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Freeman HD, Burke LC, Humphrey JG, Wilbers AJ, Vora H, Khorfan R, Solomon NL, Namm JP, Ji L, Lum SS. Fragmentation of care in breast cancer: greater than the sum of its parts. Breast Cancer Res Treat 2024:10.1007/s10549-024-07442-3. [PMID: 39096403 DOI: 10.1007/s10549-024-07442-3] [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: 05/20/2024] [Accepted: 07/19/2024] [Indexed: 08/05/2024]
Abstract
INTRODUCTION Fragmentation of care (FC, the receipt of care at > 1 institution) has been shown to negatively impact cancer outcomes. Given the multimodal nature of breast cancer treatment, we sought to identify factors associated with FC and its effects on survival of breast cancer patients. METHODS A retrospective analysis was performed of surgically treated, stage I-III breast cancer patients in the 2004-2020 National Cancer Database, excluding neoadjuvant therapy recipients. Patients were stratified into two groups: FC or non-FC care. Treatment delay was defined as definitive surgery > 60 days after diagnosis. Multivariable logistic regression was performed to identify factors predictive of FC, and survival was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS Of the 531,644 patients identified, 340,297 (64.0%) received FC. After adjustment, FC (OR 1.27, 95% CI 1.25-1.29) was independently associated with treatment delay. Factors predictive of FC included Hispanic ethnicity (OR 1.04, 95% CI: 1.01-1.07), treatment at comprehensive community cancer programs (OR 1.06, 95% CI: 1.03-1.08) and integrated network cancer programs (OR 1.55, 95% CI: 1.51-1.59), AJCC stage II (OR 1.06, 95% CI 1.05-1.07) and stage III tumors (OR 1.06, 95% CI: 1.02-1.10), and HR + /HER2 + tumors (OR 1.05, 95% CI: 1.02-1.07). Treatment delay was independently associated with increased risk of mortality (HR 1.23, 95% CI 1.20-1.26), whereas FC (HR 0.87, 95% CI 0.86-0.88) showed survival benefit. CONCLUSIONS While treatment delay negatively impacts survival in breast cancer patients, our findings suggest FC could be a marker for multispecialty care that may mitigate some of these effects.
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Affiliation(s)
- Hadley D Freeman
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Linnea C Burke
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Ja'Neil G Humphrey
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Ashley J Wilbers
- Division of Breast Surgery, Department of Surgery, Washington University, St. Louis, MO, USA
| | - Halley Vora
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Rhami Khorfan
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Naveenraj L Solomon
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Jukes P Namm
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Liang Ji
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Sharon S Lum
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA.
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Zidan T, Iskafi H, Ali A, Barham H, Al-Sayed Ahmad M, Masalma R, Hossoon A, Barham A, Shawahna R. Experiences of Multiple Myeloma Patients With Treatment in the Palestinian Practice: A Multicenter Qualitative Study in a Resource-Limited Healthcare System. Cureus 2024; 16:e63365. [PMID: 39070431 PMCID: PMC11283748 DOI: 10.7759/cureus.63365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Background Multiple myeloma is a crippling cancer that puts a significant strain on patients and their families alike. The long and exhausting treatment journey with the disease is challenging not only for patients but also for healthcare systems. This exploratory study was conducted to look into these patients' experiences with their treatment and explore their recommendations and views to improve the Palestinian healthcare system, which can be viewed as an evolving healthcare system within a resource-limited and developing country. Methods The consolidated criteria for reporting qualitative research (COREQ) checklist was used for conducting this multicenter exploratory qualitative study. A total number of eight patients with multiple myeloma who received treatment in the Palestinian healthcare system participated in semi-structured in-depth interviews. The semi-structured in-depth interviews followed a set interview schedule. Thematic analysis of the data was done using the qualitative interpretive description approach. Results A total of 5.48 h (329 min) of total interview time was analyzed. Among the patients, 6 (75%) were males, 5 (63.5%) lived in urban areas, 5 (62.5%) reported satisfaction with their household income, 6 (75%) underwent bone marrow transplantation, and all of them (100%) had governmental insurance. The qualitative data that emerged after analysis were classified into three major themes and multiple sub-themes. The three major themes were: (1) treatment side effects, (2) factors affecting treatment experience, and (3) recommendations to improve healthcare service. Conclusion The results of this qualitative study offer insight into how people with multiple myeloma view the healthcare system in Palestine and shed light on the variable and challenging experiences with their treatment, side effects, and communication with healthcare providers within the context of a resource-limited and developing country. Future research should involve hemato-oncology doctors and benefit from their expertise in the field.
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Affiliation(s)
- Thabet Zidan
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Hala Iskafi
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Ahmad Ali
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Husam Barham
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Mahdi Al-Sayed Ahmad
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Raed Masalma
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Ahmed Hossoon
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Ali Barham
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Ramzi Shawahna
- Department of Physiology, Pharmacology and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
- Clinical Research, An-Najah National University Hospital, Nablus, PSE
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Turbow SD, Perkins MM, Vaughan CP, Klemensen T, Culler SD, Rask KJ, Clevenger CK, Ali MK. Fragmented Readmissions From a Nursing Facility in Medicare Beneficiaries. J Appl Gerontol 2024:7334648241254282. [PMID: 38798097 DOI: 10.1177/07334648241254282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Over one-third of Medicare beneficiaries discharged to nursing facilities require readmission. When those readmissions are to a different hospital than the original admission, or "fragmented readmissions," they carry increased risks of mortality and subsequent readmissions. This study examines whether Medicare beneficiaries readmitted from a nursing facility are more likely to have a fragmented readmission than beneficiaries readmitted from home among a 2018 cohort of Medicare beneficiaries, and examined whether this association was affected by a diagnosis of Alzheimer's Disease (AD). In fully adjusted models, readmissions from a nursing facility were 19% more likely to be fragmented (AOR 1.19, 95% CI 1.16, 1.22); this association was not affected by a diagnosis of AD. These results suggest that readmission from nursing facilities may contribute to care fragmentation for older adults, underscoring it as a potentially modifiable pre-hospital risk factor for fragmented readmissions.
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Affiliation(s)
- Sara D Turbow
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Molly M Perkins
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Camille P Vaughan
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Veterans Affairs Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta, GA, USA
| | - Terry Klemensen
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven D Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | | | - Mohammed K Ali
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Turbow S, Walker T, Culler S, Ali MK. Care fragmentation and readmission mortality and length of stay before and during the COVID-19 pandemic: data from the National Readmissions Database, 2018-2020. BMC Health Serv Res 2024; 24:622. [PMID: 38741088 DOI: 10.1186/s12913-024-11073-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 05/03/2024] [Indexed: 05/16/2024] Open
Abstract
IMPORTANCE A quarter of all 30-day readmissions involve fragmented care, where patients return to a different hospital than their original admission; these readmissions are associated with increased in-hospital mortality and longer lengths-of-stay (LOS). The stress on healthcare systems at the beginning of the COVID-19 pandemic could worsen care fragmentation and related outcomes. OBJECTIVE To compare fragmented readmissions in 2020 versus 2018-2019 and assess whether mortality and LOS in fragmented readmissions differed in the two time periods. DESIGN Observational study SETTING: National Readmissions Database (NRD), 2018-2020 PARTICIPANTS: All adults (> 18 y/o) with 30-day readmissions MAIN OUTCOMES AND MEASURES: We examined the percentage of fragmented readmissions over 2018-2020. Using unadjusted and adjusted logistic and linear regressions, we estimated the associations between fragmented readmissions and in-hospital mortality and LOS. RESULTS 24.0-25.7% of readmissions in 2018-2020 and 27.3%-31.0% of readmissions for COVID-19 were fragmented. 2018-2019 fragmented readmissions were associated with 18-20% higher odds of in-hospital mortality compared to nonfragmented readmissions. Fragmented readmissions for COVID-19 were associated with an 18% increase in in-hospital mortality (AOR 1.18, 95% CI 1.12, 1.24). The LOS of fragmented readmissions in March-November 2018-2019 were on average 0.81 days longer, while fragmented readmissions between March-November of 2020 were associated with a 0.88-1.03 day longer LOS. CONCLUSIONS AND RELEVANCE A key limitation is that the NRD does not contain information on several patient/hospital-level factors that may be associated with the outcomes of interest. We observed increased fragmentation during COVID-19, but its impact on in-hospital mortality and LOS remained consistent with previous years.
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Affiliation(s)
- Sara Turbow
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, USA.
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Tiffany Walker
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, USA
| | - Steven Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mohammed K Ali
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Gogna S, Zangbar B, Rafieezadeh A, Hanna K, Shnaydman I, Con J, Bronstein M, Klein J, Prabhakaran K. Fragmentation of Care After Geriatric Trauma: A Nationwide Analysis of outcomes and Predictors. Am Surg 2024; 90:1007-1014. [PMID: 38062751 DOI: 10.1177/00031348231220569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
The health care system for the elderly is fragmented, that is worsened when readmission occurs to different hospitals. There is limited investigation into the impact of fragmentation on geriatric trauma patient outcomes. The aim of this study was to compare the outcomes following readmissions after geriatric trauma. The Nationwide Readmissions Database (2016-2017) was queried for elderly trauma patients (aged ≥65 years) readmitted due to any cause. Patients were divided into 2 groups according to readmission: index vs non-index hospital. Outcomes were 30 and 180-day complications, mortality, and the number of subsequent readmissions. Multivariable logistic regression was performed to analyze the independent predictors of fragmentation of care. A total of 36,176 trauma patients were readmitted, of which 3856 elderly patients (aged ≥65 years) were readmitted: index hospital (3420; 89%) vs non-index hospital (436; 11%). Following 1:2 propensity matching, elderly with non-index hospital readmission had higher rates of death and MI within 180 days (P = .01 and .02, respectively). They had statistically higher 30 and 180-day pneumonia (P < .01), CHF (P < .01), arrhythmias (P < .01), MI (P < .01), sepsis (P < .01), and UTI (P < .01). On multivariable binary logistic regression analysis, pneumonia (OR 1.70, P = .03), congestive heart failure (CHF) (OR 1.80, P = .03), female gender (OR .72, P = .04), and severe Head and Neck trauma (AIS≥3) (OR 1.50, P < .01) on index admission were independent predictors of fragmentation of care. While the increase in time to readmission (OR 1.01, P < .01) was also associated independently with non-index hospital admission. Fragmented care after geriatric trauma could be associated with higher mortality and complications.
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Affiliation(s)
- Shekhar Gogna
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Bardiya Zangbar
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Aryan Rafieezadeh
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Kamil Hanna
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ilya Shnaydman
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Jorge Con
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Matthew Bronstein
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Joshua Klein
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
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Feng TL, Stoessl AJ, Harrison RA. Integrated Care in Neurology: The Current Landscape and Future Directions. Can J Neurol Sci 2024:1-9. [PMID: 38679923 DOI: 10.1017/cjn.2024.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
The rising burden of neurological disorders poses significant challenges to healthcare systems worldwide. There has been an increasing momentum to apply integrated approaches to the management of several chronic illnesses in order to address systemic healthcare challenges and improve the quality of care for patients. The aim of this paper is to provide a narrative review of the current landscape of integrated care in neurology. We identified a growing body of research from countries around the world applying a variety of integrated care models to the treatment of common neurological conditions. Based on our findings, we discuss opportunities for further study in this area. Finally, we discuss the future of integrated care in Canada, including unique geographic, historical, and economic considerations, and the role that integrated care may play in addressing challenges we face in our current healthcare system.
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Affiliation(s)
- Tanya L Feng
- Division of Neurology, The University of British Columbia, Vancouver, BC, Canada
| | - A Jon Stoessl
- Division of Neurology, The University of British Columbia, Vancouver, BC, Canada
- Pacific Parkinson's Research Centre, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Rebecca A Harrison
- Division of Neurology, The University of British Columbia, Vancouver, BC, Canada
- British Columbia Cancer Agency, Vancouver, BC, Canada
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Balian J, Mallick S, Le N, Porter G, Vadlakonda A, Ali K, Kronen E, Benharash P. Association of Interhospital Transfer With Outcomes of Extracorporeal Membrane Oxygenation: A Contemporary Analysis. Am Surg 2024:31348241248699. [PMID: 38634485 DOI: 10.1177/00031348241248699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has emerged as a life-sustaining measure for individuals with end-stage cardiopulmonary derangements. An estimated one-third of patients must be transferred to a specialized center to receive this intervention. Therefore, the present study sought to characterize the impact of interhospital transfer (IHT) status on outcomes following ECMO. METHODS The 2016-2020 National Inpatient Sample was queried to identify all adult (≥18 years) hospitalizations for ECMO. Patients were stratified based on transfer status from another acute care hospital. Multivariable regression models were developed to assess the association between transfer status and outcomes of interest. Patient and operative factors associated with IHT were identified using regression. RESULTS Of an estimated 61,180 hospitalizations entailing ECMO, 21,410 (35.0%) were transfers. Annual transfer volume doubled over the study period, from 2915 to 5945 (nptrend < .001). The predicted morality risk of non-transfers decreased between 2016 and 2020 but remained similar in transferred patients. Following adjustment, transfer was associated with increased odds of in-hospital mortality, complications, duration of stay, and hospitalization costs. Patients experiencing transfer were less likely to be of black race and private insurance status. CONCLUSION Despite increasing transfer volume and utilization of ECMO, IHT was associated with significant mortality and hospital complication risks. Further work to reduce adverse outcomes, resource burden, and socioeconomic differences within IHT may improve accessibility to this life-saving modality.
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Affiliation(s)
- Jeffrey Balian
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, CA, USA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, CA, USA
| | - Nguyen Le
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, CA, USA
| | - Giselle Porter
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, CA, USA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, CA, USA
| | - Elsa Kronen
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, CA, USA
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
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Graham LA, Illarmo S, Gray CP, Harris AHS, Wagner TH, Hawn MT, Iannuzzi JC, Wren SM. Mapping the Discharge Process After Surgery. JAMA Surg 2024; 159:438-444. [PMID: 38381415 PMCID: PMC10882508 DOI: 10.1001/jamasurg.2023.7539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/28/2023] [Indexed: 02/22/2024]
Abstract
Importance Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. Objective To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. Design, Setting, and Participants This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Exposure Postoperative hospital discharge. Main Outcomes and Measures Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. Results At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. Conclusions and Relevance These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Caroline P. Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Alex H. S. Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Mary T. Hawn
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - James C. Iannuzzi
- Department of Surgery, San Francisco VA Medical Center, San Francisco, California
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco
| | - Sherry M. Wren
- Department of General Surgery, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
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Kim S, Hadaya J, Joachim K, Ali K, Mallick S, Cho NY, Benharash P, Lee H. Care fragmentation is associated with increased mortality after ileostomy creation. Surgery 2024; 175:1000-1006. [PMID: 38161087 DOI: 10.1016/j.surg.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/06/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Ileostomy is the mainstay treatment option for various gastrointestinal conditions. Given the increased risk of post-discharge complications and high readmission rates that can be further aggravated by receiving care at different facilities (care fragmentation), further examination is necessary. We thus used a national cohort to explore the associations of care fragmentation among ileostomy patients experiencing adverse outcomes and increased hospitalization expenditures. METHODS All adult hospitalizations for ileostomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Those readmitted within 90 days after discharge were included for analysis. Patients treated at a different facility than the original location where the index ileostomy was performed were categorized into the care-fragmented cohort. Multivariable regressions were developed to characterize the association of the care-fragmented cohort with postoperative outcomes, readmissions, and expenditures. RESULTS Of 52,254 patients with ileostomy creation hospitalizations with 90-day nonelective readmission, 9,045 (17.3%) experienced care fragmentation. Following risk adjustment, those experiencing care fragmentation faced increased odds of mortality (adjusted odds ratio 1.81, 95% confidence interval 1.54-2.12), cardiac (adjusted odds ratio 1.63, 95% confidence interval 1.42-1.85), respiratory (adjusted odds ratio 1.71, 95% confidence interval 1.53-1.91), infectious (adjusted odds ratio 1.33, 95% confidence interval 1.23-1.43), and thromboembolic (adjusted odds ratio 1.28, 95% confidence interval 1.13-1.45) complications. Furthermore, patients experiencing care fragmentation were more likely to have increased hospitalization costs ($1,700, 95% confidence interval 0.8-2.5). CONCLUSION Care fragmentation in ileostomy patients demonstrated an increased risk for mortality, postoperative complications, and increased hospitalization expenses. To mitigate risks for adverse outcomes, future studies should evaluate the impacts of inter-hospital communication with the goal of improving care continuity and optimizing healthcare delivery for care-fragmented populations.
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Affiliation(s)
- Shineui Kim
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA. https://twitter.com/shineeshink
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, CA
| | - Kole Joachim
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA. https://twitter.com/NamYong_Cho
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, CA
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA.
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Matthews EB. The Impact of Delivery Reform on Health Information Exchange with Behavioral Health Providers: Results from a National Representative Survey of Ambulatory Physicians. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024:10.1007/s10488-024-01367-1. [PMID: 38512556 DOI: 10.1007/s10488-024-01367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
Health information exchange (HIE) is an effective way to coordinate care, but HIE between health and behavioral health providers is limited. Recent delivery reform models, including the Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) prioritize interprofessional collaboration, but little is known about their impact on behavioral health HIE. This study explores whether delivery reform participation affects behavioral health HIE among ambulatory health providers using pooled 2015-2019 data from the National Electronic Health Record Survey, a nationally representative survey of ambulatory physicians' technology use (n = 8,703). The independent variable in this analysis was provider participation in ACO, PCMH, Hybrid ACO-PCMH, or standard care. The dependent variable was HIE with behavioral health providers. Chi square analysis estimated unweighted rates of behavioral health HIE across reform models. Logistic regression estimated the impact of delivery reform participation on rates of behavioral health HIE. Unweighted estimates indicated that Hybrid ACO-PCMH providers had the highest rates of HIE (n = 330, 33%). In the fully adjust model, rates of HIE were higher among ACO (AOR = 2.66, p < .01), PCMH (AOR = 4.73, p < .001) and Hybrid ACO-PCMH participants (AOR = 5.55, p < .001) compared to standard care, but they did not significantly vary between delivery models. Physicians infrequently engage in HIE with behavioral health providers. Compared to standard care, higher rates of HIE were found across all models of delivery reform. More work is needed to identify common elements of delivery reform models that are most effective in supporting this behavior.
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Affiliation(s)
- Elizabeth B Matthews
- Graduate School of Social Service, Fordham University, 113 W. 60th st. 7th Fl, New York, NY, 10023, USA.
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Choi DW, Kim S, Kim SJ, Kim DW, Ryu KS, Kim JH, Chang YJ, Han KT. Relationship between patient outcomes and patterns of fragmented cancer care in older adults with gastric cancer: A nationwide cohort study in South Korea. J Geriatr Oncol 2024; 15:101685. [PMID: 38104479 DOI: 10.1016/j.jgo.2023.101685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Fragmented cancer care, defined as receipt of care from multiple hospitals, has been shown to be associated with poor patient outcomes and high expense. However, evidence regarding the effects of hospital choice by patients with cancer on overall survival are lacking. Thus, we investigated the relationship between patterns of fragmented care and five-year mortality in patients with gastric cancer. MATERIALS AND METHODS Using the Korean National Health Insurance senior cohort of adults aged ≥60 years, we identified patients with gastric cancer who underwent gastrectomy during 2007-2014. We examined the distribution of the study population by five-year mortality, and used Kaplan-Meier survival curves/log-rank test and Cox proportional hazard model to compare five-year mortality with fragmented cancer care. RESULTS Among the participants, 19.5% died within five years. There were more deaths among patients who received fragmented care, especially those who transferred to smaller hospitals (46.6%) than to larger ones (40.0%). The likelihood of five-year mortality was higher in patients who received fragmented cancer care upon moving from large to small hospitals than those who did not transfer hospitals (hazard ratio, 1.28; 95% confidence interval, 1.10-1.48, P = .001). Moreover, mortality was higher among patients treated in large hospitals or in the capital area for initial treatment, and this association was greater for patients from rural areas. DISCUSSION Fragmentation of cancer care was associated with reduced survival, and the risk of mortality was higher among patients who moved from large to small hospitals.
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Affiliation(s)
- Dong-Woo Choi
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Seungju Kim
- Department of Nursing, College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Republic of Korea
| | - Dong Wook Kim
- Department of Information and Statistics, RINS, Gyeongsang National University, Jinju, Republic of Korea
| | - Kwang Sun Ryu
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Jae Ho Kim
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Yoon-Jung Chang
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Kyu-Tae Han
- Division of Cancer Control & Policy, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea.
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12
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Urie BR, Laskowski T, Richard M, Tihonov N, Katz D, d'Audiffret A, Lim S. Impact of Care Fragmentation after Major Lower Extremity Amputation. Ann Vasc Surg 2024; 100:47-52. [PMID: 38122975 DOI: 10.1016/j.avsg.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/14/2023] [Accepted: 10/22/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Care fragmentation (CF) is a known risk factor for unplanned readmission, morbidity, and mortality after surgery. The goal of this study was to evaluate the impact of CF on outcomes of major lower extremity amputation for peripheral vascular disease. METHODS Health-care Cost and Utilization Project Database for NY (2016) and MD/FL (2016-2017) were queried using International Classification of Diseases 10thedition to identify patients who underwent above the knee-, through the knee-, and below the knee-amputation for peripheral vascular disease. Patients with CF were identified as those with admissions to ≥2 hospitals during the study period. We compared the postamputation outcomes of mortality, readmission rate, length of stay (LOS) and hospital charges. RESULTS We identified a total of 13,749 encounters of 2,742 patients who underwent major lower extremity amputations. There were 1,624 (59.2%) patients with CF. Patients with CF were younger (68.4 years old vs. 69.7 years old, P = 0.005), with higher Charlson Comorbidity Indices (4.4 vs. 4.1, P < 0.001), and required more hospital resources on index admission ($113,699 vs. $91,854, P < 0.001). These patients were prevalent for higher 30-, and 90-day readmission rates (34.7% vs. 24.5%, P < 0.001 and 54.7% vs. 42.0%, P < 0.001, respectively). On their first postamputation readmission, LOS (16.3 days vs. 14.7 days, P = 0.004) and hospital charge ($48,964 vs. $44,388, P = 0.002) were significantly higher. Multivariate regression analysis demonstrated that the CF was an independent predictor for 30-day (hazard ratio (HR) 1.65, 95% confidence interval (CI) 1.39-1.96, P < 0.001) and 90-day (HR 1.66, 95% CI 1.42-1.95, P < 0.001) readmission after the major lower extremity amputation, but not for mortality (HR 0.83, 95% CI 0.56-1.23, P = 0.36). CONCLUSIONS CF after major lower extremity amputation is associated with higher readmission rate, LOS, and hospital charge. Collaboration of care providers to maintain continuity of care for peripheral vascular disease patients may enhance quality of care and reduce health care cost.
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Affiliation(s)
- Braedon R Urie
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Taylor Laskowski
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Michele Richard
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Nikita Tihonov
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Daniel Katz
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Alexandre d'Audiffret
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL
| | - Sungho Lim
- Section of Vascular and Endovascular Surgery, Department of Cardio-Vascular and Thoracic Surgery, Rush University Medical College, Chicago, IL.
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13
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Tsai J. Theorizing Pathways Between Eviction Filings and Increased Mortality Risk. JAMA 2024; 331:570-571. [PMID: 38497705 DOI: 10.1001/jama.2023.27978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Jack Tsai
- School of Public Health, University of Texas Health Science Center at Houston
- National Center on Homelessness Among Veterans, US Department of Veterans Affairs, Washington, DC
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14
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Wongchan N, Nilmanat K, Chinnawong T. Situational Analysis of Barriers to Continuity of End-of-Life Care in Urban Areas, Bangkok. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2024; 20:48-64. [PMID: 37975832 DOI: 10.1080/15524256.2023.2282354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
This qualitative study was designed to describe the continuity of end-of-life care and identify barriers to continuity in urban Bangkok. Continuity of care is considered an essential part of palliative care to promote the quality of life of patients at the end of life. The majority of studies have been conducted exploring continuity of care in rural communities. However, few studies have focused on urban areas, particularly in big cities. Twelve healthcare providers were the participants, including nurses in inpatient units, and in the Health Community and Continuity of Care Unit, a palliative care physician, and social workers. The data collection consisted of individual interviews, field notes, and observations. Content analysis was used to analyze data and identify barriers. The continuity of end-of-life care in a selected setting was fragmented. Three main barriers to the continuity of end-of-life care consisted of misunderstandings about patients who required palliative care, staff workloads, and incomplete patient information. The development of a comprehensive patient information sheet for communication among a multidisciplinary team could promote continuity of end-of-life care from hospital to home. An interprofessional training course on continuity of end-of-life care is also recommended. Finally, the staff workload should be monitored and managed.
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Affiliation(s)
- Nisa Wongchan
- Faculty of Nursing, Prince of Songkla University, Songkhla, Thailand
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15
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Adler-Milstein J, Linden A, Hsia RY, Everson J. Electronic connectivity between hospital pairs: impact on emergency department-related utilization. J Am Med Inform Assoc 2023; 31:15-23. [PMID: 37846192 PMCID: PMC10746309 DOI: 10.1093/jamia/ocad204] [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: 07/07/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE To use more precise measures of which hospitals are electronically connected to determine whether health information exchange (HIE) is associated with lower emergency department (ED)-related utilization. MATERIALS AND METHODS We combined 2018 Medicare fee-for-service claims to identify beneficiaries with 2 ED encounters within 30 days, and Definitive Healthcare and AHA IT Supplement data to identify hospital participation in HIE networks (HIOs and EHR vendor networks). We determined whether the 2 encounters for the same beneficiary occurred at: the same organization, different organizations connected by HIE, or different organizations not connected by HIE. Outcomes were: (1) whether any repeat imaging occurred during the second ED visit; (2) for beneficiaries with a treat-and-release ED visit followed by a second ED visit, whether they were admitted to the hospital after the second visit; (3) for beneficiaries discharged from the hospital followed by an ED visit, whether they were admitted to the hospital. RESULTS In adjusted mixed effects models, for all outcomes, beneficiaries returning to the same organization had significantly lower utilization compared to those going to different organizations. Comparing only those going to different organizations, HIE was not associated with lower levels of repeat imaging. HIE was associated with lower likelihood of hospital admission following a treat-and-release ED visit (1.83 percentage points [-3.44 to -0.21]) but higher likelihood of admission following hospital discharge (2.78 percentage points [0.48-5.08]). DISCUSSION Lower utilization for beneficiaries returning to the same organization could reflect better access to information or other factors such as aligned incentives. CONCLUSION HIE is not consistently associated with utilization outcomes reflecting more coordinated care in the ED setting.
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Affiliation(s)
- Julia Adler-Milstein
- Division of Clinical Informatics and Digital Transformation, Department of Medicine, University of California, San Francisco, San Francisco, CA 94131, United States
| | - Ariel Linden
- Division of Clinical Informatics and Digital Transformation, Department of Medicine, University of California, San Francisco, San Francisco, CA 94131, United States
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA 94110, United States
| | - Jordan Everson
- US Department of Health and Human Services, Office of the National Coordinator for Health IT, Washington, DC 20201, United States
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16
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Djulbegovic B, Greenberg CS. Hematology referral madness syndrome. Blood Adv 2023; 7:6702-6704. [PMID: 37729619 PMCID: PMC10641470 DOI: 10.1182/bloodadvances.2023011434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/15/2023] [Accepted: 09/16/2023] [Indexed: 09/22/2023] Open
Affiliation(s)
- Benjamin Djulbegovic
- Division of Medical Hematology and Oncology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Charles S. Greenberg
- Division of Medical Hematology and Oncology, Department of Medicine, Medical University of South Carolina, Charleston, SC
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17
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Malakellis M, Wong Shee A, Murray M, Alston L, Versace VL, Allender S, Mc Namara K. A qualitative system model to describe the causes and drivers of frequent potentially avoidable presentations to the emergency department. Heliyon 2023; 9:e21304. [PMID: 38027925 PMCID: PMC10658286 DOI: 10.1016/j.heliyon.2023.e21304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 10/13/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Frequent potentially avoidable presentations to Emergency Departments (EDs) represent a complex problem, driven by multiple interdependent and interacting factors that change over time and influence one another. We sought to describe and map the drivers of frequent potentially avoidable presentations to a regional ED, servicing regional and rural areas, and identify possible solutions from the perspectives of key stakeholders. This study used a qualitative, community-based systems dynamics approach utilising Group Model Building (GMB). Data were collected from two 3-h online workshops embedded with small-group discussions and conducted with stakeholder groups operating within a regional health system. Stakeholders were guided through a series of participatory tasks to develop a causal loop diagram (CLD) using Systems Thinking in Community Knowledge Exchange software (n=29, workshop one), identify potential action points and generate a prioritised action list to intervene in the system (n=21, workshop two). Data were collected through note taking, real-time system mapping, and recording the workshops. Each action was considered against the Public Health 12 framework describing twelve leverage points to intervene in a system. A CLD illustrating the complex and interrelated factors that drive frequent potentially avoidable ED presentations was developed and classified into four categories: (1) access to services; (2) coordination; (3) patient needs; and (4) knowledge and skills. Nine action areas were identified, with many relating to care and service coordination. Most actions aligned with lower-level system impact actions. This study provides an in-depth understanding of influencing factors and potential solutions for frequent potentially avoidable ED presentations across a regional health system. The CLD demonstrates frequent potentially avoidable ED presentations are a complex problem and identified that a prevention response should engage with system- and individual-level solutions. Further work is needed to prioritise actions to support the implementation of higher-level system impacts.
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Affiliation(s)
- Mary Malakellis
- Deakin Rural Health, School of Medicine, Deakin University, Warrnambool, Victoria, Australia
| | - Anna Wong Shee
- Deakin Rural Health, School of Medicine, Deakin University, Warrnambool, Victoria, Australia
- Grampians Health, Ballarat, Victoria, Australia
| | - Margaret Murray
- Deakin Rural Health, School of Medicine, Deakin University, Warrnambool, Victoria, Australia
| | - Laura Alston
- Deakin Rural Health, School of Medicine, Deakin University, Warrnambool, Victoria, Australia
- Colac Area Health Research Unit, Colac, Victoria, Australia
| | - Vincent L. Versace
- Deakin Rural Health, School of Medicine, Deakin University, Warrnambool, Victoria, Australia
| | - Steven Allender
- Global Centre for Preventative Health and Nutrition, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Kevin Mc Namara
- Deakin Rural Health, School of Medicine, Deakin University, Warrnambool, Victoria, Australia
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18
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Ando T, Sasaki T, Abe Y, Nishimoto Y, Hirata T, Haruta J, Arai Y. Measurement of polydoctoring as a crucial component of fragmentation of care among patients with multimorbidity: Cross-sectional study in Japan. J Gen Fam Med 2023; 24:343-349. [PMID: 38025930 PMCID: PMC10646296 DOI: 10.1002/jgf2.651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/03/2023] [Accepted: 09/11/2023] [Indexed: 12/01/2023] Open
Abstract
Background Care fragmentation, characterized by the uncoordinated involvement of multiple healthcare providers, leads to inefficient and ineffective healthcare, posing a significant challenge in managing patients with multimorbidity. In this context, "polydoctoring," where patients see multiple specialists, emerges as a crucial aspect of care fragmentation. This study seeks to develop an indicator to assess polydoctoring, which can subsequently enhance the management of multimorbidity. Methods Baseline survey data from the Kawasaki Aging and Wellbeing Project (KAWP) involving independent community-dwelling older adults aged 85-89 were utilized in this cross-sectional study. Polydoctoring measure was defined as the number of regularly visited facilities (RVFs). The association of RVF with the Fragmentation of Care Index (FCI) and the outcome measures of polypharmacy and ambulatory care costs were examined as indicators of care fragmentation. Results The analysis comprised 968 participants, with an average of 4.70 comorbid chronic conditions; 65.3% of the participants had two or more RVFs, indicating polydoctoring. A significant correlation between RVF and FCI was observed. Modified Poisson regression analyses revealed associations between higher RVF and increased prevalence ratio of polypharmacy. Likewise, a higher RVF was associated with higher outpatient medical costs. Conclusions RVF was significantly correlated with FCI, polypharmacy, and higher outpatient medical costs. Unlike complex indices, RVF is simple and intuitively comprehensible. Further research is needed to evaluate the impact of care fragmentation on patient outcomes, considering factors such as RVF thresholds, patient multimorbidity, and social support. Understanding the influence of polydoctoring can enhance care quality and efficiency for patients with multimorbidity.
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Affiliation(s)
- Takayuki Ando
- Center for General Medicine EducationKeio University School of MedicineTokyoJapan
| | - Takashi Sasaki
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
| | - Yukiko Abe
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
| | - Yoshinori Nishimoto
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
- Department of NeurologyKeio University School of MedicineTokyoJapan
| | - Takumi Hirata
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
- Institute for Clinical and Translational ScienceNara Medical UniversityKashiharaJapan
| | - Junji Haruta
- Center for General Medicine EducationKeio University School of MedicineTokyoJapan
- Medical Education CenterKeio University School of MedicineTokyoJapan
| | - Yasumichi Arai
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
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19
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Tseng LO, Newton C, Hall D, Lee EJ, Chang H, Poureslami I, Vasarhelyi K, Lacaille D, Mitton C. Primary care family physicians' experiences with clinical integration in qualitative and mixed reviews: a systematic review protocol. BMJ Open 2023; 13:e067576. [PMID: 37433736 DOI: 10.1136/bmjopen-2022-067576] [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] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Clinical (service) integration in primary care settings describes how comprehensive care is coordinated by family physicians (FPs) over time across healthcare contexts to meet patient care needs. To improve care integration and healthcare service planning, a systematic approach to understanding its numerous influencing factors is paramount. The objective of this study is to generate a comprehensive map of FP-perceived factors influencing clinical integration across diseases and patient demographics. METHODS AND ANALYSIS We developed the protocol with the guidance of the Joanna Briggs Institute systematic review methodology framework. An information specialist built search strategies for MEDLINE, EMBASE and CINAHL databases using keywords and MeSH terms iteratively collected from a multidisciplinary team. Two reviewers will work independently throughout the study process, from article selection to data analysis. The identified records will be screened by title and abstract and reviewed in the full text against the criteria: FP in primary care (population), clinical integration (concept) and qualitative and mixed reviews published in 2011-2021 (context). We will first describe the characteristics of the review studies. Then, we will extract qualitative, FP-perceived factors and group them by content similarities, such as patient factors. Lastly, we will describe the types of extracted factors using a custom framework. ETHICS AND DISSEMINATION Ethics approval is not required for a systematic review. The identified factors will help generate an item bank for a survey that will be developed in the Phase II study to ascertain high-impact factors for intervention(s), as well as evidence gaps to guide future research. We will share the study findings with various knowledge users to promote awareness of clinical integration issues through multiple channels: publications and conferences for researchers and care providers, an executive summary for clinical leaders and policy-makers, and social media for the public.
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Affiliation(s)
- L Olivia Tseng
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology and Evaluation (C2E2), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Christie Newton
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - David Hall
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- Department of Family & Community Practice, Vancouver Coastal Health Authority (VCHA), Vancouver, British Columbia, Canada
| | - Esther J Lee
- Complex Care Program, BC Children's Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, Division of General Pediatrics, UBC, Vancouver, British Columbia, Canada
| | - Howard Chang
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Iraj Poureslami
- Respiratory Medicine Division, University of British Columbia, Vancouver, British Columbia, Canada
| | - Krisztina Vasarhelyi
- Department of Family & Community Practice, Vancouver Coastal Health Authority (VCHA), Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Diane Lacaille
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Department of Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation (C2E2), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
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20
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Hahn Z, Hotchkiss J, Atwood C, Smith C, Totten A, Boudreau E, Folmer R, Chilakamarri P, Whooley M, Sarmiento K. Travel Burden as a Measure of Healthcare Access and the Impact of Telehealth within the Veterans Health Administration. J Gen Intern Med 2023:10.1007/s11606-023-08125-3. [PMID: 37340257 DOI: 10.1007/s11606-023-08125-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Travel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts' intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers. OBJECTIVE The Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented. DESIGN Retrospective, observational, utilizing administrative data. SUBJECTS VA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT). MAIN MEASURES Observed distance: distance between Veteran's home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran's home and nearest VA facility offering in-person equivalent of telehealth service. KEY RESULTS In-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices. CONCLUSIONS Veterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources.
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Affiliation(s)
- Zachary Hahn
- Togus VA Medical Center, 1 VA Ctr, Augusta, ME, 04330, USA.
| | | | | | - Connor Smith
- Portland VA Medical Center, Portland, OR, USA
- Oregon Health and Science University, Portland, OR, USA
| | | | - Eilis Boudreau
- Portland VA Medical Center, Portland, OR, USA
- Oregon Health and Science University, Portland, OR, USA
| | - Robert Folmer
- Portland VA Medical Center, Portland, OR, USA
- Oregon Health and Science University, Portland, OR, USA
| | | | - Mary Whooley
- San Francisco VA Medical Center, San Francisco, CA, USA
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21
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McAlister FA. Care Fragmentation After Hospital Discharge: Often Ignored, But Important. JACC. ADVANCES 2023; 2:100398. [PMID: 38938249 PMCID: PMC11198500 DOI: 10.1016/j.jacadv.2023.100398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Finlay A. McAlister
- Division of General Internal Medicine, University of Alberta, Edmonton, Canada
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22
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Verma A, Madrigal J, Coaston T, Ascandar N, Williamson C, Benharash P. Care Fragmentation Following Hospitalization for Atrial Fibrillation in the United States. JACC. ADVANCES 2023; 2:100375. [PMID: 38938260 PMCID: PMC11198211 DOI: 10.1016/j.jacadv.2023.100375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/15/2023] [Accepted: 03/10/2023] [Indexed: 06/29/2024]
Abstract
Background Despite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain unstudied. Objectives The present study used a national database to determine the incidence of and risk factors associated with CF. Outcomes following CF were also examined. Methods All adults who were discharged alive following hospitalization for AF (index facility) were identified within the 2016 to 2019 Nationwide Readmissions Database. Patients requiring nonelective rehospitalization within 30 days of discharge were categorized into 2 groups. The CF cohort included those readmitted to a nonindex facility, while others were classified as noncare fragmentation. Multivariable regression was used to evaluate factors associated with CF, as well as its impact on in-hospital mortality, length of stay, and costs at rehospitalization. Results Of an estimated 686,942 patients who met study criteria and survived to discharge, 13.6% (n = 93,376) experienced unplanned readmission within 30 days. Among those readmitted, 21.3% (n = 19,906) were readmitted to a nonindex facility. Patients who experienced CF were younger, more commonly male and less frequently readmitted for AF. Upon multivariable adjustment, male sex, Medicaid insurance (ref: private), and transfer status were associated with increased odds of CF. Upon readmission, CF was associated with a 18% increment in relative odds of in-hospital mortality, a 0.3-day increment in length of stay, and an additional $1,500 in hospitalization costs. Conclusions CF was associated with significant clinical and financial burden. Further studies are needed to address factors which contribute to increased mortality and resource use following CF.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Josef Madrigal
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Troy Coaston
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nameer Ascandar
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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23
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Turbow SD, Ali MK, Culler SD, Rask KJ, Perkins MM, Clevenger CK, Vaughan CP. Association of Fragmented Readmissions and Electronic Information Sharing With Discharge Destination Among Older Adults. JAMA Netw Open 2023; 6:e2313592. [PMID: 37191959 PMCID: PMC10189568 DOI: 10.1001/jamanetworkopen.2023.13592] [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: 12/22/2022] [Accepted: 03/31/2023] [Indexed: 05/17/2023] Open
Abstract
Importance When an older adult is hospitalized, where they are discharged is of utmost importance. Fragmented readmissions, defined as readmissions to a different hospital than a patient was previously discharged from, may increase the risk of a nonhome discharge for older adults. However, this risk may be mitigated via electronic information exchange between the admission and readmission hospitals. Objective To determine the association of fragmented hospital readmissions and electronic information sharing with discharge destination among Medicare beneficiaries. Design, Setting, and Participants This cohort study retrospectively examined data from Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues in 2018 and their 30-day readmission for any reason. The data analysis was completed between November 1, 2021, and October 31, 2022. Exposures Same hospital vs fragmented readmissions and presence of the same health information exchange (HIE) at the admission and readmission hospitals vs no information shared between the admission and readmission hospitals. Main Outcomes and Measures The main outcome was discharge destination following the readmission, including home, home with home health, skilled nursing facility (SNF), hospice, leaving against medical advice, or dying. Outcomes were examined for beneficiaries with and without Alzheimer disease using logistic regressions. Results The cohort included 275 189 admission-readmission pairs, representing 268 768 unique patients (mean [SD] age, 78.9 [9.0] years; 54.1% female and 45.9% male; 12.2% Black, 82.1% White, and 5.7% other race and ethnicity). Of the 31.6% fragmented readmissions in the cohort, 14.3% occurred at hospitals that shared an HIE with the admission hospital. Beneficiaries with same hospital/nonfragmented readmissions tended to be older (mean [SD] age, 78.9 [9.0] vs 77.9 [8.8] for fragmented with same HIE and 78.3 [8.7] years for fragmented without HIE; P < .001). Fragmented readmissions were associated with 10% higher odds of discharge to an SNF (adjusted odds ratio [AOR], 1.10; 95% CI, 1.07-1.12) and 22% lower odds of discharge home with home health (AOR, 0.78; 95% CI, 0.76-0.80) compared with same hospital/nonfragmented readmissions. When the admission and readmission hospital shared an HIE, beneficiaries had 9% to 15% higher odds of discharge home with home health (patients without Alzheimer disease: AOR, 1.09 [95% CI, 1.04-1.16]; patients with Alzheimer disease: AOR, 1.15 [95% CI, 1.01-1.32]) compared with fragmented readmissions where information sharing was not available. Conclusions and Relevance In this cohort study of Medicare beneficiaries with 30-day readmissions, whether a readmission is fragmented was associated with discharge destination. Among fragmented readmissions, shared HIE across admission and readmission hospitals was associated with higher odds of discharge home with home health. Efforts to study the utility of HIE for care coordination for older adults should be pursued.
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Affiliation(s)
- Sara D. Turbow
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mohammed K. Ali
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Steven D. Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Molly M. Perkins
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Camille P. Vaughan
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta, Georgia
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Kehoe MacLeod K. Using Independent Contracting Arrangements in Integrated Care Programs for Older Adults: Implications for Clients and the Home Care Workforce in a Time of Neoliberal Restructuring. J Appl Gerontol 2023; 42:536-543. [PMID: 36201193 DOI: 10.1177/07334648221130743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Integrated care programs reshape the processes of health and social care delivery in the home care sector to be more continuous, cooperative, equitable, and efficient. An independent contracting model is one approach being used to overcome issues related to home care fragmentation. To better understand the implications of this model of service delivery for clients and carers, interviews were conducted in 2013 with 22 key informants. Data were analyzed using thematic analysis and interpreted using a feminist political economy framework. This study finds that independent contracting arrangements improve care continuity for clients while simultaneously reinforcing precarious working conditions for home care workers. This research calls for reform to this model of service delivery to better support home care workers as they provide the care necessary for older adults to age in place.
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Affiliation(s)
- Krystal Kehoe MacLeod
- Centre for Research in Integrated Care, 96944University of New Brunswick Saint John, New Brunswick, Canada
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Smith AD, Moog TM, Burgess KW, McCreary M, Okuda DT. Factors associated with the misdiagnosis of neuromyelitis optica spectrum disorder. Mult Scler Relat Disord 2023; 70:104498. [PMID: 36610360 DOI: 10.1016/j.msard.2023.104498] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/05/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune condition that is associated with severe disability. Approximately 40% of individuals are misdiagnosed with multiple sclerosis (MS) or other diseases. We aimed to define factors that influence the misdiagnosis of people with NMOSD and provide strategies for reducing error rates. METHODS A retrospective study was performed involving all people with a confirmed diagnosis of NMOSD within a single academic institution. Comprehensive clinical timelines were constructed for each individual that included presenting symptoms, provider type and timing of evaluations, aquaporin 4-IgG (AQP4) results, and MRI scans. Two-sample comparisons of continuous and categorial variables were performed for people accurately diagnosed with NMOSD and those originally misdiagnosed with another medical condition. A subanalysis of only AQP4-IgG positive people was also performed. RESULTS The study cohort included 199 people fulfilling International Panel criteria for NMOSD with 71 people (62 female; mean age at first symptom presentation (standard deviation (SD)) = 32.8 years (y) (SD 16.1)) being initially misdiagnosed and 128 people (106 female; 41.14y (SD 15.41)) who were accurately diagnosed. Of the 199 people with NMOSD, 166 had a positive serostatus. Identified factors associated with misdiagnosis, regardless of AQP4-IgG serostatus, were the presence of protracted nausea/vomiting/hiccups without any accompanying neurological symptoms, 23 (32.4%) versus 16 (12.5%) (p = 0.001), a longer median (range) time to see a neuroimmunology specialist 4.2y (0.14-31.8) versus 0.5y (0.0-21.2) (p<0.0001), and a delay in acquiring an MRI study, 4.7y (0.0-27.3) versus 0.3y (0.0-20.2) (p<0.0001). A greater proportion of people misdiagnosed were identified with a negative live-cell based AQP4-IgG serum test result, 13/13 (100%) versus 22/114 (19.3%) (p<0.0001). Additionally, the mean (SD) time between a first negative and successive live-cell based AQP4-IgG positive test result was greater for people misdiagnosed with another condition, 3.9y (SD 5.0) versus 1.5y (SD 2.1) (p = 0.01). Although not significant between groups, a rash was also reported in 63/199 people with NMOSD, with 31/63 having an anti-nuclear antibody titer ≥ 1:160. CONCLUSION Defined factors can help guide both generalists and specialists in the pursuit of strategies aimed at efficiently diagnosing those with NMOSD such that effective care can be delivered.
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Affiliation(s)
- Alexander D Smith
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tatum M Moog
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katy W Burgess
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Morgan McCreary
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Darin T Okuda
- Department of Neurology, Neuroinnovation Program, Multiple Sclerosis & Neuroimmunology Imaging Program, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Thomas MK, Heincelman ME, Zhang J, Marsden J, Dulin J, Robbins P, Hunt K, Mauldin P, Moran WP, Kalivas B. Understanding the association between admission source and in-hospital delirium: A cross-sectional study. J Investig Med 2023; 71:32-37. [PMID: 36655322 DOI: 10.1136/jim-2022-002342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Patients admitted via interhospital transfer (IHT) experience increased risk-adjusted mortality, adverse events, length of stay, and discharge to facility; however, the etiology is not well understood. We hypothesize that IHTs are more likely to experience in-hospital delirium as compared with admissions to the hospital via the emergency department (ED) and clinic. This is a cross-sectional study of all adult admissions to medical, surgical, neurological, and obstetrics and gynecology services at an academic medical center who were screened for delirium between August 2018 and January 2020. Unit of analysis was admission source (IHT vs ED vs clinic) as the independent variable and the primary outcome was in-hospital delirium, assessed with initial brief confusion assessment method (bCAM) screening. 30,100 hospitalizations were included in this study with 3925 admissions (13.0%) screening positive for delirium at the initial bCAM assessment. The prevalence of delirium was much higher in IHTs at 22.3% (1334/5971) when compared with clinic at 5.8% (244/4214) and ED at 11.8% (2347/19,915) admissions. Multivariable logistic regression adjusting for demographics and comorbidities showed that IHT admissions had higher odds (OR 1.91, 95% CI 1.74 to 2.10) and clinic admissions had lower odds (OR 0.56, 95% CI 0.48 to 0.64) of in-hospital delirium compared with ED admissions. Increased odds of delirium in IHT admissions may contribute to the observed increased length of stay, discharge to facility, and mortality. These results emphasize the importance of routine screening and possible intervention prior to patient transfer.
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Affiliation(s)
- Meghan K Thomas
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Marc E Heincelman
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jennifer Dulin
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrick Robbins
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kelly Hunt
- Public Health, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrick Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Benjamin Kalivas
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.,Psychiatry, Medical University of South Carolina, Charleston, South Carolina, USA
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Graham LA, Schoemaker L, Rose L, Morris AM, Aouad M, Wagner TH. Expansion of the Veterans Health Administration Network and Surgical Outcomes. JAMA Surg 2022; 157:1115-1123. [PMID: 36223115 PMCID: PMC9558067 DOI: 10.1001/jamasurg.2022.4978] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/16/2022] [Indexed: 01/11/2023]
Abstract
Importance The US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding. Objective To investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders. Design, Setting, and Participants This was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019. Interventions The VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital. Main Outcomes and Measures Postoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days. Results A total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]). The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P = .01). However, there was no difference in postoperative mortality, readmissions, or emergency department visits. Conclusions and Relevance Expanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.
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Affiliation(s)
- Laura A. Graham
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Lena Schoemaker
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Arden M. Morris
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
| | - Marion Aouad
- Department of Economics, University of California, Irvine
| | - Todd H. Wagner
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement Research and Education Center, Stanford School of Medicine, Stanford, California
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Wolf M, Hasselström JK, Carlsson A, Euler MV, Hasselström J. Identifying factors explaining practice variation in secondary stroke prevention in primary care: a cohort study based on all patients with ischaemic stroke in the Stockholm region. BMJ Open 2022; 12:e064277. [PMID: 36410815 PMCID: PMC9680155 DOI: 10.1136/bmjopen-2022-064277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe the practice variation in dispensation of secondary stroke preventive drugs among patients at different primary care centres (PCCs) in Stockholm region and to identify factors that may explain the variation. DESIGN Cohort study using administrative data from the Stockholm region. SETTING Stockholm Health Care Region, Sweden, serving a population of 2.3 million inhabitants, hospital and PCC data. PARTICIPANTS All patients (n=9761) with ischaemic stroke treated in hospital from 1 July 2009 to 30 June 2014 were included. Of these, 7562 patients registered with 187 PCCs were analysed. Exclusion criteria were; deceased patients, age <18, haemorrhagic stroke and/or switching PCC. PRIMARY AND SECONDARY OUTCOME MEASURES As primary outcome the impact of PCC organisation variables and patient characteristics on the dispensation of statins, antiplatelets, antihypertensives and anticoagulants were analysed. Secondarily, the unadjusted practice variation of preventive drug dispensation of 187 PCCs is described. RESULTS There was up to fourfold practice variation in dispensation of all secondary preventive drugs. Factors associated with a lower level of dispensed statins were privately run PCCs (OR 0.91 (95% CI 0.82 to 1.00)) and the patient being woman. Increased statin use was associated with a higher number of specialists in family medicine (OR 1.03 (95% CI 1.01 to 1.05)) and a higher proportion of patients registered with a specific physician (OR 1.37 (95% CI 1.11 to 1.68)). Women had on average a lower number of dispensed antihypertensives. CONCLUSIONS A high practice variation for dispensation of all secondary preventive drugs was observed. Patient and PCC level factors indicating good continuity of care and high level of general practitioner education were associated with higher use of statins. Findings are of importance to policymakers as well as individual providers of care, and more research and actions are needed to minimise inequality in healthcare.
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Affiliation(s)
- Maria Wolf
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
| | - Jakob K Hasselström
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Axel Carlsson
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
| | - Mia von Euler
- Department of Neurology and Rehabilitation, Örebro universitet Fakulteten för medicin och hälsa, Orebro, Sweden
| | - Jan Hasselström
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
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Zinger ND, Blomberg SN, Lippert F, Krafft T, Christensen HC. Impact of integrating out-of-hours services into Emergency Medical Services Copenhagen: a descriptive study of transformational years. Int J Emerg Med 2022; 15:40. [PMID: 36008756 PMCID: PMC9414103 DOI: 10.1186/s12245-022-00442-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background Many emergency medical services and out-of-hours systems are facing an increasing demand for primary, ambulance, and secondary care services caused by population aging and a higher prevalence of long-term and complex conditions. In order to ensure safety and efficiency for future demands, many systems are changing their dispersed healthcare services towards a more integrated care system. Therefore, an evaluation of the production and performance over time of such a unified system is desirable. Methods This retrospective quantitative study was performed with dispatch and financial accounting data of Copenhagen Emergency Medical Services for the period 2010–2019. Copenhagen Emergency Medical Services operates both an emergency number and a medical helpline for out-of-hours services. The number of calls to the emergency number, the centralized out-of-hours medical helpline, the number of dispatches, and the annual expenditure of the system are described for both the periods before and after the major reforms. Production of the emergency number and the centralized medical helpline were analyzed separately. Results The average number of dispatches increased from 328 per 10,000 inhabitants in 2010 to 361 per 10,000 inhabitants in 2019. The newly initiated medical helpline received 533 calls per 10,000 inhabitants in its first year and 5 years later 548 calls per 10,000 inhabitants. A cost increase of 10% was observed in the first year after the reforms, but it decreased again to 8% in the following year. Conclusions There is a population demand for a centralized telephone access point for (semi-)emergency medical services. A more integrated EMS system is promising for a sustainable healthcare provision for a growing population with complex healthcare demands and multi-morbidities.
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Affiliation(s)
- Nienke D Zinger
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Stig Nikolaj Blomberg
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Freddy Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Krafft
- Department of Health, Ethics & Society, CAPHRI School of Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Helle Collatz Christensen
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark. .,Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark.
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Nakikj D, Kreda D, Gehlenborg N. New Ways for Patients to Make Sense of Their EHR Data Using the Discovery Web-application: A Think-aloud Evaluation Study (Preprint). JMIR Form Res 2022; 7:e41346. [PMID: 37010887 PMCID: PMC10131650 DOI: 10.2196/41346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In the United States, patients can access their electronic health record (EHR) data through patient portals. However, current patient portals are mainly focused on a single provider, with very limited data sharing capabilities and put low emphasis on independent sensemaking of the EHR data. This makes it very challenging for patients to switch between different portals and aggregate the data to obtain a complete picture of their medical history and to make sense of it. Owing to this fragmentation, patients are exposed to numerous inconveniences such as medical errors, repeated tests, and limited self-advocacy. OBJECTIVE To overcome the limitations of EHR patient portals, we designed and developed Discovery-a web-based application that aggregates EHR data from multiple providers and present them to the patient for efficient exploration and sensemaking. To learn how well Discovery meets the patients' sensemaking needs and what features should such applications include, we conducted an evaluation study. METHODS We conducted a remote study with 14 participants. In a 60-minute session and relying on the think-aloud protocol, participants were asked to complete a variety of sensemaking tasks and provide feedback upon completion. The audio materials were transcribed for analysis and the video recordings of the users' interactions with Discovery were annotated to provide additional context. These combined textual data were thematically analyzed to surface themes that reflect how participants used Discovery's features, what sensemaking of their EHR data really entails, and what features are desirable to support that process better. RESULTS We found that Discovery provided much needed features and could be used in a variety of everyday scenarios, especially for preparing and during clinical visits and also for raising awareness, reflection, and planning. According to the study participants, Discovery provided a robust set of features for supporting independent exploration and sensemaking of their EHR data: summary and quick overview of the data, finding prevalence, periodicity, co-occurrence, and pre-post of medical events, as well as comparing medical record types and subtypes across providers. In addition, we extracted important design implications from the user feedback on data exploration with multiple views and nonstandard user interface elements. CONCLUSIONS Patient-centered sensemaking tools should have a core set of features that can be learned quickly and support common use cases for a variety of users. The patients should be able to detect time-oriented patterns of medical events and get enough context and explanation on demand in a single exploration view that feels warm and familiar and relies on patient-friendly language. However, this view should have enough plasticity to adjust to the patient's information needs as the sensemaking unfolds. Future designs should include the physicians in the patient's sensemaking process and improve the communication in clinical visits and via messaging.
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Affiliation(s)
- Drashko Nakikj
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, United States
| | - David Kreda
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, United States
| | - Nils Gehlenborg
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, United States
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Kerrissey M. Commentary on "Integrating network theory into the study of integrated healthcare". Soc Sci Med 2022; 305:115035. [PMID: 35654681 DOI: 10.1016/j.socscimed.2022.115035] [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: 04/08/2022] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
As medicine continues to advance, fragmentation problems in care delivery - and the promise of care integration to solve them - will remain central. But focused research over the past thirty years has yet to uncover the key factors that enable integrated care. In their paper, Burns and colleagues offer a path to new discovery in this well-trodden area: drawing on network theory to better understand the social processes through which integrated care is produced. Social processes are a vital and understudied aspect of integration, and applying network theory may help to refocus integration in a more comprehensive way. However, to transform our understanding of integrated care - and to enable impact in practice - will require expansion beyond the usual network approaches to also capture the communication and work processes that occur among entities. This is no small endeavor. It will take considerable humility, open-mindedness, and focus.
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Affiliation(s)
- Michaela Kerrissey
- Harvard TH Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02116, USA.
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Jain U, Jain B, Dee EC, Jain P, Palakodeti S. Integrated practice units present an opportunity over siloed survivorship care settings. Support Care Cancer 2022; 30:6375-6379. [PMID: 35290514 DOI: 10.1007/s00520-022-06964-0] [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: 09/08/2021] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
Given the rapidly rising cancer burden in the USA, the need to innovate survivorship care for oncology patients is rising rapidly. The current body of empirical evidence in survivorship care has focused on care provided by general practitioners (GP) and specialists/surgeons (SS). In particular, current evaluations address cost of care, cancer recurrence, quality of life, and overall survival of patients, with results indicating no statistically significant differences in GP- and SS-led care models and little emphasis on the broader characteristics of care settings. We fill this gap in survivorship care by introducing a perspective on the potential for holistic care delivery with a multidisciplinary team approach at integrated practice units (IPUs). Additionally, we propose a comprehensive examination of survivorship care across GP-, SS-, and IPU-led settings to provide researchers and practitioners with solid ground to determine the optimal survivorship care model, considering four key characteristics: (1) operating mode and skills, (2) cost and accountability of care, (3) health outcome measurement, and (4) workflow and scheduling.
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Affiliation(s)
- Urvish Jain
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pankaj Jain
- Indiana University of Pennsylvania, Indiana, PA, USA.,Highmark Health, Pittsburgh, PA, USA
| | - Sandeep Palakodeti
- Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106, USA.
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Kawsara A, Osman M, Sulaiman S, Sattar Y, El Shaer A, Alkhouli M. Interhospital readmissions and early post-discharge outcomes of transcatheter mitral valve edge-to-edge repair. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 41:10-16. [DOI: 10.1016/j.carrev.2022.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 11/29/2022]
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French WW, Scales CD, Viprakasit DP, Sur RL, Friedlander DF. Predictors and Cost Comparison of Subsequent Urinary Stone Care at Index versus Non-Index Hospitals. Urology 2022; 164:124-132. [PMID: 35093397 DOI: 10.1016/j.urology.2022.01.023] [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: 09/01/2021] [Revised: 11/27/2021] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine the effects of care fragmentation, or the engagement of different health care systems along the continuum of care, on patients with urinary stone disease. METHODS All-payer data from the 2016 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify a cohort of adult patients with an emergency department visit for a diagnosis of urolithiasis, who subsequently re-presented to an index or non-index hospital for renal colic and/or urological intervention. Patient demographics, regional data, and procedural information were collected and 30-day episode-based costs were calculated. Multivariable logistic and gamma generalized linear regression were utilized to identify predictors of receiving subsequent care at an index hospital and associated costs, respectively. RESULTS Of the 33,863 patients who experienced a subsequent encounter related to nephrolithiasis, 9,593 (28.3%) received care at a non-index hospital. Receiving subsequent care at the index hospital was associated with fewer acute care encounters prior to surgery (2.5 vs. 2.7; p <0.001) and less days to surgery (29 vs. 42; p < 0.001). Total episode-based costs were higher in the non-index setting, with a mean difference of $783 (Non-index: $13,672, 95% CI $13,292 - $14,053; Index: $12,889, 95% CI $12,677 - $13,102; p < 0.001). CONCLUSIONS Re-presentation to a unique healthcare facility following an initial diagnosis of urolithiasis is associated with a greater number of episode-related health encounters, longer time to definitive surgery, and increased costs.
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Affiliation(s)
- William W French
- Department of Urology, University of North Carolina Medical Center, Chapel Hill, NC, USA.
| | - Charles D Scales
- Departments of Surgery (Urology) and Population Health Science, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
| | - Davis P Viprakasit
- Department of Urology, University of North Carolina Medical Center, Chapel Hill, NC, USA.
| | - Roger L Sur
- Department of Urology, University of California San Diego Medical Center, San Diego, CA, USA.
| | - David F Friedlander
- Department of Urology, University of North Carolina Medical Center, Chapel Hill, NC, USA.
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Krasovsky T, Barak S, Dishon-Berkovits M, Sadeh Y, Landa J, Brezner A, Silberg T. Factors associated with Multidisciplinary Healthcare Resource Utilization Following Discharge from Pediatric Rehabilitation: A One-year Follow-up Study. Phys Occup Ther Pediatr 2022; 42:579-594. [PMID: 35440261 DOI: 10.1080/01942638.2022.2061887] [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] [Indexed: 10/18/2022]
Abstract
AIMS To characterize multidisciplinary healthcare resource utilization (mHRU), including physical, occupational, speech and psychosocial therapy one-year following discharge from prolonged inpatient and outpatient pediatric rehabilitation in Israel and to identify factors associated with long-term mHRU. METHODS According to Andersen's model of health service use, predisposing (child's age and sex), enabling (district of origin, income level, parental education, insurance) and need factors (injury type, functional status, family psychosocial risk) were collected from parents of children hospitalized for >1 month in a large rehabilitation hospital in Israel, and phone interviews were held 3-months (T1), 6-months (T2) and 12-months (T3) post-discharge. The effect of time and the role of various factors on mHRU, operationalized as number of therapy sessions in the previous 2 weeks, were evaluated. RESULTS Sixty-one families participated at T1 and T2, and 46 participated at T3. HRU was similar over time. Predisposing factors (age) and need factors (functional status and psychosocial risk) were associated with specific disciplines of mHRU, but enabling factors were not. CONCLUSIONS mHRU is high and stable 12-months post-discharge. The lack of impact of enabling factors on mHRU, and the discipline-specific impact of predisposing and need factors, support equity of care provision for children following prolonged rehabilitation.
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Affiliation(s)
- Tal Krasovsky
- Department of Physical Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.,Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Sharon Barak
- Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel.,Kaye Academic College of Education, Physical Education, Beer-Sheva, Israel.,College of Public Health, Ben Gurion University, Beer-Sheva, Israel
| | | | - Yaara Sadeh
- Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel.,The Louis and Gabi Weisfeld School of Social Work, Bar Ilan University, Ramat Gan, Israel
| | - Jana Landa
- Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amichai Brezner
- Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Tamar Silberg
- Department of Pediatric Rehabilitation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel.,Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel
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36
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Integration processes within the Croatian palliative care model in 2014 – 2020. Health Policy 2022; 126:207-215. [DOI: 10.1016/j.healthpol.2022.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 11/20/2022]
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Social vulnerability and fragmentation of postoperative surgical care among patients undergoing hepatopancreatic surgery. Surgery 2021; 171:1043-1050. [PMID: 34538339 DOI: 10.1016/j.surg.2021.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Regionalization of hepatopancreatic surgery to high-volume hospitals has been associated with fragmentation of postoperative care and, in turn, inferior outcomes after surgery. The objective of this study was to examine the association of social vulnerability with the likelihood of experiencing fragmentation of postoperative care (FPC) after hepatopancreatic surgery. METHODS Patients who underwent hepatopancreatic surgery and had at least 1 readmission within 90 days were identified using Medicare 100% Standard Analytical Files between 2013 and 2017. Fragmentation of postoperative care was defined as readmission at a hospital other than the index institution where the initial surgery was performed. The association of social vulnerability index and its components with fragmentation of postoperative care was examined. RESULTS Among 11,142 patients, 8,053 (72.3%) underwent pancreatectomy, and 3,089 (27.7%) underwent hepatectomy. The overall incidence of fragmentation of postoperative care was 32.9% (n = 3,667). Patients who experienced fragmentation of postoperative care were older (73 years [interquartile range: 69-77]FPC vs 72 years [interquartile range: 68-77]non-FPC) and had a higher Charlson comorbidity score (4 [interquartile range: 2-8]FPC vs 3 [interquartile range: 2-8]non-FPC) (both P < .001). Median overall social vulnerability index was higher among patients who experienced fragmentation of postoperative care (52.5 [interquartile range: 29.3-70.4]FPC vs 51.3 [interquartile range: 27.9-69.4]non-FPC, P = .02). On multivariable analysis, the odds of experiencing fragmentation of postoperative care was higher with increasing overall social vulnerability index (odds ratio: 1.14; 95% confidence interval 1.01-1.30). Additionally, the odds of experiencing fragmentation of postoperative care were higher among patients with high vulnerability owing to their socioeconomic status (odds ratio: 1.28; 95% confidence interval 1.12-1.45) or their household composition and disability (odds ratio: 1.35; 95% confidence interval 1.19-1.54), whereas high vulnerability owing to minority status and language was inversely associated with fragmentation of postoperative care (odds ratio: 0.73; 95% confidence interval 0.64-0.84). CONCLUSION Social vulnerability was strongly associated with the odds of experiencing fragmented postoperative care after hepatopancreatic surgery.
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Doose M, Sanchez JI, Cantor JC, Plascak JJ, Steinberg MB, Hong CC, Demissie K, Bandera EV, Tsui J. Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems. JCO Oncol Pract 2021; 17:e637-e644. [PMID: 33974834 DOI: 10.1200/op.20.01089] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation. MATERIALS AND METHODS We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation. RESULTS Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer-accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (P > .05). CONCLUSION The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.
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Affiliation(s)
- Michelle Doose
- Helthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD.,Rutgers School of Public Health, Piscataway, NJ.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Janeth I Sanchez
- Helthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Joel C Cantor
- Rutgers Center for State Health Policy, New Brunswick, NJ.,Rutgers Edward J. Bloustein School of Planning and Public Policy, New Brunswick, NJ
| | | | | | - Chi-Chen Hong
- University at Buffalo, Buffalo, NY.,Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Elisa V Bandera
- Rutgers School of Public Health, Piscataway, NJ.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Jennifer Tsui
- Rutgers Center for State Health Policy, New Brunswick, NJ.,Keck School of Medicine, University of Southern California, Los Angeles, CA
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Siqueira M, Coube M, Millett C, Rocha R, Hone T. The impacts of health systems financing fragmentation in low- and middle-income countries: a systematic review protocol. Syst Rev 2021; 10:164. [PMID: 34078460 PMCID: PMC8170990 DOI: 10.1186/s13643-021-01714-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 05/19/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Health systems are often fragmented in low- and middle-income countries (LMICs). This can increase inefficiencies and restrict progress towards universal health coverage. The objective of the systematic review described in this protocol will be to evaluate and synthesize the evidence concerning the impacts of health systems financing fragmentation in LMICs. METHODS Literature searches will be conducted in multiple electronic databases, from their inception onwards, including MEDLINE, EMBASE, LILACS, CINAHL, Scopus, ScienceDirect, Scielo, Cochrane Library, EconLit, and JSTOR. Gray literature will be also targeted through searching OpenSIGLE, Google Scholar, and institutional websites (e.g., HMIC, The World Bank, WHO, PAHO, OECD). The search strings will include keywords related to LMICs, health system financing fragmentation, and health system goals. Experimental, quasi-experimental, and observational studies conducted in LMICs and examining health financing fragmentation across any relevant metric (e.g., the presence of different health funders/insurers, risk pooling mechanisms, eligibility categories, benefits packages, premiums) will be included. Studies will be eligible if they compare financing fragmentation in alternative settings or at least two-time points. The primary outcomes will be health system-related goals such as health outcomes (e.g., mortality, morbidity, patient-reported outcome measures) and indicators of access, services utilization, equity, and financial risk protection. Additional outcomes will include intermediate health system objectives (e.g., indicators of efficiency and quality). Two reviewers will independently screen all citations, abstract data, and full-text articles. Potential conflicts will be resolved through discussion and, when necessary, resolved by a third reviewer. The methodological quality (or risk of bias) of selected studies will be appraised using established checklists. Data extraction categories will include the studies' objective and design, the fragmentation measurement and domains, and health outcomes linked to the fragmentation. A narrative synthesis will be used to describe the results and characteristics of all included studies and to explore relationships and findings both within and between the studies. DISCUSSION Evidence on the impacts of health system fragmentation in LMICs is key for identifying evidence gaps and priority areas for intervention. This knowledge will be valuable to health system policymakers aiming to strengthen health systems in LMICs. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020201467.
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Affiliation(s)
- Marina Siqueira
- Institute for Health Policy Studies, IEPS, Itapeva St 286, Conjunto 81-84, Bela Vista, São Paulo, SP, 01332-000, Brazil.
| | - Maíra Coube
- Institute for Health Policy Studies, IEPS, Itapeva St 286, Conjunto 81-84, Bela Vista, São Paulo, SP, 01332-000, Brazil
| | - Christopher Millett
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK
| | - Rudi Rocha
- Institute for Health Policy Studies, IEPS, Itapeva St 286, Conjunto 81-84, Bela Vista, São Paulo, SP, 01332-000, Brazil
| | - Thomas Hone
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK
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Sawan MJ, Wennekers D, Sakiris M, Gnjidic D. Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review. J Gen Intern Med 2021; 36:1371-1379. [PMID: 33537953 PMCID: PMC8131426 DOI: 10.1007/s11606-020-06442-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/10/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Hospital discharge has a significant impact on the continuity of care for people living with dementia. Clear guidance on medication management should be provided to caregivers of people living with dementia to ensure appropriate use of medications post-discharge. AIM Identify and appraise the impact of interventions at hospital discharge to guide caregivers in the medication management for people living with dementia. METHOD A systematic search of original studies was performed in Medline, Embase, PsycINFO, and CINAHL. Articles published in English that reported on interventions to guide caregivers in medication management for people living with dementia were included. Two authors independently reviewed titles and abstract. Full-text articles were assessed for eligibility and quality assessment was conducted by two authors. RESULTS A total of five studies were included with a range of interventions that were typically delivered post-discharge by a multidisciplinary team and most targeted administration of medications by caregivers. Overall, three types of discharge interventions were identified including a pre-discharge caregiver educational intervention, a post-discharge multidisciplinary team intervention, and discharge summary documentation intervention at transitions of care. Of these, a pre-discharge caregiver education led to shorter hospital stay (25 days vs. 31 days, p = 0.005). A post-discharge intervention that included follow-up visits resulted in lower use of high-risk medications (19% vs. 40%), and reduction in 30-day re-hospitalization rates (11% vs. 20%). In contrast, in another post-discharge intervention study, no difference in one-month re-hospitalization rates (8.4% vs. 8.0%, p = 0.82) was demonstrated. In another study, a post-discharge hospital educational program provided to caregivers led to significantly reduced caregiver burden (31.7 ± 17.6 (SD) pre-intervention to 27.7 ± 16.9 (SD) post-intervention (p = 0.037)). DISCUSSION Current findings suggest there is a need for well-designed interventions to guide caregivers in all aspects of medication management for people living with dementia, and should include support for caregivers in care coordination.
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Affiliation(s)
- Mouna J Sawan
- School of Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.
| | - Damian Wennekers
- School of Pharmacy, Faculty of Science, University of Utrecht, Utrecht, The Netherlands
| | - Marissa Sakiris
- School of Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Danijela Gnjidic
- School of Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.,Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
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Kaltenborn Z, Paul K, Kirsch JD, Aylward M, Rogers EA, Rhodes MT, Usher MG. Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers. BMC Health Serv Res 2021; 21:338. [PMID: 33853590 PMCID: PMC8045386 DOI: 10.1186/s12913-021-06323-5] [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: 11/23/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background Super-utilizers with 4 or more admissions per year frequently receive low-quality care and disproportionately contribute to healthcare costs. Inpatient care fragmentation (admission to multiple different hospitals) in this population has not been well described. Objective To determine the prevalence of super-utilizers who receive fragmented care across different hospitals and to describe associated risks, costs, and health outcomes. Research design We analyzed inpatient data from the Health Care Utilization Project’s State Inpatient and Emergency Department database from 6 states from 2013. After identifying hospital super-utilizers, we stratified by the number of different hospitals visited in a 1-year period. We determined how patient demographics, costs, and outcomes varied by degree of fragmentation. We then examined how fragmentation would influence a hospital’s ability to identify super-utilizers. Subjects Adult patients with 4 or more inpatient stays in 1 year. Measures Patient demographics, cost, 1-year hospital reported mortality, and probability that a single hospital could correctly identify a patient as a super-utilizer. Results Of the 167,515 hospital super-utilizers, 97,404 (58.1%) visited more than 1 hospital in a 1-year period. Fragmentation was more likely among younger, non-white, low-income, under-insured patients, in population-dense areas. Patients with fragmentation were more likely to be admitted for chronic disease management, psychiatric illness, and substance abuse. Inpatient fragmentation was associated with higher yearly costs and lower likelihood of being identified as a super-utilizer. Conclusions Inpatient care fragmentation is common among super-utilizers, disproportionately affects vulnerable populations. It is associated with high yearly costs and a decreased probability of correctly identifying super-utilizers. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06323-5.
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Affiliation(s)
- Zach Kaltenborn
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Koushik Paul
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA
| | - Jonathan D Kirsch
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA
| | - Michael Aylward
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Elizabeth A Rogers
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Michael T Rhodes
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.
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Lazzati A, Chatellier G, Paolino L, Batahei S, Katsahian S. Postoperative care fragmentation in bariatric surgery and risk of mortality: a nationwide study. Surg Obes Relat Dis 2021; 17:1327-1333. [PMID: 33865727 DOI: 10.1016/j.soard.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/02/2021] [Accepted: 03/04/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Readmission after bariatric surgery may to lead to fragmentation of care if readmission occurs at a facility other than the index hospital. The effect of readmission to a nonindex hospital on postoperative mortality remains unclear for bariatric surgery. OBJECTIVES To determine postoperative mortality rates according to readmission destinations. SETTING Nationwide analysis of all surgical facilities in France. METHODS Multicenter, nationwide study of adult patients undergoing bariatric surgery from January 1, 2013, through December 31, 2018. Data from all surgical facilities in France were extracted from a national hospital discharge database. RESULTS In a cohort of 278,600 patients who received bariatric surgery, 12,760 (4.6%) were readmitted within 30 days. In cases of readmission, 23% of patients were admitted to a nonindex hospital. Patients readmitted to a nonindex facility had different characteristics regarding sex (men, 23.6% versus 18.2%, respectively; P < .001), co-morbidities (Charlson Co-morbidity Index, .74 versus .53, respectively; P < .001), and travel distance (38.3 km versus 26.9 km, respectively; P < .001) than patients readmitted to the index facility. The main reasons for readmission were leak/peritonitis and abdominal pain. The overall mortality rate after readmission was .56%. The adjusted odds ratio (OR) of mortality for the nonindex group was 4.96 (95% confidence interval [CI], 3.1-8.1; P < .001). In the subgroups of patients with a gastric leak, the mortality rate was 1.5% and the OR was 8.26 (95% CI, 3.7-19.6; P < .001). CONCLUSION Readmissions to a nonindex hospital are associated with a 5-fold greater mortality rate. The management of readmission for complications after bariatric surgery should be considered as a major issue to reduce potentially preventable deaths.
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Affiliation(s)
- Andrea Lazzati
- Department of General Surgery, Centre Hospitalier Intercommunal de Créteil, Créteil, France; INSERM IMRB U955, Université Paris-Est Créteil, Créteil, France.
| | - Gilles Chatellier
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Unité d'Épidémiologie et de Recherche Clinique, INSERM, Centre d'Investigation Clinique 1418, Module Épidémiologie Clinique, HEGP, Paris, France; Université de Paris, Paris, France
| | - Luca Paolino
- Department of General Surgery, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Sarah Batahei
- Department of General Surgery, Nutrition Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Sandrine Katsahian
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Unité d'Épidémiologie et de Recherche Clinique, INSERM, Centre d'Investigation Clinique 1418, Module Épidémiologie Clinique, HEGP, Paris, France; Université de Paris, Paris, France; Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, 15 Rue de l'école de médecine, Paris, France
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Ansmann L, Hower KI, Wirtz MA, Kowalski C, Ernstmann N, McKee L, Pfaff H. Measuring social capital of healthcare organizations reported by employees for creating positive workplaces - validation of the SOCAPO-E instrument. BMC Health Serv Res 2020; 20:272. [PMID: 32234055 PMCID: PMC7106807 DOI: 10.1186/s12913-020-05105-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/12/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In highly segmented and complex healthcare organizations social capital is assumed to be of high relevance for the coordination of tasks in healthcare. So far, comprehensively validated instruments on social capital in healthcare organizations are lacking. The aim of this work is to validate an instrument measuring social capital in healthcare organizations. METHODS This validation study is based on a cross-sectional survey of 1050 hospital employees from 49 German hospitals which specialize in breast cancer care. Social capital was assessed by a six-item scale. Reliability analyses and confirmatory factor analyses were conducted to determine the content validity of items within the theory-driven one-dimensional scale structure. The scale's associations with measures of the social aspects of the work environment (identification, social support, open communication climate) were estimated to test convergent validity. Criterion-related validity was evaluated by conducting structural equation modelling to examine the predictive validity of the scale with measures of work engagement, well-being and burnout. RESULTS A one-dimensional structure of the instrument could be identified (CFI = .99; RMSEA = .06). Convergent validity was shown by hypothesis-consistent correlations with social support offered by supervisors and colleagues, a climate of open communication, and employee commitment to the organization. Criterion-related validity of the social capital scale was proved by its prediction of employee work engagement (R2 = .10-.13 for the three subscales), well-being (R2 = .13), and burnout (R2 = .06-.11 for the three subscales). CONCLUSIONS The confirmed associations between social capital and work engagement, burnout as well as well-being stress the importance of social capital as a vital resource for employee health and performance in healthcare organizations. In healthcare organizations this short instrument can be used as an efficient instrument to measure the organizations' social capital.
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Affiliation(s)
- Lena Ansmann
- Division for Organizational Health Services Research, Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany.
| | - Kira Isabel Hower
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | | | | | - Nicole Ernstmann
- Center for Health Communication and Health Services Research, Department of Psychosomatic Medicine and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Lorna McKee
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Holger Pfaff
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
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