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Clemson L, Lannin NA, Wales K, Salkeld G, Rubenstein L, Gitlin L, Barris S, Mackenzie L, Cameron ID. Occupational Therapy Predischarge Home Visits in Acute Hospital Care: A Randomized Trial. J Am Geriatr Soc 2016; 64:2019-2026. [PMID: 27603152 DOI: 10.1111/jgs.14287] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether an enhanced occupational therapy discharge planning intervention that involved pre- and postdischarge home visits, goal setting, and follow-up (the HOME program) would be superior to a usual care intervention in which an occupational therapy in-hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care. DESIGN Randomized controlled trial. SETTING Acute and medical wards. PARTICIPANTS Individuals aged 70 and older (N = 400). MEASUREMENTS Primary outcomes: activities daily living (ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index (LLDI)). RESULTS Occupational therapist recommendations differed significantly between groups (P < .001) (HOME n = 892 recommendations; control n = 329 recommendations). There was no difference between groups in ADLs (Nottingham Extended Activities of Daily Living scale (NEADL): β = -0.17, 95% confidence interval (CI) = -0.99-0.66) or participation (LLDI-Frequency: β = -0.23, 95% CI = -2.05-1.59; LLDI-Limitation: β = -0.14, 95% CI = -2.86-2.58). Both groups maintained prehospital functional status at 90 days, and there was no difference between groups in the number of people with unplanned readmissions (HOME 23.5%, n = 43; control 21.9%, n = 37). When groups were combined, being male (P = .03) or having lower perceived participation because of physical problems (P = .04) resulted in higher risk of unplanned readmissions. CONCLUSION HOME discharge planning, which had a strong emphasis on task modification, well-being, and prevention strategies, implemented twice as many occupational therapy recommendations as the in-hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in-hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in-hospital consultation.
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Affiliation(s)
- Lindy Clemson
- Ageing, Work, and Health Research Unit, Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia. .,Australian Research Council Centre of Excellence in Population Ageing Research, Lidcombe, New South Wales, Australia.
| | - Natasha A Lannin
- Alfred Clinical School, Faculty of Health Sciences, La Trobe University, Melbourne, Victoria, Australia
| | - Kylie Wales
- Ageing, Work, and Health Research Unit, Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia
| | - Glenn Salkeld
- School of Public Health, Faculty of Medicine, University of Sydney, Lidcombe, New South Wales, Australia
| | - Laurence Rubenstein
- Department of Geriatric Medicine, University of Oklahoma, Oklahoma City, Oklahoma
| | - Laura Gitlin
- Center for Innovative Care in Aging, School of Nursing, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Sarah Barris
- Australian Health Service Alliance, Camberwell, Victoria, Australia
| | - Lynette Mackenzie
- Ageing, Work, and Health Research Unit, Faculty of Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Sydney Medical School Northern, St Leonards, New South Wales, Australia
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152
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Beddoes-Ley L, Khaw D, Duke M, Botti M. A profile of four patterns of vulnerability to functional decline in older general medicine patients in Victoria, Australia: a cross sectional survey. BMC Geriatr 2016; 16:150. [PMID: 27492449 PMCID: PMC4974723 DOI: 10.1186/s12877-016-0323-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 07/28/2016] [Indexed: 11/10/2022] Open
Abstract
Background There are limited published data reporting Australian hospitalized elders’ vulnerability to functional decline to guide best practice interventions. The objectives of this study were to describe the prevalence of vulnerability to functional decline and explore profiles of vulnerability related to the performance of physical activity in a representative group of elders in a single centre in Victoria, Australia. Methods A cross-sectional survey of patients aged ≥ 70 years (Mean age 82.4, SD 7 years) admitted to a general medical ward of an Australian tertiary-referral metropolitan public hospital from March 2010 to March 2011 (n = 526). Patients were screened using the Vulnerable Elders Survey (VES-13). Distinct typologies of physical difficulties were identified using latent class analysis. Results Most elders scored ≥3/10 on the VES-13 and were rated vulnerable to functional decline (n = 480, 89.5 %). Four distinct classes of physical difficulty were identified: 1) Elders with higher physical functioning (n = 114, 21.7 %); 2) Ambulant elders with diminished strength (n = 24, 4.6 %); 3) Elders with impaired mobility, strength and ability to stoop (n = 267, 50.8 %) and 4) Elders with extensive physical impairment (n = 121, 23 %) Vulnerable elders were distributed through all classes. Conclusions Older general medicine patients in Victoria, Australia, are highly vulnerable to functional decline. We identified four distinct patterns of physical difficulties associated with vulnerability to functional decline that can inform health service planning, delivery and education.
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Affiliation(s)
- Lenore Beddoes-Ley
- School of Nursing & Midwifery, Deakin University, Geelong, 3220, Australia. .,Deakin University-Alfred Hospital Nursing Research Centre, Prahran, 3181, Australia.
| | - Damien Khaw
- Deakin University-Epworth Hospital Centre for Clinical Nursing Research, Richmond, 3121, Australia
| | - Maxine Duke
- School of Nursing & Midwifery, Deakin University, Geelong, 3220, Australia
| | - Mari Botti
- School of Nursing & Midwifery, Deakin University, Geelong, 3220, Australia.,Deakin University-Epworth Hospital Centre for Clinical Nursing Research, Richmond, 3121, Australia
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153
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Leyenaar JK, Desai AD, Burkhart Q, Parast L, Roth CP, McGalliard J, Marmet J, Simon TD, Allshouse C, Britto MT, Gidengil CA, Elliott MN, McGlynn EA, Mangione-Smith R. Quality Measures to Assess Care Transitions for Hospitalized Children. Pediatrics 2016; 138:peds.2016-0906. [PMID: 27471218 PMCID: PMC9534577 DOI: 10.1542/peds.2016-0906] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Transitions between sites of care are inherent to all hospitalizations, yet we lack pediatric-specific transitions-of-care quality measures. We describe the development and validation of new transitions-of-care quality measures obtained from medical record data. METHODS After an evidence review, a multistakeholder panel prioritized quality measures by using the RAND/University of California, Los Angeles modified Delphi method. Three measures were endorsed, operationalized, and field-tested at 3 children's hospitals and 2 community hospitals: quality of hospital-to-home transition record content, timeliness of discharge communication between inpatient and outpatient providers, and ICU-to-floor transition note quality. Summary scores were calculated on a scale from 0 to 100; higher scores indicated better quality. We examined between-hospital variation in scores, associations of hospital-to-home transition quality scores with readmission and emergency department return visit rates, and associations of ICU-to-floor transition quality scores with ICU readmission and length of stay. RESULTS A total of 927 charts from 5 hospitals were reviewed. Mean quality scores were 65.5 (SD 18.1) for the hospital-to-home transition record measure, 33.3 (SD 47.1) for the discharge communication measure, and 64.9 (SD 47.1) for the ICU-to-floor transition measure. The mean adjusted hospital-to-home transition summary score was 61.2 (SD 17.1), with significant variation in scores between hospitals (P < .001). Hospital-to-home transition quality scores were not associated with readmissions or emergency department return visits. ICU-to-floor transition note quality scores were not associated with ICU readmissions or hospital length of stay. CONCLUSIONS These quality measures were feasible to implement in diverse settings and varied across hospitals. The development of these measures is an important step toward standardized evaluation of the quality of pediatric transitional care.
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Affiliation(s)
| | - Arti D. Desai
- Department of Pediatrics, University of Washington, Seattle, Washington,Seattle Children’s Research Institute, Seattle, Washington
| | | | | | | | | | - Jordan Marmet
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Tamara D. Simon
- Department of Pediatrics, University of Washington, Seattle, Washington,Seattle Children’s Research Institute, Seattle, Washington
| | | | - Maria T. Britto
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Courtney A. Gidengil
- RAND Corporation, Boston, Massachusetts,Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | | | - Elizabeth A. McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, California
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington,Seattle Children’s Research Institute, Seattle, Washington
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154
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Statile AM, Schondelmeyer AC, Thomson JE, Brower LH, Davis B, Redel J, Hausfeld J, Tucker K, White DL, White CM. Improving Discharge Efficiency in Medically Complex Pediatric Patients. Pediatrics 2016; 138:peds.2015-3832. [PMID: 27412640 DOI: 10.1542/peds.2015-3832] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Children with medical complexity have unique needs when facilitating transitions from hospital to home. Defining readiness for discharge is challenging, and preparation requires coordination of family, education, equipment, and medications. Our multidisciplinary team aimed to increase the percentage of medically complex hospital medicine patients discharged within 2 hours of meeting medical discharge goals from 50% to 80%. METHODS We used quality improvement methods to identify key drivers and inform interventions. Medical discharge goals were defined on admission for each patient. Interventions included implementation of a complex care inpatient team with electronic admission order set, weekly care coordination rounds, needs assessment tool, and medication pathway. The primary measure, percentage of patients discharged within 2 hours of meeting medical discharge goals, was followed on a run chart. The secondary measures, pre- and post-intervention length of stay and 30-day readmission rate, were compared by using Wilcoxon rank-sum and χ(2) tests, respectively. RESULTS The percentage of medically complex patients discharged within 2 hours of meeting medical discharge goals improved from 50% to 88% over 17 months and sustained for 6 months. In preintervention-postintervention comparison, median length of stay did not change (3.1 days [interquartile range, 1.8-7.0] vs 2.9 days [interquartile range, 1.7-6.1]; P = .67) and 30-day readmission rate was not impacted (30.7% vs 26.4%; P = .51). CONCLUSIONS Efficient discharge for medically complex patients requires support of a multidisciplinary team to proactively address discharge needs, ensuring patients are ready for discharge when medical goals are met.
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Affiliation(s)
- Angela M Statile
- Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio James M. Anderson Center for Health Systems Excellence
| | - Joanna E Thomson
- Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio James M. Anderson Center for Health Systems Excellence
| | - Laura H Brower
- Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Blair Davis
- James M. Anderson Center for Health Systems Excellence
| | | | - Julie Hausfeld
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Karen Tucker
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Denise L White
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio James M. Anderson Center for Health Systems Excellence
| | - Christine M White
- Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio James M. Anderson Center for Health Systems Excellence
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155
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Mittal MK, Rabinstein AA, Mandrekar J, Brown RD, Flemming KD. A population-based study for 30-d hospital readmissions after acute ischemic stroke. Int J Neurosci 2016; 127:305-313. [PMID: 27356861 DOI: 10.1080/00207454.2016.1207642] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine post-stroke 30-d readmission rate, its predictors, its impact on mortality and to identify potentially preventable causes of post-stroke 30-d readmission in a population-based study. PATIENTS AND METHODS We identified all acute ischemic strokes (AIS) using the International Classification of Diseases 9th revision codes (433.x1, 434.xx and 436) via the Rochester Epidemiology Project (REP) between January 2007 and December 2011. Acute stroke care in Olmsted County is provided by two medical centers, Saint Marys Hospital and Olmsted Medical Center Hospital. All readmissions to these two hospitals were accounted for this study. Thirty-day readmission data was abstracted through manual chart review. The REP linkage database was used to identify the status (living/dead) of all patients at last follow up. RESULTS Forty-one (7.6%, 95% CI 5.7%-10.2%) of total 537 AIS patients were readmitted 30-d post-stroke. In a multivariable logistic regression model, discharge to nursing home following index stroke (OR: 0.29, 95% CI 0.08-0.84) was an independent negative predictor of unplanned 30-d readmission. In a subgroup of patients with dementia, being married at time of index stroke was found to be a negative predictor of readmission (OR: 0.10, 95% CI 0.005-0.58). Only 2.8% of the patients had potentially preventable readmissions. Hospital readmission had no significant impact on patient's short-term (three months) or long-term (one or two years) mortality (p > 0.05). CONCLUSION Post-stroke 30-d readmission rate is low in AIS patients from Olmsted County. Further research is needed in regarding discharge checklists, protocols and stroke transitional programs to reduce potentially preventable readmissions.
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Affiliation(s)
- Manoj K Mittal
- a Department of Neurology/Mayo Clinic , Rochester , MN , USA
| | | | - Jay Mandrekar
- b Division of Biomedical Statistics and Informatics/Mayo Clinic , Rochester , MN , USA
| | - Robert D Brown
- a Department of Neurology/Mayo Clinic , Rochester , MN , USA
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156
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Rafferty A, Denslow S, Michalets EL. Pharmacist-Provided Medication Management in Interdisciplinary Transitions in a Community Hospital (PMIT). Ann Pharmacother 2016; 50:649-55. [PMID: 27273678 DOI: 10.1177/1060028016653139] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Medication management during transitions of care (TOC) impacts clinical outcomes. Published literature on TOC implementation is increasing, but data remains limited regarding the optimal role for the inpatient pharmacist, particularly in the community health setting. OBJECTIVE To evaluate the impact of a dedicated inpatient TOC pharmacist on re-presentations following discharge. METHODS This is a prospective study with historical control. All adult patients discharging home from study units were eligible. The TOC pharmacist (1) reviewed medication history and admission reconciliation, (2) met the patient/caregiver to assess barriers, (3) reviewed discharge reconciliation, (4) performed discharge education, and (5) communicated with next level of care. The primary outcome was 30 day re-presentation rate. Secondary outcomes included 60, 90, and 365 day re-presentation rates. IRB approval was obtained. RESULTS Three hundred and eighty four patients met inclusion criteria. When compared to 1,221 control patients, the intervention had an 11% absolute and 50.2% relative reduction in 30 day re-presentation rate (OR 0.43, 95% CI 0.30-0.61, NNT 9). Reductions in re-presentations at 60, 90 and 365 days remained statistically significant. Utilization avoidance was $786,347. For every $1 invested in pharmacist time, $12 was saved. The TOC pharmacist made a total of 904 interventions (mean 2.4 per patient). CONCLUSION This study provides new information from previous studies and represents the largest study with significant and sustained reductions in re-presentations. Integrating a pharmacist into an interdisciplinary team for medication management during TOC in a community health system is beneficial for patients and financially favorable for the institution.
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Affiliation(s)
- Aubrie Rafferty
- Mission Hospital and UNC Eshelman School of Pharmacy, Asheville Campus; Asheville, NC, USA
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157
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Hansen LO, Baker D. Timely discharge communication: Just the fax? J Hosp Med 2016; 11:455-6. [PMID: 26913963 DOI: 10.1002/jhm.2559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 01/13/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Luke O Hansen
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David Baker
- The Join Commission, Oakbrook Terrace, Illinois
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158
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Abstract
BACKGROUND The utilization outcomes of nurse practitioners (NPs) in the acute care setting have not been widely studied. OBJECTIVE The purpose of this study was to determine the impact on utilization outcomes of NPs on medical teams who take care of patients admitted to a cardiovascular intensive care unit. METHODS A retrospective 2-group comparative design was used to evaluate the outcomes of 185 patients with ST- or non ST-segment elevation myocardial infarction or heart failure who were admitted to a cardiovascular intensive care unit in an urban medical center. Patients received care from a medical team that included a cardiac acute care NP (n = 109) or medical team alone (n = 76). Patient history, cardiac assessment, medical interventions, discharge disposition, discharge time, and 3 utilization outcomes (ie, length of stay, 30-day readmission, and time of discharge) were compared between the 2 treatment groups. Logistic regression was used to identify predictors of 30-day readmission. RESULTS Patients receiving care from a medical team that included an NP were rehospitalized approximately 50% less often compared with those receiving care from a medical team without an NP. Thirty-day hospital readmission (P = .011) and 30-day return rates to the emergency department (P = .021) were significantly lower in the intervention group. Significant predictors for rehospitalization included diagnosis of heart failure versus myocardial infarction (odds ratio [OR], 3.153, P = 0.005), treatment by a medical team without NP involvement (OR, 2.905, P = 0.008), and history of diabetes (OR, 2.310, P = 0.032). CONCLUSIONS The addition of a cardiac acute care NP to medical teams caring for myocardial infarction and heart failure patients had a positive impact on 30-day emergency department return and hospital readmission rates.
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159
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Occelli P, Touzet S, Rabilloud M, Ganne C, Poupon Bourdy S, Galamand B, Debray M, Dartiguepeyrou A, Chuzeville M, Comte B, Turkie B, Tardy M, Luiggi JS, Jacquet-Francillon T, Gilbert T, Bonnefoy M. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatr 2016; 16:57. [PMID: 26940678 PMCID: PMC4776355 DOI: 10.1186/s12877-016-0233-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 02/25/2016] [Indexed: 11/29/2022] Open
Abstract
Background In France, for patients aged 75 or older, it has been estimated that the hospital readmission rate within 30 days is 14 %, a quarter being avoidable. Some evidence suggests that interventions “bridging” the transition from hospital to home and involving a designated professional (usually nurses) are the most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a care transition program from hospital to home for elderly admitted to short-stay units. Methods This is a multicentre, stepped-wedge cluster randomised trial. The program will be implemented at three times of the transition: 1) during the patient’s stay in hospital: development of a discharge plan, creation of a transitional care file, and notification of the primary care physician about inpatient care and hospital discharge by the transition nurse; 2) on the day of discharge: meeting between the transition nurse and the patient to review the follow-up recommendations; and 3) for 4 weeks after discharge: follow-up by the transition nurse. The primary outcome is the 30-day unscheduled hospital readmission or emergency visit rate after the index hospital discharge. The patients enrolled will be aged 75 or older, hospitalized in an acute care geriatric unit, and at risk of hospital readmission or an emergency visit after returning home. In all, 630 patients will be included over a 14-month period. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. Discussion Our study makes it possible to evaluate the specific effect of a bridging intervention involving a designated professional intervening before, during, and after hospital discharge. The strengths of the study design are methodological and practical. It permits the estimation of the intervention effect using between- and within-cluster comparisons; the study of the fluctuations in unscheduled hospital readmission or emergency visit rates; the participation of all clusters in the intervention condition; the implementation of the intervention in each cluster successively. Trial Registration This study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02421133). Registered 9 March 2015.
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Affiliation(s)
- Pauline Occelli
- Hospices Civils de Lyon, Unité de recherche sur la qualité et la sécurité des soins du Pôle Information Médicale Evaluation Recherche , Lyon, 69003, France.
| | - Sandrine Touzet
- Hospices Civils de Lyon, Unité de recherche sur la qualité et la sécurité des soins du Pôle Information Médicale Evaluation Recherche , Lyon, 69003, France.
| | - Muriel Rabilloud
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, 69003, France. .,Université de Lyon, Lyon, 69000, France. .,Université Lyon 1, Villeurbanne, 69100, France. .,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, 69100, France.
| | - Christell Ganne
- Hospices Civils de Lyon, Unité de recherche sur la qualité et la sécurité des soins du Pôle Information Médicale Evaluation Recherche , Lyon, 69003, France.
| | - Stéphanie Poupon Bourdy
- Hospices Civils de Lyon, Unité de recherche sur la qualité et la sécurité des soins du Pôle Information Médicale Evaluation Recherche , Lyon, 69003, France.
| | - Béatrice Galamand
- Hospices Civils de Lyon, Centre Hospitalier de Lyon Sud - Pavillon Michel PERRET, Pierre-Bénite, 69495, France.
| | | | | | | | - Brigitte Comte
- Hôpital Édouard Herriot - Pavillon E, Lyon, 69003, France.
| | - Basile Turkie
- Clinique des Portes du Sud, Vénissieux, 69200, France.
| | - Magali Tardy
- Centre Hospitalier de Saint-Chamond, Saint-Chamond, 42400, France.
| | | | | | - Thomas Gilbert
- Hospices Civils de Lyon, Centre Hospitalier de Lyon Sud - Pavillon Michel PERRET, Pierre-Bénite, 69495, France.
| | - Marc Bonnefoy
- Hospices Civils de Lyon, Centre Hospitalier de Lyon Sud - Pavillon Michel PERRET, Pierre-Bénite, 69495, France.
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160
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Wolf O, Åberg H, Tornberg U, Jonsson KB. Do Orthogeriatric Inpatients Have a Correct Medication List? A Pharmacist-Led Assessment of 254 Patients in a Swedish University Hospital. Geriatr Orthop Surg Rehabil 2016; 7:18-22. [PMID: 26929852 PMCID: PMC4748162 DOI: 10.1177/2151458515625295] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction: Comorbidities and polypharmacy complicate the treatment of geriatric patients with acute orthopedic injuries. A correct medication history and an updated medication list are a prerequisite for safe treatment of these debilitated patients. Published evidence suggests favorable outcomes with comanaged care. The aim of this study was to assess the accuracy of the inpatient medication lists generated at admission and investigate the efficacy of a dedicated ward-based pharmacist to find and correct mistakes in these lists. Methods: A total of 254 patients were enrolled. The ward-based pharmacist performed the assessment regarding the accuracy of the medication list generated at admission by the method of medication reconciliation. Number of discrepancies and types of discrepancy were noted. Results: The 254 patients (176 women) had a mean age of 85 years (standard deviation 7.4 years, range 42-100 years). The most common reason for orthopedic admission was hip fracture. The mean number of discrepancies was 2.1 for all patients (range 0-13). Omission of a prescribed drug was the most common mistake. Fifty-six (22%) of the 254 assessed patients had a correct medication list. Discussion: The many discrepancies in our study may have several explanations but highlight the difficulties in taking a correct medication history of patients in a stressful environment with an extremely high workload. Moreover, electronic medication lists create challenges. Implementing new electronic tools for health care requires feedback, redesign, and adaptation to meet various needs of the users. Conclusion: In conclusion, orthogeriatric patients have an unsatisfactory high number of discrepancies in their medication lists. Clinical pharmacists can accurately identify many of these mistakes.
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Affiliation(s)
- Olof Wolf
- Department of Orthopaedics, Institution of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Henrik Åberg
- Department of Orthopaedics, Institution of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Ulrika Tornberg
- Department of Orthopaedics, Institution of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Kenneth B Jonsson
- Department of Orthopaedics, Institution of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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161
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Mekonnen AB, McLachlan AJ, Brien JAE. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open 2016; 6:e010003. [PMID: 26908524 PMCID: PMC4769405 DOI: 10.1136/bmjopen-2015-010003] [Citation(s) in RCA: 291] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Pharmacists play a role in providing medication reconciliation. However, data on effectiveness on patients' clinical outcomes appear inconclusive. Thus, the aim of this study was to systematically investigate the effect of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions. DESIGN Systematic review and meta-analysis. METHODS We searched PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO from inception to December 2014. Included studies were all published studies in English that compared the effectiveness of pharmacist-led medication reconciliation interventions to usual care, aimed at improving medication reconciliation programmes. Meta-analysis was carried out using a random effects model, and subgroup analysis was conducted to determine the sources of heterogeneity. RESULTS 17 studies involving 21,342 adult patients were included. Eight studies were randomised controlled trials (RCTs). Most studies targeted multiple transitions and compared comprehensive medication reconciliation programmes including telephone follow-up/home visit, patient counselling or both, during the first 30 days of follow-up. The pooled relative risks showed a more substantial reduction of 67%, 28% and 19% in adverse drug event-related hospital revisits (RR 0.33; 95% CI 0.20 to 0.53), emergency department (ED) visits (RR 0.72; 95% CI 0.57 to 0.92) and hospital readmissions (RR 0.81; 95% CI 0.70 to 0.95) in the intervention group than in the usual care group, respectively. The pooled data on mortality (RR 1.05; 95% CI 0.95 to 1.16) and composite readmission and/or ED visit (RR 0.95; 95% CI 0.90 to 1.00) did not differ among the groups. There was significant heterogeneity in the results related to readmissions and ED visits, however. Subgroup analyses based on study design and outcome timing did not show statistically significant results. CONCLUSION Pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. This review supports the implementation of pharmacist-led medication reconciliation programmes that include some component aimed at improving medication safety.
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Affiliation(s)
- Alemayehu B Mekonnen
- Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
- School of Pharmacy, University of Gondar, Gondar, Ethiopia
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
- Centre for Education and Research on Ageing, Concord Hospital, Sydney, Australia
| | - Jo-anne E Brien
- Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, St Vincent's Hospital Clinical School, University of New South Wales, Sydney, Australia
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162
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Abstract
BACKGROUND Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug-related harms and less favourable effectiveness. The concept of medication review is a key element in improving the quality of prescribing and in preventing adverse drug events. Although there is no generally accepted definition of medication review, it can be broadly defined as a systematic assessment of pharmacotherapy for an individual patient that aims to optimise patient medication by providing a recommendation or by making a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes. OBJECTIVES We examined whether delivery of a medication review by a physician, pharmacist or other healthcare professional leads to improvement in health outcomes of hospitalised adult patients compared with standard care. SEARCH METHODS We searched the Specialised Register of the Cochrane Effective Practice and Organisation of Care (EPOC) Group; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to November 2014, as well as International Pharmaceutical Abstracts and Web of Science to May 2015. In addition, we searched reference lists of included trials and relevant reviews. We searched trials registries and contacted experts to identify additional published and unpublished trials. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) of medication review in hospitalised adult patients. We excluded trials of outclinic and paediatric patients. Our primary outcome was all-cause mortality, and secondary outcomes included hospital readmissions, emergency department contacts and adverse drug events. DATA COLLECTION AND ANALYSIS Two review authors independently included trials, extracted data and assessed trials for risk of bias. We contacted trial authors for clarification of data and for additional unpublished data. We calculated risk ratios for dichotomous data and mean differences for continuous data (with 95% confidence intervals (CIs)). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall certainty of evidence for the most important outcomes. MAIN RESULTS We identified 6600 references (4647 references in our initial review) and included 10 trials (3575 participants). Follow-up ranged from 30 days to one year. Nine trials provided mortality data (3218 participants, 466 events), with a risk ratio of 1.02 (95% CI 0.87 to 1.19) (low-certainty evidence). Seven trials provided hospital readmission data (2843 participants, 1043 events) with a risk ratio of 0.95 (95% CI 0.87 to 1.04) (high-certainty evidence). Four trials provided emergency department contact data (1442 participants, 244 events) with a risk ratio of 0.73 (95% CI 0.52 to 1.03) (low-certainty evidence). The estimated reduction in emergency department contacts of 27% (with a CI ranging from 48% reduction to 3% increase in contacts) corresponds to a number needed to treat for an additional beneficial outcome of 37 for a low-risk population and 12 for a high-risk population over one year. Subgroup and sensitivity analyses did not significantly alter our results. AUTHORS' CONCLUSIONS We found no evidence that medication review reduces mortality or hospital readmissions, although we did find evidence that medication review may reduce emergency department contacts. However, because of short follow-up ranging from 30 days to one year, important treatment effects may have been overlooked. High-quality trials with long-term follow-up (i.e. at least up to a year) are needed to provide more definitive evidence for the effect of medication review on clinically important outcomes such as mortality, readmissions and emergency department contacts, and on outcomes such as adverse events. Therefore, if used in clinical practice, medication reviews should be undertaken as part of a clinical trial with long-term follow-up.
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Affiliation(s)
- Mikkel Christensen
- Bispebjerg HospitalDepartment of Clinical PharmacologyBispebjerg Bakke 23CopenhagenDenmark2400
| | - Andreas Lundh
- RigshospitaletThe Nordic Cochrane CentreBlegdamsvej 9, 7811CopenhagenDenmarkDK‐2100
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163
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Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf 2016; 25:726-30. [PMID: 26795914 DOI: 10.1136/bmjqs-2015-004734] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Joshua M Pevnick
- Department of Medicine, Division of General Internal Medicine, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Rita Shane
- Department of Pharmacy Services, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Jeffrey L Schnipper
- BWH Hospitalist Service and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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164
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Abstract
OBJECTIVE Although recent studies have shown that 30-day readmissions following sepsis are common, the overall fiscal impact of these rehospitalizations and their variability between hospitals relative to other high-risk conditions, such as congestive heart failure and acute myocardial infarction, are unknown. The objectives of this study were to characterize the frequency, cost, patient-level risk factors, and hospital-level variation in 30-day readmissions following sepsis compared with congestive heart failure and acute myocardial infarction. DESIGN A retrospective cohort analysis of hospitalizations from 2009 to 2011. SETTING All acute care, nonfederal hospitals in California. PATIENTS Hospitalizations for sepsis (n = 240,198), congestive heart failure (n = 193,153), and acute myocardial infarction (n = 105,684) identified by administrative discharge codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcomes were the frequency and cost of all-cause 30-day readmissions following hospitalization for sepsis compared with congestive heart failure and acute myocardial infarction. Variability in predicted readmission rates between hospitals was calculated using mixed-effects logistic regression analysis. The all-cause 30-day readmission rates were 20.4%, 23.6%, and 17.7% for sepsis, congestive heart failure, and acute myocardial infarction, respectively. The estimated annual costs of 30-day readmissions in the state of California during the study period were $500 million/yr for sepsis, $229 million/yr for congestive heart failure, and $142 million/yr for acute myocardial infarction. The risk- and reliability-adjusted readmission rates across hospitals ranged from 11.0% to 39.8% (median, 19.9%; interquartile range, 16.1-26.0%) for sepsis, 11.3% to 38.4% (median, 22.9%; interquartile range, 19.2-26.6%) for congestive heart failure, and 3.6% to 40.8% (median, 17.0%; interquartile range, 12.2-20.0%) for acute myocardial infarction. Patient-level factors associated with higher odds of 30-day readmission following sepsis included younger age, male gender, Black or Native American race, a higher burden of medical comorbidities, urban residence, and lower income. CONCLUSION Sepsis is a leading contributor to excess healthcare costs due to hospital readmissions. Interventions at clinical and policy levels should prioritize identifying effective strategies to reduce sepsis readmissions.
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165
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Parker SL, McGirt MJ, Bekelis K, Holland CM, Davies J, Devin CJ, Atkins T, Knightly J, Groman R, Zyung I, Asher AL. The National Neurosurgery Quality and Outcomes Database Qualified Clinical Data Registry: 2015 measure specifications and rationale. Neurosurg Focus 2015; 39:E4. [DOI: 10.3171/2015.9.focus15355] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Meaningful quality measurement and public reporting have the potential to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. Recent developments in national quality reporting programs, such as the Centers for Medicare & Medicaid Services Qualified Clinical Data Registry (QCDR) reporting option, have enhanced the ability of specialty groups to develop relevant quality measures of the care they deliver. QCDRs will complete the collection and submission of Physician Quality Reporting System (PQRS) quality measures data on behalf of individual eligible professionals. The National Neurosurgery Quality and Outcomes Database (N2QOD) offers 21 non-PQRS measures, initially focused on spine procedures, which are the first specialty-specific measures for neurosurgery. Securing QCDR status for N2QOD is a tremendously important accomplishment for our specialty. This program will ensure that data collected through our registries and used for PQRS is meaningful for neurosurgeons, related spine care practitioners, their patients, and other stakeholders. The 2015 N2QOD QCDR is further evidence of neurosurgery’s commitment to substantively advancing the health care quality paradigm. The following manuscript outlines the measures now approved for use in the 2015 N2QOD QCDR. Measure specifications (measure type and descriptions, related measures, if any, as well as relevant National Quality Strategy domain[s]) along with rationale are provided for each measure.
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Affiliation(s)
| | - Matthew J. McGirt
- 2Department of Neurosurgery, Carolina Neurosurgery & Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Kimon Bekelis
- 3Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Jason Davies
- 5Department of Neurological Surgery, State University of New York at Buffalo, New York
| | - Clinton J. Devin
- 6Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tyler Atkins
- 2Department of Neurosurgery, Carolina Neurosurgery & Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Jack Knightly
- 7Department of Neurological Surgery, Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Rachel Groman
- 8Clinical Affairs and Quality Improvement, Hart Health Strategies, Washington, DC; and
| | - Irene Zyung
- 9American Association of Neurological Surgeons, Rolling Meadows, Illinois
| | - Anthony L. Asher
- 2Department of Neurosurgery, Carolina Neurosurgery & Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina
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166
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Reichard JS, Savage S, Eckel SF. Pharmacy-Initiated Transitions of Care Services: An Opportunity to Impact Patient Satisfaction. Hosp Pharm 2015; 50:911-917. [PMID: 27729679 DOI: 10.1310/hpj5010-911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE A transitions of care program at an academic teaching hospital was designed to reengineer the fragmented discharge process. The team included a pharmacy technician, called a transition specialist, who coordinated the medication needs of discharging patients. This study intends to assess the impact of the transitions of care program on patient satisfaction scores. METHODS Two datasets of Press Ganey and Hospital Consumer Assessment of Healthcare Providers (HCAHPS) were analyzed. Patients eligible for inclusion were age 18 years or older and successfully discharged from the study facility. All participants received usual care by a servicebased pharmacist, medication counseling by a nurse prior to discharge, and other standard of care services by the inpatient medical team. The intervention group received the previously stated usual care plus services by the transitions of care program. RESULTS The results from HCAHPS scores proved inconclusive. The results from the Press Ganey dataset found that the surgery transplant service demonstrated statistically significant improvement for satisfaction scores, and they warrant further review. CONCLUSIONS Results demonstrate that HCAHPS metrics do not correlate with the successes or lack thereof of the transitions of care program. Press Ganey might be a potential surrogate marker for assessing the impact of this program. This study is the first to qualitatively evaluate pharmacy transitions of care service using patient satisfaction scores.
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Affiliation(s)
| | - Scott Savage
- Associate Director of Pharmacy, The University of North Carolina Hospitals and Clinics , Chapel Hill, North Carolina
| | - Stephen F Eckel
- Associate Director of Pharmacy, The University of North Carolina Hospitals and Clinics, Chapel Hill, North Carolina; Clinical Assistant Professor, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina
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167
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The Risk Factors of Readmission in Postoperative Gynecologic Oncology Patients at a Single Institution. Int J Gynecol Cancer 2015; 25:1697-703. [DOI: 10.1097/igc.0000000000000535] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IntroductionHospital readmission rates are an important measure of quality care and have recently been tied to reimbursement. This study seeks to identify the risk factors for postoperative readmission in patients treated by a gynecologic oncology service.MethodsA 7-year retrospective review (2007–2013) of all patients operated on by the University of Virginia gynecologic oncology service who were readmitted within 30 days of discharge was performed. Abstracted data included demographics, dates of surgery, operative details, cancer history, and relevant medical history. The readmitted patients (n = 166) were compared with randomly selected controls (n = 168) from the same service in a matching time frame and analyzed using univariate and multivariate models.ResultsIn the study period, 2993 operations were performed. One hundred sixty-six unique patients (5.5%) were readmitted within 30 days of discharge from their operative procedure. On multivariate analysis, the factors that were associated with a higher risk of readmission were a history of psychiatric disease, postoperative complication, type of insurance, surgical modality, and lysis of adhesions at the time of surgery. The most common readmission diagnoses were infection (44%), nausea/vomiting (28%), thrombosis (6%), bowel leak (4%), and bleeding (4%).ConclusionsPostoperative readmissions are a common problem and are increasingly important as a measure of quality. Although patients were generally admitted for infections or gastrointestinal complaints, we also found that individual factors such as mental health and socioeconomic status also contributed. Our data suggest that we can preoperatively identify high-risk individuals for whom extra resources can be directed postoperatively to avoid unnecessary readmissions.
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168
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Mathew AT, Strippoli GFM, Ruospo M, Fishbane S. Reducing hospital readmissions in patients with end-stage kidney disease. Kidney Int 2015; 88:1250-1260. [PMID: 26466320 DOI: 10.1038/ki.2015.307] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/18/2015] [Accepted: 07/01/2015] [Indexed: 01/18/2023]
Abstract
ESKD patients have a large burden of disease, with high rates of readmission to hospital compared with the general population. A readmission after an acute index hospital discharge is either planned or unplanned. A proportion of unplanned readmissions are potentially avoidable, and could have been prevented with optimized transitional care. Readmissions pose financial cost to the health care system and emotional cost to patients and caregivers. In other chronic diseases with high readmission risk, such as congestive heart failure, interventions have improved transitional care and reduced readmission risk. In reviewing the existing literature on readmissions in ESKD, the definition and risk of readmission varied widely by study, with many potentially associated factors including comorbid diseases such as anemia and hypoalbuminemia. An ESKD patient's requisite follow-up in the outpatient dialysis facility provides an opportunity to improve transitional care at the time of discharge. Despite this, our review of existing literature found no studies which have tested interventions to reduce the risk of readmission in ESKD patients. We propose a framework to define the determinants of avoidable readmission in ESKD, and use this framework to define a research agenda. Avoidable readmissions in ESKD patients is a topic prime for in-depth study, given the high-risk nature in this patient population, financial and societal costs, and potential for risk modification through targeted interventions.
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Affiliation(s)
- Anna T Mathew
- Division of Kidney Diseases and Hypertension, Hofstra North Shore-LIJ School of Medicine, Great Neck, New York, USA
| | - Giovanni F M Strippoli
- Diaverum Medical Scientific Office, Lund, Sweden.,School of Public Health, University of Sydney, Sydney, NSW, Australia.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.,Diaverum Academy, Bari, Italy
| | - Marinella Ruospo
- Diaverum Medical Scientific Office, Lund, Sweden.,Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Steven Fishbane
- Division of Kidney Diseases and Hypertension, Hofstra North Shore-LIJ School of Medicine, Great Neck, New York, USA
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169
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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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170
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Arundel C, Logan J, Ayana R, Gannuscio J, Kerns J, Swenson R. Safe Medication Reconciliation: An Intervention to Improve Residents' Medication Reconciliation Skills. J Grad Med Educ 2015; 7:407-11. [PMID: 26457147 PMCID: PMC4597952 DOI: 10.4300/jgme-d-14-00565.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Medication errors during hospitalization are a major patient safety concern. Medication reconciliation is an effective tool to reduce medication errors, yet internal medicine residents rarely receive formal education on the process. OBJECTIVE We assessed if an educational intervention on quality improvement principles and effective medication reconciliation for internal medicine residents will lead to fewer medication discrepancies and more accurate discharge medication lists. METHODS From July 2012 to May 2013, internal medicine residents from 3 academic institutions who were rotating at the Washington DC VA Medical Center received twice-monthly interactive educational sessions on medication reconciliation, using both institutional summary metrics and data from their own discharges. Sessions were led by a faculty member or chief resident. Accuracy of discharge instructions for residents in the intervention group was compared to the accuracy of discharge data from June 2012 for a group of residents who did not receive the intervention. We used χ(2) analysis to assess for differences. RESULTS The number of duplicate medications (23% versus 12%, P = .01); extraneous medications (14% versus 6%, P = .014); medications sorted by disease or indication (25% versus 77%, P < .001); and the number of discrepancies in discharge summaries (34% versus 11%, P < .001) statistically improved. No difference in the number of omissions was found between the 2 groups (17% versus 15%, P = .62). CONCLUSIONS An educational intervention targeting internal medicine residents can be implemented with reasonable staff and time costs, and is effective in reducing the number of medication discrepancies at discharge.
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Affiliation(s)
- Cherinne Arundel
- Corresponding author: Cherinne Arundel, MD, Veterans Affairs Medical Center, Department of Medicine, Hospitalist Division, 50 Irving Street NW, Washington, DC 20422, 202.745.8000, ext 57067,
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171
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Lisenby KM, Carroll DN, Pinner NA. Evaluation of a Pharmacist-Specific Intervention on 30-Day Readmission Rates for High-Risk Patients with Pneumonia. Hosp Pharm 2015; 50:700-9. [PMID: 26823619 PMCID: PMC4686476 DOI: 10.1310/hpj5008-700] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pharmacist interventions have been shown to have an impact on reducing readmission rates, however further research is necessary to target resources to high-risk populations and determine the most effective bundle of interventions. OBJECTIVE To evaluate the effect of a pharmacist-bundled intervention on 30-day readmission rates for high-risk patients with pneumonia. METHODS A pilot study with a historical control conducted at a community, teaching-affiliated medical center. Up to 65 selected subjects were included if they had pneumonia and any of the following high-risk criteria: admission within 6 months, at least 5 scheduled home medications, chronic obstructive pulmonary disease (COPD), or heart failure. A retrospective chart review was conducted to compile the historical control group that received usual care between June and November 2013. Patients admitted from December 2013 through March 2014 were reviewed to receive a bundled intervention. The primary outcome was 30-day readmission rates. Risk factors and reasons for readmission, pharmacist clinical interventions, and the time interval between discharge and readmission were also evaluated. RESULTS A trend toward a reduced 30-day readmission rate was observed in the intervention group (n = 43) compared to those who received usual care (n = 65) (27.9% vs 40.0%; relative risk [RR], 0.6977; 95% CI, 0.3965-1.2278; P = .2119). The most commonly identified high-risk inclusion criteria were having at least 5 scheduled home medications and COPD. The time interval between discharge and readmission did not considerably differ between groups (10.8 vs 10.6 days). CONCLUSIONS The pharmacist-bundled intervention was associated with a reduced 30-day readmission rate for high-risk patients with pneumonia.
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Affiliation(s)
- Katelin M. Lisenby
- Assistant Clinical Professor, Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, Alabama
- Assistant Clinical Professor, Department of Family Medicine, University of Alabama College of Community Health Sciences, University Medical Center, Tuscaloosa, Alabama
| | - Douglas N. Carroll
- Internal Medicine Clinician and PGY1 Residency Program Director, DCH Regional Medical Center, Tuscaloosa, Alabama.
| | - Nathan A. Pinner
- Assistant Clinical Professor, Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, Alabama
- Assistant Clinical Professor, Department of Family Medicine, University of Alabama College of Community Health Sciences, University Medical Center, Tuscaloosa, Alabama
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172
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Donnelly JP, Hohmann SF, Wang HE. Unplanned Readmissions After Hospitalization for Severe Sepsis at Academic Medical Center-Affiliated Hospitals. Crit Care Med 2015; 43:1916-27. [PMID: 26082977 PMCID: PMC4537666 DOI: 10.1097/ccm.0000000000001147] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE In the United States, national efforts to reduce hospital readmissions have been enacted, including the application of substantial insurance reimbursement penalties for hospitals with elevated rates. Readmissions after severe sepsis remain understudied and could possibly signify lapses in care and missed opportunities for intervention. We sought to characterize 7- and 30-day readmission rates following hospital admission for severe sepsis as well as institutional variations in readmission. DESIGN Retrospective analysis of 345,657 severe sepsis discharges from University HealthSystem Consortium hospitals in 2012. SETTING United States. PATIENTS We applied the commonly cited method described by Angus et al for identification of severe sepsis, including only discharges with sepsis present at admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified unplanned, all-cause readmissions within 7 and 30 days of discharge using claims-based algorithms. Using mixed-effects logistic regression, we determined factors associated with 30-day readmission. We used risk-standardized readmission rates to assess institutional variations. Among 216,328 eligible severe sepsis discharges, there were 14,932 readmissions within 7 days (6.9%; 95% CI, 6.8-7.0) and 43,092 within 30 days (19.9%; 95% CI, 19.8-20.1). Among those readmitted within 30 days, 66.9% had an infection and 40.3% had severe sepsis at readmission. Patient severity, length of stay, and specific diagnoses were associated with increased odds of 30-day readmission. Observed institutional 7-day readmission rates ranged from 0% to 12.3%, 30-day rates from 3.6% to 29.1%, and 30-day risk-standardized readmission rates from 14.1% to 31.1%. Greater institutional volume, teaching status, trauma services, location in the Northeast, and lower ICU rates were associated with poor risk-standardized readmission rate performance. CONCLUSIONS Severe sepsis readmission places a substantial burden on the healthcare system, with one in 15 and one in five severe sepsis discharges readmitted within 7 and 30 days, respectively. Hospitals and clinicians should be aware of this important sequela of severe sepsis.
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Affiliation(s)
- John P. Donnelly
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham AL
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham AL
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham AL
| | - Samuel F. Hohmann
- University HealthSystem Consortium and Department of Health Systems Management, Rush University, Chicago IL
| | - Henry E. Wang
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham AL
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173
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Lee JK, Alshehri S, Kutbi HI, Martin JR. Optimizing pharmacotherapy in elderly patients: the role of pharmacists. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2015; 4:101-111. [PMID: 29354524 PMCID: PMC5741014 DOI: 10.2147/iprp.s70404] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
As the world's population ages, global health care systems will face the burden of chronic diseases and polypharmacy use among older adults. The traditional tasks of medication dispensing and provision of basic education by pharmacists have evolved to active engagement in direct patient care and collaborative team-based care. The care of older patients is an especially fitting mission for pharmacists, since the key to geriatric care often lies with management of chronic diseases and polypharmacy use, and preventing harmful consequences of both. Because most chronic conditions are treated with medications, pharmacists, with their extensive training in pharmacotherapy and pharmacokinetics, are in a unique and critical position in the management of them. Pharmacists have the expertise to detect, resolve, and prevent medication errors and drug-related problems, such as overtreatment, undertreatment, adverse drug events, and nonadherence. Pharmacists are also competent in critically reviewing and applying clinical guidelines to the care of individual patients, and in some instances confront the lack of data (common in older adults) to provide the best possible patient-centered care. The current review aimed to depict the evidence of geriatric pharmacy care, demonstrate current impact of pharmacists' interventions on older patients, survey the tools used by pharmacists to provide effective care, and explore their role in pharmacotherapy optimization in elders. The findings of the current review strongly support previous studies that showed positive impact of pharmacists' interventions on older patients' health-related outcomes. There is a clear role for pharmacists working directly or collaboratively to improve medication use and management in older populations. Therefore, in global health care systems, teams caring for elders should involve pharmacists to optimize pharmacotherapy.
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Affiliation(s)
- Jeannie K Lee
- Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Samah Alshehri
- Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA.,Department of Clinical Pharmacy, King Abdulaziz University College of Pharmacy, Jeddah, Saudi Arabia
| | - Hussam I Kutbi
- Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA.,Department of Clinical Pharmacy, King Abdulaziz University College of Pharmacy, Jeddah, Saudi Arabia
| | - Jennifer R Martin
- Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA.,Arizona Health Sciences Library, University of Arizona, Tucson, AZ, USA
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174
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Ensing HT, Stuijt CCM, van den Bemt BJF, van Dooren AA, Karapinar-Çarkit F, Koster ES, Bouvy ML. Identifying the Optimal Role for Pharmacists in Care Transitions: A Systematic Review. J Manag Care Spec Pharm 2015; 21:614-36. [PMID: 26233535 PMCID: PMC10397897 DOI: 10.18553/jmcp.2015.21.8.614] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A transition from one health care setting to another increases the risk of medication errors. Several strategies have been applied to improve care transitions and reduce adverse clinical outcomes. Pharmacist intervention during and after hospitalization has been frequently studied and show a variable effect on these outcomes. OBJECTIVE To identify the components of pharmacist intervention that improve clinical outcomes during care transitions. METHODS MEDLINE, EMBASE, International Pharmaceutical Abstracts, and Web of Science databases were searched for randomized controlled trials (RCTs) that studied pharmacist intervention with regard to hospitalization. Two reviewers independently screened all references published from inception to November 2014, extracted data, and assessed risk of bias. RESULTS A total of 30 studies met the inclusion criteria. A model was created to categorize and cluster components of pharmacist intervention. The average number of components deployed, stages of hospitalization covered, and intervention targets were equally distributed between effective and ineffective studies. A best evidence synthesis of 15 studies revealed strong evidence for a clinical medication review in multifaceted programs (5 effective vs. 0 ineffective studies). Conflicting evidence was found for an isolated postdischarge intervention, admission medication reconciliation, combining postdischarge interventions with in-hospital interventions, and covering of multiple stages. Closely collaborating with other health care providers enhanced the effectiveness. CONCLUSIONS Although there is a need for well-designed and well-reported RCTs, the study heterogeneity enabled a best evidence synthesis to elucidate effective components of pharmacist intervention. In isolated postdischarge intervention programs, evidence tends towards collaborating with nurses and tailoring to individual patient needs. In multifaceted intervention programs, performing medication reconciliation alone is insufficient in reducing postdischarge clinical outcomes and should be combined with active patient counseling and a clinical medication review. Furthermore, close collaboration between pharmacists and physicians is beneficial. Finally, it is important to secure continuity of care by integrating pharmacists in these multifaceted programs across health care settings. Ultimately, pharmacists need to know patient clinical background and previous hospital experience.
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Affiliation(s)
- Hendrik T Ensing
- Utrecht University of Applied Sciences, Bolognalaan 101, P.O. Box 85182, 3508 AD Utrecht, the Netherlands.
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Chiang LY, Liu J, Flood KL, Carroll MB, Piccirillo JF, Stark S, Wang A, Wildes TM. Geriatric assessment as predictors of hospital readmission in older adults with cancer. J Geriatr Oncol 2015; 6:254-61. [PMID: 25976445 PMCID: PMC4536088 DOI: 10.1016/j.jgo.2015.04.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/31/2015] [Accepted: 04/21/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hospital readmission is a common, costly problem. Little is known regarding risk factors for readmission in older adults with cancer. This study aims to identify factors associated with 30-day readmission in a cohort of older medical oncology patients. SETTING/PARTICIPANTS Adults age 65 and over hospitalized to an Oncology Acute Care for Elders Unit at Barnes-Jewish Hospital. MEASUREMENTS Standard geriatric screening tests were administered in routine clinical care. Clinical data and 30-day readmission status were obtained through medical record review. RESULTS 677 patients met the inclusion criteria. 77% were white and 53% were male. Thoracic (32%), hematologic (20%), and gastrointestinal (18%) malignancies were most common. The 30-day unplanned readmission rate was 35.2%. Multivariable analyses identified complete dependence in feeding (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.29-10.65), and some dependence (1.58, 1.04-2.41) and complete dependence (2.64, 1.70-4.12) in housekeeping, prior to admission, as associated with higher odds of readmission. Age<75 (1.49, 1.04-2.14), African-American race (1.59, 1.06-2.39), potentially inappropriate medications (1.36, 0.94-1.99), and higher-risk reasons for index admission (1.93, 1.34-2.78) also increased odds of readmission. These factors were organized into a prognostic index. CONCLUSION Hospital readmission was common and higher than previously reported rates in general medical populations. We identified several previously unrecognized factors associated with increased risk for readmission, including some geriatric assessment parameters, and developed a practical tool that can be used by clinicians to assess risk of 30-day readmission.
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Affiliation(s)
- Leslie Y Chiang
- Washington University School of Medicine, St. Louis, United States
| | - Jingxia Liu
- Washington University School of Medicine, St. Louis, United States
| | | | - Maria B Carroll
- Washington University School of Medicine, St. Louis, United States
| | - Jay F Piccirillo
- Washington University School of Medicine, St. Louis, United States
| | - Susan Stark
- Washington University School of Medicine, St. Louis, United States
| | - Adam Wang
- Washington University School of Medicine, St. Louis, United States
| | - Tanya M Wildes
- Washington University School of Medicine, St. Louis, United States.
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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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Abstract
BACKGROUND We have previously identified risk factors for readmission following congenital heart surgery - Hispanic ethnicity, failure to thrive, and original hospital stay more than 10 days. As part of a quality initiative, changes were made to the discharge process in hopes of reducing the impact. All discharges were carried out with an interpreter, medications were delivered to the hospital before discharge, and phone calls were made to families within 72 hours following discharge. We hypothesised that these changes would decrease readmissions. METHODS The current cohort of 635 patients underwent surgery in 2012. Demographic, preoperative, operative, and postoperative variables were evaluated. Univariate and multivariate risk factor analyses were performed. Comparisons were made between the initial (2009) and the current (2012) cohorts. RESULTS There were 86 readmissions of 77 patients during 2012. Multivariate risk factors for readmission were risk adjustment for congenital heart surgery score and initial hospital stay >10 days. In comparing 2009 with 2012, the overall readmission rate was similar (10 versus 12%, p=0.27). Although there were slight decreases in the 2012 readmissions for those patients with Hispanic ethnicity (18 versus 16%, p=0.79), failure to thrive (23 versus 17%, p=0.49), and initial hospital stay >10 days (22 versus 20%, p=0.63), they were not statistically significant. CONCLUSIONS Potential risk factors for readmission following paediatric cardiothoracic surgery have been identified. Although targeted modifications in discharge processes can be made, they may not reduce readmissions. Efforts should continue to identify modifiable factors that can reduce the negative impact of hospital readmissions.
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179
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Jennings JH, Thavarajah K, Mendez MP, Eichenhorn M, Kvale P, Yessayan L. Predischarge Bundle for Patients With Acute Exacerbations of COPD to Reduce Readmissions and ED Visits. Chest 2015; 147:1227-1234. [DOI: 10.1378/chest.14-1123] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Bradley EH, Sipsma H, Horwitz LI, Ndumele CD, Brewster AL, Curry LA, Krumholz HM. Hospital strategy uptake and reductions in unplanned readmission rates for patients with heart failure: a prospective study. J Gen Intern Med 2015; 30:605-11. [PMID: 25523470 PMCID: PMC4395590 DOI: 10.1007/s11606-014-3105-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/10/2014] [Accepted: 11/06/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite recent reductions in national unplanned readmission rates, we have relatively little understanding of which hospital strategies are most associated with changes in risk-standardized readmission rates (RSRR). OBJECTIVE We examined associations between the change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies over 12-18 months in a national sample of hospitals. DESIGN We conducted a prospective study of hospitals using a Web-based survey at baseline (November 2010-May 2011, n = 599, 91.0% response rate) and 12-18 months later (November 2011-October 2012, n = 501, 83.6% response rate), with RSRR measured at the same time points. The final analytic sample included 478 hospitals. PARTICIPANTS The study included hospitals participating in the Hospital-to-Home (H2H) and State Action on Avoidable Rehospitalizations (STAAR) initiatives. MAIN MEASURES We examined associations between change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies previously demonstrated to have increased between baseline and follow-up, using unadjusted and adjusted linear regression. KEY RESULTS The average number of strategies taken up from baseline to follow-up was 1.6 (SE = 0.06); approximately one-quarter (25.3%) of hospitals took up at least three new strategies. Hospitals that adopted the strategy of routinely discharging patients with a follow-up appointment already scheduled experienced significant reductions in RSRR (reduction of 0.63 percentage point, p value < 0.05). Hospitals that took up three or more strategies had significantly greater reductions in RSRR compared to hospitals that took up only zero to two strategies (reduction of 1.29 versus 0.57 percentage point, p value < 0.05). Among the 117 hospitals that took up three or more strategies, 93 unique combinations of strategies were used. CONCLUSIONS Although most individual strategies were not associated with RSRR reduction, hospitals that took up any three or more strategies showed significantly greater reduction in RSRR compared to hospitals that took up fewer than three strategies.
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Affiliation(s)
- Elizabeth H Bradley
- Department of Health Policy and Management, Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, 06520-8034, CT, USA,
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Rice YB, Barnes CA, Rastogi R, Hillstrom TJ, Steinkeler CN. Tackling 30-Day, All-Cause Readmissions with a Patient-Centered Transitional Care Bundle. Popul Health Manag 2015; 19:56-62. [PMID: 25919315 DOI: 10.1089/pop.2014.0163] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In 2008, Kaiser Permanente Northwest identified the transition from hospital to home as a pivotal quality improvement opportunity and used multiple patient-centered data collection methods to identify unmet needs contributing to preventable readmissions. A transitional care bundle that crosses care settings and organizational functions was developed to meet needs expressed by patients. It comprises 5 elements: risk stratification, a specialized phone number for discharged patients, timely postdischarge follow-up, standardized patient discharge instructions and same-day discharge summaries, and pharmacist-supported medication reconciliation. The transitional care bundle has been in place for 6 years. Readmission rates decreased from 12.1% to 10.6%, Hospital Consumer Assessment of Healthcare Providers and Systems scores for the discharge instruction composite moved from below the 50(th) to above the 90(th) national percentile, average time to the first postdischarge appointment decreased from 9.7 days to 5.3 days, and error rates on the discharge medication list decreased from 57% to 21% (P<.0001 for all). The program, which continues to evolve to address sustainability challenges and organizational initiatives, suggests the potential of a multicomponent, patient-centered care bundle to address the complex, interrelated drivers of preventable readmissions.
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Affiliation(s)
| | - Carol Ann Barnes
- 2 Care Management Institute , Kaiser Permanente, Oakland, California
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Abstract
Hospital readmission is a high-priority health care quality measure and target for cost reduction. Despite broad interest in readmission, relatively little research has focused on patients with diabetes. The burden of diabetes among hospitalized patients, however, is substantial, growing, and costly, and readmissions contribute a significant portion of this burden. Reducing readmission rates of diabetic patients has the potential to greatly reduce health care costs while simultaneously improving care. Risk factors for readmission in this population include lower socioeconomic status, racial/ethnic minority, comorbidity burden, public insurance, emergent or urgent admission, and a history of recent prior hospitalization. Hospitalized patients with diabetes may be at higher risk of readmission than those without diabetes. Potential ways to reduce readmission risk are inpatient education, specialty care, better discharge instructions, coordination of care, and post-discharge support. More studies are needed to test the effect of these interventions on the readmission rates of patients with diabetes.
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Affiliation(s)
- Daniel J Rubin
- Section of Endocrinology, Diabetes, and Metabolism, School of Medicine, Temple University, 3322 N. Broad ST., Ste 205, Philadelphia, PA, 19140, USA.
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The association of acute kidney injury in the critically ill and postdischarge outcomes: a cohort study*. Crit Care Med 2015; 43:354-64. [PMID: 25474534 DOI: 10.1097/ccm.0000000000000706] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Hospital readmissions contribute significantly to the cost of inpatient care and are targeted as a marker for quality of care. Little is known about risk factors associated with hospital readmission in survivors of critical illness. We hypothesized that acute kidney injury in patients who survived critical care would be associated with increased risk of 30-day postdischarge hospital readmission, postdischarge mortality, and progression to end-stage renal disease. DESIGN Two center observational cohort study. SETTING Medical and surgical ICUs at the Brigham and Women's Hospital and the Massachusetts General Hospital in Boston, Massachusetts. PATIENTS We studied 62,096 patients, 18 years old and older, who received critical care between 1997 and 2012 and survived hospitalization. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS : All data was obtained from the Research Patient Data Registry at Partners HealthCare. The exposure of interest was acute kidney injury defined as meeting Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease Risk, Injury or Failure criteria occurring 3 days prior to 7 days after critical care initiation. The primary outcome was hospital readmission in the 30 days following hospital discharge. The secondary outcome was mortality in the 30 days following hospital discharge. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both acute kidney injury and readmission status. Adjustment included age, race (white vs nonwhite), gender, Deyo-Charlson Index, patient type (medical vs surgical) and sepsis. Additionally, long-term progression to End Stage Renal Disease in patients with acute kidney injury was analyzed with a risk-adjusted Cox proportional hazards regression model. The absolute risk of 30-day readmission was 12.3%, 19.0%, 21.2%, and 21.1% in patients with No Acute Kidney Injury, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Injury, and Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Failure, respectively. In patients who received critical care and survived hospitalization, acute kidney injury was a robust predictor of hospital readmission and post-discharge mortality and remained so following multivariable adjustment. The odds of 30-day post-discharge hospital readmission in patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, or Failure fully adjusted were 1.44 (95% CI, 1.25-1.66), 1.98 (95% CI, 1.66-2.36), and 1.55 (95% CI, 1.26-1.91) respectively, relative to patients without acute kidney injury. Further, the odds of 30-day post-discharge mortality in patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, or Failure fully adjusted per our primary analysis were 1.39 (95% CI, 1.28-1.51), 1.46 (95% CI, 1.30-1.64), and 1.42 (95% CI, 1.26-1.61) respectively, relative to patients without acute kidney injury. The addition of the propensity score to the multivariable model did not change the point estimates significantly. Finally, taking into account age, gender, race, Deyo-Charlson Index, and patient type, we observed a relationship between acute kidney injury and development of end-stage renal disease. Patients with Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease class Risk, Injury, Failure experienced a significantly higher risk of end-stage renal disease during follow-up than patients without acute kidney injury (hazard ratio, 2.03; 95% CI, 1.56-2.65; hazard ratio, 3.99; 95% CI, 3.04-5.23; hazard ratio, 10.40; 95% CI, 8.54-12.69, respectively). CONCLUSIONS Patients who suffer acute kidney injury are among a high-risk group of ICU survivors for adverse outcomes. In patients treated with critical care who survive hospitalization, acute kidney injury is a robust predictor of subsequent unplanned hospital readmission. In critical illness survivors, acute kidney injury is also associated with the odds of 30-day postdischarge mortality and the risk of subsequent end-stage renal disease.
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Abstract
Medication Reconciliation (MedRec) is the comprehensive process of medication verification, clarification and documentation in an effort to avoid medication errors. There are many reasons that contribute to the inadequacies of current day inpatient MedRec. Among these include the limited medical literacy of patients, communication between providers and teams of providers, and the intrinsic difficulties of medical charting. Although the best approach to inpatient MedRec is not known, the following outlines the 10 most important aspects, or "Commandments", for effective inpatient MedRec. The tenets are not listed in any particular order of importance.
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Affiliation(s)
- Henry K Siu
- Department of Medicine, Division of Cardiology, Thomas Jefferson University , Philadelphia, PA , USA
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Decision support tool use in colorectal surgery: what is the role? J Surg Res 2015; 194:69-76. [DOI: 10.1016/j.jss.2014.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/16/2014] [Accepted: 09/05/2014] [Indexed: 10/24/2022]
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Kim H, Thyer BA. Does transitional care prevent older adults from rehospitalization? A review. ACTA ACUST UNITED AC 2015; 12:261-71. [PMID: 25661896 DOI: 10.1080/15433714.2013.827140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The purpose of the authors in this article is to present a review of experimental research assessing whether transitional care is effective in preventing older adults from rehospitalization in the United States. The prevalence of rehospitalization among Medicare beneficiaries is high, but a considerable portion of rehospitalizations could have been prevented and decreased. One strategy which can prevent these unplanned rehospitalizations is transitional care. Older adults age 65 and over, in particular, are considered to be potential beneficiaries of transitional care. Studies examining the effects of transitional care were identified through electronic bibliographic databases and manual searches from inception through April 2011, limited to English language. A total of nine experimental studies meeting the inclusionary criteria were reviewed. Seven of nine studies detected positive effects of transitional care in preventing older adults from rehospitalization, although these effects varied at different follow-up periods. Based on this narrative review it may be concluded that the published experimental studies support the hypothesis that transitional care generally prevents rehospitalization among the elderly. Additional studies involving more traditionally under-represented clients, and with longer follow-up periods are needed.
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Affiliation(s)
- Hyejin Kim
- a College of Social Work, Florida State University , Tallahassee , Florida , USA
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Effectiveness of an electronic tool for medication reconciliation in a general surgery department. Int J Clin Pharm 2015; 37:159-67. [PMID: 25557203 DOI: 10.1007/s11096-014-0057-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Medication reconciliation is a key tool in the prevention of adverse drug events. OBJECTIVE To assess the impact of an electronic reconciliation tool in decreasing unintended discrepancies between medications prescribed after surgery and the patient's usual treatment. SETTING General Surgery Department of Gregorio Marañón's University General Hospital, Madrid. METHOD A pre-post intervention study with no equivalent control group was carried out between June 2009 and December 2010. Patients hospitalized in the General Surgery Department for 24 h or more, and whose prescriptions prior to admission included three or more drugs were included in the study. Patients were interviewed to gather information about their usual treatment drugs. Discrepancies between the latter and the drugs prescribed after surgery were assessed before and after the medication reconciliation electronic tool was implemented. MAIN OUTCOME MEASURE Proportion of patients with at least one unintended discrepancy. RESULTS A total of 107 patients in the pre-intervention phase and 84 patients in the post-intervention phase were included. We detected 1,678 discrepancies, 167 were found to be unintended. The number of patients with at least one unintended discrepancy was 43 (40.2 %) in the pre-intervention phase, and 38 (38.1 %) in the post-intervention phase, p = 0.885. The percentage of unintended discrepancies over the total amount of drugs reconciled was lower in the post-intervention phase than in the pre-intervention phase (6.6 vs. 10.6 %), p = 0.002. Regarding unintended discrepancies 79.2 % were grade C severity (the error reached the patient but caused no harm), 13.6 % grade D (the error reached the patient and required monitoring or intervention to preclude harm) and 7.1 % grade E (the error may have contributed to or resulted in temporary harm to the patient and required intervention). CONCLUSION Implementation of an electronic tool facilitated the process of medication reconciliation in a general surgery unit. The proportion of unintended discrepancies over the total amount of drugs reconciled was reduced after the implementation of the reconciliation programme. However, we could not demonstrate a more significant impact due to some methodological limitations.
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Auger KA, Simon TD, Cooperberg D, Gay J, Kuo DZ, Saysana M, Stille CJ, Fisher ES, Wallace S, Berry J, Coghlin D, Jhaveri V, Kairys S, Logsdon T, Shaikh U, Srivastava R, Starmer AJ, Wilkins V, Shen MW. Summary of STARNet: Seamless Transitions and (Re)admissions Network. Pediatrics 2015; 135:164-75. [PMID: 25489017 PMCID: PMC4279069 DOI: 10.1542/peds.2014-1887] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine.
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Affiliation(s)
- Katherine A. Auger
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tamara D. Simon
- Division of Hospital Medicine, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, Seattle, Washington
| | - David Cooperberg
- St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - James Gay
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Dennis Z. Kuo
- Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michele Saysana
- Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Christopher J. Stille
- General Academic Pediatrics, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, Colorado
| | - Erin Stucky Fisher
- University of California San Diego School of Medicine, San Diego, California
| | - Sowdhamini Wallace
- Section of Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Jay Berry
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital; Harvard Medical School, Boston, Massachusetts
| | - Daniel Coghlin
- Hasbro Children’s Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Vishu Jhaveri
- Blue Cross Blue Shield of Arizona representing Blue Cross Blue Shield Association, Phoenix, Arizona
| | - Steven Kairys
- Jersey Shore Medical Center, Neptune Township, New Jersey
| | - Tina Logsdon
- Children’s Hospital Association, Overland Park, Kansas
| | - Ulfat Shaikh
- University of California Davis Health System, Sacramento, California
| | - Rajendu Srivastava
- Division of Inpatient Medicine, Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah; and
| | - Amy J. Starmer
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital; Harvard Medical School, Boston, Massachusetts
| | - Victoria Wilkins
- Division of Inpatient Medicine, Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah; and
| | - Mark W. Shen
- Dell Medical School, University of Texas Austin, Austin, Texas
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Auerbach A. Science and scholarship: ten volumes of the Journal Hospital Medicine. J Hosp Med 2015; 10:64-6. [PMID: 25470813 DOI: 10.1002/jhm.2299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/20/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California
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Fan L, Lukin W, Zhao J, Sun J, Hou XY. Interventions targeting the elderly population to reduce emergency department utilisation: a literature review. Emerg Med J 2014; 32:738-43. [DOI: 10.1136/emermed-2014-203770] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 11/27/2014] [Indexed: 11/03/2022]
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Kramer JS, Stewart MR, Fogg SM, Schminke BC, Zackula RE, Nester TM, Eidem LA, Rosendale JC, Ragan RH, Bond JA, Goertzen KW. A quantitative evaluation of medication histories and reconciliation by discipline. Hosp Pharm 2014; 49:826-38. [PMID: 25477614 DOI: 10.1310/hpj4909-826] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/OBJECTIVE Medication reconciliation at transitions of care decreases medication errors, hospitalizations, and adverse drug events. We compared inpatient medication histories and reconciliation across disciplines and evaluated the nature of discrepancies. METHODS We conducted a prospective cohort study of patients admitted from the emergency department at our 760-bed hospital. Eligible patients had their medication histories conducted and reconciled in order by the admitting nurse (RN), certified pharmacy technician (CPhT), and pharmacist (RPh). Discharge medication reconciliation was not altered. Admission and discharge discrepancies were categorized by discipline, error type, and drug class and were assigned a criticality index score. A discrepancy rating system systematically measured discrepancies. RESULTS Of 175 consented patients, 153 were evaluated. Total admission and discharge discrepancies were 1,461 and 369, respectively. The average number of medications per participant at admission was 8.59 (1,314) with 9.41 (1,374) at discharge. Most discrepancies were committed by RNs: 53.2% (777) at admission and 56.1% (207) at discharge. The majority were omitted or incorrect. RNs had significantly higher admission discrepancy rates per medication (0.59) compared with CPhTs (0.36) and RPhs (0.16) (P < .001). RPhs corrected significantly more discrepancies per participant than RNs (6.39 vs 0.48; P < .001); average criticality index reduction was 79.0%. Estimated prevented adverse drug events (pADEs) cost savings were $589,744. CONCLUSIONS RPhs committed the fewest discrepancies compared with RNs and CPhTs, resulting in more accurate medication histories and reconciliation. RPh involvement also prevented the greatest number of medication errors, contributing to considerable pADE-related cost savings.
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Affiliation(s)
| | - Michael R Stewart
- NetApp, Wichita, Kansas (formerly with Wesley Medical Center) , Wichita, Kansas
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Burke RE, Guo R, Prochazka AV, Misky GJ. Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Serv Res 2014; 14:423. [PMID: 25244946 PMCID: PMC4180324 DOI: 10.1186/1472-6963-14-423] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 09/16/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic attempts to identify best practices for reducing hospital readmissions have been limited without a comprehensive framework for categorizing prior interventions. Our research aim was to categorize prior interventions to reduce hospital readmissions using the ten domains of the Ideal Transition of Care (ITC) framework, to evaluate which domains have been targeted in prior interventions and then examine the effect intervening on these domains had on reducing readmissions. METHODS Review of literature and secondary analysis of outcomes based on categorization of English-language reports published between January 1975 and October 2013 into the ITC framework. RESULTS 66 articles were included. Prior interventions addressed an average of 3.5 of 10 domains; 41% demonstrated statistically significant reductions in readmissions. The most common domains addressed focused on monitoring patients after discharge, patient education, and care coordination. Domains targeting improved communication with outpatient providers, provision of advanced care planning, and ensuring medication safety were rarely included. Increasing the number of domains included in a given intervention significantly increased success in reducing readmissions, even when adjusting for quality, duration, and size (OR per domain, 1.5, 95% CI 1.1 - 2.0). The individual domains most associated with reducing readmissions were Monitoring and Managing Symptoms after Discharge (OR 8.5, 1.8 - 41.1), Enlisting Help of Social and Community Supports (OR 4.0, 1.3 - 12.6), and Educating Patients to Promote Self-Management (OR 3.3, 1.1 - 10.0). CONCLUSIONS Interventions to reduce hospital readmissions are frequently unsuccessful; most target few domains within the ITC framework. The ITC may provide a useful framework to consider when developing readmission interventions.
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Affiliation(s)
- Robert E Burke
- Department of Veterans Affairs Medical Center, Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80220, USA.
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Farris KB, Carter BL, Xu Y, Dawson JD, Shelsky C, Weetman DB, Kaboli PJ, James PA, Christensen AJ, Brooks JM. Effect of a care transition intervention by pharmacists: an RCT. BMC Health Serv Res 2014; 14:406. [PMID: 25234932 PMCID: PMC4262237 DOI: 10.1186/1472-6963-14-406] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 09/10/2014] [Indexed: 11/10/2022] Open
Abstract
Background Pharmacists may improve medication-related outcomes during transitions of care. The aim of the Iowa Continuity of Care Study was to determine if a pharmacist case manager (PCM) providing a faxed discharge medication care plan from a tertiary care institution to primary care could improve medication appropriateness and reduce adverse events, rehospitalization and emergency department visits. Methods Design. Randomized, controlled trial of 945 participants assigned to enhanced, minimal and usual care groups conducted 2007 to 2012. Subjects. Participants with cardiovascular-related conditions and/or asthma or chronic obstructive pulmonary disease were recruited from the University of Iowa Hospital and Clinics following admission to general medicine, family medicine, cardiology or orthopedics. Intervention. The minimal group received admission history, medication reconciliation, patient education, discharge medication list and medication recommendations to inpatient team. The enhanced group also received a faxed medication care plan to their community physician and pharmacy and telephone call 3–5 days post-discharge. Participants were followed for 90 days post-discharge. Main Outcomes and Measures. Medication appropriateness index (MAI), adverse events, adverse drug events and post-discharge healthcare utilization were compared by study group using linear and logistic regression, as models accommodating random effects due to pharmacists indicated little clustering. Results Study groups were similar at baseline and the intervention fidelity was high. There were no statistically significant differences by study group in medication appropriateness, adverse events or adverse drug events at discharge, 30-day and 90-day post-discharge. The average MAI per medication as 0.53 at discharge and increased to 0.75 at 90 days, and this was true across all study groups. Post-discharge, about 16% of all participants experienced an adverse event, and this did not differ by study group (p > 0.05). Almost one-third of all participants had any type of healthcare utilization within 30 days post-discharge, where 15% of all participants had a 30-day readmission. Healthcare utilization post-discharge was not statistically significant different at 30 or 90 days by study group. Conclusion The pharmacist case manager did not affect medication use outcomes post-discharge perhaps because quality of care measures were high in all study groups. Trial registration Clinicaltrials.gov registration: NCT00513903, August 7, 2007.
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Affiliation(s)
- Karen B Farris
- College of Pharmacy, University of Michigan, 428 Church St, Ann Arbor MI 48109-1065, USA.
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Tricco AC, Antony J, Ivers NM, Ashoor HM, Khan PA, Blondal E, Ghassemi M, MacDonald H, Chen MH, Ezer LK, Straus SE. Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis. CMAJ 2014; 186:E568-78. [PMID: 25225226 DOI: 10.1503/cmaj.140289] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group. METHODS We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted. RESULTS We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89). INTERPRETATION We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).
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Affiliation(s)
- Andrea C Tricco
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Jesmin Antony
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Noah M Ivers
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Huda M Ashoor
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Paul A Khan
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Erik Blondal
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Marco Ghassemi
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Heather MacDonald
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Maggie H Chen
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Lianne Kark Ezer
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
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Hesselink G, Zegers M, Vernooij-Dassen M, Barach P, Kalkman C, Flink M, Ön G, Olsson M, Bergenbrant S, Orrego C, Suñol R, Toccafondi G, Venneri F, Dudzik-Urbaniak E, Kutryba B, Schoonhoven L, Wollersheim H. Improving patient discharge and reducing hospital readmissions by using Intervention Mapping. BMC Health Serv Res 2014; 14:389. [PMID: 25218406 PMCID: PMC4175223 DOI: 10.1186/1472-6963-14-389] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 09/10/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge. METHODS The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance. RESULTS Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change. CONCLUSIONS This study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.
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Affiliation(s)
- Gijs Hesselink
- />Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Marieke Zegers
- />Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Myrra Vernooij-Dassen
- />Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- />Radboud University Medical Center, Kalorama Foundation, Nijmegen, The Netherlands
- />Department of Primary Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Paul Barach
- />Patient Safety Center, University Medical Center Utrecht, Utrecht, The Netherlands
- />Department of Health Studies, University of Stavanger, Stavanger, Norway
- />University College Cork, Cork, Ireland
| | - Cor Kalkman
- />Patient Safety Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Flink
- />Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- />Department of Social Work, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Ön
- />Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- />Quality and Patient Safety, Karolinska University Hospital, Stockholm, Sweden
| | - Mariann Olsson
- />Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- />Department of Social Work, Karolinska University Hospital, Stockholm, Sweden
| | - Susanne Bergenbrant
- />Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Carola Orrego
- />Avedis Donabedian Institute, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Rosa Suñol
- />Avedis Donabedian Institute, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Giulio Toccafondi
- />Clinical Risk Management and Patient Safety Centre, Tuscany region, Italy
| | - Francesco Venneri
- />Clinical Risk Management and Patient Safety Centre, Tuscany region, Italy
| | | | - Basia Kutryba
- />National Center for Quality Assessment in Health Care, Krakow, Poland
| | - Lisette Schoonhoven
- />Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Hub Wollersheim
- />Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - on behalf of the European HANDOVER Research Collaborative
- />Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- />Radboud University Medical Center, Kalorama Foundation, Nijmegen, The Netherlands
- />Department of Primary Care, Radboud University Medical Center, Nijmegen, The Netherlands
- />Patient Safety Center, University Medical Center Utrecht, Utrecht, The Netherlands
- />Department of Health Studies, University of Stavanger, Stavanger, Norway
- />University College Cork, Cork, Ireland
- />Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- />Department of Social Work, Karolinska University Hospital, Stockholm, Sweden
- />Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- />Quality and Patient Safety, Karolinska University Hospital, Stockholm, Sweden
- />Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
- />Avedis Donabedian Institute, Universidad Autónoma de Barcelona, Barcelona, Spain
- />Clinical Risk Management and Patient Safety Centre, Tuscany region, Italy
- />National Center for Quality Assessment in Health Care, Krakow, Poland
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Warden BA, Freels JP, Furuno JP, Mackay J. Pharmacy-managed program for providing education and discharge instructions for patients with heart failure. Am J Health Syst Pharm 2014; 71:134-9. [PMID: 24375606 DOI: 10.2146/ajhp130103] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The impact of a pharmacy-managed program for providing education and discharge instructions for patients with heart failure (HF) was evaluated. METHODS A before-and-after quasiexperimental design was used to quantify the effect of a pharmacist-managed HF medication education and discharge instruction program on the incidence of 30-day readmission rates and adherence to targeted Joint Commission core measures for HF (the provision of discharge instructions and the prescribing of an angiotensin-converting-enzyme inhibitor [ACEI]/angiotensin II receptor blocker [ARB] at discharge or documentation of the reason if therapy was not prescribed). Adult patients admitted to Oregon Health and Science University's cardiology unit with systolic HF exacerbation as their primary diagnosis between December 2010 and March 2011 were included. Throughout patients' hospitalization, the pharmacist collaborated with the multidisciplinary team to make treatment and monitoring recommendations; provided discharge medication reconciliation, discharge medication recommendations, and discharge instructions; answered patient-specific questions; and gave the patient a complete discharge medication list. RESULTS The study enrolled 35 patients and compared results against a historical control group of 115 patients. The frequency of discharge counseling increased significantly (p = 0.007), as did the rate of ACEI/ARB prescribing at discharge (p = 0.02). Both 30-day all-cause and HF-related readmissions were reduced compared with baseline (p = 0.02 and p = 0.11, respectively). CONCLUSION Pharmacist involvement in medication reconciliation and discharge counseling for HF patients was associated with a significant increase in adherence with the Joint Commission's core measures, a significant reduction in 30-day all-cause readmissions, and a positive effect on patient satisfaction.
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Affiliation(s)
- Bruce A Warden
- Bruce A. Warden, Pharm.D., BCPS, is Clinical Pharmacist; and Jessica Pryor Freels, Pharm.D., M.S., is Clinical Operations Manager, Oregon Health and Science University (OHSU), Portland. Jon P. Furuno, Ph.D., is Associate Professor, Department of Pharmacy Practice, Oregon State University/OHSU College of Pharmacy. John Mackay, Pharm.D., BCPS (AQ-Cardiology), is Advanced Heart Failure Clinical Pharmacist, OHSU
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Okumura LM, Rotta I, Correr CJ. Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review. Int J Clin Pharm 2014. [PMID: 25052621 DOI: 10.1007/s11096‐014‐9982‐1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.
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Affiliation(s)
- Lucas Miyake Okumura
- PGY 2 Oncology and Hematology Clinical Hospital, Federal University of Paraná, Curitiba, PR, Brazil,
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Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review. Int J Clin Pharm 2014; 36:882-91. [PMID: 25052621 DOI: 10.1007/s11096-014-9982-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 07/10/2014] [Indexed: 10/25/2022]
Abstract
Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.
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Reducing the Readmission Burden of COPD: A Focused Review of Recent Interventions. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014. [DOI: 10.1007/s40138-014-0050-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Leppin AL, Gionfriddo MR, Kessler M, Brito JP, Mair FS, Gallacher K, Wang Z, Erwin PJ, Sylvester T, Boehmer K, Ting HH, Murad MH, Shippee ND, Montori VM. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med 2014; 174:1095-107. [PMID: 24820131 PMCID: PMC4249925 DOI: 10.1001/jamainternmed.2014.1608] [Citation(s) in RCA: 550] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Reducing early (<30 days) hospital readmissions is a policy priority aimed at improving health care quality. The cumulative complexity model conceptualizes patient context. It predicts that highly supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions. OBJECTIVE To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features--including their impact on treatment burden and on patients' capacity to enact postdischarge self-care--that might explain their varying effects. DATA SOURCES We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies. STUDY SELECTION Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home. DATA EXTRACTION AND SYNTHESIS Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model. MAIN OUTCOMES AND MEASURES Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge. RESULTS In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 [95% CI, 0.73-0.91]; P < .001; I² = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P = .01). In exploratory subgroup analyses, interventions with many components (interaction P = .001), involving more individuals in care delivery (interaction P = .05), and supporting patient capacity for self-care (interaction P = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers. CONCLUSIONS AND RELEVANCE Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.
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Affiliation(s)
- Aaron L Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Michael R Gionfriddo
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota2Mayo Graduate School, Mayo Clinic, Rochester, Minnesota
| | - Maya Kessler
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota3Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juan Pablo Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota3Department of Medicine, Mayo Clinic, Rochester, Minnesota4Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Katie Gallacher
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Zhen Wang
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota4Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Tanya Sylvester
- medical student at St Louis University School of Medicine, St Louis, Missouri
| | - Kasey Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota8graduate student at University of Minnesota School of Public Health, Minneapolis
| | - Henry H Ting
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota4Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Nathan D Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota3Department of Medicine, Mayo Clinic, Rochester, Minnesota4Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
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