1
|
Chang ET, Huynh A, Yoo C, Yoon J, Zulman DM, Ong MK, Klein M, Eng J, Roy S, Stockdale SE, Jimenez EE, Denietolis A, Needleman J, Asch SM. Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis. J Gen Intern Med 2024:10.1007/s11606-024-08923-3. [PMID: 39075268 DOI: 10.1007/s11606-024-08923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/26/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. OBJECTIVE The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs. DESIGN Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. PARTICIPANTS Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. INTERVENTION PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. MAIN OUTCOMES AND MEASURES Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. KEY RESULTS Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM. CONCLUSIONS AND RELEVANCE VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes. TRIAL REGISTRATION PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.
Collapse
Affiliation(s)
- Evelyn T Chang
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Alexis Huynh
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
| | - Caroline Yoo
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
| | - Jean Yoon
- VHA Health Economics Resource Center (HERC), Menlo Park, CA, USA
- Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA
| | - Donna M Zulman
- VHA HSR Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael K Ong
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Klein
- Department of Medicine, VHA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Jessica Eng
- On Lok Program of All-Inclusive Care for the Elderly (PACE), San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, CA, USA
| | - Sudip Roy
- VHA Salisbury Healthcare System, Salisbury, NC, USA
| | - Susan E Stockdale
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA
| | - Elvira E Jimenez
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Behavioral Neurology, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Angela Denietolis
- VHA Office of Primary Care, 810 Vermont Ave, Washington, DC, 20420, USA
| | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven M Asch
- VHA HSR Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
2
|
Nummedal MA, King S, Uleberg O, Pedersen SA, Bjørnsen LP. Non-emergency department (ED) interventions to reduce ED utilization: a scoping review. BMC Emerg Med 2024; 24:117. [PMID: 38997631 PMCID: PMC11242019 DOI: 10.1186/s12873-024-01028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
Collapse
Affiliation(s)
- Målfrid A Nummedal
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sarah King
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Oddvar Uleberg
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sindre A Pedersen
- The Medicine and Health Library, Library Section for Research Support, Data and Analysis, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lars Petter Bjørnsen
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| |
Collapse
|
3
|
Tyler N, Hodkinson A, Planner C, Angelakis I, Keyworth C, Hall A, Jones PP, Wright OG, Keers R, Blakeman T, Panagioti M. Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2023; 6:e2344825. [PMID: 38032642 PMCID: PMC10690480 DOI: 10.1001/jamanetworkopen.2023.44825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Importance Discharge from the hospital to the community has been associated with serious patient risks and excess service costs. Objective To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community. Data Sources CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022. Study Selection Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified. Data Extraction and Synthesis At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Main Outcomes and Measures The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake. Results Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits. Conclusions and Relevance These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.
Collapse
Affiliation(s)
- Natasha Tyler
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Alexander Hodkinson
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Claire Planner
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Ioannis Angelakis
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- Institute of Population Health, Department of Primary Care & Mental Health, University of Liverpool, Liverpool, United Kingdom
| | | | - Alex Hall
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | | | | | - Richard Keers
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
- Pharmacy Department, Pennine Care NHS Foundation Trust, Aston-Under-Lyne, United Kingdom
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Tom Blakeman
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Maria Panagioti
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| |
Collapse
|
4
|
Pu YC, Chou HC, Huang CT, Sheng WH. Readmission outcomes following infectious hospitalization: same-care unit performed better than different-care unit. BMC Health Serv Res 2023; 23:236. [PMID: 36899370 PMCID: PMC10007781 DOI: 10.1186/s12913-023-09220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 02/24/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Previous studies showed that same-hospital readmission is associated with better outcomes than different-hospital readmission. However, little is known about whether readmission to the same care unit (same-care unit readmission) after infectious hospitalization performs better than readmission to a different care unit at the same hospital (different-care unit readmission). METHODS This retrospective study screened patients rehospitalized within 30 days following admission to two acute medical wards for infectious diseases from 2013 to 2015 and included only those readmitted for unplanned medical reasons. Outcomes of interest included hospital mortality and length of stay of readmitted patients. RESULTS Three hundred and fifteen patients were included; of those, 149(47%) and 166(53%) were classified as same-care unit and different-care unit readmissions, respectively. Same-care unit patients were more likely to be older(76 years vs. 70 years; P = 0.001), have comorbid chronic kidney disease(20% vs. 9%; P = 0.008), and have a shorter time to readmission(13 days vs. 16 days; P = 0.020) than different-care unit patients. Univariate analysis showed that same-care unit patients had a shorter length of stay than different-care unit patients(13 days vs. 18 days; P = 0.001), but had similar hospital mortality(20% vs. 24%; P = 0.385). The multivariable linear regression model indicated that same-care unit readmission was associated with a 5-day shorter hospital stay than different-care unit readmission(P = 0.002). CONCLUSION Among patients readmitted within 30 days after hospitalization for infectious diseases, same-care unit readmission was associated with a shorter length of hospital stay than different-care unit readmission. Whenever feasible, it is encouraged to allocate a readmitted patient to the same care unit in hope of pursuing continuity and quality of care.
Collapse
Affiliation(s)
- Yi-Chin Pu
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiao-Chen Chou
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Ta Huang
- Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan. .,Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan.
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| |
Collapse
|
5
|
LaBedz SL, Prieto-Centurion V, Mutso A, Basu S, Bracken NE, Calhoun EA, DiDomenico RJ, Joo M, Pickard AS, Pittendrigh B, Williams MV, Illendula S, Krishnan JA. Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study. J Gen Intern Med 2022; 37:4103-4111. [PMID: 35260961 PMCID: PMC9708982 DOI: 10.1007/s11606-022-07461-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/04/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Minority-serving hospitals (MSHs) need evidence-based strategies tailored to the populations they serve to improve patient-centered outcomes after hospitalization. METHODS We conducted a pragmatic randomized clinical trial (RCT) from October 2014 to January 2017 at a MSH comparing the effectiveness of a stakeholder-supported Navigator intervention vs. Usual care on post-hospital patient experience, outcomes, and healthcare utilization. Community health workers and peer coaches delivered the intervention which included (1) in-hospital visits to assess barriers to health/healthcare and to develop a personalized Discharge Patient Education Tool (DPET); (2) a home visit to review the DPET; and (3) telephone-based peer coaching. The co-primary outcomes were between-group comparisons of 30-day changes in Patient-Reported Outcomes Measurement Information System (PROMIS) measures of anxiety and informational support (minimum important difference is 2 to 5 units change); a p-value <0.025 was considered significant using intention-to-treat analysis. Secondary outcomes included death, ED visits, or readmissions and measures of emotional, social, and physical health at 30 and 60 days. RESULTS We enrolled 1029 adults hospitalized with heart failure (28%), pneumonia (22%), MI (10%), COPD (11%), or sickle cell disease (29%). Over 80% were non-Hispanic Black. Overall, there were no significant between-group differences in the 30-day change in anxiety (adjusted difference: -1.6, 97.5% CI -3.3 to 0.1, p=0.03), informational support (adjusted difference: -0.01, 97.5% CI -2.0 to 1.9, p=0.99), or any secondary outcomes. Exploratory analyses suggested the Navigator intervention improved anxiety among participants with COPD, a primary care provider, a hospitalization in the past 12 months, or higher baseline anxiety; among participants without health insurance, the intervention improved informational support (all p-values <0.05). CONCLUSIONS In this pragmatic RCT at a MSH, the Navigator intervention did not improve post-hospital anxiety, informational support, or other outcomes compared to Usual care. Benefits observed in participant subgroups should be confirmed in future studies. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02114515.
Collapse
Affiliation(s)
- Stephanie L LaBedz
- Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA.
| | - Valentin Prieto-Centurion
- Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Amelia Mutso
- Department of Pharmacology & Regenerative Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Sanjib Basu
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Nina E Bracken
- Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Elizabeth A Calhoun
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert J DiDomenico
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Min Joo
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - A Simon Pickard
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Mark V Williams
- Division of Hospital Medicine, Department of Internal Medicine, Washington University, St. Louis, MO, USA
| | - Sai Illendula
- Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Jerry A Krishnan
- Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
- Population Health Sciences Program, University of Illinois Hospital & Health Sciences System, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
6
|
Dugani SB, Kiliaki SA, Nielsen ML, Coons TJ, Fischer KM, Parikh RS, Pagali SR, Liwonjo A, Schroeder DR, Croghan IT, Burton MC. Post-discharge early assessment with remote video link (PEARL) initiative for patients discharged from hospital medicine services. Hosp Pract (1995) 2022; 50:379-386. [PMID: 36107464 PMCID: PMC9691619 DOI: 10.1080/21548331.2022.2125726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The COVID-19 pandemic impacted the availability and accessibility of outpatient care following hospital discharge. Hospitalists (physicians) and hospital medicine advanced practice providers (HM-APPs) coordinate discharge care of hospitalized patients; however, it is unknown if they can deliver post-discharge virtual care and overcome barriers to outpatient care. The objective was to develop and provide post-discharge virtual care for patients discharged from hospital medicine services. METHODS We developed the Post-discharge Early Assessment with Remote video Link (PEARL) initiative for HM-APPs to conduct a post-discharge video visit (to review recommendations) and telephone follow-up (to evaluate adherence) with patients 2-6 days following hospital discharge. Participants included patients discharged from hospital medicine services at an institution's hospitals in Rochester (May 2020-August 2020) and Austin (November 2020-February 2021) in Minnesota, US. HM-APPs also interviewed patients about their experience with the video visit and completed a survey on their experience with PEARL. RESULTS Of 386 eligible patients, 61.4% were enrolled (n = 237/386) including 48.1% women (n = 114/237). In patients with complete video visit and telephone follow-up (n = 141/237), most were prescribed new medications (83.7%) and took them as prescribed (93.2%). Among five classes of chronic medications, patient-reported adherence ranged from 59.2% (narcotics) to 91.5% (anti-hypertensives). Patient-reported self-management of 12 discharge recommendations ranged from 40% (smoking cessation) to 100% (checking rashes). Patients reported benefit from the video visit (agree: 77.3%) with an equivocal preference for video visits over clinic visits. Among HM-APPs who responded to the survey (88.2%; n = 15/17), 73.3% reported benefit from visual contact with patients but were uncertain if video visits would reduce emergency department visits. CONCLUSION In this novel initiative, HM-APPs used video visits to provide care beyond their hospital role, reinforce discharge recommendations for patients, and reduce barriers to outpatient care. The effect of this initiative is under evaluation in a randomized controlled trial.
Collapse
Affiliation(s)
- Sagar B. Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | | | - Megan L. Nielsen
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | - Trevor J. Coons
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen M. Fischer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Riddhi S. Parikh
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Anne Liwonjo
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Lake City, MN
| | | | - Ivana T. Croghan
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Department of Medicine, Clinical Research Office, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
7
|
Chang ET, Newberry S, Rubenstein LV, Motala A, Booth MJ, Shekelle PG. Quality Measures for Patients at Risk of Adverse Outcomes in the Veterans Health Administration: Expert Panel Recommendations. JAMA Netw Open 2022; 5:e2224938. [PMID: 35917129 DOI: 10.1001/jamanetworkopen.2022.24938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite longstanding efforts to improve health care quality for patients with complex needs who are at highest risk for hospitalization or death, to our knowledge, no guidance exists on what constitutes measurable high-quality care for this heterogeneous population. Identifying quality measures that are cross-cutting (ie, relevant to multiple chronic conditions and disease states) may enable health care professionals and health care systems to better design and report on quality improvement efforts for this patient population. OBJECTIVE To identify quality measures of care and prioritize quality-of-care concepts in the ambulatory primary care setting for patients in the Veterans Health Administration (VHA) who have complex care needs and are at high risk for adverse outcomes, such as hospitalization or death. EVIDENCE REVIEW In this expert panel assessment and prioritization, relevant measure concepts for future quality measure development in 3 care categories (assessment, management, and other features of health care) were extracted from a systematic review, conducted from June 2020 to June 2021, of published studies that suggested, evaluated, or used indicators of quality care for patients at high risk of adverse outcomes. Measure concepts associated with single conditions, surgical or other specialty care settings, and inpatient care were excluded. A panel of 14 experts (10 VHA leaders and staff, 2 non-VHA physician investigators, and 2 veterans) discussed and rated the importance of the remaining set of potentially relevant measure concepts using a modified RAND/UCLA Appropriateness Method on January 15, 2021. Measure concepts were rated on a scale of 1 to 9, with 9 being the highest priority. A median rating of 7.5 or greater was used as the cutoff to identify the highest-priority items. FINDINGS The systematic review identified 519 measure concepts, from which 15 domains and 49 measure concepts were proposed for expert panel consideration. After panel discussions and changes to measure concepts, the expert panel rated 63 measure concepts in 13 domains. The measure concepts with the highest median ratings focused on caregiver availability and support, COVID-19 vaccination, and pneumonia vaccination (all rated 9.0); housing instability (rated 8.5); and physical function, depression symptoms, cognitive impairment, prescription regimen, primary care follow-up after an emergency department visit or hospitalization, and timely transmission of discharge information to primary care (all rated 8.0). Recommendations to improve care included timely assessment of housing instability, caregiver support, physical function, depression symptoms, and cognitive impairment; annual prescription regimen review; coordinated transitions in care; and preventive care including vaccinations. CONCLUSIONS AND RELEVANCE The expert panelists identified a parsimonious set of high-priority, evidence-based, cross-cutting quality measure concepts for improving care of patients at high risk for adverse health outcomes in the VHA. These quality measures may inform both future research for patients at high risk and health care system quality improvement.
Collapse
Affiliation(s)
- Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at UCLA, Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles
| | | | | | - Aneesa Motala
- RAND Corporation, Santa Monica, California
- University of Southern California, Los Angeles
| | | | - Paul G Shekelle
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at UCLA, Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles
- RAND Corporation, Santa Monica, California
| |
Collapse
|
8
|
Chauhan U, McAlister FA. Comparison of Mortality and Hospital Readmissions Among Patients Receiving Virtual Ward Transitional Care vs Usual Postdischarge Care: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2219113. [PMID: 35763296 PMCID: PMC9240908 DOI: 10.1001/jamanetworkopen.2022.19113] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Virtual wards (VWs) include patient assessment in their homes by health care personnel and offer ongoing assessment and case management via home, telephone, and/or clinic visits. The association between VWs and patient outcomes during the transition from the hospital to home are unclear; earlier reviews on this topic have often conflated telemonitoring programs with VW models. OBJECTIVE To evaluate the use of VW transition systems for community-dwelling individuals after medical discharge. DATA SOURCES English-language articles indexed in PubMed or Cochrane and published between January 1, 2000, and June 15, 2021. STUDY SELECTION Randomized clinical trials comparing VW care with usual postdischarge care. Studies were stratified by diagnosis. DATA EXTRACTION AND SYNTHESIS Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline, 2 reviewers independently identified studies and extracted data. DerSimonian-Laird inverse variance weighted random-effects models were used to compute relative risks (RRs) for dichotomous outcomes and mean differences for continuous outcomes. MAIN OUTCOMES AND MEASURES All-cause mortality, hospital readmissions, emergency department visits, health care costs, readmission length of stay, quality of life, and functional status. RESULTS Twenty-four randomized clinical trials (11 in patients with heart failure, 3 in patients with chronic obstructive pulmonary disease, 4 in patients at high-risk for readmission, and 6 in mixed patient populations) with 10 876 patients were included (20 more trials than earlier reviews). In patients with heart failure, VWs were associated with fewer deaths (RR, 0.86; 95% CI, 0.76-0.97) and fewer readmissions (RR, 0.84; 95% CI, 0.74-0.96). However, similar associations were not seen in randomized clinical trials enrolling patients with other diagnoses (RR, 0.93; 95% CI, 0.83-1.04 for mortality and RR, 0.96; 95% CI, 0.88-1.05 for readmissions). Across all studies, VWs were associated with fewer emergency department visits (RR, 0.83; 95% CI, 0.70-0.98) and shorter readmission lengths of stay (mean difference, -1.94 days; 95% CI, -3.28 to -0.60 days). Three of 7 studies that evaluated health care expenses reported statistically significant lower costs with VW transition systems. CONCLUSIONS AND RELEVANCE Although postdischarge VW interventions appear to be associated with fewer subsequent emergency department visits, shorter readmission lengths of stay, and lower health care costs, fewer deaths and readmissions were seen only in trials enrolling patients with heart failure.
Collapse
Affiliation(s)
- Utkarsh Chauhan
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A. McAlister
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
9
|
Staples JA, Wiksyk B, Liu G, Desai S, van Walraven C, Sutherland JM. External validation of the modified LACE+, LACE+, and LACE scores to predict readmission or death after hospital discharge. J Eval Clin Pract 2021; 27:1390-1397. [PMID: 33963605 DOI: 10.1111/jep.13579] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Unplanned hospital readmissions are common adverse events. The LACE+ score has been used to identify patients at the highest risk of unplanned readmission or death, yet the external validity of this score remains uncertain. METHODS We constructed a cohort of patients admitted to hospital between 1 October 2014 and 31 January 2017 using population-based data from British Columbia (Canada). The primary outcome was a composite of urgent hospital readmission or death within 30 days of index discharge. The primary analysis sought to optimize clinical utility and international generalizability by focusing on the modified LACE+ (mLACE+) score, a variation of the LACE+ score which excludes the Case Mix Group score. Predictive performance was assessed using model calibration and discrimination. RESULTS Among 368,154 hospitalized individuals, 31,961 (8.7%) were urgently readmitted and 5428 (1.5%) died within 30 days of index discharge (crude composite risk of readmission or death, 9.95%). The mLACE+ score exhibited excellent calibration (calibration-in-the-large and calibration slope no different than ideal) and adequate discrimination (c-statistic, 0.681; 95%CI, 0.678 to 0.684). Higher risk dichotomized mLACE+ scores were only modestly associated with the primary outcome (positive likelihood ratio 1.95, 95%CI 1.93 to 1.97). Predictive performance of the mLACE+ score was similar to that of the LACE+ and LACE scores. CONCLUSION The mLACE+, LACE+ and LACE scores predict hospital readmission with excellent calibration and adequate discrimination. These scores can be used to target interventions designed to prevent unplanned hospital readmission.
Collapse
Affiliation(s)
- John A Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada.,Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, Canada.,Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada
| | - Bradley Wiksyk
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Guiping Liu
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Sameer Desai
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Carl van Walraven
- Ottawa Hospital Research Institute (OHRI), Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Jason M Sutherland
- Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada.,Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| |
Collapse
|
10
|
Schusselé Filliettaz S, Moiroux S, Marchand G, Gilles I, Peytremann-Bridevaux I. Transitional shared decision-making processes for patients with complex needs: A feasibility study. J Eval Clin Pract 2021; 27:1326-1334. [PMID: 33742747 DOI: 10.1111/jep.13561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Shared decision-making (SDM) processes, combining patients' and professionals' perspectives, are especially necessary for patients with complex needs (CNs) during their care transitions. In 2016, we started implementing interprofessional and interinstitutional SDM processes (IIPs) for patients admitted to a short-stay unit (SSU) for inpatient care and then followed-up by primary care providers. Two types of IIPs were identified: (a) iterative IIPs, and (b) meeting IIPs. These differed in terms of the timing of SDM processes: whereas the former were multilateral and iterative, meeting IIPs were simultaneous. However, the two processes had similar outcomes and participants had similar characteristics. The intervention included other components, such as CNs assessment and a care coordinator position. The present study aimed to assess the feasibility of the intervention's implementation. METHODS The intervention's feasibility was assessed using fidelity and coverage indicators. We collected data from the patients' records on (a) patients' and professionals' characteristics, (b) the fidelity (CNs evaluations and occurrences of IIPs), and (c) the intervention's coverage (types of IIPs, participants). RESULTS The study included 453 patients between September 2017 and February 2019: mean age of 82.3 years, 65.6% women and 61.1% considered to have CNs. For patients with CNs, iterative IIPs and meeting IIPs occurred in 78.3% and 23.8% of cases, respectively. 35.1% of iterative IIPs and 8.8% of meeting IIPs for patients with CNs involved patients or their informal caregivers, inpatient professionals, primary care physicians and homecare professionals. DISCUSSION These results showed that an intervention targeting the implementation of formalized IIPs for SDM in transitional care was feasible. However, to improve the evaluation of such interventions, other methods should be used to measure their appropriateness and acceptability. Additionally, assessing the effects of IIPs would legitimize their funding, supporting their sustainability and generalisability.
Collapse
Affiliation(s)
- Séverine Schusselé Filliettaz
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Association for the Promotion of Integrated Patient Care Networks (PRISM), Geneva, Switzerland
| | | | | | - Ingrid Gilles
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | | |
Collapse
|
11
|
Chang ET, Yoon J, Esmaeili A, Zulman DM, Ong MK, Stockdale SE, Jimenez EE, Chu K, Atkins D, Denietolis A, Asch SM. Outcomes of a randomized quality improvement trial for high-risk Veterans in year two. Health Serv Res 2021; 56 Suppl 1:1045-1056. [PMID: 34145564 PMCID: PMC8515223 DOI: 10.1111/1475-6773.13674] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year. DATA SOURCES VHA administrative data for five demonstration sites from August 2013 to March 2019. DATA SOURCES Administrative data extracted from VHA's Corporate Data Warehouse. STUDY DESIGN Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences. PRINCIPAL FINDINGS Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73). CONCLUSIONS Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.
Collapse
Affiliation(s)
- Evelyn T. Chang
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Department of MedicineVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Department of MedicineDavid Geffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Jean Yoon
- VA Health Economics Resource Center (HERC)Menlo ParkCaliforniaUSA
- Department of General Internal MedicineUCSF School of MedicineSan FranciscoCaliforniaUSA
| | - Aryan Esmaeili
- VA Health Economics Resource Center (HERC)Menlo ParkCaliforniaUSA
| | - Donna M. Zulman
- VA HSR&D Center for Innovation to ImplementationMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineMenlo ParkCaliforniaUSA
| | - Michael K. Ong
- Department of MedicineVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Department of MedicineDavid Geffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
- Department of Health Policy and ManagementFielding School of Public Health, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Susan E. Stockdale
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Department of Psychiatry and Biobehavioral SciencesUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Elvira E. Jimenez
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Behavioral NeurologyGeffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Karen Chu
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
| | - David Atkins
- VA Health Services Research and DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | - Steven M. Asch
- VA HSR&D Center for Innovation to ImplementationMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineMenlo ParkCaliforniaUSA
| | | |
Collapse
|
12
|
Marafino BJ, Escobar GJ, Baiocchi MT, Liu VX, Plimier CC, Schuler A. Evaluation of an intervention targeted with predictive analytics to prevent readmissions in an integrated health system: observational study. BMJ 2021; 374:n1747. [PMID: 34380667 PMCID: PMC8356037 DOI: 10.1136/bmj.n1747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system. DESIGN Observational study. SETTING 21 hospitals operated by Kaiser Permanente Northern California. PARTICIPANTS 1 539 285 eligible index hospital admissions corresponding to 739 040 unique patients from June 2010 to December 2018. 411 507 patients were discharged post-implementation of the Transitions Program; 80 424 (19.5%) of these patients were at medium or high predicted risk and were assigned to receive the intervention after discharge. INTERVENTION Patients admitted to hospital were automatically assigned to be followed by the Transitions Program in the 30 days post-discharge if their predicted risk of 30 day readmission or mortality was greater than 25% on the basis of electronic health record data. MAIN OUTCOME MEASURES Non-elective hospital readmissions and all cause mortality in the 30 days after hospital discharge. RESULTS Difference-in-differences estimates indicated that the intervention was associated with significantly reduced odds of 30 day non-elective readmission (adjusted odds ratio 0.91, 95% confidence interval 0.89 to 0.93; absolute risk reduction 95% confidence interval -2.5%, -3.1% to -2.0%) but not with the odds of 30 day post-discharge mortality (1.00, 0.95 to 1.04). Based on the regression discontinuity estimate, the association with readmission was of similar magnitude (absolute risk reduction -2.7%, -3.2% to -2.2%) among patients at medium risk near the risk threshold used for enrollment. However, the regression discontinuity estimate of the association with post-discharge mortality (-0.7% -1.4% to -0.0%) was significant and suggested benefit in this subgroup of patients. CONCLUSIONS In an integrated health system, the implementation of a comprehensive readmissions prevention intervention was associated with a reduction in 30 day readmission rates. Moreover, there was no association with 30 day post-discharge mortality, except among medium risk patients, where some evidence for benefit was found. Altogether, the study provides evidence to suggest the effectiveness of readmission prevention interventions in community settings, but further research might be required to confirm the findings beyond this setting.
Collapse
Affiliation(s)
- Ben J Marafino
- Biomedical Informatics Training Program, Department of Biomedical Data Science, School of Medicine, Stanford University, Stanford, CA, USA
| | - Gabriel J Escobar
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Michael T Baiocchi
- Department of Epidemiology and Population Health, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Vincent X Liu
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Critical Care Medicine, Kaiser Permanente Medical Center, Santa Clara, CA, USA
| | - Colleen C Plimier
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Alejandro Schuler
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Biomedical Data Science, School of Medicine, Stanford University, Stanford, CA, USA
| |
Collapse
|
13
|
Taylor YJ, Kowalkowski M, Spencer MD, Evans SM, Hall MN, Rissmiller S, Shrestha R, McWilliams A. Realizing a learning health system through process, rigor and culture change. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100478. [PMID: 34175095 DOI: 10.1016/j.hjdsi.2020.100478] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 07/28/2020] [Accepted: 09/18/2020] [Indexed: 12/19/2022]
Abstract
While many healthcare organizations strive to achieve the patient care benefits of being a learning health system (LHS), myriad challenges stand in the way of successful implementation. The reality of creating a true LHS requires top-to-bottom commitment to culture change with the necessary vision, leadership, and investment. The Center for Outcomes Research and Evaluation (CORE) is a multidisciplinary research unit embedded within a large, vertically integrated healthcare system in the southeastern United States. We used a two-pronged approach to: a) methodically recruit a team of experts, while generating early wins that demonstrated real success; and b) build relationships and buy-in across organizational leadership. Building out a team with diverse expertise created the ability to deploy pragmatic, data-driven research designs that fit seamlessly into real-world care delivery, resulting in agile study execution that aligns with health system timelines. Case study examples from hospital readmissions and antibiotic stewardship illustrate how our LHS operationalizes practice-informed research and research-informed practice. Lessons from this experience can serve as a blueprint for other healthcare systems or networks seeking to expand the promise of the LHS framework to improve health for patients and communities.
Collapse
Affiliation(s)
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, USA.
| | | | - Susan M Evans
- Center for Outcomes Research and Evaluation, Atrium Health, USA.
| | - Mary N Hall
- Division of Medical Education and Research, Atrium Health, USA; Medical Group Division, Atrium Health, USA.
| | | | | | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, USA; Medical Group Division, Atrium Health, USA; Department of Internal Medicine, Hospital Medicine, Atrium Health, USA.
| |
Collapse
|
14
|
Rogers JR, Lee J, Zhou Z, Cheung YK, Hripcsak G, Weng C. Contemporary use of real-world data for clinical trial conduct in the United States: a scoping review. J Am Med Inform Assoc 2021; 28:144-154. [PMID: 33164065 DOI: 10.1093/jamia/ocaa224] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/11/2020] [Accepted: 09/02/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Real-world data (RWD), defined as routinely collected healthcare data, can be a potential catalyst for addressing challenges faced in clinical trials. We performed a scoping review of database-specific RWD applications within clinical trial contexts, synthesizing prominent uses and themes. MATERIALS AND METHODS Querying 3 biomedical literature databases, research articles using electronic health records, administrative claims databases, or clinical registries either within a clinical trial or in tandem with methodology related to clinical trials were included. Articles were required to use at least 1 US RWD source. All abstract screening, full-text screening, and data extraction was performed by 1 reviewer. Two reviewers independently verified all decisions. RESULTS Of 2020 screened articles, 89 qualified: 59 articles used electronic health records, 29 used administrative claims, and 26 used registries. Our synthesis was driven by the general life cycle of a clinical trial, culminating into 3 major themes: trial process tasks (51 articles); dissemination strategies (6); and generalizability assessments (34). Despite a diverse set of diseases studied, <10% of trials using RWD for trial process tasks evaluated medications or procedures (5/51). All articles highlighted data-related challenges, such as missing values. DISCUSSION Database-specific RWD have been occasionally leveraged for various clinical trial tasks. We observed underuse of RWD within conducted medication or procedure trials, though it is subject to the confounder of implicit report of RWD use. CONCLUSION Enhanced incorporation of RWD should be further explored for medication or procedure trials, including better understanding of how to handle related data quality issues to facilitate RWD use.
Collapse
Affiliation(s)
- James R Rogers
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Junghwan Lee
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Ziheng Zhou
- Institute of Human Nutrition, Columbia University, New York, New York, USA
| | - Ying Kuen Cheung
- Department of Biostatistics, Columbia University, New York, New York, USA, and
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, New York, USA.,Medical Informatics Services, New York-Presbyterian Hospital, New York, New York, USA
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| |
Collapse
|
15
|
Kowalkowski M, Eaton T, McWilliams A, Tapp H, Rios A, Murphy S, Burns R, Gutnik B, O'Hare K, McCurdy L, Dulin M, Blanchette C, Chou SH, Halpern S, Angus DC, Taylor SP. Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS). BMC Health Serv Res 2021; 21:544. [PMID: 34078374 PMCID: PMC8170654 DOI: 10.1186/s12913-021-06521-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sepsis survivors experience high morbidity and mortality, and healthcare systems lack effective strategies to address patient needs after hospital discharge. The Sepsis Transition and Recovery (STAR) program is a navigator-led, telehealth-based multicomponent strategy to provide proactive care coordination and monitoring of high-risk patients using evidence-driven, post-sepsis care tasks. The purpose of this study is to evaluate the effectiveness of STAR to improve outcomes for sepsis patients and to examine contextual factors that influence STAR implementation. METHODS This study uses a hybrid type I effectiveness-implementation design to concurrently test clinical effectiveness and gather implementation data. The effectiveness evaluation is a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial at eight hospitals in North Carolina comparing clinical outcomes between sepsis survivors who receive Usual Care versus care delivered through STAR. Each hospital begins in a Usual Care control phase and transitions to STAR in a randomly assigned sequence (one every 4 months). During months that a hospital is allocated to Usual Care, all eligible patients will receive usual care. Once a hospital transitions to STAR, all eligible patients will receive STAR during their hospitalization and extending through 90 days from discharge. STAR includes centrally located nurse navigators using telephonic counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted with suspected sepsis, defined by clinical criteria for infection and organ failure, are included. Planned enrollment is 4032 patients during a 36-month period. The primary effectiveness outcome is the composite of all-cause hospital readmission or mortality within 90 days of discharge. A mixed-methods implementation evaluation will be conducted before, during, and after STAR implementation. DISCUSSION This pragmatic evaluation will test the effectiveness of STAR to reduce combined hospital readmissions and mortality, while identifying key implementation factors. Results will provide practical information to advance understanding of how to integrate post-sepsis management across care settings and facilitate implementation, dissemination, and sustained utilization of best-practice post-sepsis management strategies in other heterogeneous healthcare delivery systems. TRIAL REGISTRATION NCT04495946 . Submitted July 7, 2020; Posted August 3, 2020.
Collapse
Affiliation(s)
- Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.
| | - Tara Eaton
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.,Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, Charlotte, USA
| | - Aleta Rios
- Ambulatory Care Management, Atrium Health, Charlotte, USA
| | | | - Ryan Burns
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Bella Gutnik
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | | | - Lewis McCurdy
- Division of Infectious Disease, Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Michael Dulin
- Academy for Population Health Innovation, University of North Carolina Charlotte & Mecklenburg County Public Health Department, Charlotte, USA.,Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
| | - Christopher Blanchette
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA.,Health Economics and Outcomes Research Strategy, Novo Nordisk, Plainsboro Township, USA
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Scott Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | | |
Collapse
|
16
|
Takahashi PY, Chandra A, McCoy RG, Borkenhagen LS, Larson ME, Thorsteinsdottir B, Hickman JA, Swanson KM, Hanson GJ, Naessens JM. Outcomes of a Nursing Home-to-Community Care Transition Program. J Am Med Dir Assoc 2021; 22:2440-2446.e2. [PMID: 33984293 DOI: 10.1016/j.jamda.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Most transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes. DESIGN Propensity-matched control-intervention trial. INTERVENTION Patients in the intervention group received care management following nursing stay (a home visit and nursing phone calls). SETTING AND PARTICIPANTS Patients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF. METHODS Program enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use. RESULTS Each group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001). CONCLUSIONS AND IMPLICATIONS We found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.
Collapse
Affiliation(s)
- Paul Y Takahashi
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA.
| | - Anupam Chandra
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Lynn S Borkenhagen
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mary E Larson
- Employee and Community Health, Mayo Clinic, Rochester, MN, USA
| | | | - Joel A Hickman
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kristi M Swanson
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Gregory J Hanson
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Geriatric Medicine and Gerontology, Mayo Clinic, Rochester, MN, USA; Division of Community Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - James M Naessens
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
17
|
Reyes B, Diaz S, Engstrom G, Ouslander J. Adherence to care transitions recommendations among high-risk hospitalized older patients. J Am Geriatr Soc 2021; 69:1638-1645. [PMID: 33772760 DOI: 10.1111/jgs.17137] [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: 01/06/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES Evidence on the effectiveness of inpatient hospital geriatric consultation is scant, and it is unknown whether adherence to specific recommendations will improve care and patient outcomes. This study was conducted to provide insights from a quality improvement project that may help guide further improvements in the effectiveness of these consultations made as a component of a care transitions program (CTP). DESIGN Secondary analysis of the implementation of a multicomponent CTP for high-risk hospitalized patients aged 75 and older. SETTING A 400-bed community teaching hospital. PARTICIPANTS Two hundred and two patients admitted to non-ICU beds who met high-risk criteria. INTERVENTION Inpatient comprehensive geriatric consultation including care transition recommendations, telephone and in-person follow-up weekly for 4 weeks after discharge, and collaboration with post-acute organizations and primary care and specialist physicians to implement recommendations. MEASUREMENTS Primary outcomes for this analysis was 30-day hospital readmissions and adherence to transition of care recommendations. RESULTS The 142 patients with at least one post-discharge visit received 936 care transition recommendations. Overall, 663 (71%) of the 936 care transition recommendations were adhered to (71%). The adherence rate was lower in the 22 patients who were readmitted to the hospital within 30 days (63%) compared to 72% adherence in the 120 patients who were not readmitted. This was not a statistically significant difference, and there were no significant differences in the number and percent adherence in any recommendation category between the two groups. CONCLUSION We found adherence to just over two-thirds of care transition recommendations, similar to a small number of other studies. We did not find a relationship between the number of recommendations and adherence to them with 30-day readmissions to the hospital. Future studies of CTPs should consider several strategies may enhance geriatric consultation care transitions recommendations and adherence to them, and improve patient outcomes.
Collapse
Affiliation(s)
- Bernardo Reyes
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Sanya Diaz
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Gabriella Engstrom
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Joseph Ouslander
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| |
Collapse
|
18
|
Sitammagari K, Murphy S, Kowalkowski M, Chou SH, Sullivan M, Taylor S, Kearns J, Batchelor T, Rivet C, Hole C, Hinson T, McCreary P, Brown R, Dunn T, Neuwirth Z, McWilliams A. Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic. Ann Intern Med 2021; 174:192-199. [PMID: 33175567 PMCID: PMC7711652 DOI: 10.7326/m20-4076] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pandemics disrupt traditional health care operations by overwhelming system resource capacity but also create opportunities for care innovation. OBJECTIVE To describe the development and rapid deployment of a virtual hospital program, Atrium Health hospital at home (AH-HaH), within a large health care system. DESIGN Prospective case series. SETTING Atrium Health, a large integrated health care organization in the southeastern United States. PATIENTS 1477 patients diagnosed with coronavirus disease 2019 (COVID-19) from 23 March to 7 May 2020 who received care via AH-HaH. INTERVENTION A virtual hospital model providing proactive home monitoring and hospital-level care through a virtual observation unit (VOU) and a virtual acute care unit (VACU) in the home setting for eligible patients with COVID-19. MEASUREMENTS Patient demographic characteristics, comorbid conditions, treatments administered (intravenous fluids, antibiotics, supplemental oxygen, and respiratory medications), transfer to inpatient care, and hospital outcomes (length of stay, intensive care unit [ICU] admission, mechanical ventilation, and death) were collected from electronic health record data. RESULTS 1477 patients received care in either the AH-HaH VOU or VACU or both settings, with a median length of stay of 11 days. Of these, 1293 (88%) patients received care in the VOU only, with 40 (3%) requiring inpatient hospitalization. Of these 40 patients, 16 (40%) spent time in the ICU, 7 (18%) required ventilator support, and 2 (5%) died during their hospital admission. In total, 184 (12%) patients were ever admitted to the VACU, during which 21 patients (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required respiratory inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted as an inpatient to a conventional hospital. Of these 24 patients, 10 (42%) required ICU admission, 1 (3%) required a ventilator, and none died during their hospital admission. LIMITATION Generalizability is limited to patients with a working telephone and the ability to comply with the monitoring protocols. CONCLUSION Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond. PRIMARY FUNDING SOURCE Atrium Health.
Collapse
Affiliation(s)
- Kranthi Sitammagari
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Stephanie Murphy
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
| | - Matthew Sullivan
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Stephanie Taylor
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - James Kearns
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Thomas Batchelor
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Carly Rivet
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Colleen Hole
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Tony Hinson
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Pamela McCreary
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Ryan Brown
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Todd Dunn
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Zeev Neuwirth
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
| |
Collapse
|
19
|
Misra-Hebert AD, Rothberg MB, Fox J, Ji X, Hu B, Milinovich A, Zafirau W, Onuzuruike A, Stange KC. Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100518. [PMID: 33412440 DOI: 10.1016/j.hjdsi.2020.100518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 12/03/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Home visits after hospital discharge may reduce future healthcare utilization. We assessed the association of home visits by advanced practice registered nurses (APRN) and paramedics with healthcare utilization and mortality, and provider and patient experience. METHODS We conducted a retrospective cohort study using convergent mixed methods in one health system including adult medical patients discharged to home from November 2017-September 2019. We assessed outcomes for home visit vs. matched comparison patients at 30, 90, and 180 days, including hospital admission, emergency department (ED) use, and death: Phase 1 (APRN or paramedic visits assigned by geographic location) and Phase 2 (APRN and paramedic visit teams assigned to patients). Patients declining home visits and those accepting were also compared. Semi-structured interviews were conducted with home visit patients and providers, primary care providers, and nurse care coordinators. RESULTS In Phase 1, the 101 home visit matched to 303 comparison patients showed no differences in readmissions, ED visits, or death at 30, 90, and 180 days. In Phase 2, 157 home visit matched to 471 comparison patients had fewer 30-day readmissions (19.1% vs. 28.7%, p 0.024) and no differences in other outcomes. Compared with patients declining home visits, patients accepting had lower odds of 30-day readmission. In 44 interviews, themes of Medication Understanding, Knowledge Gap after Discharge, Patient Medical Complexity, Social Context, and Patient Engagement/Need for Reassurance emerged. CONCLUSION Post-discharge home visits by APRNs and paramedics working together were associated with reduced 30-day readmissions. Identified themes could inform strategies to improve patient support.
Collapse
Affiliation(s)
- Anita D Misra-Hebert
- Department of Internal Medicine, Cleveland Clinic Community Care, USA; Healthcare Delivery and Implementation Science Center, Cleveland Clinic, USA; Center for Value-Based Care Research, Cleveland Clinic Community Care, USA; Department of Quantitative Health Sciences, Cleveland Clinic, USA.
| | - Michael B Rothberg
- Department of Internal Medicine, Cleveland Clinic Community Care, USA; Center for Value-Based Care Research, Cleveland Clinic Community Care, USA
| | - Jaqueline Fox
- Center for Value-Based Care Research, Cleveland Clinic Community Care, USA
| | - Xinge Ji
- Department of Quantitative Health Sciences, Cleveland Clinic, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, USA
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic, USA
| | - William Zafirau
- Department of Connected Care, Cleveland Clinic Community Care, USA
| | - Anthony Onuzuruike
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Kurt C Stange
- Center for Community Health Integration, Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
20
|
Ouslander JG, Reyes B, Diaz S, Engstrom G. Thirty-Day Hospital Readmissions in a Care Transitions Program for High-Risk Older Adults. J Am Geriatr Soc 2020; 68:1307-1312. [PMID: 31994723 DOI: 10.1111/jgs.16314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/01/2019] [Accepted: 12/12/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe the causes of 30-day hospital readmissions among high-risk older adults during implementation of a multicomponent care transitions program. DESIGN Secondary analysis of data from the evaluation of a multicomponent care transitions program for hospitalized high-risk older adults. SETTING A 400-bed community teaching hospital. PARTICIPANTS Patients aged 75 and older admitted to non-intensive care unit beds who met specific criteria for high risk of complications and hospital readmissions. The intervention group included 202 patients, of whom 37 were readmitted to the hospital as an inpatient or on observation status within 30 days of discharge. MEASUREMENTS Root-cause analyses on each readmission were conducted by hospital physicians and post-acute care (PAC) organization staff. Additional data were collected by trained project staff using the medical record and postdischarge telephone or in-person follow-up visits. These data were reviewed and adjudicated among the authors, and each readmission was rated with unanimous agreement as "preventable," "possibly preventable," or "not preventable." RESULTS No significant differences were found in demographic and clinical characteristics of intervention patients readmitted versus those not readmitted. A higher proportion of the 37 patients who were readmitted did not have a postdischarge visit than the 165 patients who were not readmitted (15 [41%] vs 45 [27%]; P = .11). Among the 37 readmissions, 14 (38%) were rated as not preventable, 14 (38%) as possibly preventable, and 9 (24%) as preventable. Readmissions were rated as preventable or possibly preventable for a variety of reasons that provide insight into how care transitions programs for high-risk older adults might be made more effective. CONCLUSION Root-cause analyses of hospital readmissions among high-risk older adults by hospital physicians and PAC providers can identify strategies that might enhance the effectiveness of care transitions interventions in this complex population. J Am Geriatr Soc 68:1307-1312, 2020.
Collapse
Affiliation(s)
- Joseph G Ouslander
- Department of Integrated Medical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Bernardo Reyes
- Department of Integrated Medical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Sanya Diaz
- Department of Integrated Medical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Gabriella Engstrom
- Department of Integrated Medical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| |
Collapse
|
21
|
Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial. Trials 2019; 20:660. [PMID: 31783900 PMCID: PMC6884908 DOI: 10.1186/s13063-019-3792-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/05/2019] [Indexed: 12/29/2022] Open
Abstract
Background Hospital mortality for patients with sepsis has recently declined, but sepsis survivors still suffer from significant long-term mortality and morbidity. There are limited data that support effective strategies to address post-discharge management of patients hospitalized with sepsis. Methods The Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS) study is a pragmatic, randomized controlled trial at three hospitals within a single healthcare delivery system comparing clinical outcomes between sepsis survivors who receive usual care versus care delivered through the Sepsis Transition and Recovery (STAR) program. The STAR program includes a centrally located nurse navigator using telephone counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies for patients during hospitalization and the 30 days after hospital discharge, including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted through the Emergency Department with suspected infection (i.e., antibiotics initiated, bacterial cultures drawn) and deemed, by previously developed risk-stratification models, high risk for readmission or death are included. Eligible patients are randomly allocated 1:1 to either Arm 1, usual care or Arm 2, STAR. Planned enrollment is 708 patients during a 6-month period. The primary outcome is the composite of all-cause hospital readmissions and mortality assessed 30 days post discharge. Secondary outcomes include 30- and 90-day hospital readmissions, mortality, emergency department visits, acute care-free days alive, and acute care and total costs. Discussion This pragmatic evaluation provides the most comprehensive assessment to date of a strategy to improve delivery of recommended post-sepsis care. Trial registration ClinicalTrials.gov, NCT03865602. Registered retrospectively on 6 March 2019.
Collapse
|
22
|
Taylor YJ, Roberge J, Rossman W, Jones J, Generoso C, Bobay C, DeSilva B, Evans C, Pracht M, Dulin MF, Davis CJ. A Population Health Approach to Transitional Care Management for High-Risk Patients with Diabetes: Outcomes at a Rural Hospital. Popul Health Manag 2019; 23:278-285. [PMID: 31765271 DOI: 10.1089/pop.2019.0119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Patient transitions from inpatient to home care are an important area of focus for reducing costly unplanned hospital readmissions. In rural settings, the challenge of reducing unplanned readmissions is amplified by limited access to both ambulatory and acute care as well as high levels of social disadvantage. In addition, there is a scarcity of evidence regarding strategies that have been proven to improve care transitions and related patient outcomes in this setting. This paper describes the process for implementation and results of a telephone-based transitional care management (TCM) program designed to reduce readmissions for patients with diabetes in a rural hospital in Scotland County, North Carolina. Data were collected from July 2016 to January 2019 using billing records to identify adult patients with high or very high risk of readmission based on length of stay, acuity, comorbidity, and emergency department visits (LACE) scores. Care managers contacted eligible patients by phone after discharge to review discharge instructions, assess need for home health services and transportation assistance, and schedule primary care follow-up visits. Overall, 13.8% of 15,271 discharges were targeted for TCM; 68.2% of these involved a patient with diabetes. The post-intervention 30-day readmission rate was 18.0% among patients identified as high or very high risk versus 8.8% among the overall population and did not differ significantly between TCM participants with diabetes and those without (22.9% vs.18.8%; P = 0.525). Findings highlight challenges with implementing transition of care interventions in rural settings, which include staffing, patient volume, and accessing data from out-of-network providers.
Collapse
Affiliation(s)
- Yhenneko J Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Jason Roberge
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Whitney Rossman
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer Jones
- Scotland Health Care System, Laurinburg, North Carolina, USA
| | | | - Cindy Bobay
- Care Management, Atrium Health, Mint Hill, North Carolina, USA
| | - Barbara DeSilva
- Care Management, Atrium Health, Mint Hill, North Carolina, USA
| | - Constance Evans
- Information and Analytics Services, Atrium Health, Charlotte, North Carolina, USA
| | - Matthew Pracht
- Scotland Health Care System, Laurinburg, North Carolina, USA
| | - Michael F Dulin
- Academy for Population Health Innovation, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Cheryl J Davis
- Scotland Health Care System, Laurinburg, North Carolina, USA
| |
Collapse
|
23
|
Huckfeldt PJ, Reyes B, Engstrom G, Yang Q, Diaz S, Fahmy S, Ouslander JG. Evaluation of a Multicomponent Care Transitions Program for High‐Risk Hospitalized Older Adults. J Am Geriatr Soc 2019; 67:2634-2642. [DOI: 10.1111/jgs.16189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 01/23/2023]
Affiliation(s)
| | - Bernardo Reyes
- Charles E. Schmidt College of MedicineFlorida Atlantic University Boca Raton Florida
| | - Gabriella Engstrom
- Charles E. Schmidt College of MedicineFlorida Atlantic University Boca Raton Florida
| | - Qingnan Yang
- School of Public HealthUniversity of Minnesota Minneapolis Minnesota
| | - Sanya Diaz
- Charles E. Schmidt College of MedicineFlorida Atlantic University Boca Raton Florida
| | - Samer Fahmy
- Charles E. Schmidt College of MedicineFlorida Atlantic University Boca Raton Florida
- Boca Raton Regional Hospital Boca Raton Florida
| | - Joseph G. Ouslander
- Charles E. Schmidt College of MedicineFlorida Atlantic University Boca Raton Florida
| |
Collapse
|
24
|
Rubenstein LV. Finding Joy in the Practice of Implementation Science: What Can We Learn from a Negative Study? J Gen Intern Med 2019; 34:9-11. [PMID: 30357591 PMCID: PMC6318180 DOI: 10.1007/s11606-018-4715-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lisa V Rubenstein
- University of California Los Angeles David Geffen School of Medicine and Fielding School of Public Health, RAND Corporation, Santa Monica, CA, USA.
| |
Collapse
|