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Ellison JE, Kumar S, Steingrimsson JA, Adhikari D, Charlesworth CJ, McConnell KJ, Trivedi AN, Trikalinos TA, Forbes SP, Panagiotou OA. Comparison of Low-Value Care Among Commercial and Medicaid Enrollees. J Gen Intern Med 2023; 38:954-960. [PMID: 36175761 PMCID: PMC10039208 DOI: 10.1007/s11606-022-07823-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low-value healthcare is costly and inefficient and may adversely affect patient outcomes. Despite increases in low-value service use, little is known about how the receipt of low-value care differs across payers. OBJECTIVE To evaluate differences in the use of low-value care between patients with commercial versus Medicaid coverage. DESIGN Retrospective observational analysis of the 2017 Rhode Island All-payer Claims Database, estimating the probability of receiving each of 14 low-value services between commercial and Medicaid enrollees, adjusting for patient sociodemographic and clinical characteristics. Ensemble machine learning minimized the possibility of model misspecification. PARTICIPANTS Medicaid and commercial enrollees aged 18-64 with continuous coverage and an encounter at which they were at risk of receiving a low-value service. INTERVENTION Enrollment in Medicaid or Commercial insurance. MAIN MEASURES Use of one of 14 validated measures of low-value care. KEY RESULTS Among 110,609 patients, Medicaid enrollees were younger, had more comorbidities, and were more likely to be female than commercial enrollees. Medicaid enrollees had higher rates of use for 7 low-value care measures, and those with commercial coverage had higher rates for 5 measures. Across all measures of low-value care, commercial enrollees received more (risk difference [RD] 6.8 percentage points; CI: 6.6 to 7.0) low-value services than their counterparts with Medicaid. Commercial enrollees were also more likely to receive low-value services typically performed in the emergency room (RD 11.4 percentage points; CI: 10.7 to 12.2) and services that were less expensive (RD 15.3 percentage points; CI 14.6 to 16.0). CONCLUSION Differences in the provision of low-value care varied across measures, though average use was slightly higher among commercial than Medicaid enrollees. This difference was more pronounced for less expensive services indicating that financial incentives may not be the sole driver of low-value care.
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Affiliation(s)
- Jacqueline E Ellison
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Soryan Kumar
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jon A Steingrimsson
- Center for Statistical Sciences, Brown University School of Public Health, Providence, RI, USA
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | | | | | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, USA
- Department of Emergency Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Amal N Trivedi
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Thomas A Trikalinos
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Shaun P Forbes
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
| | - Orestis A Panagiotou
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA.
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Hollenbeck BK, Kaufman SR, Oerline M, Modi PK, Caram ME, Shahinian VB, Ellimoottil C. Effects of Advanced Practice Providers on Single-specialty Surgical Practice. Ann Surg 2023; 277:e40-e45. [PMID: 33914476 PMCID: PMC8989058 DOI: 10.1097/sla.0000000000004846] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effects of adding advanced practice providers to surgical practices on surgical complications, readmissions, mortality, episode spending, length of stay, and access to care. SUMMARY BACKGROUND DATA There has been substantial growth in the number of nurse practitioners and physician assistants (ie, advanced practice providers) in the United States. The extent to which advanced practice providers have been integrated into surgical practice, and their impact on surgical outcomes and access is unclear. METHODS Using a 20% sample of national Medicare claims, we performed a retrospective cohort study of fee-for-service beneficiaries undergoing one of 4 major procedures (coronary artery bypass graft, colectomy, major joint replacement, and cystectomy) between 2010 and 2016. We limited our study population for each procedure to patients treated by single-specialty surgical groups to ensure that the advanced practice providers have direct interactions with its surgeons and patients. All outcomes were measured at the practice level for the year before and the year after the addition of the first advanced practice provider. Outcomes included: complications, readmission, mortality, episode payments, length of stay. Models were adjusted for age, race, sex, comorbidity, socioeconomic class and procedure type. Secondary outcome: practice-level office visits by surgical group type. RESULTS The number of advanced practice providers increased by 13%, from 6713 to 7596 between 2010 and 2016. The largest relative increases occurred in general (46.9%) and urologic (27.6%) surgical practices. The year after an advanced practice provider was added to a surgical practice, the odds of complications were 17% and 16% lower at 30- and 90-days postprocedure, respectively. Additionally, 90-day readmissions were 18% less likely and length of stay was 0.33 days shorter (a 7.1% reduction). Average 30-day and90-day episode spending was $1294.73 and $1427.76 lower, respectively ( P < 0.001). General surgical, orthopedic, and urology practices realized increases of 49.0 (95% CI 13.5-84.5), 112.0 (95% CI 83.0-140.5), and 205.0 (95% CI 117.5-292.0) in-office visits per surgeon, respectively. CONCLUSIONS The addition of advanced practice providers to single-specialty surgical groups is associated with improvements in surgical outcomes and access. Future work should clarify the mechanisms by which advanced practice providers within surgical practices contribute to health outcomes to identify best practices for deployment.
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Affiliation(s)
| | | | - Mary Oerline
- Departments of Urology, University of Michigan, Ann Arbor
| | - Parth K. Modi
- Departments of Urology, University of Michigan, Ann Arbor
| | | | - Vahakn B. Shahinian
- Departments of Urology, University of Michigan, Ann Arbor
- Departments of Medicine, University of Michigan, Ann Arbor
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De Vocht K, Verheyen K, Michels NR. Learning objectives of Belgian general practitioner trainees regarding their hospital training: A qualitative study. Eur J Gen Pract 2022; 28:173-181. [PMID: 35833734 PMCID: PMC9291655 DOI: 10.1080/13814788.2022.2081319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background In Europe, hospital training is integrated in the postgraduate curriculum of General Practitioners (GPs) according to the European Directives. However, little is known about the specific learning objectives of GP trainees during this training. Objectives This exploratory study investigated GP trainees’ expected learning objectives for their hospital training and the factors influencing the learning process. Methods Semi-structured interviews were conducted in three focus groups consisting of first-year GP trainees before their hospital training. Data were coded thematically and analysed in NVivo. Results A total of 22 Belgian GP trainees (55% females, average age of 26.2 years) were interviewed. Three major themes emerged: learning objectives, factors influencing learning and organisational aspects. GP trainees mainly wanted to improve their knowledge of common conditions by conducting consultations and follow certain patients’ hospitalisation trajectory. Emergency medicine or internal medicine was the preferred specialty. Other GP trainees wanted to learn more about some specific conditions. Conversely, an overloaded work schedule was dreaded to hinder effective learning. Regular meetings and supervision from their hospital trainer were deemed crucial to strengthen GP trainees’ learning trajectory. Conclusion GP trainees wanted to learn more about both common conditions and some specific conditions. Their previous year in a GP setting strengthened their confidence and facilitated purposeful learning. Relieving GP trainees from administrative tasks when working as supplementary doctors could strike a better balance between the continuity of the clinical department and their personal learning objectives.
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Affiliation(s)
- Kimberley De Vocht
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Katleen Verheyen
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Nele R Michels
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Gray BM, Vandergrift JL, Stevens JP, Landon BE. Evolving Practice Choices by Newly Certified and More Senior General Internists : A Cross-Sectional and Panel Comparison. Ann Intern Med 2022; 175:1022-1027. [PMID: 35576587 DOI: 10.7326/m21-4636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hospital medicine has grown as a field. However, no study has examined trends in career choices by internists over the past decade. OBJECTIVE To measure changes in practice setting for general internists. DESIGN Using Medicare fee-for-service claims (2008 to 2018) and data from the American Board of Internal Medicine, practice setting types were measured annually for general internists initially certifying between 1990 and 2017. SETTING General internists (non-subspecializing) treating Medicare fee-for-service beneficiaries. PATIENTS Medicare fee-for-service beneficiaries aged 65 years and older with at least 20 evaluation and management (E&M) visits annually. MEASUREMENTS Practice setting types were defined as hospitalist (>95% inpatient E&M), outpatient only (100% outpatient E&M), or mixed. RESULTS 67 902 general internists, comprising 80% of all general internists initially certified from 1990 to 2017 (n = 84 581), were studied. From 2008 to 2018, both hospitalists and outpatient-only physicians increased as percentages of general internists (25% to 40% and 23% to 38%, respectively). This was accompanied by a 56% decline in the percentage of mixed-practice physicians (52% to 23%) as these physicians largely migrated to outpatient-only practice. By 2018, 71% of newly certified general internists practiced as hospitalists compared with only 8% practicing as outpatient-only physicians. Most (86% of hospitalists in 2013) had the same practice type 5 years later. This retention rate was similar across early career and more senior physicians (86% and 85% for the 1999 and 2012 initial certification cohorts, respectively) and for the outpatient-only practice type (95%) but was only 57% for the mixed practice type. LIMITATION Practice setting measurement relied only on Medicare fee-for-service claims. CONCLUSION Newly certified general internists are largely choosing hospital medicine as their career choice whereas more senior physicians increasingly see patients only in the outpatient setting. PRIMARY FUNDING SOURCE This study did not receive direct funding.
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Affiliation(s)
- Bradley M Gray
- American Board of Internal Medicine, Philadelphia, Pennsylvania (B.M.G., J.L.V.)
| | | | - Jennifer P Stevens
- Department of Medicine and The Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts (J.P.S.)
| | - Bruce E Landon
- Department of Medicine and The Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, and Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (B.E.L.)
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Wang ES, Velásquez ST, Mader M, Boggan JC, Liao JE, Leykum LK, Pugh J. Triaging Admissions: A Survey of Internal Medicine Resident Experiences and Perceptions and Recommendations on Inpatient Triage Education. Am J Med 2022; 135:919-924.e6. [PMID: 35390308 DOI: 10.1016/j.amjmed.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Emily S Wang
- Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio; South Texas Veterans Health Care System, Medicine Service, San Antonio.
| | - Sadie Trammell Velásquez
- Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio; South Texas Veterans Health Care System, Medicine Service, San Antonio
| | - Michael Mader
- Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio; South Texas Veterans Health Care System, Medicine Service, San Antonio
| | - Joel C Boggan
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jeff E Liao
- Division of Hospital Medicine, Massachusetts General Hospital, Boston
| | - Luci K Leykum
- South Texas Veterans Health Care System, Medicine Service, San Antonio; Department of Medicine, University of Texas at Austin Dell Medical School
| | - Jacqueline Pugh
- Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio; South Texas Veterans Health Care System, Medicine Service, San Antonio
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Multifaceted quality improvement initiatives improve rate of pediatric hand injury reduction. CAN J EMERG MED 2022; 24:426-433. [DOI: 10.1007/s43678-022-00279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 02/08/2022] [Indexed: 11/25/2022]
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Continuity of care and multimorbidity in the 50+ Swiss population: An analysis of claims data. SSM Popul Health 2022; 17:101063. [PMID: 35308585 PMCID: PMC8928125 DOI: 10.1016/j.ssmph.2022.101063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 11/20/2022] Open
Abstract
Objective To assess the relationship between continuity of care (COC) and multimorbidity in the older general population in Switzerland, accounting for relevant determinants of COC, and to apply various expressions of multimorbidity derived from claims data. Methods We used data on 240′000 insured individuals aged 50+ for the period 2015–2018, received from one of the largest Swiss health insurance company. We calculated Bice-Boxerman index based on all doctor visits (overall COC) and visits to the general practitioners (COC GP). We analyzed the relationship between COC and multimorbidity using generalized linear and probit models. To express multimorbidity, we applied three approaches based on pharmacy-cost groups (PCGs) assigned to an individual. First, we used simple PCG counts. Second, we expressed multimorbidity via clinically relevant disease groups derived from PCGs. Finally, a data-driven approach allowed defining distinct clusters representing different patient complexities. Results The association between overall COC and multimorbidity expressed in PCG counts was modest: COC among individuals with 3+ PCGs was 2 percentage points higher than COC among individuals with 0 PCGs. The approach of clinically relevant disease groups showed larger variation in COC and its association with multimorbidity. The data-driven approach showed that most complex (“high-cost high-need”) individuals tended to have higher overall COC. Additionally, 70% of the sample visited exclusively one general practitioner (COC GP = 1.0). Other important factors associated with COC in the Swiss context were insurance model with gatekeeping, level of deductibles, and region of residence. Conclusions Multimorbid patients require regular medical attention often involving multiple healthcare providers, which can lead to varying COC, depending on types of doctors seen and specific condition of the patient. Insurance models with gatekeeping may facilitate COC, prompting developments of better-designed models of care. This represents important implications for policymakers, health insurance representatives, medical professionals and hospital managers. We investigated the relationship between multimorbidity and COC, using claims-based data. We applied three approaches of expressing multimorbidity in claims data: simple counts, expert-based and data-driven. Association between COC and multimorbidity expressed in simple counts was modest, while expert-based approach showed larger heterogeneity. Data-driven approach revealed that most complex individuals tended to have higher COC.
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Rasendran C, Imran Y, Talcott KE. Incremental Economic Burden of Depression in Ophthalmic Patients. Am J Ophthalmol 2021; 229:184-193. [PMID: 33845017 DOI: 10.1016/j.ajo.2021.03.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 03/27/2021] [Accepted: 03/28/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE We sought to analyze the incremental economic burden of depression on adults with concurrent ophthalmic conditions in the United States. DESIGN Retrospective cross-sectional study. METHODS Using the Medical Expenditure Panel Survey from 2016 to 2018, ophthalmic patients with ≥1 outpatient visit were identified by International Classification of Diseases, 10th revision, Clinical Modification codes and stratified based on the presence of concurrent depression. A multivariate 2-part regression model was used to determine incremental economic burden, health care sector utilization, and expenditures. RESULTS Of 7279 ophthalmic patients, 1123 (15.43%) were diagnosed with depression (mean expenditures $17,017.25 ± $2019.13) and 6156 patients (84.57%) without depression (mean expenditures $9924.50 ± $692.94). Patients with depression were more likely to be female, white, lower income, use Medicare/Medicaid, and to have comorbidities (P < .001). These patients faced $5894.86 (95% confidence interval $4222.33-$7348.36, P < .001) in incremental economic expenditures because of depression, resulting in an additional $22.4 billion annually when extrapolating nationally. These patients had higher utilization for all health care service sectors (P < .025 for all) and higher expenditures for outpatient (P = .022) and prescription medications (P = .029) when adjusted for sociodemographic variables and comorbidities. Depression was responsible for 6.9% of inpatient admissions (the second-leading cause) for this cohort of patients. CONCLUSION Ophthalmic patients with depression had a higher incremental economic burden and health care service sector utilization and expenditures. Patients with ophthalmic pathologies, including dry eye syndrome, blindness, and retinopathies, were more likely to be depressed. As psychiatric and ophthalmic conditions may have a bidirectional relationship, exacerbating disease severity and financial burden for patients with both, ophthalmologists may need to be more cognizant of the burden of depression among patients.
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Goodwin JS, Li S, Hommel E, Nattinger AB, Kuo YF, Raji M. Association of Inpatient Continuity of Care With Complications and Length of Stay Among Hospitalized Medicare Enrollees. JAMA Netw Open 2021; 4:e2120622. [PMID: 34383060 PMCID: PMC9026593 DOI: 10.1001/jamanetworkopen.2021.20622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Continuity in primary care is associated with improved outcomes, but less information is available on the association of continuity of care in the hospital with hospital complications. OBJECTIVE To assess whether the number of hospitalists providing care is associated with subsequent hospital complications and length of stay. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used multilevel logistic regression models to analyze Medicare claims for medical admissions from 2016 to 2018 with a length of stay longer than 4 days. Admissions with multiple charges on the same day from a hospitalist or an intensive care unit (ICU) stay during hospital days 1 to 3 were excluded. The data were accessed and analyzed from November 1, 2020, to April 30, 2021. EXPOSURES The number of different hospitalists who submitted charges during hospital days 1 to 3. MAIN OUTCOMES AND MEASURES Overall length of stay and transfer to ICU or a new diagnosis of drug toxic effects on hospital day 4 or later. RESULTS Among the 617 680 admissions, 362 376 (58.7%) were women, with a mean (SD) age of 80.2 (8.4) years. In 306 037 admissions (49.6%), the same hospitalist provided care on days 1 to 3, while 2 hospitalists provided care in 274 658 admissions (44.5%), and 3 hospitalists provided care in 36 985 admissions (6.0%). There was no significant association between the number of different hospitalists on days 1 to 3 and either length of stay or subsequent ICU transfers. Admissions seeing 2 or 3 hospitalists had a slightly greater adjusted odds of subsequent new diagnoses of drug toxic effects (2 hospitalists: odds ratio [OR], 1.04; 95% CI, 1.02-1.07; 3 hospitalists: OR, 1.07; 95% CI, 1.03-1.12). CONCLUSIONS AND RELEVANCE There was little evidence that receiving care from multiple hospitalists was associated with worse outcomes for patients receiving all their general medical care from hospitalists.
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Affiliation(s)
- James S Goodwin
- Sealy Center on Aging, Departments of Internal Medicine and Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston
| | - Shuang Li
- Sealy Center on Aging, Departments of Internal Medicine and Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston
| | - Erin Hommel
- Sealy Center on Aging, Departments of Internal Medicine and Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston
| | - Ann B Nattinger
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Yong-Fang Kuo
- Sealy Center on Aging, Departments of Internal Medicine and Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston
| | - Mukaila Raji
- Sealy Center on Aging, Departments of Internal Medicine and Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston
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Goodwin JS, Li S, Zhou J, Kuo YF, Nattinger A. Variation among hospitals in the continuity of care for older hospitalized patients: a cross-sectional cohort study. BMC Health Serv Res 2021; 21:552. [PMID: 34090431 PMCID: PMC8180074 DOI: 10.1186/s12913-021-06584-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/27/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Little is known about how continuity of care for hospitalized patients varies among hospitals. We describe the number of different general internal medicine physicians seeing hospitalized patients during a medical admission and how that varies by hospital. METHODS We conducted a retrospective study of a national 20% sample of Medicare inpatients from 01/01/16 to 12/31/18. In patients with routine medical admissions (length of stay of 3-6 days, no Intensive Care Unit stay, and seen by only one generalist per day), we assessed odds of receiving all generalist care from one generalist. We calculated rates for each hospital, adjusting for patient and hospital characteristics in a multi-level logistic regression model. RESULTS Among routine medical admissions with 3- to 6-day stays, only 43.1% received all their generalist care from the same physician. In those with a 3-day stay, 50.1% had one generalist providing care vs. 30.8% in those with a 6-day stay. In a two-level (admission and hospital) logistic regression model controlling for patient characteristics and length of stay, the odds of seeing just one generalist did not vary greatly by patient characteristics such as age, race/ethnicity, comorbidity or reason for admission. There were large variations in continuity of care among different hospitals and geographic areas. In the highest decile of hospitals, the adjusted mean percentage of patients receiving all generalist care from one physician was > 84.1%, vs. < 24.1% in the lowest decile. This large degree of variation persisted when hospitals were stratified by size, ownership, location or teaching status. CONCLUSIONS Continuity of care provided by generalist physicians to medical inpatients varies widely among hospitals. The impact of this variation on quality of care is unknown.
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Affiliation(s)
- James S. Goodwin
- Sealy Center on Aging, University of Texas Medical Branch, University Blvd, Galveston, TX 77555-0177 USA
| | - Shuang Li
- Sealy Center on Aging, University of Texas Medical Branch, University Blvd, Galveston, TX 77555-0177 USA
| | - Jie Zhou
- Sealy Center on Aging, University of Texas Medical Branch, University Blvd, Galveston, TX 77555-0177 USA
| | - Yong-Fang Kuo
- Sealy Center on Aging, University of Texas Medical Branch, University Blvd, Galveston, TX 77555-0177 USA
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Affiliation(s)
- James S Goodwin
- Sealy Center on Aging, The University of Texas Medical Branch at Galveston
- Department of Medicine, The University of Texas Medical Branch at Galveston
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12
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Flugelman MY, Jaffe R, Luria G, Yagil D. Trust in the referring physician reduces anxiety in an integrated community-to-hospital care system. Isr J Health Policy Res 2020; 9:7. [PMID: 32393391 PMCID: PMC7216639 DOI: 10.1186/s13584-020-00365-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 02/10/2020] [Indexed: 11/26/2022] Open
Abstract
Background Continuity of care between the community and hospital is considered of prime importance for quality of care and patient satisfaction, and for trust in the medical system. In a unique model of continuity of care, cardiologists at our hospital serve as primary, community-based cardiologists one day a week. They refer patients from the community to our hospital for interventional procedures such as coronary angiography and angioplasty. We examined the hypotheses that patient anxiety during hospital-based coronary angiography is lower when a patient trusts the referring cardiologist and when the performing cardiologist also treated him/her in the community. Methods We administered questionnaires to 64 patients in our cardiology department within 90 min of completion of coronary angiography. The questions assessed anxiety, trust in the medical system and trust in the referring physician. Data were also collected regarding patients’ demographic variables, the number of visits to the referring physician, and whether the physician who performed the coronary angiography was the physician who referred the patient to the hospital. Results Mean levels (on 7-point Likert scales) were 2.1, 5.6 and 6.7 for patient anxiety, trust in the medical system and trust in the referring physician, respectively. Multivariate regression analysis showed that trust in the referring physician was significantly and negatively correlated with anxiety level. The number of visits to referring physicians, patients’ demographic characteristics and whether the physician who performed the angiography was the same physician who referred the patient from the community were not found to be associated with patient anxiety. Conclusion In this study, trusting the referring physician was associated with lower anxiety among patients who underwent coronary angiography. This trust seemed to have more positive impact than did previous contact with the physician who performed the procedure.
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Affiliation(s)
- Moshe Y Flugelman
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal Street, 34632, Haifa, Israel. .,Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
| | - Ronen Jaffe
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal Street, 34632, Haifa, Israel.,Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Gil Luria
- Department of Human Services, University of Haifa, Haifa, Israel
| | - Dana Yagil
- Department of Human Services, University of Haifa, Haifa, Israel
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Goodwin JS, Li S, Kuo YF. Association of the Work Schedules of Hospitalists With Patient Outcomes of Hospitalization. JAMA Intern Med 2020; 180:215-222. [PMID: 31764937 PMCID: PMC6902197 DOI: 10.1001/jamainternmed.2019.5193] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The working schedules of hospitalists vary widely. Discontinuous schedules, such as 24 hours on and 48 hours off, result in several hospitalists providing care during a patient's hospital stay. Poor continuity of care during hospitalization may be associated with poor patient outcomes. OBJECTIVE To determine whether admitted patients receiving care from hospitalists with more discontinuous schedules experience worse outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used conditional models to assess Medicare claims data for 114 777 medical admissions of patients with a 3-day to 6-day length of stay from January 1, 2014, through November 30, 2016, who received all general medical care from hospitalists in 229 hospitals in Texas. Data were analyzed from November 2018 to June 2019. EXPOSURES For each admission, the weighted mean of schedule continuity for the treating hospitalists, assessed as the percentage of all their working days in that year that were part of a block of 7 or more consecutive working days, was calculated. MAIN OUTCOMES AND MEASURES The primary outcome was patient mortality in the 30 days after discharge. Secondary outcomes were readmission rates and Medicare costs in the 30 days after discharge, and discharge destination. RESULTS Of the 114 777 patient admissions, the mean (SD) age was 79.9 (8.3) years, and 70 047 (61.0%) were women. For admissions in the lowest quartile for continuity of hospitalist schedules, the hospitalists providing care worked 0% to 30% of their total working days as part of a block of 7 or more consecutive days vs 67% to 100% for hospitalists providing care for patients in the highest quartile for continuity. Patient characteristics were not associated with the continuity of working schedules for the hospitalist(s) providing care. In conditional logistic regression models, admitted patients cared for by hospitalists in the highest quartile of schedule continuity (vs the lowest quartile) had lower 30-day mortality after discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.81-0.95), lower readmission rates (aOR, 0.94; 95% CI, 0.90-0.99), higher rates of discharge to the home (aOR, 1.08; 95% CI, 1.03-1.13), and lower 30-day postdischarge costs (-$223; 95% CI, -$441 to -$7). The results were similar across a range of different methods for defining continuity of hospitalist schedules and selecting the cohort. CONCLUSIONS AND RELEVANCE Hospitalist schedules vary widely. Admitted patients receiving care from hospitalists with schedules that promote inpatient continuity of care may experience better outcomes of hospitalization.
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Affiliation(s)
- James S Goodwin
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch at Galveston.,Sealy Center on Aging, The University of Texas Medical Branch at Galveston.,Department of Internal Medicine, The University of Texas Medical Branch at Galveston
| | - Shuang Li
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch at Galveston.,Sealy Center on Aging, The University of Texas Medical Branch at Galveston
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch at Galveston.,Sealy Center on Aging, The University of Texas Medical Branch at Galveston
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14
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Reilly BM. Preexisting Conditions. N Engl J Med 2019; 381:1586-1589. [PMID: 31618547 DOI: 10.1056/nejmms1904668] [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] [Indexed: 11/19/2022]
Affiliation(s)
- Brendan M Reilly
- From the Geisel School of Medicine, Dartmouth College, Hanover, NH
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15
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Lee JH, Kim AJ, Kyong TY, Jang JH, Park J, Lee JH, Lee MJ, Kim JS, Suh YJ, Kwon SR, Kim CW. Evaluating the Outcome of Multi-Morbid Patients Cared for by Hospitalists: a Report of Integrated Medical Model in Korea. J Korean Med Sci 2019; 34:e179. [PMID: 31243937 PMCID: PMC6597483 DOI: 10.3346/jkms.2019.34.e179] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/06/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The lack of medical personnel has led to the employment of hospitalists in Korean hospitals to provide high-quality medical care. However, whether hospitalists' care can improve patients' outcomes remains unclear. We aimed to analyze the outcome in patients cared for by hospitalists. METHODS A retrospective review was conducted in 1,015 patients diagnosed with pneumonia or urinary tract infection from March 2017 to July 2018. After excluding 306 patients, 709 in the general ward who were admitted via the emergency department were enrolled, including 169 and 540 who were cared for by hospitalists (HGs) and non-hospitalists (NHGs), respectively. We compared the length of hospital stay (LOS), in-hospital mortality, readmission rate, comorbidity, and disease severity between the two groups. Comorbidities were analyzed using Charlson comorbidity index (CCI). RESULTS HG LOS (median, interquartile range [IQR], 8 [5-12] days) was lower than NHG LOS (median [IQR], 10 [7-15] days), (P < 0.001). Of the 30 (4.2%) patients who died during their hospital stay, a lower percentage of HG patients (2.4%) than that of NHG patients (4.8%) died, but the difference between the two groups was not significant (P = 0.170). In a subgroup analysis, HG LOS was shorter than NHG LOS (median [IQR], 8 [5-12] vs. 10 [7-16] days, respectively, P < 0.001) with CCI of ≥ 5 points. CONCLUSION Hospitalist care can improve the LOS of patients, especially those with multiple comorbidities. Further studies are warranted to evaluate the impact of hospitalist care in Korea.
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Affiliation(s)
- Jung Hwan Lee
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Ah Jin Kim
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea.
| | - Tae Young Kyong
- Department of Hospital Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hun Jang
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jeongmi Park
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jeong Hoon Lee
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Man Jong Lee
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jung Soo Kim
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Young Ju Suh
- Department of Biomedical Sciences, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Seong Ryul Kwon
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Cheol Woo Kim
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
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16
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Yun JY, Kim KH, Joo GJ, Kim BN, Roh MS, Shin MS. Changing characteristics of the empathic communication network after empathy-enhancement program for medical students. Sci Rep 2018; 8:15092. [PMID: 30305683 PMCID: PMC6180138 DOI: 10.1038/s41598-018-33501-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 10/01/2018] [Indexed: 12/29/2022] Open
Abstract
The Empathy-Enhancement Program for Medical Students (EEPMS) comprises five consecutive weekly sessions and aims to improve medical students' empathic ability, an essential component of humanistic medical professionalism. Using a graph theory approach for the Ising network (based on l1-regularized logistic regression) comprising emotional regulation, empathic understanding of others' emotion, and emotional expressivity, this study aimed to identify the central components or hubs of empathic communication and the changed profile of integration among these hubs after the EEPMS. Forty medical students participated in the EEPMS and completed the Depression Anxiety Stress Scale-21, the Empathy Quotient-Short Form, the Jefferson Scale of Empathy, and the Emotional Expressiveness Scale at baseline and after the EEPMS. The Ising model-based network of empathic communication was retrieved separately at two time points. Agitation, self-efficacy for predicting others' feelings, emotional concealment, active emotional expression, and emotional leakage ranked in the top 20% in terms of nodal strength and betweenness and closeness centralities, and they became hubs. After the EEPMS, the 'intentional emotional expressivity' component became less locally segregated (P = 0.014) and more directly integrated into those five hubs. This study shows how to quantitatively describe the qualitative item-level effects of the EEPMS. The key role of agitation in the network highlights the importance of stress management in preserving the capacity for empathic communication. The training effect of EEPMS, shown by the reduced local segregation and enhanced integration of 'intentional emotional expressivity' with hubs, suggests that the EEPMS could enable medical students to develop competency in emotional expression, which is an essential component of empathic communication.
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Affiliation(s)
- Je-Yeon Yun
- Yeongeon Student Support Centre, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Seoul National University Hospital, Seoul, Republic of Korea.
| | - Kyoung Hee Kim
- Yeongeon Student Support Centre, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Geum Jae Joo
- Yeongeon Student Support Centre, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bung Nyun Kim
- Department of Psychiatry and Behavioural Science, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myoung-Sun Roh
- Department of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Min-Sup Shin
- Department of Psychiatry and Behavioural Science, Seoul National University College of Medicine, Seoul, Republic of Korea
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17
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Xiao R, Miller JA, Zafirau WJ, Gorodeski EZ, Young JB. Impact of Home Health Care on Health Care Resource Utilization Following Hospital Discharge: A Cohort Study. Am J Med 2018; 131:395-407.e35. [PMID: 29180024 DOI: 10.1016/j.amjmed.2017.11.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/04/2017] [Accepted: 11/09/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND As healthcare costs rise, home health care represents an opportunity to reduce preventable adverse events and costs following hospital discharge. No studies have investigated the utility of home health care within the context of a large and diverse patient population. METHODS A retrospective cohort study was conducted between 1/1/2013 and 6/30/2015 at a single tertiary care institution to assess healthcare utilization after discharge with home health care. Control patients discharged with "self-care" were matched by propensity score to home health care patients. The primary outcome was total healthcare costs in the 365-day post-discharge period. Secondary outcomes included follow-up readmission and death. Multivariable linear and Cox proportional hazards regression were used to adjust for covariates. RESULTS Among 64,541 total patients, 11,266 controls were matched to 6,363 home health care patients across 11 disease-based Institutes. During the 365-day post-discharge period, home health care was associated with a mean unadjusted savings of $15,233 per patient, or $6,433 after adjusting for covariates (p < 0.0001). Home health care independently decreased the hazard of follow-up readmission (HR 0.82, p < 0.0001) and death (HR 0.80, p < 0.0001). Subgroup analyses revealed that home health care most benefited patients discharged from the Digestive Disease (death HR 0.72, p < 0.01), Heart & Vascular (adjusted savings of $11,453, p < 0.0001), Medicine (readmission HR 0.71, p < 0.0001), and Neurological (readmission HR 0.67, p < 0.0001) Institutes. CONCLUSIONS Discharge with home health care was associated with significant reduction in healthcare utilization and decreased hazard of readmission and death. These data inform development of value-based care plans.
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Affiliation(s)
- Roy Xiao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Ohio
| | - Jacob A Miller
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Ohio
| | | | | | - James B Young
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Ohio.
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Karsanji DJ, Pannu N, Manns BJ, Hemmelgarn BR, Tan Z, Jindal K, Scott-Douglas N, James MT. Disparity between Nephrologists' Opinions and Contemporary Practices for Community Follow-Up after AKI Hospitalization. Clin J Am Soc Nephrol 2017; 12:1753-1761. [PMID: 29025786 PMCID: PMC5672966 DOI: 10.2215/cjn.01450217] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 07/21/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Recent guidelines suggest that patients should be evaluated after AKI for resolution versus progression of CKD. There is uncertainty as to the role of nephrologists in this process. The objective of this study was to compare the follow-up recommendations from nephrologists with contemporary processes of care for varying scenarios of patients hospitalized with AKI. DESIGN, SETTING PARTICIPANTS, & MEASUREMENTS We surveyed Canadian nephrologists using a series of clinical vignettes of patients hospitalized with severe AKI and asked them to rank their likelihood of recommending follow-up for each patient after hospital discharge. We compared these responses with administrative health data on rates of community follow-up with nephrologists for patients hospitalized with AKI in Alberta, Canada between 2005 and 2014. RESULTS One hundred forty-five nephrologists participated in the survey (46% of the physician membership of the Canadian Society of Nephrology). Nephrologists surveyed indicated that they would definitely or probably re-evaluate patients in 87% of the scenarios provided, with a higher likelihood of follow-up for patients with a history of preexisting CKD (89%), heart failure (92%), receipt of acute dialysis (91%), and less complete recovery of kidney function (98%). In contrast, only 24% of patients with similar characteristics were seen by a nephrologist in Alberta within 1 year after a hospitalization with AKI, with a trend toward lower rates of follow-up over more recent years of the study. Follow-up with a nephrologist was significantly less common among patients over the age of 80 years old (20%) and more common among patients with preexisting CKD (43%) or a nephrology consultation before or during AKI hospitalization (78% and 41%, respectively). CONCLUSIONS There is a substantial disparity between the opinions of nephrologists and actual processes of care for nephrology evaluation of patients after hospitalization with severe AKI.
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Affiliation(s)
| | - Neesh Pannu
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Braden J. Manns
- Division of Nephrology, Department of Medicine
- Department of Community Health Sciences
- O’Brien Institute for Public Health, and
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; and
| | - Brenda R. Hemmelgarn
- Division of Nephrology, Department of Medicine
- Department of Community Health Sciences
- O’Brien Institute for Public Health, and
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; and
| | - Zhi Tan
- Division of Nephrology, Department of Medicine
| | - Kailash Jindal
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nairne Scott-Douglas
- Division of Nephrology, Department of Medicine
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; and
| | - Matthew T. James
- Division of Nephrology, Department of Medicine
- Department of Community Health Sciences
- O’Brien Institute for Public Health, and
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; and
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19
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Kuo YF, Adhikari D, Eke CG, Goodwin JS, Raji MA. Processes and Outcomes of Congestive Heart Failure Care by Different Types of Primary Care Models. J Card Fail 2017; 24:9-18. [PMID: 28870732 DOI: 10.1016/j.cardfail.2017.08.459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 08/10/2017] [Accepted: 08/25/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Having nurse practitioners (NPs) as primary care providers for patients with congestive heart failure (CHF) is 1 way to address the growing shortage of primary care physicians (PCPs). METHODS AND RESULTS We used inverse probability of treatment weighted with propensity score to examine the processes and outcomes of care for patients under 3 care models. Approximately 72.9%, 0.8%, and 26.3% of CHF patients received care under the PCP model, the NP model, and the shared care model, respectively. Patients under the NP or shared care models were more likely than those under the PCP model to be referred to cardiologists (odds ratio 1.35, 95% confidence interval 1.32-1.37; odds ratio 1.32, 95% confidence interval 1.30-1.35) and to get guideline-recommended medications. NPs and PCPs had similar rates of emergency room (ER) visits and Medicare spending after adjusting for processes of care. Patients under the shared care model had a higher burden of comorbidity and experienced a higher rate of ER visits and hospitalizations than those under the PCP model. CONCLUSION The delivery of CHF care mirrors the severity of comorbidity in these patients. The high rate of hospitalization and ER visits in the shared care model underscores the need to design and implement more effective chronic disease management and integrated care programs.
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Affiliation(s)
- Yong-Fang Kuo
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas; Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas.
| | - Deepak Adhikari
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Chiemeziem G Eke
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - James S Goodwin
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas; Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A Raji
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
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Santamaría-García H, Baez S, García AM, Flichtentrei D, Prats M, Mastandueno R, Sigman M, Matallana D, Cetkovich M, Ibáñez A. Empathy for others' suffering and its mediators in mental health professionals. Sci Rep 2017; 7:6391. [PMID: 28743987 PMCID: PMC5527046 DOI: 10.1038/s41598-017-06775-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/16/2017] [Indexed: 12/30/2022] Open
Abstract
Empathy is a complex cognitive and affective process that allows humans to experience concern for others, comprehend their emotions, and eventually help them. In addition to studies with healthy subjects and various neuropsychiatric populations, a few reports have examined this domain focusing on mental health workers, whose daily work requires the development of a saliently empathic character. Building on this research line, the present population-based study aimed to (a) assess different dimensions of empathy for pain in mental health workers relative to general-physicians and non-medical workers; and (b) evaluate their relationship with relevant factors, such as moral profile, age, gender, years of experience, and workplace type. Relative to both control groups, mental health workers exhibited higher empathic concern and discomfort for others' suffering, and they favored harsher punishment to harmful actions. Furthermore, this was the only group in which empathy variability was explained by moral judgments, years of experience, and workplace type. Taken together, these results indicate that empathy is continuously at stake in mental health care scenarios, as it can be affected by contextual factors and social contingencies. More generally, they highlight the importance of studying this domain in populations characterized by extreme empathic demands.
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Affiliation(s)
- Hernando Santamaría-García
- Centro de Memoria y Cognición Intellectus, Hospital Universitario San Ignacio, Bogotá, Colombia
- Pontificia Universidad Javeriana, Psychiatry and Physiology Department, Bogotá, Colombia
- Grupo de Investigación Cerebro y Cognición Social, Bogotá, Colombia
- Laboratory of Experimental Psychology and Neuroscience (LPEN), Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Sandra Baez
- Grupo de Investigación Cerebro y Cognición Social, Bogotá, Colombia
- Laboratory of Experimental Psychology and Neuroscience (LPEN), Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
- Departamento de Psicología, Universidad de los Andes, Bogotá, Colombia
| | - Adolfo M García
- Laboratory of Experimental Psychology and Neuroscience (LPEN), Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
- Faculty of Education, National University of Cuyo (UNCuyo), Mendoza, Argentina
| | | | - María Prats
- IntramedPortal www.intramed.net, Buenos Aires, CABA, Argentina
| | | | - Mariano Sigman
- Universidad Torcuato di Tella, Laboratorio de Neurociencias, Buenos, Aires, Argentina
| | - Diana Matallana
- Centro de Memoria y Cognición Intellectus, Hospital Universitario San Ignacio, Bogotá, Colombia
- Pontificia Universidad Javeriana, Aging Institute Bogotá, Bogotá, Colombia
| | - Marcelo Cetkovich
- Laboratory of Experimental Psychology and Neuroscience (LPEN), Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Agustín Ibáñez
- Laboratory of Experimental Psychology and Neuroscience (LPEN), Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina.
- National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina.
- Universidad Autónoma del Caribe, Barranquilla, Colombia.
- Center for Social and Cognitive Neuroscience (CSCN), School of Psychology, Universidad Adolfo Ibáñez, Santiago de Chile, Chile.
- Australian Research Council Centre of Excellence in Cognition and its Disorders, Sydney, Australia.
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Huang HH, Chen CY, Tsay JH, Chou YJ, Huang N. Factors in Maintaining a Stable Patient-Physician Relationship among Individuals with Schizophrenia. Community Ment Health J 2017; 53:578-588. [PMID: 28281097 DOI: 10.1007/s10597-017-0123-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 02/20/2017] [Indexed: 10/20/2022]
Abstract
This study aimed to determine whether adequate continuity of care (COC) existed among individuals with schizophrenia, and what the associated determinants were. The National Health Insurance Research Database of Taiwan was used to identify individuals with newly diagnosed schizophrenia from 2000 to 2009. Two outcome indicators were first derived to conduct the continuity assessment based on the usual provider continuity (UPC) index and the continuity of care index (COCI). The average scores of the UPC and COCI were 0.78 and 0.67, respectively. Patients who have been hospitalized, with lower income, and unemployed had significantly poorer continuity of care. In addition, patients were cared for by higher caseload physicians, treated at mental health specialty institutions, and at hospital outpatient settings also experienced significantly poorer continuity. Patients cared for by middle-aged physicians, psychiatrists, and treated at private institutions had significantly better continuity of mental health care.
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Affiliation(s)
- Hsin-Hui Huang
- Institute of Public Health, National Yang Ming University, No.155, Sec. 2, Linong St., Beitou Dist., Taipei City, 112, Taiwan, Republic of China
| | - Chuan-Yu Chen
- Institute of Public Health, National Yang Ming University, No.155, Sec. 2, Linong St., Beitou Dist., Taipei City, 112, Taiwan, Republic of China
| | - Jen-Huoy Tsay
- Department of Social Work, National Taiwan University, No.1, Sec. 4, Roosevelt Rd., Da'an Dist., Taipei City, 106, Taiwan, Republic of China
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang Ming University, No.155, Sec. 2, Linong St., Beitou Dist., Taipei City, 112, Taiwan, Republic of China
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming University, Room 201, The Medical Building II, No.155, Section 2, Li-Nong Street, Taipei, 112, Taiwan, Republic of China.
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Doohan N, DeVoe J. The Chief Primary Care Medical Officer: Restoring Continuity. Ann Fam Med 2017; 15:366-371. [PMID: 28694275 PMCID: PMC5505458 DOI: 10.1370/afm.2078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/17/2017] [Accepted: 02/08/2017] [Indexed: 11/09/2022] Open
Abstract
The year 2016 marked the 20th anniversary of the hospitalist profession, with more than 50,000 physicians identifying as hospitalists. The Achilles heel of hospitalist medicine, however, is discontinuity. Despite many current payment and delivery systems rewarding this discontinuity and severing long-term relationships between patient and primary care teams at the hospital door, primary care does not stop being important when a person is admitted to the hospital. The notion of a broken primary care continuum is not an academic construct, it causes real harm to patients. As a step toward fixing the discontinuity in our health care systems, we propose that every hospital needs a Chief Primary Care Medical Officer (CPCMO), an expert in practice across the spectrum of care. The CPCMO can lead hospital efforts to create systems that ensure primary care's continuum is complete, while strengthening physician collaboration across specialties, and moving toward achieving the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers. For hospitals operating on value-based payment structures, anticipated improvement in measurable outcomes such as decreased length of stay, decreased readmission rates, improved transitions of care, improved patient satisfaction, improved access to primary care, and improved patient health, will enhance the rate of return on the hospital's investment. The speciality of family medicine should reevaluate our purpose, and reembrace our mission as personal physicians by championing the creation of Chief Primary Care Medical Officers.
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Affiliation(s)
- Noemi Doohan
- Department of Family and Community Medicine, University of California Davis, Sacramento, California
| | - Jennifer DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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Ankuda CK, Mitchell SL, Gozalo P, Mor V, Meltzer D, Teno JM. Association of Physician Specialty with Hospice Referral for Hospitalized Nursing Home Patients with Advanced Dementia. J Am Geriatr Soc 2017; 65:1784-1788. [PMID: 28369754 DOI: 10.1111/jgs.14888] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Hospitalists hospice referral patterns have been unstudied. This study aims to examine hospice referral rates by attending type for hospitalized nursing home (NH) residents with advanced cognitive impairment (ACI) at the time of discharge between 2000 and 2010. DESIGN Retrospective cohort study. PARTICIPANTS Hospitalized NH residents age ≥66 drawn from the 20% sample of Medicare beneficiaries with ACI, 4 or more activities of daily living (ADL) impairments on last minimum data set (MDS) assessment completed within 120 days of admission (n = 128,989). MEASUREMENTS Hospice referral was defined as referral to hospice within 1 day after hospital discharge. Attending physician type was determined by Part B physician billing for 100% of the billings during that admission. Continuity of care was defined as the hospital physician also billing for an outpatient visit within 120 days of that hospital admission. Number of ADL impairments, cognitive measures, pre-admission illnesses and illness severity were derived from the MDS. RESULTS Of the 105,329 hospitalized patients with ACI that survived to discharge (72.3% white, 30.6% male), the hospice referral rate at the time of hospital discharge increased from 2.8% in 2000 to 11.2% in 2010. Using a multivariate, hospital fixed effects model examining changes in the distribution of inpatient attending physicians, hospitalists compared to generalist physicians were more likely to refer these patients to hospice at discharge (AOR 1.17, 95% CI 1.09-1.26). Continuity of physician care from the outpatient setting to the hospital was associated with lower hospice referral (AOR 0.78, 95% CI 0.73-0.85). CONCLUSION Hospice referrals for NH-dwelling persons with ACI admitted to the hospital increased between 2000 and 2011 and disproportionately so when the attending physician was a hospitalist.
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Affiliation(s)
- Claire K Ankuda
- Robert Wood Johnson Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Susan L Mitchell
- Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts
| | - Pedro Gozalo
- Health Services, Policy, and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Vince Mor
- Health Services, Policy, and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island.,Veterans Administration Medical Center, Providence, Rhode Island
| | - David Meltzer
- Section of Hospital Medicine, University of Chicago, Chicago, Illinois
| | - Joan M Teno
- Division of Gerontology and Geriatric Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
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Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients' experience with hospitalist service handovers. J Hosp Med 2016; 11:675-681. [PMID: 27167097 DOI: 10.1002/jhm.2608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 04/04/2016] [Accepted: 04/18/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Inpatient service handoffs occur when physicians who care for hospitalized patients end a period of clinical service and handover a panel of patients to an oncoming physician. Despite the large amount of research on handoffs, none has described the patient perspective when cared for by a hospitalist physician during a service handoff. OBJECTIVE To describe hospitalized patients' experiences regarding inpatient service changes, and develop a conceptual framework to inform future efforts to improve service-level handoffs. METHODS Interview-based qualitative analysis using in-depth, semistructured interviews of hospitalized patients on a nonteaching hospitalist service. Patients were interviewed between October 2014 and December 2014 at an academic medical center whose inpatient stay spanned a weekly service change. We utilized an inductive approach with no a priori hypotheses and used a constant comparative method to generate emerging themes to develop a conceptual model that captured the patient experience during the transition. RESULTS Of patients who agreed to participate (40/43), most (85%) were unaware that a transition had occurred between their hospitalists. Six major themes emerged related to patients' experiences with hospitalist service handoffs: (1) importance of physician-patient communication, (2) desire for transparency in transitions, (3) an indifference toward transitions, (4) importance of hospitalist-specialist communication, (5) formation of new opportunities from a transition, and (6) effects of bedside manner. CONCLUSIONS Hospitalized patients desire improved communication and a more formalized transition process between hospitalists during service handoffs. Hospitalists should recognize that this transition may represent an opportunity to improve the hospitalized patient's experience and satisfaction. Journal of Hospital Medicine 2016;11:675-681. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Charlie M Wray
- Section of Hospital Medicine, University of Chicago Medical Center, Chicago, Illinois.
| | - Jeanne M Farnan
- Section of Hospital Medicine, University of Chicago Medical Center, Chicago, Illinois
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Vineet M Arora
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
- Section of General Internal Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - David O Meltzer
- Section of Hospital Medicine, University of Chicago Medical Center, Chicago, Illinois
- Department of Economics, University of Chicago, Chicago, Illinois
- Harris School of Public Policy Studies, University of Chicago, Chicago, Illinois
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25
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Bracco MM, Mafra ACCN, Abdo AH, Colugnati FAB, Dalla MDB, Demarzo MMP, Abrahamsohn I, Rodrigues AP, Delgado AVFDA, Dos Prazeres GA, Teixeira JC, Possa S. Implementation of integration strategies between primary care units and a regional general hospital in Brazil to update and connect health care professionals: a quasi-experimental study protocol. BMC Health Serv Res 2016; 16:380. [PMID: 27519520 PMCID: PMC4983016 DOI: 10.1186/s12913-016-1626-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 08/03/2016] [Indexed: 11/24/2022] Open
Abstract
Background Better communication among field health care teams and points of care, together with investments focused on improving teamwork, individual management, and clinical skills, are strategies for achieving better outcomes in patient-oriented care. This research aims to implement and evaluate interventions focused on improving communication and knowledge among health teams based on points of care in a regional public health outreach network, assessing the following hypotheses: 1) A better-working communication process between hospitals and primary health care providers can improve the sharing of information on patients as well as patients’ outcomes. 2) A skill-upgrading education tool offered to health providers at their work sites can improve patients’ care and outcomes. Methods/Design A quasi-experimental study protocol with a mixed-methods approach (quantitative and qualitative) was developed to evaluate communication tools for health care professionals based in primary care units and in a general hospital in the southern region of São Paulo City, Brazil. The usefulness and implementation processes of the integration strategies will be evaluated, considering: 1) An Internet-based communication platform that facilitates continuity and integrality of care to patients, and 2) A tailored updating distance-learning course on ambulatory care sensitive conditions for clinical skills improvements. The observational study will evaluate a non-randomized cohort of adult patients, with historical controls. Hospitalized patients diagnosed with an ambulatory care sensitive condition will be selected and followed for 1 year after hospital discharge. Data will be collected using validated questionnaires and from patients’ medical records. Health care professionals will be evaluated related to their use of education and communication tools and their demographic and psychological profiles. The primary outcome measured will be the patients’ 30-day hospital readmission rates. A sample size of 560 patients was calculated to fit a valid logistic model. In addition, qualitative approaches will be used to identify subjective perceptions of providers about the implementation process and of patients about health system use. Discussion This research project will gather relevant information about implementation processes for education and communication tools and their impact on human resources training, rates of readmission, and patient-related outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1626-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mario Maia Bracco
- Hospital Municipal Dr. Moysés Deutsch, M'Boi Mirim, São Paulo, Brazil. .,Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Ana Carolina Cintra Nunes Mafra
- Hospital Municipal Dr. Moysés Deutsch, M'Boi Mirim, São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alexandre Hannud Abdo
- School of Medicine, University of São Paulo, São Paulo, Brazil.,Garoa Hacker Club, São Paulo, Brazil
| | | | - Marcello Dala Bernardina Dalla
- Secretariat of Health of Espírito Santo State, Espírito Santo, Brazil.,Superior School of Sciences of Santa Casa de Misericórdia of Vitória - EMESCAM, Vitória, Brazil
| | | | | | | | | | | | | | - Silvio Possa
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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26
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Meijer LJ, de Groot E, Blaauw-Westerlaken M, Damoiseaux RAMJ. Intraprofessional collaboration and learning between specialists and general practitioners during postgraduate training: a qualitative study. BMC Health Serv Res 2016; 16:376. [PMID: 27514868 PMCID: PMC4982222 DOI: 10.1186/s12913-016-1619-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 08/02/2016] [Indexed: 12/01/2022] Open
Abstract
Background During postgraduate training, general practitioners and other specialists must learn how to deliver shared care to patients; however, the development of formal intraprofessional education is often hampered by curricular constraints. Delivering shared care in everyday work provides trainees with opportunities for informal learning from, about and with one another. Methods Twelve semi-structured interviews were undertaken with trainee general practitioners and specialists (internal medicine or surgery). A thematic analysis of the input was undertaken and a qualitative description developed. Results Trainees from different disciplines frequently interact, often by telephone, but generally they learn in a reactive manner. All trainees are highly motivated by the desire to provide good patient care. Specialist trainees learn about the importance of understanding the background of the patient from GPs, while GP trainees gain medical knowledge from the interaction. Trainees from different disciplines are not very motivated to build relationships with each other and have fewer opportunities to do so. Supervisors can play an important role in providing intraprofessional learning opportunities for trainees. Conclusions During postgraduate training, opportunities for intraprofessional learning occur, but there is much room for improvement. For example, supervisors could increase the involvement of trainees in collaborative tasks and create more awareness of informal learning opportunities. This could assist trainees to learn collaborative skills that will enhance patient care. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1619-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Loes J Meijer
- University Medical Center Utrecht, Julius Center for Health Science and Primary Care, Broederplein 43, Zeist, 3703 CD, The Netherlands.
| | - Esther de Groot
- University Medical Center Utrecht, Julius Center for Health Science and Primary Care, Broederplein 43, Zeist, 3703 CD, The Netherlands
| | | | - Roger A M J Damoiseaux
- University Medical Center Utrecht, Julius Center for Health Science and Primary Care, Broederplein 43, Zeist, 3703 CD, The Netherlands
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27
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Murtaugh CM, Deb P, Zhu C, Peng TR, Barrón Y, Shah S, Moore SM, Bowles KH, Kalman J, Feldman PH, Siu AL. Reducing Readmissions among Heart Failure Patients Discharged to Home Health Care: Effectiveness of Early and Intensive Nursing Services and Early Physician Follow-Up. Health Serv Res 2016; 52:1445-1472. [PMID: 27468707 DOI: 10.1111/1475-6773.12537] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To compare the effectiveness of two "treatments"-early, intensive home health nursing and physician follow-up within a week-versus less intense and later postacute care in reducing readmissions among heart failure (HF) patients discharged to home health care. DATA SOURCES National Medicare administrative, claims, and patient assessment data. STUDY DESIGN Patients with a full week of potential exposure to the treatments were followed for 30 days to determine exposure status, 30-day all-cause hospital readmission, other health care use, and mortality. An extension of instrumental variables methods for nonlinear statistical models corrects for nonrandom selection of patients into treatment categories. Our instruments are the index hospital's rate of early aftercare for non-HF patients and hospital discharge day of the week. DATA EXTRACTION METHODS All hospitalizations for a HF principal diagnosis with discharge to home health care between July 2009 and June 2010 were identified from source files. PRINCIPAL FINDINGS Neither treatment by itself has a statistically significant effect on hospital readmission. In combination, however, they reduce the probability of readmission by roughly 8 percentage points (p < .001; confidence interval = -12.3, -4.1). Results are robust to changes in implementation of the nonlinear IV estimator, sample, outcome measure, and length of follow-up. CONCLUSIONS Our results call for closer coordination between home health and medical providers in the clinical management of HF patients immediately after hospital discharge.
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Affiliation(s)
- Christopher M Murtaugh
- VNSNY Center for Home Care Policy and Research, 1250 Broadway, 7th Floor, New York, 10001, NY
| | - Partha Deb
- Department of Economics, Hunter College and the Graduate Center, City University of New York, New York, NY.,NBER, Cambridge, MA
| | - Carolyn Zhu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,James J. Peters VA Medical Center, Bronx, NY
| | - Timothy R Peng
- Center for Home Care Policy and Research and Business Intelligence and Outcomes, Visiting Nurse Service of New York, New York, NY
| | - Yolanda Barrón
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
| | - Shivani Shah
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
| | | | - Kathryn H Bowles
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY.,School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Jill Kalman
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Penny H Feldman
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
| | - Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,James J. Peters VA Medical Center, Bronx, NY
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Wang CL, Ding ST, Hsieh MJ, Shu CC, Hsu NC, Lin YF, Chen JS. Factors associated with emergency department visit within 30 days after discharge. BMC Health Serv Res 2016; 16:190. [PMID: 27225191 PMCID: PMC4879744 DOI: 10.1186/s12913-016-1439-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 05/24/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Post-discharge care remains a challenge because continuity of care is often interrupted and adverse events frequently occur. Previous studies have focused on early readmission but few have investigated emergency department (ED) visit after discharge. METHODS This retrospective observational study was conducted between April 2011 and March 2012 in a referral center in Taiwan. Patients discharged from the general medical wards during the study period were analyzed and their characteristics, hospital course, and associated factors were collected. An ED visit within 30 days of discharge was the primary outcome while readmission or death at home were secondary outcomes. RESULTS There were 799 discharged patients analyzed, including 96 (12 %) with an ED visit of 12.4 days post-discharge and 111 (14 %) with readmissions at 13.3 days post-discharge. Sixty patients were admitted after their ED visit. Underlying chronic illnesses were associated with 72 % of ED visits. By multivariate analysis, Charlson score and the use of naso-gastric tube were independent risk factors for ED visit within 30 days after discharge. CONCLUSIONS Early ED visit after discharge is as high as 12 %. Patients with chronic illness and those requiring a naso-gastric tube or external biliary drain are at high risk for post-discharge ED visit.
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Affiliation(s)
- Chuan-Lan Wang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.,Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Shih-Tan Ding
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.,Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chung Shu
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan. .,College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Nin-Chieh Hsu
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Feng Lin
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jin-Shing Chen
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Napolitano F, Napolitano P, Garofalo L, Recupito M, Angelillo IF. Assessment of Continuity of Care among Patients with Multiple Chronic Conditions in Italy. PLoS One 2016; 11:e0154940. [PMID: 27140202 PMCID: PMC4854373 DOI: 10.1371/journal.pone.0154940] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/21/2016] [Indexed: 11/25/2022] Open
Abstract
The aims of the present study were to evaluate the extent of continuity of care and to investigate its association with several factors among a sample of outpatients with chronic diseases in Italy. The survey was conducted, using face to face interview, from March to December 2014 in a random sample of 633 outpatients with chronic conditions who were going in cardiology, metabolic disorders, and respiratory ambulatory center of four hospitals. A multivariate ordered logistic regression model was used to identify factors associated with the outpatients continuity of care. The mean of the Bice-Boxerman continuity of care (COC) index related to the entire sample was 0.44, and 27.9%, 58.4%, 13.7% had a low, intermediate, and high value of the index based on the tertiles of the distribution. The results of the ordered logistic regression analysis showed that female patients, those older, those who had a lower score of Katz Index of independence in activities of daily living, those who had a lower Charlson et al. comorbidity score, and those who had no hospitalization in the last year, were significantly more likely to have a higher value of the COC index. Patients who had completed a secondary school education had significantly lower odds of having a high value of COC index in comparison to patients with a college degree educational level. Policy makers and clinicians involved in the care of patients should implement comprehensively and efficiently efforts in order to improve the continuity of care in patients with chronic diseases.
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Affiliation(s)
- Francesco Napolitano
- Department of Experimental Medicine, Second University of Naples, Via Luciano Armanni, Naples, Italy
| | - Paola Napolitano
- Department of Experimental Medicine, Second University of Naples, Via Luciano Armanni, Naples, Italy
| | - Luca Garofalo
- Department of Experimental Medicine, Second University of Naples, Via Luciano Armanni, Naples, Italy
| | - Marianna Recupito
- Department of Experimental Medicine, Second University of Naples, Via Luciano Armanni, Naples, Italy
| | - Italo F. Angelillo
- Department of Experimental Medicine, Second University of Naples, Via Luciano Armanni, Naples, Italy
- * E-mail:
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Kuo YF, Goodwin JS, Chen NW, Lwin KK, Baillargeon J, Raji MA. Diabetes Mellitus Care Provided by Nurse Practitioners vs Primary Care Physicians. J Am Geriatr Soc 2015; 63:1980-8. [PMID: 26480967 PMCID: PMC4743647 DOI: 10.1111/jgs.13662] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare processes and cost of care of older adults with diabetes mellitus cared for by nurse practitioners (NPs) with processes and cost of those cared for by primary care physicians (PCPs). DESIGN Retrospective cohort study. SETTING Primary care in communities. PARTICIPANTS Individuals with a diagnosis of diabetes mellitus in 2009 who received all their primary care from NPs or PCPs were selected from a national sample of Medicare beneficiaries (N = 64,354). MEASUREMENTS Propensity score matching within each state was used to compare these two cohorts with regard to rate of eye examinations, low-density lipoprotein cholesterol (LDL-C) and glycosylated hemoglobin (HbA1C) testing, nephropathy monitoring, specialist consultation, and Medicare costs. The two groups were also compared regarding medication adherence and use of statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (for individuals with a diagnosis of hypertension), and potentially inappropriate medications (PIMs). RESULTS Nurse practitioners and PCPs had similar rates of LDL-C testing (odds ratio (OR) = 1.01, 95% confidence interval (CI) = 0.94-1.09) and nephropathy monitoring (OR = 1.05, 95% CI = 0.98-1.03), but NPs had lower rates of eye examinations (OR = 0.89, 95% CI = 0.84-0.93) and HbA1C testing (OR = 0.88, 95% CI = 0.79-0.98). NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21-1.37), endocrinologists (OR = 1.64, 95% CI = 1.48-1.82), and nephrologists (OR = 1.90, 95% CI = 1.67-2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01-1.12). There was no statistically significant difference in adjusted Medicare spending between the two groups (P = .56). CONCLUSION Nurse practitioners were similar to PCPs or slightly lower in their rates of diabetes mellitus guideline-concordant care. NPs used specialist consultations more often but had similar overall costs of care to PCPs.
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Affiliation(s)
- Yong-Fang Kuo
- Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
- Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
| | - James S. Goodwin
- Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
- Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
| | - Nai-Wei Chen
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Kyaw K. Lwin
- Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A. Raji
- Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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Aller MB, Vargas I, Coderch J, Calero S, Cots F, Abizanda M, Farré J, Llopart JR, Colomés L, Vázquez ML. Development and testing of indicators to measure coordination of clinical information and management across levels of care. BMC Health Serv Res 2015; 15:323. [PMID: 26268694 PMCID: PMC4535786 DOI: 10.1186/s12913-015-0968-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 07/24/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Coordination across levels of care is becoming increasingly important due to rapid advances in technology, high specialisation and changes in the organization of healthcare services; to date, however, the development of indicators to evaluate coordination has been limited. The aim of this study is to develop and test a set of indicators to comprehensively evaluate clinical coordination across levels of care. METHODS A systematic review of literature was conducted to identify indicators of clinical coordination across levels of care. These indicators were analysed to identify attributes of coordination and classified accordingly. They were then discussed within an expert team and adapted or newly developed, and their relevance, scientific soundness and feasibility were examined. The indicators were tested in three healthcare areas of the Catalan health system. RESULTS 52 indicators were identified addressing 11 attributes of clinical coordination across levels of care. The final set consisted of 21 output indicators. Clinical information transfer is evaluated based on information flow (4) and the adequacy of shared information (3). Clinical management coordination indicators evaluate care coherence through diagnostic testing (2) and medication (1), provision of care at the most appropriate level (2), completion of diagnostic process (1), follow-up after hospital discharge (4) and accessibility across levels of care (4). The application of indicators showed differences in the degree of clinical coordination depending on the attribute and area. CONCLUSION A set of rigorous and scientifically sound measures of clinical coordination across levels of care were developed based on a literature review and discussion with experts. This set of indicators comprehensively address the different attributes of clinical coordination in main transitions across levels of care. It could be employed to identify areas in which health services can be improved, as well as to measure the effect of efforts to improve clinical coordination in healthcare organizations.
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Affiliation(s)
- Marta-Beatriz Aller
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, 08022, Barcelona, Spain.
| | - Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, 08022, Barcelona, Spain.
| | - Jordi Coderch
- Grup de Recerca en Serveis Sanitaris i Resultats en Salut, Serveis de Salut Integrats Baix Empordà, Carrer Hospital, 17-19 Edif. Fleming, 17230, Palamós, Spain.
| | - Sebastià Calero
- Catalan Health Institute, Gran Via de les Corts Catalanes, 587, 08007, Barcelona, Spain.
| | - Francesc Cots
- IMIM - Hospital del Mar Medical Research Institute, Carrer Dr. Aiguader, 88, 08003, Barcelona, Spain.
| | - Mercè Abizanda
- Institut de Prestacions d'Assistència Mèdica al Personal Municipal, Carrer Viladomat, 127, 08015, Barcelona, Spain.
| | - Joan Farré
- Centre Integral de Salut Cotxers, Avinguda de Borbó, 18 - 30, 08016, Barcelona, Spain.
| | - Josep Ramon Llopart
- Health Policy and Health Services Research Group; Division of Management, Planning and Organizational Development, Badalona Healthcare Services, Via Augusta, 9-13, 08911, Badalona, Spain.
| | - Lluís Colomés
- Health Policy and Health Services Research Group; Strategic Planning Division, SAGESSA Group, Avinguda del Dr. Josep Laporte, 2, 43204, Reus, Spain.
| | - María Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, 08022, Barcelona, Spain.
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Driessen J, Bellon JE, Stevans J, James AE, Minnier T, Reynolds BR, Zhang Y. Innovative approaches to interprofessional care at the University of Pittsburgh Medical Center. J Interprof Care 2015; 29:520-1. [PMID: 26171868 DOI: 10.3109/13561820.2015.1040114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The enactment of the Affordable Care Act expands coverage to millions of uninsured Americans and creates a new workforce landscape. Interprofessional Collaborative Practice (ICP) is no longer a choice but a necessity. In this paper, we describe four innovative approaches to interprofessional practice at the University of Pittsburgh Medical Center. These models demonstrate innovative applications of ICP to inpatient and outpatient care, relying on non-physician providers, training programs, and technology to deliver more appropriate care to specific patient groups. We also discuss the ongoing evaluation plans to assess the effects of these interprofessional practices on patient health, quality of care, and healthcare costs. We conclude that successful implementation of interprofessional teams involves more than just a reassignment of tasks, but also depends on structuring the environment and workflow in a way that facilitates team-based care.
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Affiliation(s)
- Julia Driessen
- a Graduate School of Public Health, Health Policy and Management, University of Pittsburgh , Pittsburgh , PA , USA .,b Health Policy Institute, University of Pittsburgh , Pittsburgh , PA , USA
| | - Johanna E Bellon
- a Graduate School of Public Health, Health Policy and Management, University of Pittsburgh , Pittsburgh , PA , USA .,b Health Policy Institute, University of Pittsburgh , Pittsburgh , PA , USA
| | - Joel Stevans
- b Health Policy Institute, University of Pittsburgh , Pittsburgh , PA , USA .,c School of Health and Rehabilitation Sciences, University of Pittsburgh , Pittsburgh , PA , USA
| | - A Everette James
- a Graduate School of Public Health, Health Policy and Management, University of Pittsburgh , Pittsburgh , PA , USA .,b Health Policy Institute, University of Pittsburgh , Pittsburgh , PA , USA
| | - Tami Minnier
- d University of Pittsburgh Medical Center , Pittsburgh , PA , USA , and
| | - Benjamin R Reynolds
- e Office of Advanced Practice Providers, University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Yuting Zhang
- a Graduate School of Public Health, Health Policy and Management, University of Pittsburgh , Pittsburgh , PA , USA .,b Health Policy Institute, University of Pittsburgh , Pittsburgh , PA , USA
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Abstract
BACKGROUND Growth in the care of hospitalized patients by hospitalists has the potential to increase the productivity of office-based primary care physicians (PCPs) by allowing them to focus on outpatient practice. OBJECTIVE Our aim was to examine the association between utilization of hospitalists and the productivity of office-based PCPs. DESIGN/PARTICIPANTS The cross-sectional study was conducted using the 2008 Health Tracking Physician Survey Restricted Use File linked to the Area Resource File. We analyzed a total of 1,158 office-based PCPs representing a weighted total of 97,355 physicians. MAIN MEASURES Utilization of hospitalists was defined as the percentage of a PCP's hospitalized patients treated by a hospitalist. The measures of PCPs' productivity were: (1) number of hospital visits per week, (2) number of office and outpatient clinic visits per week, and (3) direct patient care time per visit. KEY RESULTS We found that the use of hospitalists was significantly associated with a decreased number of hospital visits. The use of hospitalists was also associated with an increased number of office visits, but this was only significant for high users. Physicians who used hospitalists for more than three-quarters of their hospitalized patients had an extra 8.8 office visits per week on average (p = 0.05), which was equivalent to a 10 % increase in productivity over the predicted mean of 87 visits for physicians who did not use hospitalists. We did not find any significant differences in direct patient care time per visit. CONCLUSIONS Our study demonstrates that the increase in productivity for the one-third of PCPs who use hospitalists extensively may not be sufficient to offset the current loss of PCP workforce. However, our findings provide cautious optimism that if more PCPs effectively and efficiently used hospitalists, this could help mitigate a PCP shortage and improve access to primary care services.
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Boonyasai RT, Lin YL, Brotman DJ, Kuo YF, Goodwin JS. Characteristics of primary care providers who adopted the hospitalist model from 2001 to 2009. J Hosp Med 2015; 10:75-82. [PMID: 25627347 PMCID: PMC4311567 DOI: 10.1002/jhm.2269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/07/2014] [Accepted: 09/13/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND The characteristics of primary care providers (PCPs) who use hospitalists are unknown. METHODS Retrospective study using 100% Texas Medicare claims from 2001 through 2009. Descriptive statistics characterized proportion of PCPs using hospitalists over time. Trajectory analysis and multilevel models of 1172 PCPs with ≥20 inpatients in every study year characterized how PCPs adopted the hospitalist model and PCP factors associated with this transition. RESULTS Hospitalist use increased between 2001 and 2009. PCPs who adopted the hospitalist model transitioned rapidly. In multilevel models, hospitalist use was associated with US training (odds ratio [OR] 1.46, 95% confidence interval [CI]: 1.23-1.73 in 2007-2009), family medicine specialty (OR: 1.46, 95% CI: 1.25-1.70 in 2007-2009), and having high outpatient volumes (OR: 1.32, 95% CI: 1.20-1.44 in 2007-2009). Over time, relative hospitalist use decreased among female PCPs (OR: 1.91, 95% CI: 1.46-2.50 in 2001-2003; OR: 1.50, 95% CI: 1.15-1.95 in 2007-2009), those in urban locations (OR: 3.34, 95% CI: 2.72-4.09 in 2001-2003; OR: 2.22, 95% CI: 1.82-2.71 in 2007-2009), and those with higher inpatient volumes (OR: 1.05, 95% CI: 0.95-1.18 in 2001-2003; OR: 0.55, 95% CI: 0.51-0.60 in 2007-2009). Longest-practicing PCPs were more likely to transition in the early 2000s, but this effect disappeared by the end of the study period (OR: 1.35, 95% CI: 1.06-1.72 in 2001-2003; OR: 0.92, 95% CI: 0.73-1.17 in 2007-2009). PCPs with practice panels dominated by patients who were white, male, or had comorbidities are more likely to use hospitalists. CONCLUSIONS PCP characteristics are associated with hospitalist use. The association between PCP characteristics and hospitalist use has evolved over time.
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Affiliation(s)
- Romsai T. Boonyasai
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore Maryland
| | - Yu-Li Lin
- Sealy Center on Aging, Departments of Internal Medicine and Preventive Medicine and Community Health University of Texas Medical Branch, Galveston, TX
| | - Daniel J. Brotman
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore Maryland
| | - Yong-Fang Kuo
- Sealy Center on Aging, Departments of Internal Medicine and Preventive Medicine and Community Health University of Texas Medical Branch, Galveston, TX
| | - James S. Goodwin
- Sealy Center on Aging, Departments of Internal Medicine and Preventive Medicine and Community Health University of Texas Medical Branch, Galveston, TX
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Al-Damluji MS, Dzara K, Hodshon B, Punnanithinont N, Krumholz HM, Chaudhry SI, Horwitz LI. Hospital variation in quality of discharge summaries for patients hospitalized with heart failure exacerbation. Circ Cardiovasc Qual Outcomes 2015; 8:77-86. [PMID: 25587091 DOI: 10.1161/circoutcomes.114.001227] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Single-site studies have demonstrated inadequate quality of discharge summaries in timeliness, transmission, and content, potentially contributing to adverse outcomes. However, degree of hospital-level variation in discharge summary quality for patients hospitalized with heart failure (HF) is uncertain. METHODS AND RESULTS We analyzed discharge summaries of patients enrolled in the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) study. We assessed hospital-level performance on timeliness (fraction of summaries completed on the day of discharge), documented transmission to the follow-up physician, and content (presence of components suggested by the Transitions of Care Consensus Conference). We obtained 1501 discharge summaries from 1640 (91.5%) patients discharged alive from 46 hospitals. Among hospitals contributing ≥ 10 summaries, the median hospital dictated 69.2% of discharge summaries on the day of discharge (range, 0.0%-98.0%; P<0.001); documented transmission of 33.3% of summaries to the follow-up physician (range, 0.0%-75.7%; P<0.001); and included 3.6 of 7 Transitions of Care Consensus Conference elements (range, 2.9-4.5; P<0.001). Hospital course was typically included (97.2%), but summaries were less likely to include discharge condition (30.7%), discharge volume status (16.0%), or discharge weight (15.7%). No discharge summary included all 7 Transitions of Care Consensus Conference-endorsed content elements, was dictated on the day of discharge, and was sent to a follow-up physician. CONCLUSIONS Even at the highest performing hospital, discharge summary quality is insufficient in terms of timeliness, transmission, and content. Improvements in all aspects of discharge summary quality are necessary to enable the discharge summary to serve as an effective transitional care tool.
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Affiliation(s)
- Mohammed Salim Al-Damluji
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Kristina Dzara
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Beth Hodshon
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Natdanai Punnanithinont
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Harlan M Krumholz
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Sarwat I Chaudhry
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Leora I Horwitz
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.).
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Kind AJH, Jencks S, Brock J, Yu M, Bartels C, Ehlenbach W, Greenberg C, Smith M. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study. Ann Intern Med 2014; 161:765-74. [PMID: 25437404 PMCID: PMC4251560 DOI: 10.7326/m13-2946] [Citation(s) in RCA: 818] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Measures of socioeconomic disadvantage may enable improved targeting of programs to prevent rehospitalizations, but obtaining such information directly from patients can be difficult. Measures of U.S. neighborhood socioeconomic disadvantage are more readily available but are rarely used clinically. OBJECTIVE To evaluate the association between neighborhood socioeconomic disadvantage at the census block group level, as measured by the Singh validated area deprivation index (ADI), and 30-day rehospitalization. DESIGN Retrospective cohort study. SETTING United States. PATIENTS Random 5% national sample of Medicare patients discharged with congestive heart failure, pneumonia, or myocardial infarction between 2004 and 2009 (n = 255,744). MEASUREMENTS Medicare data were linked to 2000 census data to construct an ADI for each patient's census block group, which were then sorted into percentiles by increasing ADI. Relationships between neighborhood ADI grouping and 30-day rehospitalization were evaluated using multivariate logistic regression models, controlling for patient sociodemographic characteristics, comorbid conditions and severity, and index hospital characteristics. RESULTS The 30-day rehospitalization rate did not vary significantly across the least disadvantaged 85% of neighborhoods, which had an average rehospitalization rate of 21%. However, within the most disadvantaged 15% of neighborhoods, rehospitalization rates increased from 22% to 27% with worsening ADI. This relationship persisted after full adjustment, with the most disadvantaged neighborhoods having a rehospitalization risk (adjusted risk ratio, 1.09 [95% CI, 1.05 to 1.12]) similar to that of chronic pulmonary disease (adjusted risk ratio, 1.06 [CI, 1.04 to 1.08]) and greater than that of uncomplicated diabetes (adjusted risk ratio, 0.95 [CI, 0.94 to 0.97]). LIMITATION No direct markers of care quality or access. CONCLUSION Residence within a disadvantaged U.S. neighborhood is a rehospitalization predictor of magnitude similar to chronic pulmonary disease. Measures of neighborhood disadvantage, such as the ADI, could potentially be used to inform policy and care after hospital discharge. PRIMARY FUNDING SOURCE National Institute on Aging and University of Wisconsin School of Medicine and Public Health's Institute for Clinical and Translational Research and Health Innovation Program.
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Ivins D, Blackburn B, Peterson LE, Newton WP, Puffer JC. A majority of family physicians use a hospitalist service when their patients require inpatient care. J Prim Care Community Health 2014; 6:70-6. [PMID: 25318473 DOI: 10.1177/2150131914555016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The hospitalist movement in the United States has risen in prominence over the past 2 decades with more physicians practicing as hospitalists. Our objective was to examine different strategies used by family physicians when their patients require inpatient care. METHODS Secondary analysis of a cross-sectional survey of physicians accessing the American Board of Family Medicine Web site in 2011 and the 2011 Area Resource File. Logistic regression assessed for associations between using hospitalists, managing inpatients personally, or with a group partner, and then comparing and contrasting these physicians with health care market characteristics. RESULTS A total of 3857 physicians had data on practice characteristics and could be geocoded to their county of residence. Compared with other physicians meeting inclusion criteria in the American Board of Family Medicine database, our sample was slightly older and more likely to be female. In all, 54% of respondents reported using hospitalist services while 18% reported managing hospitalized patients themselves. Respondents more likely to use hospitalist services were female and resided in urban areas. However, one third of these physicians living in isolated rural areas reported using hospitalist services. Respondents more likely to personally manage their patients in the hospital were more likely to be male and an international medical graduate. The likelihood of using hospitalist services increased with higher availability of hospitalist services. CONCLUSIONS Overall, a majority of family physicians are using hospitalist services. Family physicians seem more likely to use hospitalist services when they are available which may lead to fragmentation of care.
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Affiliation(s)
| | | | | | - Warren P Newton
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James C Puffer
- The American Board of Family Medicine, Lexington, KY, USA
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Treatment patterns and outcomes in patients with non-squamous advanced non-small cell lung cancer receiving second-line treatment in a community-based oncology network. Lung Cancer 2014; 82:469-76. [PMID: 24396885 DOI: 10.1016/j.lungcan.2013.09.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This retrospective study used the US Oncology iKnowMed(TM) database, billing claims, and chart reviews to report treatment patterns and outcomes in late-stage non-small cell lung cancer (NSCLC) in US community oncology practices. MATERIALS AND METHODS Eligibility criteria included non-squamous NSCLC, stage IIIB/IV at diagnosis, ECOG performance status (PS) <3, and initiation of 2nd-line therapy (defined as index date) between 1/1/2007 and 6/30/2011 with ≥ 1 year follow-up. Key outcomes were overall survival (OS), progression-free survival(PFS), time-to-progression (TTP), and time-to-hospitalization (post-index date). Kaplan–Meier and Cox proportional hazard models were used to characterize the distribution and predictors of outcomes. RESULTS 1168 patients were eligible for the study. The most frequent 2nd-line therapies were pemetrexed(54.4%), erlotinib-containing regimens (17.6%), and docetaxel (10.0%). Median OS and PFS were 7.5 (95%confidence interval [CI]: 6.6–8.4) and 4.1 (95% CI: 3.7–4.5) months, respectively; 57% of patients were hospitalized post-index date. EGFR testing rates were 2.3% before 2010, 15.2% in 2010, and 32.0% in 2011 (P < .001). Of EGFR-positive patients, 50.0% received erlotinib-containing regimens compared with 16.9% of EGFR-negative patients (P = 0.001). An increased risk of shorter time-to-hospitalization, after controlling for other covariates, was associated with PS = 1 (hazard ratio [HR] = 1.51; P < .001) or PS = 2(HR = 1.68; P = .001) compared with PS = 0, pre-existing comorbid fatigue (HR = 1.64; P = .003) compared with no comorbid fatigue, and progression (HR = 1.92; P < .001), when it occurred, compared with no progression. Compared with other 2nd-line treatment, erlotinib-containing regimens prolonged adjusted TTP (HR = 0.69; P = .015). CONCLUSIONS This retrospective observational study provides new insights into treatment patterns,biomarker testing, and outcomes in advanced NSCLC within the context of a large community oncology network. Outcomes of these community practice patients, although poor, were similar to those reported in 2nd-line clinical trials for relevant regimens. EGFR testing in community practice rose rapidly after 2010.
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Kim JJ, Lee JS, Olafsson S, Laine L. Low adherence to Helicobacter pylori testing in hospitalized patients with bleeding peptic ulcer disease. Helicobacter 2014; 19:98-104. [PMID: 24617668 DOI: 10.1111/hel.12114] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Helicobacter pylori (H. pylori) testing in patients with bleeding ulcers is recommended by society guidelines and considered a quality indicator. The aim of the study is to examine the proportion of patients with bleeding ulcers who had H. pylori testing and identify predictors associated with H. pylori testing. MATERIALS AND METHODS Consecutive hospitalized patients with bleeding ulcers documented endoscopically at a single center from 10/2004-5/2011 were identified retrospectively from an endoscopy database. The proportion of patients undergoing direct H. pylori testing (histology, rapid urease test, breath test or stool antigen) and any H. pylori testing (direct or serologic) were determined. RESULTS Among 330 patients with bleeding ulcers, 105 (32%, 95% CI 27-37%) underwent direct testing and another 52 (16%, 95% CI 12-20%) had serologic testing during a median follow-up of 9 months (range, 0-86). H. pylori testing occurred at the index hospitalization in 146 (93%) of the 157 patients tested. Among the 105 patients who had direct H. pylori testing, 90 (86%) had biopsy-based testing during the initial endoscopy. On multivariate analysis, undergoing biopsy of a gastric ulcer was strongly associated with having direct H. pylori testing performed (OR = 5.1, 95% CI 2.3-11.5; p < .0001). CONCLUSIONS Among patients hospitalized with bleeding ulcers, less than half received H. pylori testing and less than a third received the more accurate direct testing. Most of the direct H. pylori testing was biopsy-based with very few being tested after the index hospitalization. Efforts to increase H. pylori testing in patients with bleeding ulcers are needed to improve outcomes.
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Affiliation(s)
- John J Kim
- Loma Linda University Global Health Institute, Loma Linda, CA, USA; Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
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Segal JB, DuGoff EH. Building blocks for measuring care coordination with claims data. Popul Health Manag 2014; 17:247-52. [PMID: 24606582 DOI: 10.1089/pop.2013.0082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Tools to measure care coordination are needed to evaluate federal, state, and private sector efforts encouraging coordination to improve health outcomes and contain costs. Administrative data are a rich source of data for studying the use of medical services, thus allowing for measurement of patient level, provider level, and system measures of care coordination. Based on a review the literature and input from an expert panel, this article describes 4 key components-building blocks-of care coordination and corresponding measures. These building blocks should have utility across clinical conditions. They may be used to test hypotheses about the impact of coordinated care on medication utilization, adherence to medications, and clinical outcomes.
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Affiliation(s)
- Jodi B Segal
- 1 Johns Hopkins School of Medicine , Baltimore, Maryland
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Simoens S, Dubois C, Spinewine A, Foulon V, Paulus D. Drug substitution associated with a hospital stay in Belgium: a retrospective analysis of a claims database. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2014; 22:105-11. [DOI: 10.1111/ijpp.12048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 05/07/2013] [Indexed: 11/28/2022]
Abstract
Abstract
Objectives
This study measures the extent of drug substitution associated with a hospital stay in Belgium.
Methods
Data were extracted from the 2006–2007 dataset of the Belgian Agency of Health Insurance Funds on drug use of patients hospitalized in acute hospitals. Reimbursed drugs received in ambulatory care during the 3 months prior to hospitalization were compared with drugs received during the 3 months following hospital discharge. Both a narrow definition and a broad definition were used for drug substitution. Narrow substitution (switches between generic and originator drugs) was computed for 14 drug classes for chronic conditions with the highest public expenditure. Broad substitution (changes between chemical substances within the drug class at ATC level 4, changes in brand name) was calculated for statins and proton-pump inhibitors only.
Key findings
The database included 17 764 patients (mean age 66 ± 17 years; 60% female). In 71% of cases an originator drug was received prior to and following hospitalization. A generic drug was received prior to and following hospitalization in 25% of cases. Some form of narrow substitution occurred in 4% of cases: a generic drug was replaced by an originator drug in 2% of cases and an originator drug was replaced by a generic drug in 2% of cases. Some form of broad substitution occurred in 25% of cases for proton-pump inhibitors and 13% of cases for statins.
Conclusions
Hospitalization was not a trigger for changes between originator and generic versions of a drug. Broad substitution associated with a hospital stay was relatively limited for statins and proton-pump inhibitors.
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Affiliation(s)
- Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Cécile Dubois
- Belgian Healthcare Knowledge Centre, Brussels, Belgium
| | - Anne Spinewine
- Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- CHU Mont-Godinne, Yvoir, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Ge PS, Runyon BA. The changing role of beta-blocker therapy in patients with cirrhosis. J Hepatol 2014; 60:643-53. [PMID: 24076364 DOI: 10.1016/j.jhep.2013.09.016] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 09/13/2013] [Accepted: 09/17/2013] [Indexed: 12/11/2022]
Abstract
Cirrhosis is a leading cause of death in the United States and worldwide. Beta-blockers have been established in numerous studies as part of the cornerstone of the medical management of cirrhosis, particularly in the primary and secondary prevention of variceal hemorrhage. However, new evidence has cautioned the use of beta-blockers in patients with end-stage cirrhosis and refractory ascites. In this article, we review the beneficial effects of beta-blocker therapy, the potential harms of aggressive beta-blocker therapy, and provide suggestions regarding the appropriate use of this class of medications in patients with cirrhosis.
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Affiliation(s)
- Phillip S Ge
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Bruce A Runyon
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.
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Iloabuchi TC, Mi D, Tu W, Counsell SR. Risk factors for early hospital readmission in low-income elderly adults. J Am Geriatr Soc 2014; 62:489-94. [PMID: 24576082 DOI: 10.1111/jgs.12688] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To identify risk factors for early hospital readmission in low-income community-dwelling older adults. DESIGN Prospective cohort study. SETTING University-affiliated urban safety-net healthcare system in Indianapolis, Indiana. PARTICIPANTS Community-dwelling adults aged 65 and older with annual income less than 200% of the federal poverty level and enrolled in the Geriatric Resources for Assessment and Care of Elders (GRACE) randomized controlled trial (N = 951). MEASUREMENTS Participant health and functional status at baseline and 6, 12, 18, and 24 months. Early readmission was defined as a repeat hospitalization occurring within 30 days of a prior hospital discharge. Candidate risk factors included sociodemographic characteristics, health and functional status, prior care, lifestyle, and satisfaction with care. RESULTS Of 457 index admissions in 328 participants, 85 (19%) were followed by an early readmission. The independent risk factors for early readmission identified according to regression analysis were living alone (odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.02-2.87), fair or poor satisfaction with primary care physician (OR = 2.12, 95% CI = 1.01-4.46), not having Medicaid (OR = 1.80, 95% CI = 1.05-3.11), receiving a new assistive device in the past 6 months (OR = 2.26, 95% CI = 1.26-4.05), and staying in a nursing home in the past 6 months (OR = 5.08, 95% CI = 1.56-16.53). Age, race, sex, education, and chronic diseases were not associated with early readmission. CONCLUSION A broad range of nonmedical risk factors played a greater role than previously recognized in early hospital readmission of low-income seniors.
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Affiliation(s)
- Tochukwu C Iloabuchi
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana
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Burke RE, Whitfield E, Prochazka AV. Effect of a hospitalist-run postdischarge clinic on outcomes. J Hosp Med 2014; 9:7-12. [PMID: 24390821 DOI: 10.1002/jhm.2099] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 09/25/2013] [Accepted: 09/30/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND New post-discharge strategies to reduce adverse events are needed. OBJECTIVE To determine whether follow-up in a hospitalist-run post-discharge clinic (PDC) decreases post-discharge adverse events when compared to follow-up in a primary care clinic (PCP) or urgent care clinic (UC). DESIGN Retrospective cohort study using propensity scoring in multivariate analysis. PATIENTS Consecutive Veterans discharged home after a nonscheduled admission seen in PDC, UC, or PCP within 30 days of discharge. INTERVENTIONS Recently discharged patients are seen by housestaff who cared for them during the index admission and staffed with a rotating hospitalist in PDC; UC and PCP patients are seen by housestaff or attending ambulatory physicians. MAIN MEASURES The primary outcome was a composite of hospital readmissions, Emergency Department visits, and mortality 30 days after discharge. KEY RESULTS 5085 patients met criteria; 538 followed up in PDC (10.6%), 1848 with their PCP (36.3%), and 2699 in UC (53.1%). Patients following up in PDC were older and had a higher comorbidity burden. ICU exposure was similar between groups. Patients seen in PDC had shorter length of stay (LOS) (PDC, 3.8 days, UC, 5.0 days, PCP, 6.2 days; p = 0.04) and time to first post-discharge visit (PDC, 5.0 days, UC, 9.4 days, PCP, 13.7 days; p < 0.01). There were no differences between groups in the primary outcome in unadjusted or propensity-adjusted multivariate analysis. CONCLUSIONS Patients seen in a hospitalist-run PDC had similar 30-day post-discharge adverse outcome rates despite a 2.4-day shorter LOS compared to patients seen by their PCP. Prospective testing of PDCs is warranted.
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Affiliation(s)
- Robert E Burke
- Hospital Medicine Section, Department of Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, Colorado; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
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Burke RE, Ryan P. Postdischarge clinics: hospitalist attitudes and experiences. J Hosp Med 2013; 8:578-81. [PMID: 24101543 DOI: 10.1002/jhm.2085] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/11/2013] [Accepted: 08/14/2013] [Indexed: 11/12/2022]
Abstract
Novel methods for improving transitions of care are needed. Hospitalist-run postdischarge clinics (PDCs) may improve access to postdischarge care, but require practice change from providers. We conducted a Web-based cross-sectional survey of hospitalists at 37 academic medical centers across the United States and a large private employer of hospitalists to assess the attitudes of hospitalists toward postdischarge care and PDCs. Two hundred twenty-eight of 814 hospitalists responded to the survey (28%). Responding hospitalists commonly (55%) experienced difficulty arranging outpatient follow-up, and felt that lack of access was responsible for most patient problems after discharge (61%). Despite this, 62% felt hospitalists should not provide postdischarge care in a clinic, and 77% felt they would require extra compensation for work in a PDC. However, 74% thought such a clinic would decrease emergency department visits. Practicing in a PDC was associated with a trend toward positive attitudes about providing postdischarge care (P = 0.054). Responding hospitalists expressed difficulty arranging appropriate postdischarge care, confidence that PDCs would reduce postdischarge utilization, and reservations about working in a PDC, perhaps because of practical or financial concerns. These results are important given the current emphasis on reducing hospital readmissions. Further work evaluating the experience of hospitalists in PDCs is needed.
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Affiliation(s)
- Robert E Burke
- Hospital Medicine Section, Department of Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, Colorado; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
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Care coordination for patients with cirrhosis: a "win-win" solution for patients, caregivers, providers, and healthcare expenditures. J Hepatol 2013; 59:203-4. [PMID: 23665187 DOI: 10.1016/j.jhep.2013.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 04/21/2013] [Indexed: 12/04/2022]
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Ding ST, Wang CL, Huang YH, Shu CC, Tseng YT, Huang CT, Hsu NC, Lin YF, Tsai HB, Yang MC, Ko WJ. Demand and predictors for post-discharge medical counseling in home care patients: a prospective cohort study. PLoS One 2013; 8:e64274. [PMID: 23737976 PMCID: PMC3667835 DOI: 10.1371/journal.pone.0064274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/09/2013] [Indexed: 11/18/2022] Open
Abstract
Rationale Post-discharge care is challenging due to the high rate of adverse events after discharge. However, details regarding post-discharge care requirements remain unclear. Post-discharge medical counseling (PDMC) by telephone service was set-up to investigate its demand and predictors. Methods This prospective study was conducted from April 2011 to March 2012 in a tertiary referral center in northern Taiwan. Patients discharged for home care were recruited and educated via telephone hotline counseling when needed. The patient’s characteristics and call-in details were recorded, and predictors of PDMC use and worsening by red-flag sign were analyzed. Results During the study period, 224 patients were enrolled. The PDMC was used 121 times by 65 patients in an average of 8.6 days after discharge. The red-flag sign was noted in 17 PDMC from 16 patients. Of the PDMC used, 50% (n = 60) were for symptom change and the rest were for post-discharge care problems and issues regarding other administrative services. Predictors of PDMC were underlying malignancy and lower Barthel index (BI). On the other hand, lower BI, higher adjusted Charlson co-morbidity index (CCI), and longer length of hospital stay were associated with PDMC and red-flag sign. Conclusions Demand for PDMC may be as high as 29% in home care patients within 30 days after discharge. PDMC is needed more by patients with malignancy and lower BI. More focus should also be given to those with lower BI, higher CCI, and longer length of hospital stay, as they more frequently have red flag signs.
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Affiliation(s)
- Shih-Tan Ding
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chuan-Lan Wang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Han Huang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chung Shu
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
| | - Yu-Tzu Tseng
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Ta Huang
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nin-Chieh Hsu
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Feng Lin
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hung-Bin Tsai
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chin Yang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Wen-Je Ko
- Division of Hospital Medicine, Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Goodwin JS, Lin YL, Singh S, Kuo YF. Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists. J Gen Intern Med 2013; 28:370-6. [PMID: 23129162 PMCID: PMC3579964 DOI: 10.1007/s11606-012-2255-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 09/26/2012] [Accepted: 10/03/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND There have been no prior population-based studies of variation in performance of hospitalists. OBJECTIVE To measure the variation in performance of hospitalists. DESIGN Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models. SUBJECTS 131,710 hospitalized patients cared for by 1,099 hospitalists in 268 hospitals from 2006-2009. MAIN MEASURES We calculated, for each hospitalist, adjusted for patient and disease factors (case mix), their patients' average length of stay, rate of discharge home or to skilled nursing facility (SNF) and rate of 30-day mortality, readmissions and emergency room (ER) visits. KEY RESULTS In two-level models (admission and hospitalist), there was significant variation in average length of stay and discharge location among hospitalists, but very little variation in 30-day mortality, readmission or emergency room visit rates. There was stability over time (2008-2009 vs. 2006-2007) in hospitalist performance. In three-level models including admissions, hospitalists and hospitals, the variation among hospitalists was substantially reduced. For example, hospitals, hospitalists and case mix contributed 1.02 %, 0.75 % and 42.15 % of the total variance in 30-day mortality rates, respectively. CONCLUSIONS There is significant variation among hospitalists in length of stay and discharge destination of their patients, but much of the variation is attributable to the hospitals where they practice. The very low variation among hospitalists in 30-day readmission rates suggests that hospitalists are not important contributors to variations in those rates among hospitals.
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Affiliation(s)
- James S Goodwin
- Department of Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.
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Nephrologist follow-up improves all-cause mortality of severe acute kidney injury survivors. Kidney Int 2013; 83:901-8. [PMID: 23325077 DOI: 10.1038/ki.2012.451] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Survivors of severe acute kidney injury remain at high risk of death well after apparent recovery from the initial insult. Here we determine whether early nephrology follow-up after a hospitalization complicated by severe acute kidney injury associates with patient survival. This consisted of a cohort study of all hospitalized adults in Ontario from 1996 to 2008 with acute kidney injury who received temporary inpatient dialysis and survived for 90 days following discharge independent from dialysis. Propensity scores were used to match individuals with early nephrology follow-up, defined as a visit with a nephrologist within 90 days of discharge, to those without. The outcome was time to all-cause mortality of 3877 patients who met the eligibility criteria within a maximum follow-up of 2 years. A total of 1583 patients had early nephrology follow-up of whom 1184 were successfully matched 1:1 to those not receiving early follow-up. The incidence of all-cause mortality was lower in those patients with early nephrology follow-up compared with those without (8.4 compared with 10.6 per 100-patient years, hazard ratio 0.76 (95% CI: 0.62-0.93)). Thus, early nephrology follow-up after hospitalization with acute kidney injury and temporary dialysis was associated with improved survival. This finding requires definitive testing in a randomized controlled trial.
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Affiliation(s)
- Alison Trembly
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA.
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