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Schattner A. The spectrum of hospitalization-associated harm in the elderly. Eur J Intern Med 2023; 115:29-33. [PMID: 37391309 DOI: 10.1016/j.ejim.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/14/2023] [Accepted: 05/18/2023] [Indexed: 07/02/2023]
Abstract
Acutely ill patients are not infrequently referred to the hospital and admitted, when they could be diagnosed and managed in the ambulatory setting or by hospital-level care at home. Avoidable admissions are particularly regrettable when the wide spectrum of hospitalization-associated patient harm is considered. It includes acute discomfort to the patient due to multiple disturbing hospital stressors; an emotional trauma; the burden of multiple redundant tests begetting false-positive and incidental findings triggering further testing and cascades; highly prevalent adverse events and serious harm associated with medical care, such as nosocomial infections, delirium, falls, and adverse drug events; and a complex array of post-discharge complications including significant physical and functional decline; cognitive decline; flawed transitions of care; common post-discharge adverse events; and a substantial risk of readmission, restarting the vicious cycle and compromising patient well-being, safety, and outcomes. Elderly patients are especially vulnerable, but in-hospital patient harm is not limited to older adults and is associated with increased length of stay, escalating costs, and mortality. The myriad types of harm that often accompany hospital admission is often not fully appreciated. Better awareness may result in better preventive strategies, in finding alternatives to hospital admission in some cases, and may contribute towards an improved patient experience and safety when hospitalization is mandatory, and the provision of enhanced care in the vulnerable post-discharge period.
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Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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Cressman AM, Purohit U, Shadowitz E, Etchells E, Weinerman A, Gerson D, Shojania KG, Stroud L, Wong BM, Shadowitz S. Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study. CMAJ Open 2023; 11:E201-E207. [PMID: 36854457 PMCID: PMC9981162 DOI: 10.9778/cmajo.20220020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors. METHODS We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more. RESULTS We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit. INTERPRETATION Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.
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Affiliation(s)
- Alex M Cressman
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont.
| | - Ushma Purohit
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Ellen Shadowitz
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Edward Etchells
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Adina Weinerman
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Darren Gerson
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Kaveh G Shojania
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Lynfa Stroud
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Brian M Wong
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
| | - Steve Shadowitz
- Department of Medicine (Cressman, Purohit, Etchells, Weinerman, Gerson, Shojania, Stroud, Wong, S. Shadowitz), University of Toronto; Division of General Internal Medicine (Cressman, E. Shadowitz, Etchells, Weinerman, Shojania, Stroud, Wong, S. Shadowitz), Sunnybrook Health Sciences Centre; The Centre for Quality Improvement and Patient Safety (Etchells, Weinerman, Shojania, Wong); Wilson Centre for Education Research (Stroud); Toronto, Ont
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Lee YJ, Johnston DM, Reuland M, Lyketsos CG, Samus Q, Amjad H. Reasons for Hospitalization while Receiving Dementia Care Coordination through Maximizing Independence at Home. J Am Med Dir Assoc 2022; 23:1573-1578.e2. [PMID: 35150611 PMCID: PMC9360184 DOI: 10.1016/j.jamda.2021.12.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/17/2021] [Accepted: 12/25/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Persons living with dementia (PLWD), particularly those with higher levels of functional impairment, are at increased risk of hospitalization and higher hospital-associated health care costs. Our objective was to provide a nuanced description of reasons for hospitalizations over a 12-month period among community-living persons with dementia taking part in a dementia care coordination study using caregiver-reported data and to describe how reasons varied by disease stage. DESIGN Retrospective descriptive analysis of pooled data from 2 concurrent studies of PLWD receiving the MIND at Home dementia care coordination program. SETTING AND PARTICIPANTS Four hundred ninety-four community-dwelling PLWD with a family caregiver in the Greater Baltimore and Central Maryland region, 2015‒2019. METHODS PLWD sociodemographic, clinical, functional, cognitive, and behavioral characteristics were assessed during an in-home baseline visit. Caregiver-reported hospitalizations and primary reasons for events were recorded every 4.5 months by research staff and by memory care coordinators during program delivery for a 12-month period. Hospitalization event data were subsequently reviewed, reconciled, and coded by a trained investigator. RESULTS One hundred seventy PLWD (34.4%) had at least 1 hospitalization within 12 months of enrollment, with 316 separate events. The most common primary reason for hospitalization according to caregivers was infection (22.4%), falls (16.5%), and cardiovascular/pulmonary (12.4%). Top reasons for hospitalization were falls among persons with mild and moderate functional impairment (17.7% and 21.9% respectively) and infection among PLWD with severe impairment (30.3%). CONCLUSIONS AND IMPLICATIONS Infections and falls were the most common caregiver-reported reasons for hospitalization in PLWD receiving dementia care coordination. Reasons for hospitalization varied based on severity of functional impairment. Greater understanding of reasons for hospitalization among PLWD receiving dementia care management interventions, from multiple important perspectives, may help programs more effectively address and prevent hospitalization.
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Affiliation(s)
- Yoon Jae Lee
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Deirdre M Johnston
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Melissa Reuland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Constantine G Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Eggli Y, Halfon P, Piaget-Rossel R, Bischoff T. Measuring medically unjustified hospitalizations in Switzerland. BMC Health Serv Res 2022; 22:158. [PMID: 35130896 PMCID: PMC8822832 DOI: 10.1186/s12913-022-07569-3] [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: 11/05/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Inappropriate use of acute hospital beds is a major topic in health politics. We present here a new approach to measure unnecessary hospitalizations in Medicine and Pediatrics. Methods The necessity of a hospital admission was determined using explicit criteria related to the recorded diagnoses. Two indicators (i.e. “unjustified” and “sometimes justified” stays) were applied to more than 800,000 hospital stays and a random sample of 200 of them was analyzed by two clinicians, using routine data available in medical statistics. The validation of the indicators focused on their precision, validity and adjustment, as well as their usefulness (i.e. interest and risk of abuse). Results Rates, adjusted for case mix (i.e. age of patient, admission planned or not), showed statistically significant differences among hospitals. Only 6.5% of false positives were observed for “unjustified stays” and 17% for “sometimes justified stays”. Respectively 7 and 12% of stays had an unknown status, due to a lack of sufficiently precise data. Considering true positives only, almost one third of medical and pediatric stays were classified as not strictly justified from a medical point of view in Switzerland. Among these stays, about one fifth could have probably been avoided without risk. To enable a larger ambulatory shift, recommendations were made to strengthen the ambulatory care, notably regarding post-emergency follow-up, cardiac and pulmonary functions’ monitoring, pain management, falls prevention, and specialized at-home services that should be offered. Conclusion We recommend using “unjustified stays” and “sometimes justified stays” indicators to monitor inappropriate hospitalizations. The latter could help the planning of reinforced ambulatory care measures to pursue the ambulatory shift. Nonetheless, we clearly advise against the use of these two indicators for hospitals financing purposes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07569-3.
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Affiliation(s)
- Yves Eggli
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland.
| | - Patricia Halfon
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland
| | - Romain Piaget-Rossel
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland
| | - Thomas Bischoff
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland
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Qian AS, Qiao EM, Nalawade V, Voora RS, Kotha NV, Dameff C, Coyne CJ, Murphy JD. Impact of underlying malignancy on emergency department utilization and outcomes. Cancer Med 2021; 10:9129-9138. [PMID: 34821051 PMCID: PMC8683529 DOI: 10.1002/cam4.4414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/14/2021] [Accepted: 10/24/2021] [Indexed: 11/11/2022] Open
Abstract
PURPOSE Cancer patients frequently utilize the emergency department (ED) for a variety of diagnoses both related to and unrelated to their cancer, yet ED outcomes for cancer patients are not well documented. This study sought to define risks and identify predictors for inpatient admission and hospital mortality among cancer patients presenting to the ED. PATIENTS AND METHODS We utilized the National Emergency Department Sample to identify patients with and without a diagnosis of cancer presenting to the ED between January 2016 and December 2018. We used multivariable mixed-effects logistic regression models to assess the influence of cancer on outcomes of hospital admission after the ED visit and hospital mortality for the whole patient cohort and individual presenting diagnoses. RESULTS There were 340 million weighted ED visits, of which 8.3 million (2.3%) were associated with a cancer diagnosis. Compared to non-cancer patients, patients with cancer had an increased risk of inpatient admission (64.7% vs. 14.8%; p < 0.0001) and hospital mortality (4.6% vs. 0.5%; p < 0.0001). For each of the top 15 presenting diagnoses, cancer patients had increased risks of hospitalization (odds ratio [OR] range 2.0-13.2) or death (OR range 2.1-14.4). Although our dataset does not contain reliable estimation of stage, cancer site was the most robust individual predictor associated with the risk of hospitalization or death compared to other clinical or system-related factors. CONCLUSIONS Cancer patients in the ED have high risks for hospital admission and death when compared to patients without cancer. Cancer patients represent a distinct population and may benefit from cancer-specific risk stratification or focused interventions to improve outcomes.
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Affiliation(s)
- Alexander S Qian
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Edmund M Qiao
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Rohith S Voora
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Nikhil V Kotha
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Christian Dameff
- Department of Emergency Medicine, University of California San Diego, La Jolla, California, USA
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, La Jolla, California, USA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
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Chang ET, Asch SM, Eng J, Gutierrez F, Denietolis A, Atkins D. What Is the Return on Investment of Caring for Complex High-need, High-cost Patients? J Gen Intern Med 2021; 36:3541-3544. [PMID: 34508291 PMCID: PMC8606499 DOI: 10.1007/s11606-021-07110-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/20/2021] [Indexed: 11/26/2022]
Abstract
Randomized controlled trials to improve care for complex, high-need, high-cost patients have not consistently demonstrated a relative decrease in acute care utilization or cost savings. However, the Veterans Health Administration (VHA) has been able to glean lessons from these trials and generate realistic expectations for success. Lessons include the following: (1) combining population management tools (e.g., risk scores) and clinician judgment is more effective than either alone to identify the patients best suited for intensive management; (2) treatment adherence and engagement may contribute more to preventable emergency department visits and hospitalizations than care coordination; and (3) efforts should focus on assessing for and treating those risk factors that are most amenable to intervention. Because it is unlikely that cost savings can fund add-on intensive management programs, the VHA Office of Primary Care plans to incorporate those intensive management practices that are feasible into existing patient-centered medical homes as a high reliability organization.
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Affiliation(s)
- Evelyn T Chang
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.
- Department of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Division of General Internal Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Steven M Asch
- VA HSR&D Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jessica Eng
- VA San Francisco Healthcare System, San Francisco, CA, USA
- University of California San Francisco, School of Medicine, San Francisco, CA, USA
| | | | | | - David Atkins
- VA Health Services Research and Development, Washington, DC, USA
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Ramalho A, Castro P, Lobo M, Souza J, Santos P, Freitas A. Integrated quality assessment for diabetes care in Portuguese primary health care using prevention quality indicators. Prim Care Diabetes 2021; 15:507-512. [PMID: 33441264 DOI: 10.1016/j.pcd.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 01/25/2023]
Abstract
AIMS This study evaluates the prevention quality indicators (PQI) for Diabetes Mellitus (DM) in Portugal using contemporary data and explores their variability according to Primary Health Care (PHC) quality indicators. METHODS We conducted a retrospective observational analysis of secondary data comprising Portuguese PHC indicators by health centres group (ACES) and the National Hospital Morbidity Database. We calculated and analysed age-sex-adjusted rates for each PQI. Worse-performing ACES were identified using the 2017 median PQI values as an assessment cut-off. A multivariate logistic analysis was carried to find variables associated with the likelihood of being a worse-performing ACES for the biennium. RESULTS The median values of the indicator PQI93 - Prevention Quality Diabetes Composite were 79 and 65.2 hospitalizations per 100 000 pop, in 2016 and 2017 respectively. Diabetes long term complications (PQI 03) accounted for most of the hospitalizations. The quality indicator in PHC with greater influence on PQI93 was the proportion of DM patients with <65 years with test results for HbA1c < = 6.5%. CONCLUSIONS This study shows that some PHC quality indicators are closely related to DM care, and so their monitoring is of high importance. Diabetes long term complications (PQI 03) demand greater attention from PHC professionals.
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Affiliation(s)
- A Ramalho
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal; ACHE - American College of Healthcare Executives, Chicago, IL, USA.
| | - P Castro
- CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal; USF Camélias, ACeS Gaia - Grande Porto VII (ARS Norte) - Vila Nova de Gaia, Portugal
| | - M Lobo
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal
| | - J Souza
- CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal
| | - P Santos
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal
| | - A Freitas
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal
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Teixeira H, Freitas A, Sarmento A, Nossa P, Gonçalves H, Pina MDF. Spatial Patterns in Hospital-Acquired Infections in Portugal (2014-2017). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094703. [PMID: 33925064 PMCID: PMC8124660 DOI: 10.3390/ijerph18094703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital-Acquired Infections (HAIs) represent the most frequent adverse event associated with healthcare delivery and result in prolonged hospital stays and deaths worldwide. AIM To analyze the spatial patterns of HAI incidence from 2014 to 2017 in Portugal. METHODS Data from the Portuguese Discharge Hospital Register were used. We selected episodes of patients with no infection on admission and with any of the following HAI diagnoses: catheter-related bloodstream infections, intestinal infections by Clostridium difficile, nosocomial pneumonia, surgical site infections, and urinary tract infections. We calculated age-standardized hospitalization rates (ASHR) by place of patient residence. We used empirical Bayes estimators to smooth the ASHR. The Moran Index and Local Index of Spatial Autocorrelation (LISA) were calculated to identify spatial clusters. RESULTS A total of 318,218 HAIs were registered, with men accounting for 49.8% cases. The median length of stay (LOS) was 9.0 days, and 15.7% of patients died during the hospitalization. The peak of HAIs (n = 81,690) occurred in 2015, representing 9.4% of the total hospital admissions. Substantial spatial inequalities were observed, with the center region presenting three times the ASHR of the north. A slight decrease in ASHR was observed after 2015. Pneumonia was the most frequent HAI in all age groups. CONCLUSION The incidence of HAI is not randomly distributed in the space; clusters of high risk in the central region were seen over the entire study period. These findings may be useful to support healthcare policymakers and to promote a revision of infection control policies, providing insights for improved implementation.
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Affiliation(s)
- Hugo Teixeira
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (A.F.); (H.G.)
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, 4200-135 Porto, Portugal; (A.S.); (M.d.F.P.)
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135 Porto, Portugal
- Correspondence: or
| | - Alberto Freitas
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (A.F.); (H.G.)
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - António Sarmento
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, 4200-135 Porto, Portugal; (A.S.); (M.d.F.P.)
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135 Porto, Portugal
- Department of Infectious Diseases, Centro Hospitalar Universitário de São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Paulo Nossa
- CEGOT, Centre of Studies in Geography and Spatial Planning, University of Coimbra, 3004-530 Coimbra, Portugal;
- Department of Geography and Tourism, University of Coimbra, 3004-530 Coimbra, Portugal
| | - Hernâni Gonçalves
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; (A.F.); (H.G.)
- CINTESIS—Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - Maria de Fátima Pina
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, 4200-135 Porto, Portugal; (A.S.); (M.d.F.P.)
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135 Porto, Portugal
- ICICT/FIOCRUZ, Instituto de Comunicação e Informação Científica e Tecnológica em Saúde/Fundação Oswaldo Cruz, 21040-900 Rio De Janeiro, Brazil
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Amjad H, Borson S. Invigorating primary care for older adults living with dementia. J Am Geriatr Soc 2021; 69:1186-1189. [PMID: 33890295 DOI: 10.1111/jgs.17123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Halima Amjad
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Soo Borson
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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Landscapes on Prevention Quality Indicators: A Spatial Analysis of Diabetes Preventable Hospitalizations in Portugal (2016-2017). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228387. [PMID: 33198417 PMCID: PMC7697335 DOI: 10.3390/ijerph17228387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 11/16/2022]
Abstract
Preventable hospitalizations due to complications of diabetes mellitus (DM), represented by the related prevention quality indicators (PQI), are ambulatory care-sensitive conditions that can be prevented and controlled through effective primary health care (PHC) treatment. It is important to reduce mortality and promote the quality of life to diabetic patients in regions with higher hospitalization rates. The study aims to analyze the results of the DM age-sex-adjusted PQI, by groups of health centers (ACES), distributed in the Portuguese territory. The most representative PQI at a national level were identified, and the trends were mapped and analyzed. Also, it presents the ACES with the highest age-adjusted rates of avoidable hospitalizations for DM. The absolute number of preventable hospitalizations for all DM complications in Portugal has decreased by 20%, thus passing from the rate of 79 in 2016 to 65.2/100,000 inhabitants in 2017. Despite the improvement in results for PQI 03, 20 of 48 ACES that were above the national 2017 median rate in 2016, achieved better results the following year, and for the overall preventable diabetes hospitalizations (PQI 93) only 11 out 39, revealing the need for further studies and PHC actions to improve the diabetic quality of life.
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Nguyen NH, Luo J, Ohno-Machado L, Sandborn WJ, Singh S. Burden and Outcomes of Fragmentation of Care in Hospitalized Patients With Inflammatory Bowel Diseases: A Nationally Representative Cohort. Inflamm Bowel Dis 2020; 27:1026-1034. [PMID: 32944753 PMCID: PMC8205632 DOI: 10.1093/ibd/izaa238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Fragmentation of care (FoC) may adversely impact health care quality in patients with chronic diseases. We conducted a US nationally representative cohort study to evaluate the burden and outcomes of FoC in hospitalized patients with inflammatory bowel disease (IBD). METHODS Using Nationwide Readmissions Database 2013, we created 2 cohorts of superutilizer patients with IBD with 2 hospitalizations (cohort 1: FoC, defined as readmission to nonindex hospital vs no FoC) or 3 hospitalizations (cohort 2: multiple episodes of fragmentation vs single episode of fragmentation vs no FoC) between January and June 2013, which were followed through December 2013. We evaluated burden, pattern, and outcomes of fragmentation (6-month risk of readmission, risk of surgery, and inpatient mortality). RESULTS In cohort 1, of 6073 patients with IBD with 2 admissions within 6 months, 1394 (23%) experienced FoC. Fragmentation of care was associated with modestly higher risk of readmission within 6 months (31% vs 28%, P < 0.01; adjusted relative risk, 1.11 [1.01-1.21]), without differences in risk of surgery (2.8% vs 4.3%, P = 0.19) or in-hospital mortality (0.2% vs 0.5%, P = 0.22). In cohort 2, of 1717 patients with 3 hospitalizations within 6 months, the number of patients with multiple episodes of fragmentation was associated with higher risk of readmission compared with patients with single episode of fragmentation or no FoC (52% vs 49% vs 43%, P = 0.03). CONCLUSIONS In a US cohort study, FoC is associated with a modestly higher risk of readmission, without higher risk of surgery or mortality in superutilizer patients with IBD. Future studies focusing on impact of outpatient care and postdischarge coordination are warranted in superutilizer patients.
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Affiliation(s)
| | - Jiyu Luo
- Division of Biostatistics and Bioinformatics, La Jolla, California
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California
| | | | - Siddharth Singh
- Division of Gastroenterology, La Jolla, California,Division of Biostatistics and Bioinformatics, La Jolla, California,Address correspondence to: Siddharth Singh, MD, MS, Division of Gastroenterology, University of California San Diego, 9452 Medical Center Drive, ACTRI 1W501, La Jolla, CA 92093, USA. E-mail:
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12
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Evaluation of Hospitalizations Preventable with Idealized Outpatient Care and Continuity of Care. J Healthc Qual 2020; 43:145-152. [PMID: 32168121 DOI: 10.1097/jhq.0000000000000259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Unnecessary hospitalizations may pose the risk of iatrogenic complications, suboptimal patient experience, and increased cost. Administrative data lack granularity to understand the proportion and causes of hospitalizations preventable through optimizing care continuum (HPOCC). We aim to identify the incidence and causes of HPOCC through clinician-adjudicated chart review. METHODS A retrospective review was performed for inpatient admissions from the emergency department (ED) over 1 week. Each admission was reviewed by a clinician to determine whether it is an HPOCC defined as not requiring inpatient care with the assumption of idealized outpatient care and social support. RESULTS Of the 515 patients admitted from the ED, 31 (6.0%) patients were judged to have had an HPOCC. Causes of HPOCC include urgent diagnostics (9, 29.0%), unnecessary transfer from a long-term facility (7, 23.0%), needing IV therapy (5, 16.0%), benign incidental finding (5, 16.0%), diagnostic uncertainty in complex chronic illness (3, 10.0%), and lack of access to care for disposition (2, 6.0%). CONCLUSION Hospitalizations preventable through optimizing care continuum account for about 1 in every 15 hospitalizations in an urban academic medical center. The need for urgent diagnostics accounts for a plurality of HPOCC and could be an important target for quality improvement.
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Velásquez ST, Wang ES, White AA, Chadha J, Mader M, Leykum LK, Pugh J. Hospitalists as Triagists: Description of the Triagist Role across Academic Medical Centers. J Hosp Med 2020; 12:87-90. [PMID: 31634098 DOI: 10.12788/jhm.3327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
From the hospitalist perspective, triaging involves the evaluation of a patient for potential admission to an inpatient service. Although traditionally done by residents, many academic hospitalist groups have assumed the responsibility for triaging. We conducted a cross-sectional survey of 235 adult hospitalists at 10 academic medical centers (AMCs) to describe the similarities and differences in the triagist role and assess the activities and skills associated with the role. Eight AMCs have a defined triagist role; at the others, hospitalists supervise residents/advanced practice providers. The triagist role is generally filled by a faculty physician and shared by all hospitalists.We found significant variability in verbal communication practices (P = .02) and electronic communication practices (P < .0001) between the triagist and the current provider (eg, emergency department, clinic provider), and in the percentage of patients evaluated in person (P < .0001). Communication skills, personal efficiency, and systems knowledge are dominant themes of attributes of an effective triagist.
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Affiliation(s)
- Sadie Trammell Velásquez
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas
| | - Emily S Wang
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas
| | - Andrew A White
- University of Washington School of Medicine, Department of Medicine, Seattle, Washington
| | - Jagriti Chadha
- University of Kentucky, Division of Hospital Medicine, Lexington, Kentucky
| | - Michael Mader
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas
| | - Luci K Leykum
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas
| | - Jacqueline Pugh
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas
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Singotani RG, Karapinar F, Brouwers C, Wagner C, de Bruijne MC. Towards a patient journey perspective on causes of unplanned readmissions using a classification framework: results of a systematic review with narrative synthesis. BMC Med Res Methodol 2019; 19:189. [PMID: 31585528 PMCID: PMC6778387 DOI: 10.1186/s12874-019-0822-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 08/15/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Several literature reviews have been published focusing on the prevalence and/or preventability of hospital readmissions. To our knowledge, none focused on the different causes which have been used to evaluate the preventability of readmissions. Insight into the range of causes is crucial to understand the complex nature of readmissions. We conducted a systematic review to: (1) evaluate the range of causes of unplanned readmissions in a patient journey, and (2) present a cause classification framework that can support future readmission studies. METHODS A literature search was conducted in PUBMED and EMBASE using "readmission" and "avoidability" or "preventability" as key terms. Studies that specified causes of unplanned readmissions were included. The causes were classified into eight preliminary root causes: Technical, Organization (integrated care), Organization (hospital department level), Human (care provider), Human (informal caregiver), Patient (self-management), Patient (disease), and Other. The root causes were based on expert opinions and the root cause analysis tool of PRISMA (Prevention and Recovery Information System for Monitoring and Analysis). The range of different causes were analyzed using Microsoft Excel. RESULTS Forty-five studies that reported 381 causes of readmissions were included. All studies reported causes related to organization of care at the hospital department level. These causes were often reported as preventable. Twenty-two studies included causes related to patient's self-management and 19 studies reported causes related to patient's disease. Studies differed in which causes were seen as preventable or unpreventable. None reported causes related to technical failures and causes due to integrated care issues were reported in 18 studies. CONCLUSIONS This review showed that causes for readmissions were mainly evaluated from a hospital perspective. However, causes beyond the scope of the hospital can also play a major role in unplanned readmissions. Opinions regarding preventability seem to depend on contextual factors of the readmission. This study presents a cause classification framework that could help future readmission studies to gain insight into a broad range of causes for readmissions in a patient journey.
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Affiliation(s)
- R. G. Singotani
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands
| | - F. Karapinar
- Department of clinical pharmacy, Onze Lieve Vrouwe Gasthuis (OLVG), location West, Jan Tooropstraat 164, 1061 AE Amsterdam, The Netherlands
| | - C. Brouwers
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands
| | - C. Wagner
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands
- Netherlands institute for Health Services research, Otterstraat 118-124, 3513 CR Utrecht, The Netherlands
| | - M. C. de Bruijne
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands
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Maust DT, Kim HM, Chiang C, Langa KM, Kales HC. Predicting Risk of Potentially Preventable Hospitalization in Older Adults with Dementia. J Am Geriatr Soc 2019; 67:2077-2084. [PMID: 31211418 PMCID: PMC6896207 DOI: 10.1111/jgs.16030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Reducing potentially preventable hospitalization (PPH) among older adults with dementia is a goal of Healthy People 2020, yet no tools specifically identify patients with dementia at highest risk. The objective was to develop a risk prediction model to identify older adults with dementia at high imminent risk of PPH. DESIGN A 30-day risk prediction model was developed using multivariable logistic regression. Patients from fiscal years (FY) 2009 to 2011 were split into development and validation cohorts; FY2012 was used for prediction. SETTING Community-dwelling older adults (≥65 years of age) with dementia who received care through the Veterans Health Administration. PARTICIPANTS There were 1 793 783 participants. MEASUREMENTS Characteristics associated with hospitalization risk were (1) age and other demographic factors; (2) outpatient, emergency department, and inpatient utilization; (3) medical and psychiatric diagnoses; and (4) prescribed medication use including changes to psychotropic medications (eg, initiation or dosage increase). Model discrimination was determined by the C statistic for each of the three cohorts. Finally, to determine whether predicted 30-day risk strata were stable over time, the observed PPH rate was calculated out to 1 year. RESULTS In the development cohort, .6% of patients experienced PPH within 30 days. The C statistic for the development cohort was .83 (95% confidence interval [CI] = .83-.84) and .83 in the prediction cohort (95% CI = .82-.84). Patients in the top 10% of predicted 30-day PPH risk accounted for more than 50% of 30-day PPH admissions in all three cohorts. In addition, those predicted to be at elevated 30-day risk remained at higher risk throughout a year of follow-up. CONCLUSION It is possible to identify older adults with dementia at high risk of imminent PPH, and their risk remains elevated for an entire year. Given the negative outcomes associated with acute hospitalization for those with dementia, healthcare systems and providers may be able to engage these high-risk patients proactively to avoid unnecessary hospitalization. J Am Geriatr Soc 67:2077-2084, 2019.
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Affiliation(s)
- Donovan T. Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - H. Myra Kim
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Claire Chiang
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Kenneth M. Langa
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Helen C. Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Nguyen NH, Ohno-Machado L, Sandborn WJ, Singh S. Obesity Is Independently Associated With Higher Annual Burden and Costs of Hospitalization in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2019; 17:709-718.e7. [PMID: 30012429 DOI: 10.1016/j.cgh.2018.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 04/10/2018] [Accepted: 07/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Approximately 15%-40% patients with inflammatory bowel diseases (IBD) are obese. There is an inconsistent association between obesity and IBD phenotype and course. We conducted a nationally representative cohort study to estimate and compare the burden, costs, and causes for hospitalization in obese vs non-obese patients with IBD. METHODS Using the Nationwide Readmissions Database 2013, we identified obese (based on administrative claims code) and non-obese patients who had been hospitalized at least once, from January through June 2013, and followed them for re-hospitalization until December 2013. We compared annual burden (total days spent in hospital), costs, causes, and outcomes of hospitalization between obese and non-obese patients after 1:1 propensity score matching. RESULTS We identified 42,285 patients with IBD, of which 12.4% were obese. After propensity score matching, we included 5128 obese and 5128 non-obese IBD patients in our analysis. Compared to non-obese patients, obese patients spent more days in hospital annually (median, 8 vs 5 days) (P < .01), with higher hospitalization-related costs (median, $17,277 vs $11,847) (P < .01); this pattern persisted in subsets of high-need and high-cost patients. Compared to non-obese patients, obese patients were more likely to be hospitalized with preventable admissions (19% vs 15%) or cardiopulmonary complications (16% vs 12%). CONCLUSIONS In an analysis of data on patients with IBD from the Nationwide Readmissions Database 2013, we found obesity to be independently associated with higher burden and costs of hospitalizations. Strategies should be considered to target obesity as adjunctive therapy for patients with IBD.
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Affiliation(s)
- Nghia H Nguyen
- Department of Internal Medicine, University of California San Diego, La Jolla, California
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California; Division of Gastroenterology, University of California San Diego, La Jolla, California.
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Nguyen NH, Khera R, Ohno-Machado L, Sandborn WJ, Singh S. Annual Burden and Costs of Hospitalization for High-Need, High-Cost Patients With Chronic Gastrointestinal and Liver Diseases. Clin Gastroenterol Hepatol 2018; 16:1284-1292.e30. [PMID: 29474966 PMCID: PMC6056327 DOI: 10.1016/j.cgh.2018.02.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We estimated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases, and identified characteristics of high-need, high-cost patients, in a nationally representative sample. METHODS Using Nationwide Readmissions Database 2013, we identified patients with at least 1 hospitalization between January and June 2013, and a diagnosis of inflammatory bowel diseases (IBDs), chronic liver diseases (CLDs), functional gastrointestinal disorders (FGIDs), gastrointestinal hemorrhage, or pancreatic diseases, with 6 months or more of follow up. We calculated days spent in hospital/month and estimated costs of the entire cohort, and identified characteristics of high-need, high-cost patients (top decile of days spent in hospital/month). RESULTS Patients with IBD (n = 47,402), CLDs (n = 376,810), FGIDs (n = 351,583), gastrointestinal hemorrhage (n = 190,881), or pancreatic diseases (n = 98,432), hospitalized at least once, spent a median of 6 to 7 days (interquartile range, 3-14 d) in the hospital each year (total for all diseases). Compared to patients in the lowest decile (median, 0.13-0.14 d/mo spent in the hospital), patients in the highest decile spent a median 3.7-4.1 days/month in hospital (total for all diseases), with hospitalization costs ranging from $7502/month to $8925/month and 1 hospitalization every 2 months. Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients. Based on multivariate logistic regression, high-need, high-cost patients were more likely to have Medicare/Medicaid insurance, lower income status, index hospitalization in a large rural hospital, high comorbidity burden, obesity, and infection-related hospitalization. CONCLUSIONS In a nationwide database analysis of patients with IBD, CLD, FGID, gastrointestinal hemorrhage, or pancreatic diseases hospitalized at least once, we found that a small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs. Population health management directed toward these patients would facilitate high-value care.
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Affiliation(s)
- Nghia H. Nguyen
- Department of Internal Medicine, University of California San Diego, La Jolla, California
| | - Rohan Khera
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas
| | - Lucila Ohno-Machado
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - William J. Sandborn
- Health System Department of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Health System Department of Biomedical Informatics, University of California San Diego, La Jolla, California.
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Zhou K, Vidyarthi A, Matchar D, Cheung YB, Lam SW, Ong M. The relationship between workload and length of stay in Singapore. Health Policy 2018; 122:769-774. [PMID: 29729904 DOI: 10.1016/j.healthpol.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/20/2018] [Accepted: 04/03/2018] [Indexed: 11/26/2022]
Abstract
Prior studies link higher workload with longer length of stay (LOS) in the US. Unlike U.S. hospitals, Singaporean hospitals, like other major hospitals in the Asia-Pacific, are partially occupied by patients with non-acute needs due to insufficient alternative facilities. We examined the association between workload and length of stay (LOS) and the impact of workload on 30-day re-hospitalization and inpatient mortality rates in retrospective cohort in this setting. We defined workload as the daily number of patients per physician team. 13,097 hospitalizations of 10,000 patients were included. We found that higher workload was associated with shorter LOS (coefficient, -0.044 [95%CI, -0.083, -0.01]), especially for patients with longer stays (hazard ratios, not significantly greater than 1 before Day 4, 1.04 [95%CI, 1.01, 1.07] at Day 4 and 1.16 [95%CI, 1.10, 1.24] at Day 10), without affecting inpatient mortality (odds ratio (OR), 1.03 [95%CI, 0.99, 1.05]) or 30-day re-hospitalization (OR, 1.01 [95%CI, 0.99, 1.04]). This result differs from studies in the US and may reflect regional differences in the use of acute hospital beds for non-acute needs.
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Affiliation(s)
- Ke Zhou
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.
| | - Arpana Vidyarthi
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Medicine, National University Health System, Singapore
| | - David Matchar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Medicine, Duke University, Durham, NC, United States; Department of Pathology, Duke University, Durham, NC, United States
| | - Yin Bun Cheung
- Center for Quantitative Medicine, Duke-NUS Medical School, Singapore; Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Finland
| | - Shao Wei Lam
- SingHealth Health Services Research Centre, Singapore Health Services, Singapore
| | - Marcus Ong
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore; Associate Director, Health Systems and Services Research, Duke-NUS Medical School, Singapore
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Characterizing Potentially Preventable Admissions: A Mixed Methods Study of Rates, Associated Factors, Outcomes, and Physician Decision-Making. J Gen Intern Med 2018; 33:737-744. [PMID: 29340940 PMCID: PMC5910342 DOI: 10.1007/s11606-017-4285-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 09/29/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Potentially preventable admissions are a target for healthcare cost containment. OBJECTIVE To identify rates of, characterize associations with, and explore physician decision-making around potentially preventable admissions. DESIGN A comparative cohort study was used to determine rates of potentially preventable admissions and to identify associated factors and patient outcomes. A qualitative case study was used to explore physicians' clinical decision-making. PARTICIPANTS Patients admitted from the emergency department (ED) to the general medicine (GM) service over a total of 4 weeks were included as cases (N = 401). Physicians from both emergency medicine (EM) and GM that were involved in the cases were included (N = 82). APPROACH Physicians categorized admissions as potentially preventable. We examined differences in patient characteristics, admission characteristics, and patient outcomes between potentially preventable and control admissions. Interviews with participating physicians were conducted and transcribed. Transcriptions were systematically analyzed for key concepts regarding potentially preventable admissions. KEY RESULTS EM and GM physicians categorized 22.2% (90/401) of admissions as potentially preventable. There were no significant differences between potentially preventable and control admissions in patient or admission characteristics. Potentially preventable admissions had shorter length of stay (2.1 vs. 3.6 days, p < 0.001). There was no difference in other patient outcomes. Physicians discussed several provider, system, and patient factors that affected clinical decision-making around potentially preventable admissions, particularly in the "gray zone," including risk of deterioration at home, the risk of hospitalization, the cost to the patient, and the presence of outpatient resources. Differences in provider training, risk assessment, and provider understanding of outpatient access accounted for differences in decisions between EM and GM physicians. CONCLUSIONS Collaboration between EM and GM physicians around patients in the gray zone, focusing on patient risk, cost, and outpatient resources, may provide an avenues for reducing potentially preventable admissions and lowering healthcare spending.
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Nguyen NH, Ohno-Machado L, Sandborn WJ, Singh S. Infections and Cardiovascular Complications are Common Causes for Hospitalization in Older Patients with Inflammatory Bowel Diseases. Inflamm Bowel Dis 2018; 24:916-923. [PMID: 29562273 DOI: 10.1093/ibd/izx089] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Prevalence of inflammatory bowel diseases (IBD) in older patients is increasing. Risk-benefit trade-offs of therapy are poorly understood in older patients, who may be at higher risk of nonIBD and/or treatment-related complications, rather than disease-related complications. We conducted a nationally representative cohort study to estimate and compare annual burden, costs, and causes for hospitalization in older versus younger patients with IBD. METHODS Using the Nationwide Readmissions Database 2013, we created a cohort of 47,402 patients with IBD who had been hospitalized at least once between January-June 2013 and followed for rehospitalization until December 2013. We estimated annual burden (total days spent in hospital), costs, and causes (based on primary discharge diagnosis) of hospitalization in older (>64y, n = 15,428), middle-age (40-64y, n = 18,476), and younger (<40y, n = 13,498) patients. RESULTS Older patients with IBD spent more days in hospital annually [median interquartile range : 7 (3-13) days] than middle-age [6 (3-12) days], and younger patients [5 ([3-11) days], with significantly higher hospitalization-related costs $15,078 (7423-30,955) vs $12,921 (6367-28,182) vs.. $10,070 (5192-22,100), P < 0.01. Older patients were significantly more likely to be hospitalized due to serious infections (14.6% vs 10.6% vs 8.4%; P < 0.01) and cardiovascular complications (9.9% vs 4.3% vs 0.8%; P < 0.01), and they were less likely due to IBD-related complications (11.8% vs 23.5% vs 41.4%; P < 0.01). CONCLUSIONS Older IBD patients have higher burden and costs of hospitalization than younger patients, mainly attributed to serious infections and cardiovascular complications, rather than disease-related complications. Careful assessment of comparative risks-benefits of different IBD therapies in older patients is warranted to identify the optimal treatment approach.
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Affiliation(s)
- Nghia H Nguyen
- Department of Internal Medicine, University of California San Diego, La Jolla, California
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Biomedical Informatics, University of California San Diego, La Jolla, California.,Division of Gastroenterology, University of California San Diego, La Jolla, California
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Amjad H, Carmichael D, Austin AM, Chang CH, Bynum JPW. Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare. JAMA Intern Med 2016; 176:1371-8. [PMID: 27454945 PMCID: PMC5061498 DOI: 10.1001/jamainternmed.2016.3553] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia. OBJECTIVE To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. DESIGN, SETTING, AND PARTICIPANTS This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included. EXPOSURES Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles. MAIN OUTCOMES AND MEASURES Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician). RESULTS Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22 004 vs $24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups. CONCLUSIONS AND RELEVANCE Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.
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Affiliation(s)
- Halima Amjad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Donald Carmichael
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Chiang-Hua Chang
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Julie P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Segal JB. More Challenges in Measuring Care Quality. J Gen Intern Med 2016; 31:589-90. [PMID: 27025847 PMCID: PMC4870432 DOI: 10.1007/s11606-016-3672-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jodi B Segal
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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