 %) readmission. CONCLUSIONS Non-medical factors are influential in the admission decisions for many patients presenting to the emergency department. Moderately and weakly acuity-driven admissions may represent a feasible target for alternative care pathways.
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Affiliation(s)
| | - Erica S Spatz
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA.,Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, CT, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA.,Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, CT, USA
| | - Marjorie S Rosenthal
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA.,Robert Wood Johnson Clinical Scholars Program, Yale School of Medicine, New Haven, CT, USA
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128
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Gholizadeh M, Delgoshaei B, Gorji HA, Torani S, Janati A. Challenges in Patient Discharge Planning in the Health System of Iran: A Qualitative Study. Glob J Health Sci 2015; 8:47426. [PMID: 26755460 PMCID: PMC4954898 DOI: 10.5539/gjhs.v8n6p168] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 05/11/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND One of the main factors relating to quality of hospitals is effective discharge planning. Discharge planning promotes the quality of inpatient care and reduces unplanned hospital readmission. The current study investigated the challenges of discharge planning observed in the health system of Iran. METHODS This qualitative research was conducted using a thematic and framework analyses to identify the challenges under each themes defined by the World Health Organization (WHO), to understand barriers in developing an effective discharge planning system in Iran health system. The data was collected from detailed semi-structured interviews and sessions of focus group discussions. This study involved 51 participants including health policy makers, hospital and health managers, faculty members, nurses, practitioners, community medicine specialists and other professionals of the Ministry of Health and Medical Education (MOHME). To reduce the bias and to increase the credibility of the study, evaluation criteria from Lincoln and Guba were used. All interviews and FGDs were recorded and transcribed, then analyzed by the software MAXQDA-11 and also manually. RESULTS According to the WHO health systems framework, challenges of effective hospital discharge planning were divided into six areas, leadership/governance, service delivery, information, financing, health workforce, and medical production(themes), in which there were 5,3,2,2,3,1 subthemes respectively. CONCLUSION It is evident from the findings of this study that changes in the perspective of policy makers, health staff and managers, strengthening of systematic approach, and establishment of required infrastructures are essential for successful implementation of effective discharge planning in health systems in Iran.
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Affiliation(s)
- Masumeh Gholizadeh
- School of Public Health, Tehran University of Medical Sciences, Tehran, Iran..
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Greenberg JK, Washington CW, Guniganti R, Dacey RG, Derdeyn CP, Zipfel GJ. Causes of 30-day readmission after aneurysmal subarachnoid hemorrhage. J Neurosurg 2015; 124:743-9. [PMID: 26361278 DOI: 10.3171/2015.2.jns142771] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hospital readmission is a common but controversial quality measure increasingly used to influence hospital compensation in the US. The objective of this study was to evaluate the causes for 30-day hospital readmission following aneurysmal subarachnoid hemorrhage (SAH) to determine the appropriateness of this performance metric and to identify potential avenues for improved patient care. METHODS The authors retrospectively reviewed the medical records of all patients who received surgical or endovascular treatment for aneurysmal SAH at Barnes-Jewish Hospital between 2003 and 2013. Two senior faculty identified by consensus the primary medical/surgical diagnosis associated with readmission as well as the underlying causes of rehospitalization. RESULTS Among 778 patients treated for aneurysmal SAH, 89 experienced a total of 97 readmission events, yielding a readmission rate of 11.4%. The median time from discharge to readmission was 9 days (interquartile range 3-17.5 days). Actual hydrocephalus or potential concern for hydrocephalus (e.g., headache) was the most frequent diagnosis (26/97, 26.8%), followed by infections (e.g., wound infection [5/97, 5.2%], urinary tract infection [3/97, 3.1%], and pneumonia [3/97, 3.1%]) and thromboembolic events (8/97, 8.2%). In most cases (75/97, 77.3%), we did not identify any treatment lapses contributing to readmission. The most common underlying causes for readmission were unavoidable development of SAH-related pathology (e.g., hydrocephalus; 36/97, 37.1%) and complications related to neurological impairment and immobility (e.g., thromboembolic event despite high-dose chemoprophylaxis; 21/97, 21.6%). The authors determined that 22/97 (22.7%) of the readmissions were likely preventable with alternative management. In these cases, insufficient outpatient medical care (for example, for hyponatremia; 16/97, 16.5%) was the most common shortcoming. CONCLUSIONS Most readmissions after aneurysmal SAH relate to late consequences of hemorrhage, such as hydrocephalus, or medical complications secondary to severe neurological injury. Although a minority of readmissions may potentially be avoided with closer medical follow-up in the transitional care environment, readmission after SAH is an insensitive and likely inappropriate hospital performance metric.
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Affiliation(s)
| | | | | | | | - Colin P Derdeyn
- Departments of 1 Neurological Surgery and.,Neurology, and.,Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Desai AD, Popalisky J, Simon TD, Mangione-Smith RM. The effectiveness of family-centered transition processes from hospital settings to home: a review of the literature. Hosp Pediatr 2015; 5:219-31. [PMID: 25832977 DOI: 10.1542/hpeds.2014-0097] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The quality of care transitions is of growing concern because of a high incidence of postdischarge adverse events, poor communication with patients, and inadequate information transfer between providers. The objective of this study was to conduct a targeted literature review of studies examining the effectiveness of family-centered transition processes from hospital- and emergency department (ED)-to-home for improving patient health outcomes and health care utilization. METHODS We conducted an electronic search (2001-2012) of PubMed, CINAHL, Cochrane, PsycInfo, Embase, and Web of Science databases. Included were experimental studies of hospital and ED-to-home transition interventions in pediatric and adult populations meeting the following inclusion criteria: studies evaluating hospital or ED-to-home transition interventions, study interventions involving patients/families, studies measuring outcomes≤30 days after discharge, and US studies. Transition processes, principal outcome measures (patient health outcomes and health care utilization), and assessment time-frames were extracted for each study. RESULTS The search yielded 3458 articles, and 16 clinical trials met final inclusion criteria. Four studies evaluated pediatric ED-to-home transitions and indicated family-tailored discharge education was associated with better patient health outcomes. Remaining trials evaluating adult hospital-to-home transitions indicated a transition needs assessment or provision of an individualized transition record was associated with better patient health outcomes and reductions in health care utilization. The effectiveness of postdischarge telephone follow-up and/or home visits on health care utilization showed mixed results. CONCLUSIONS Patient-tailored discharge education is associated with improved patient health outcomes in pediatric ED patients. Effective transition processes identified in the adult literature may inform future quality improvement research regarding pediatric hospital-to-home transitions.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington; and Seattle Children's Research Institute, Seattle, Washington
| | - Jean Popalisky
- Seattle Children's Research Institute, Seattle, Washington
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, Washington; and Seattle Children's Research Institute, Seattle, Washington
| | - Rita M Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington; and Seattle Children's Research Institute, Seattle, Washington
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Chai TY, Tonks KT, Campbell LV. Long-term glycaemic control (HbA1c), not admission glucose, predicts hospital re-admission in diabetic patients. Australas Med J 2015. [PMID: 26213582 DOI: 10.4066/amj.2015.2351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Diabetic patients are commonly hyperglycaemic on presentation. Admission hyperglycaemia is associated with adverse outcomes, particularly prolonged hospitalisation. Improving inpatient glycaemia may reduce length of hospital stay (LOS) in diabetic patients. AIMS To determine whether in-hospital recognition and treatment of admission hyperglycaemia in diabetic patients is associated with reduced LOS. METHODS Medical records were reviewed from 1 November 2011 to 31 May 2012 for 162 diabetic patients admitted with a blood glucose level (BGL) ≥11.1mmol/L. In-hospital outcomes were compared. Stepwise multiple regression was used to evaluate factors contributing to LOS. RESULTS Compared to the untreated individuals (n=67), hyperglycaemia treatment (n=95) was associated with a longer LOS (median eight vs. four days, p<0.01), higher HbA1c (9.0 vs. 7.3 per cent, p<0.01), more infections (50 vs. 25 per cent, p<0.01), and more patients with follow-up plans (35 vs. 10 per cent, p<0.01). Higher HbA1c was significantly related to more follow-up (ρs=0.30, n=110, p<0.01) with a trend to lower re-admission in those with follow-up plans (ρs=-1.41, n=162, p=0.07). CONCLUSION Recognition and treatment of admission hyperglycaemia in diabetic patients was associated with longer LOS than if untreated. Contributory factors to LOS include: illness severity, infections, and higher HbA1c. Although follow-up plans were few (27 per cent) for diabetic patients with hyperglycaemia, it was significantly more likely in those with higher HbA1c. Diabetic patients' complexities require timely multidisciplinary team involvement. Improved follow-up care, particularly for hospitalised diabetic patients identified to have chronically poor glycaemic control, may help prevent future diabetic patient re-admissions.
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Affiliation(s)
- Thora Y Chai
- School of Medicine Sydney, University of Notre Dame Australia, Darlinghurst, NSW, Australia
| | - Katherine T Tonks
- Department of Endocrinology, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Lesley V Campbell
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
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Facility-Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention. Circulation 2015; 132:101-8. [DOI: 10.1161/circulationaha.115.015351] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/01/2015] [Indexed: 11/16/2022]
Abstract
Background—
Policies to reduce unnecessary hospitalizations after percutaneous coronary intervention (PCI) are intended to improve healthcare value by reducing costs while maintaining patient outcomes. Whether facility-level hospitalization rates after PCI are associated with cost of care is unknown.
Methods and Results—
We studied 32 080 patients who received PCI at any 1 of 62 Veterans Affairs hospitals from 2008 to 2011. We identified facility outliers for 30-day risk-standardized hospitalization, mortality, and cost. Compared with the risk-standardized average, 2 hospitals (3.2%) had a lower-than-expected hospitalization rate, and 2 hospitals (3.2%) had a higher-than-expected hospitalization rate. We observed no statistically significant variation in facility-level risk-standardized mortality. The facility-level unadjusted median per patient 30-day total cost was $23 820 (interquartile range, $19 604–$29 958). Compared with the risk-standardized average, 17 hospitals (27.4%) had lower-than-expected costs, and 14 hospitals (22.6%) had higher-than-expected costs. At the facility level, the index PCI accounted for 83.1% of the total cost (range, 60.3%–92.2%), whereas hospitalization after PCI accounted for only 5.8% (range, 2.0%–12.7%) of the 30-day total cost. Facilities with higher hospitalization rates were not more expensive (Spearman ρ=0.16; 95% confidence interval, −0.09 to 0.39;
P
=0.21).
Conclusions—
In this national study, hospitalizations in the 30 day after PCI accounted for only 5.8% of 30-day cost, and facility-level cost was not correlated with hospitalization rates. This challenges the focus on reducing hospitalizations after PCI as an effective means of improving healthcare value. Opportunities remain to improve PCI value by reducing the variation in total cost of PCI without compromising patient outcomes.
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Balaban RB, Galbraith AA, Burns ME, Vialle-Valentin CE, Larochelle MR, Ross-Degnan D. A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial. J Gen Intern Med 2015; 30:907-15. [PMID: 25617166 PMCID: PMC4471016 DOI: 10.1007/s11606-015-3185-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 10/27/2014] [Accepted: 12/31/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals. OBJECTIVE To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. DESIGN Randomized controlled trial. PARTICIPANTS General medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. INTERVENTIONS PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. MAIN MEASURES The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). KEY RESULTS Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1% decrease [95% CI: -8.0%, -0.2%] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8% increase [95% CI: 4.4%, 19.0%] in readmission with no change in 30-day outpatient follow-up. CONCLUSIONS A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.
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Affiliation(s)
- Richard B Balaban
- Cambridge Health Alliance, Harvard Medical School, Somerville Hospital Primary Care, 236 Highland Ave., Somerville, MA, 02143, USA,
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Costs and Effects of an Ambulatory Geriatric Unit (the AGe-FIT Study): A Randomized Controlled Trial. J Am Med Dir Assoc 2015; 16:497-503. [DOI: 10.1016/j.jamda.2015.01.074] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 01/03/2015] [Accepted: 01/06/2015] [Indexed: 01/10/2023]
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Avaldi VM, Lenzi J, Castaldini I, Urbinati S, Di Pasquale G, Morini M, Protonotari A, Maggioni AP, Fantini MP. Hospital readmissions of patients with heart failure: the impact of hospital and primary care organizational factors in Northern Italy. PLoS One 2015; 10:e0127796. [PMID: 26010223 PMCID: PMC4444393 DOI: 10.1371/journal.pone.0127796] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/18/2015] [Indexed: 01/25/2023] Open
Abstract
Background Primary health care is essential for an appropriate management of heart failure (HF), a disease which is a major clinical and public health issue and a leading cause of hospitalization. The aim of this study was to evaluate the impact of different organizational factors on readmissions of patients with HF. Methods The study population included elderly resident in the Local Health Authority of Bologna (Northern Italy) and discharged with a diagnosis of HF from January to December 2010. Unplanned hospital readmissions were measured in four timeframes: 30 (short-term), 90 (medium-term), 180 (mid-long-term), and 365 days (long-term). Using multivariable multilevel Poisson regression analyses, we investigated the association between readmissions and organizational factors (discharge from a cardiology department, general practitioners’ monodisciplinary organizational arrangement, and implementation of a specific HF care pathway). Results The 1873 study patients had a median age of 83 years (interquartile range 77–87) and 55.5% were females; 52.0% were readmitted to the hospital for any reason after a year, while 20.1% were readmitted for HF. The presence of a HF care pathway was the only factor significantly associated with a lower risk of readmission for HF in the short-, medium-, mid-long- and long-term period (short-term: IRR [incidence rate ratio]=0.57, 95%CI [confidence interval]=0.35–0.92; medium-term: IRR=0.70, 95%CI=0.51–0.96; mid-long-term: IRR=0.79, 95%CI=0.64–0.98; long-term: IRR=0.82, 95%CI=0.67–0.99), and with a lower risk of all-cause readmission in the short-term period (IRR=0.73, 95%CI=0.57–0.94). Conclusion Our study shows that the HF care specific pathway implemented at the primary care level was associated with lower readmission rate for HF in each timeframe, and also with lower readmission rate for all causes in the short-term period. Our results suggest that the engagement of primary care professionals starting from the early post-discharge period may be relevant in the management of patients with HF.
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Affiliation(s)
- Vera Maria Avaldi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
| | - Ilaria Castaldini
- Department of Programming and Control, Bologna Local Healthcare Authority, Bologna, Italy
| | | | | | - Mara Morini
- Department of Primary Care, Bologna Local Healthcare Authority, Bologna, Italy
| | - Adalgisa Protonotari
- Department of Programming and Control, Bologna Local Healthcare Authority, Bologna, Italy
| | | | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
- * E-mail:
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The Likelihood of Hospital Readmission Among Patients With Hospital-Onset Central Line-Associated Bloodstream Infections. Infect Control Hosp Epidemiol 2015; 36:886-92. [PMID: 25990620 DOI: 10.1017/ice.2015.115] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine whether central line-associated bloodstream infections (CLABSIs) increase the likelihood of readmission. DESIGN Retrospective matched cohort study for the years 2008-2009. SETTING Acute care hospitals. PARTICIPANTS Medicare recipients. CLABSI and readmission status were determined by linking National Healthcare Safety Network surveillance data to the Centers for Medicare and Medicaid Services' Medical Provider and Analysis Review in 8 states. Frequency matching was used on International Classification of Diseases, Ninth Revision, Clinical Modification procedure code category and intensive care unit status. METHODS We compared the rate of readmission among patients with and without CLABSI during an index hospitalization. Cox proportional hazard analysis was used to assess rate of readmission (the first hospitalization within 30 days after index discharge). Multivariate models included the following covariates: race, sex, length of index hospitalization stay, central line procedure code, Gagne comorbidity score, and individual chronic conditions. RESULTS Of the 8,097 patients, 2,260 were readmitted within 30 days (27.9%). The rate of first readmission was 7.1 events/person-year for CLABSI patients and 4.3 events/person-year for non-CLABSI patients (P<.001). The final model revealed a small but significant increase in the rate of 30-day readmissions for patients with a CLABSI compared with similar non-CLABSI patients. In the first readmission for CLABSI patients, we also observed an increase in diagnostic categories consistent with CLABSI, including septicemia and complications of a device. CONCLUSIONS Our analysis found a statistically significant association between CLABSI status and readmission, suggesting that CLABSI may have adverse health impact that extends beyond hospital discharge.
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Association of early post-discharge follow-up by a primary care physician and 30-day rehospitalization among older adults. J Gen Intern Med 2015; 30:565-71. [PMID: 25451987 PMCID: PMC4395599 DOI: 10.1007/s11606-014-3106-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 08/22/2014] [Accepted: 11/06/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Rehospitalizations within 30 days of discharge are responsible for a large portion of healthcare spending. One approach to preventing rehospitalizations is early follow-up, usually defined as an office visit with a primary care physician within 7 days of discharge--an approach that is being incentivized by health plans. However, evidence regarding its effectiveness is limited. OBJECTIVE We aimed to determine whether an office visit with a primary care physician within 7 days after discharge is associated with 30-day rehospitalization. DESIGN This was an observational study set within a randomized trial. PARTICIPANTS The study included patients age 65 and older receiving care from a multi-specialty group practice and discharged from hospital to home between 26 August 2010 and 25 August 2011. To control for confounding, we identified characteristics of patients and hospital stays that are predictive of rehospitalization, and also developed high-dimensional propensity scores. Analyses used Cox proportional hazards models and took into account varying amounts of opportunity time for office visits. MAIN MEASURES We looked at 30-day rehospitalizations at any hospital. KEY RESULTS Of 3,661 patients discharged to home during the study year, 707 (19.3%) were rehospitalized within 30 days. Patients receiving an office visit within 7 days numbered 1,808 (49.4%), and of these, 1,000 (27.3%) were with a primary care physician. In models predicting rehospitalization, stratified on deciles of propensity score and controlling for additional confounders, the hazard ratios associated with office visits with a primary care physician within 7 days were 0.98 (95% CI 0.80, 1.21); for visits with any physician, the hazard ratio was HR 1.04, (95% CI 0.87, 1.25). CONCLUSIONS We found no protective effect for office visits within 7 days. Such visits may need to be specifically focused on a range of issues related to the specific reasons why patients are rehospitalized. It is likely that outpatient visits will need to be set within comprehensive transition programs.
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Affiliation(s)
- Erin G Brown
- Department of General Surgery, UC Davis Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817, USA
| | - Richard J Bold
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Sacramento, CA 95817, USA.
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Tosoian JJ, Hicks CW, Cameron JL, Valero V, Eckhauser FE, Hirose K, Makary MA, Pawlik TM, Ahuja N, Weiss MJ, Wolfgang CL. Tracking early readmission after pancreatectomy to index and nonindex institutions: a more accurate assessment of readmission. JAMA Surg 2015; 150:152-8. [PMID: 25535811 DOI: 10.1001/jamasurg.2014.2346] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
IMPORTANCE Readmission after pancreatectomy is common, but few data compare patterns of readmission to index and nonindex hospitals. OBJECTIVES To evaluate the rate of readmission to index and nonindex institutions following pancreatectomy at a tertiary high-volume institution and to identify patient-level factors predictive of those readmissions. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of a prospectively collected institutional database linked to statewide data of patients who underwent pancreatectomy at a tertiary care referral center between January 1, 2005, and December 2, 2010. EXPOSURE Pancreatectomy. MAIN OUTCOMES AND MEASURES The primary outcome was unplanned 30-day readmission to index or nonindex hospitals. Risk factors and reasons for readmission were measured and compared by site using univariable and multivariable analyses. RESULTS Among all 623 patients who underwent pancreatectomy during the study period, 134 (21.5%) were readmitted to our institution (105 [78.4%]) or to an outside institution (29 [21.6%]). Fifty-six patients (41.8%) were readmitted because of a gastrointestinal or nutritional problem related to surgery and 42 patients (31.3%) because of a postoperative infection. On multivariable analysis, factors independently associated with readmission included age 65 years or older (odds ratio [OR], 1.80; 95% CI, 1.19-2.71), preexisting liver disease (OR, 2.28; 95% CI, 1.23-4.24), distal pancreatectomy (OR, 1.77; 95% CI, 1.11-2.84), and postoperative drain placement (OR, 2.81; 95% CI, 1.00-7.14). CONCLUSIONS AND RELEVANCE In total, 21.5% of patients required early readmission after pancreatectomy. Even in the setting of a tertiary care referral center, 21.6% of these readmissions were to nonindex institutions. Specific patient-level factors were associated with an increased risk of readmission.
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Affiliation(s)
- Jeffrey J Tosoian
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Caitlin W Hicks
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John L Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vicente Valero
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frederic E Eckhauser
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kenzo Hirose
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin A Makary
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher L Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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140
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Wee SL, Vrijhoef HJM. A conceptual framework for evaluating the conceptualization, implementation and performance of transitional care programmes. J Eval Clin Pract 2015; 21:221-8. [PMID: 25494718 DOI: 10.1111/jep.12292] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 11/29/2022]
Abstract
Developed health systems want to avoid unnecessary hospital admissions by addressing the needs of chronically ill older adults throughout acute episodes of illness. Transitional care (TC) is a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location, of which the main outcome of interest is avoiding hospital readmission. Implementation of TC is complex because it entails different actions to put multiple care components into practice, with various degrees of flexibility of adapting the intervention. Furthermore, the outcome involves behaviour change required by those delivering or receiving the intervention. Although there are examples of promising interventions, the possible variations in conceptualization and implementation present a real challenge for the adaptation of efficacious TC interventions from trial to 'real-world' settings. There is a lack of a theoretical basis or explicit logic model for why adapted interventions should work. This study provides conceptual approaches for the implementation and evaluation of TC programmes. It describes a framework of (1) conceptualization - with respect to the components in an intervention and the population of interest; (2) manner and context of implementation; and (3) evaluation - how these processes of implementation impact health outcomes.
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Affiliation(s)
- Shiou-Liang Wee
- Geriatric Education and Research Institute, Alexandra Health, Singapore; Duke-National University of Singapore Graduate Medical School, Singapore
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141
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Zhao Y, Connors C, Lee AH, Liang W. Relationship between primary care visits and hospital admissions in remote Indigenous patients with diabetes: a multivariate spline regression model. Diabetes Res Clin Pract 2015; 108:106-12. [PMID: 25666107 DOI: 10.1016/j.diabres.2015.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/20/2014] [Accepted: 01/04/2015] [Indexed: 10/24/2022]
Abstract
AIMS To determine if access to primary health care (PHC) is associated with reduced hospitalisations for remote Indigenous patients with diabetes. METHODS Using individual level linked health clinic and hospital data, a retrospective cohort study was conducted to estimate annual hospital admission rate by number of clinic visits in the Northern Territory of Australia, stratified by age group, sex and the presence of comorbidities. A spline regression model was used to describe the clinic-hospital relationship with covariates. An impact index of PHC visits was derived using the first derivative of the quadratic equations evaluated at the parameter estimates. RESULTS The relationship between PHC visits and hospitalisations in diabetes care appeared to be a U-curve. Low levels of PHC visits were associated with increased hospital admissions amongst people with diabetes. The overall level of all-cause hospitalisations for patients with diabetes was minimised when the PHC visits were 7.9 per person-year (95% confidence interval 5.8-10). CONCLUSIONS Using existing empirical data, this study suggests that other things being equal, diabetes patients who had an adequate level of PHC visits are likely to have a lower level of hospitalisations than those with fewer or more PHC visits. This study highlights the importance for remote Indigenous patients with diabetes to have adequate access to PHC.
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Affiliation(s)
- Yuejen Zhao
- Health Gains Planning Branch, Department of Health, 2nd Floor, Health House, 87 Mitchell Street, Darwin 0800, NT, Australia.
| | - Christine Connors
- Chronic Conditions Strategy Unit, Department of Health, Darwin, NT, Australia
| | - Andy H Lee
- School of Public Health, Health Science, Curtin University, Perth, WA, Australia
| | - Wenbin Liang
- National Drug Research Institute, Health Science, Curtin University, Perth, WA, Australia
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142
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Herrin J, St Andre J, Kenward K, Joshi MS, Audet AMJ, Hines SC. Community factors and hospital readmission rates. Health Serv Res 2015; 50:20-39. [PMID: 24712374 PMCID: PMC4319869 DOI: 10.1111/1475-6773.12177] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To examine the relationship between community factors and hospital readmission rates. DATA SOURCES/STUDY SETTING We examined all hospitals with publicly reported 30-day readmission rates for patients discharged during July 1, 2007, to June 30, 2010, with acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). We linked these to publicly available county data from the Area Resource File, the Census, Nursing Home Compare, and the Neilsen PopFacts datasets. STUDY DESIGN We used hierarchical linear models to assess the effect of county demographic, access to care, and nursing home quality characteristics on the pooled 30-day risk-standardized readmission rate. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS The study sample included 4,073 hospitals. Fifty-eight percent of national variation in hospital readmission rates was explained by the county in which the hospital was located. In multivariable analysis, a number of county characteristics were found to be independently associated with higher readmission rates, the strongest associations being for measures of access to care. These county characteristics explained almost half of the total variation across counties. CONCLUSIONS Community factors, as measured by county characteristics, explain a substantial amount of variation in hospital readmission rates.
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Affiliation(s)
- Jeph Herrin
- Address correspondence to Jeph Herrin, Ph.D., Health Research
& Educational Trust, Chicago, IL; Division of Cardiology, Yale
University School of Medicine, New Haven CT, PO Box 2254, Charlottesville, VA
22902; e-mail:
| | - Justin St Andre
- Justin St. Andre, M.A., is with Navigant Consulting,
Inc.Chicago, IL
- Kevin Kenward, Ph.D., Maulik S. Joshi, Dr.P.H., and Stephen C. Hines, Ph.D.,
are also with the Health Research & Educational
TrustChicago, IL
- Anne-Marie J. Audet, M.D., M.Sc., is with department of Delivery
System Reform and Breakthrough Opportunities, The Commonwealth
FundNew York, NY
| | - Kevin Kenward
- Justin St. Andre, M.A., is with Navigant Consulting,
Inc.Chicago, IL
- Kevin Kenward, Ph.D., Maulik S. Joshi, Dr.P.H., and Stephen C. Hines, Ph.D.,
are also with the Health Research & Educational
TrustChicago, IL
- Anne-Marie J. Audet, M.D., M.Sc., is with department of Delivery
System Reform and Breakthrough Opportunities, The Commonwealth
FundNew York, NY
| | - Maulik S Joshi
- Justin St. Andre, M.A., is with Navigant Consulting,
Inc.Chicago, IL
- Kevin Kenward, Ph.D., Maulik S. Joshi, Dr.P.H., and Stephen C. Hines, Ph.D.,
are also with the Health Research & Educational
TrustChicago, IL
- Anne-Marie J. Audet, M.D., M.Sc., is with department of Delivery
System Reform and Breakthrough Opportunities, The Commonwealth
FundNew York, NY
| | - Anne-Marie J Audet
- Justin St. Andre, M.A., is with Navigant Consulting,
Inc.Chicago, IL
- Kevin Kenward, Ph.D., Maulik S. Joshi, Dr.P.H., and Stephen C. Hines, Ph.D.,
are also with the Health Research & Educational
TrustChicago, IL
- Anne-Marie J. Audet, M.D., M.Sc., is with department of Delivery
System Reform and Breakthrough Opportunities, The Commonwealth
FundNew York, NY
| | - Stephen C Hines
- Justin St. Andre, M.A., is with Navigant Consulting,
Inc.Chicago, IL
- Kevin Kenward, Ph.D., Maulik S. Joshi, Dr.P.H., and Stephen C. Hines, Ph.D.,
are also with the Health Research & Educational
TrustChicago, IL
- Anne-Marie J. Audet, M.D., M.Sc., is with department of Delivery
System Reform and Breakthrough Opportunities, The Commonwealth
FundNew York, NY
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143
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Wigg AJ, Chinnaratha MA, Wundke R, Volk ML. A chronic disease management model for chronic liver failure. Hepatology 2015; 61:725-8. [PMID: 24677213 DOI: 10.1002/hep.27152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/27/2014] [Indexed: 01/18/2023]
Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, Australia; Flinders University of South Australia, Adelaide, Australia
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144
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Fung CSC, Wong CKH, Fong DYT, Lee A, Lam CLK. Having a family doctor was associated with lower utilization of hospital-based health services. BMC Health Serv Res 2015; 15:42. [PMID: 25627936 PMCID: PMC4312460 DOI: 10.1186/s12913-015-0705-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 01/14/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Primary care in the United States and most countries in Asia are provided by a variety of doctors. However, effectiveness of such diversified primary care in gate-keeping secondary medical services is unknown. This study aimed to evaluate health services utilization rates of hospital emergency and admission services among people who used different primary care doctors in Hong Kong. METHOD This study was a population-based cross-sectional telephone survey using structured questionnaire on health services utilization rates and pattern in Hong Kong in 2007 to 2008. Information on the choice of primary care doctors, utilization rates and patterns of primary care service were collected. Poisson and logistic regression analyses were used to explore any differences in service utilization rates and patterns among people using different types of primary care doctors. RESULTS Out of 3148 subjects who completed the survey, 1896 (60.2%) had regular primary care doctors, of whom 1150 (60.7%) regarded their regular doctors as their family doctors (RFD). 1157 (36.8%) of them did not use any regular doctors (NRD). Only 4.3% of the RFD group (vs 7.8% of other regular doctors (ORD) and 9.6% of NRD) visited emergency service and only 1.7% (vs 3.6% of ORD and 4.0% of NRD) were admitted to hospital for their last episode of illness. Regression analyses controlling for sociodemographics and health status confirmed that respondents having RFD were less likely to use emergency service than people who had NRD (OR 0.479) or ORD (OR 0.624) or being admitted to hospital (OR 0.458 vs NRD and 0.514 vs ORD) for their last episode of illness. CONCLUSION Primary care is the most effective in gate-keeping secondary care among people with regular family doctors. People without any regular primary care doctor were more likely to use emergency service as primary care. The findings supported a family doctor-led primary care model. TRIAL REGISTRATION NUMBER ClinicalTrials.gov ID: NCT01422031.
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Affiliation(s)
- Colman SC Fung
- />Department of Family Medicine and Primary Care, the University of Hong Kong, 3/F., 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong
| | - Carlos KH Wong
- />Department of Family Medicine and Primary Care, the University of Hong Kong, 3/F., 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong
| | - Daniel YT Fong
- />School of Nursing, the University of Hong Kong, 4/F, William M.W. Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong
| | - Albert Lee
- />Centre for Health Education and Health Promotion, The Jockey Club School of Public Health and Primary Care, the Chinese University of Hong Kong, 4/F, Lek Yuen Health Centre, 9 Lek Yuen Street, Shatin, Hong Kong
| | - Cindy LK Lam
- />Department of Family Medicine and Primary Care, the University of Hong Kong, 3/F., 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong
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145
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Benneyworth BD, Downs SM, Nitu M. Retrospective Evaluation of the Epidemiology and Practice Variation of Dexmedetomidine Use in Invasively Ventilated Pediatric Intensive Care Admissions, 2007-2013. Front Pediatr 2015; 3:109. [PMID: 26734592 PMCID: PMC4679909 DOI: 10.3389/fped.2015.00109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 12/03/2015] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The study assessed dexmedetomidine utilization and practice variation over time in ventilated pediatric intensive care unit (PICU) patients; and evaluated differences in hospital outcomes between high- and low-dexmedetomidine utilization hospitals. STUDY DESIGN This serial cross-sectional analysis used administrative data from PICU admissions in the pediatric health information system (37 US tertiary care pediatric hospitals). Included admissions from 2007 to 2013 had simultaneous dexmedetomidine and invasive mechanical ventilation charges, <18 years of age, excluding neonates. Patient and hospital characteristics were compared as well as hospital-level severity-adjusted indexed length of stay (LOS), charges, and mortality. RESULTS The utilization of dexmedetomidine increased from 6.2 to 38.2 per 100 ventilated PICU patients among pediatric hospitals. Utilization ranged from 3.8 to 62.8 per 100 in 2013. Few differences in patient demographics and no differences in hospital-level volume/severity of illness measures between high- and low-utilization hospitals occurred. No differences in hospital-level, severity-adjusted indexed outcomes (LOS, charges, and mortality) were found. CONCLUSION Wide practice variation in utilization of dexmedetomidine for ventilated PICU patients existed even as use has increased sixfold. Higher utilization was not associated with increased hospital charges or reduced hospital LOS. Further work should define the expected outcome benefits of dexmedetomidine and its appropriate use.
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Affiliation(s)
- Brian D Benneyworth
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana Children's Heath Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stephen M Downs
- Indiana Children's Heath Services Research, Department of Pediatrics, Indiana University School of Medicine , Indianapolis, IN , USA
| | - Mara Nitu
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine , Indianapolis, IN , USA
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146
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Bogaev RC, Meyers DE. Medical Treatment of Heart Failure and Coronary Heart Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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147
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Agee MD, Gates Z, Reilly P. Cost-Effectiveness of a Low-Cost, Hospital-Based Primary Care Clinic. Health Serv Res Manag Epidemiol 2014; 1:2333392814557011. [PMID: 28462248 PMCID: PMC5289068 DOI: 10.1177/2333392814557011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study assesses the cost-effectiveness of an insurance administration-free, hospital-based clinic designed to provide a full array of primary care services to low-income individuals at little or no cost. In addition to low/no-cost visits, individuals have the option to purchase a low-cost health insurance plan similar to any traditional health plan (eg, prescriptions, primary care, specialty care, durable medical equipment, radiology, laboratory test results). We used 3 years of data (2009-2012) on emergency department (ED) visits and inpatient hospital admissions from clinic patients and patients at the community's 2 largest private physician groups to assess the cost-effectiveness of the hospital-based clinic in terms of ED and inpatient admission costs avoided and financial sustainability of the low-cost insurance plan. Estimated annual savings in hospital inpatient and ED costs were approximately 1.4 million. Insurance plan data indicated sound fiscal sustainability with modest provider reimbursement growth and zero annual premium growth.
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Affiliation(s)
- Mark D Agee
- Department of Economics, Pennsylvania State University, Altoona, PA, USA
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148
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Relationship Between Primary Care Physician Visits and Hospital/Emergency Use for Uncomplicated Hypertension, an Ambulatory Care-Sensitive Condition. Can J Cardiol 2014; 30:1640-8. [DOI: 10.1016/j.cjca.2014.09.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 09/24/2014] [Accepted: 09/28/2014] [Indexed: 10/24/2022] Open
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149
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Harrison MJ, Dusheiko M, Sutton M, Gravelle H, Doran T, Roland M. Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study. BMJ 2014; 349:g6423. [PMID: 25389120 PMCID: PMC4228282 DOI: 10.1136/bmj.g6423] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs). DESIGN Controlled longitudinal study. SETTING English National Health Service between 1998/99 and 2010/11. PARTICIPANTS Populations registered with each of 6975 family practices in England. MAIN OUTCOME MEASURES Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs. RESULTS Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11. CONCLUSIONS The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.
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Affiliation(s)
- Mark J Harrison
- Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, UK Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, BC, Canada
| | - Mark Dusheiko
- Centre for Health Economics, University of York, York, UK Institute for Health Economics and Management, University of Lausanne, Lausanne, Switzerland
| | - Matt Sutton
- Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, UK
| | - Hugh Gravelle
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Tim Doran
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Martin Roland
- Cambridge Centre for Health Services Research, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
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150
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Umpierrez GE, Reyes D, Smiley D, Hermayer K, Khan A, Olson DE, Pasquel F, Jacobs S, Newton C, Peng L, Fonseca V. Hospital discharge algorithm based on admission HbA1c for the management of patients with type 2 diabetes. Diabetes Care 2014; 37:2934-9. [PMID: 25168125 PMCID: PMC4207201 DOI: 10.2337/dc14-0479] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Effective treatment algorithms are needed to guide diabetes care at hospital discharge in general medicine and surgery patients with type 2 diabetes. RESEARCH DESIGN AND METHODS This was a prospective, multicenter open-label study aimed to determine the safety and efficacy of a hospital discharge algorithm based on admission HbA1c. Patients with HbA1c <7% (53.0 mmol/mol) were discharged on their preadmission diabetes therapy, HbA1c between 7 and 9% (53.0-74.9 mmol/mol) were discharged on a preadmission regimen plus glargine at 50% of hospital daily dose, and HbA1c >9% were discharged on oral antidiabetes agents (OADs) plus glargine or basal bolus regimen at 80% of inpatient dose. The primary outcome was HbA1c concentration at 12 weeks after hospital discharge. RESULTS A total of 224 patients were discharged on OAD (36%), combination of OAD and glargine (27%), basal bolus (24%), glargine alone (9%), and diet (4%). The admission HbA1c was 8.7 ± 2.5% (71.6 mmol/mol) and decreased to 7.3 ± 1.5% (56 mmol/mol) at 12 weeks of follow-up (P < 0.001). The change of HbA1c from baseline at 12 weeks after discharge was -0.1 ± 0.6, -0.8 ± 1.0, and -3.2 ± 2.4 in patients with HbA1c <7%, 7-9%, and >9%, respectively (P < 0.001). Hypoglycemia (<70 mg/dL) was reported in 22% of patients discharged on OAD only, 30% on OAD plus glargine, 44% on basal bolus, and 25% on glargine alone and was similar in patients with admission HbA1c ≤7% (26%) compared with those with HbA1c >7% (31%, P = 0.54). CONCLUSIONS Measurement of HbA1c on admission is beneficial in tailoring treatment regimens at discharge in general medicine and surgery patients with type 2 diabetes.
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Affiliation(s)
| | - David Reyes
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA
| | - Dawn Smiley
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA
| | - Kathie Hermayer
- Division of Endocrinology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Amna Khan
- Division of Endocrinology, Department of Medicine, Tulane Medical Center, New Orleans, LA
| | - Darin E Olson
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA Atlanta Veterans Affairs Medical Center, Decatur, GA
| | - Francisco Pasquel
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA
| | - Sol Jacobs
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA
| | - Christopher Newton
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA
| | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Vivian Fonseca
- Division of Endocrinology, Department of Medicine, Tulane Medical Center, New Orleans, LA
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