The Integrated Comprehensive Care Program: A Novel Home Care Initiative After Major Thoracic Surgery

Experiences and Reported Outcomes of Patients and Caregivers Enrolled in an Integrated Care Program for Thoracic Surgery: A Qualitative Evaluation

Background

Health care delivery is often poorly coordinated and fragmented. Integrated care (IC) programs represent one solution to improving continuity of care. The aim of this study was to understand experiences and reported outcomes of patients and caregivers in an IC Program that coordinates hospital and home care for thoracic surgery.

Methods

A process evaluation was undertaken using qualitative methods. We conducted semi-structured interviews with 10 patients and 8 caregivers who received IC for thoracic surgery and were discharged between June 2019 and April 2020. A phenomenological approach was used to understand and characterize patient and caregiver experiences. Thematic analysis began with a deductive approach complemented by an inductive approach.

Results

Four major themes evolved from patient and caregiver interviews, including 1) coordination and timeliness of patient care facilitated by an IC lead; 2) the provision of person-centred care and relational continuity fostered feelings of partnership with patients and caregivers; 3) clear communication and one shared digital record increased informational continuity; and 4) impacts of IC on patient and caregiver outcomes.

Conclusions

Patients and caregivers generally reported this IC Program met their health care needs, which may help inform how future IC programs are designed.

Incidence and risk factors of unplanned emergency department visits following thoracic surgery

Background

Unplanned visits for care following a surgical procedure can represent a lapse in quality of care. The purpose of this study was to define the proportion of patients undergoing thoracic surgery who return to the emergency department (ED) within 6 months after discharge and the reasons for the returns. In addition, the risk factors for ED visits after thoracic surgery were identified.

Methods

All adult patients undergoing thoracic surgery at the Leiden University Medical Center between January 1, 2016, and December 31, 2017, were reviewed. To identify potential risk factors for ED return visits, a multivariate regression analysis was performed. A subgroup analysis of patients who reported pain during the ED visit was performed to identify the risk factors for pain-related return to the ED.

Results

Of 277 patients who underwent thoracic surgery, 27.4% (n = 76) returned to the ED within 6 months after discharge. Among these patients, 41 (53.9%) presented with postoperative pain. Younger patients (odds ratio [OR], 0.98; P = .04), those who were operated on through a thoracotomy (OR, 2.92; P = .04), and those reporting a high pain score on the ward (OR, 1.98; P < .001) were at increased risk of returning to the ED.

Conclusions

The rate of patients returning to the ED after thoracic surgery was high. Pain was the most frequently reported reason for unplanned ED visits. The results of this study highlight the need to optimize the postoperative care and the follow-up of patients undergoing thoracic surgery.

Readmission After Lobectomy for Lung Cancer: Not All Complications Contribute Equally

OBJECTIVE

The aim of this study was to identify independent predictors of hospital readmission for patients undergoing lobectomy for lung cancer.

SUMMARY BACKGROUND DATA

Hospital readmission after lobectomy is associated with increased mortality. Greater than 80% of the variability associated with readmission after surgery is at the patient level. This underscores the importance of using a data source that includes detailed clinical information.

METHODS

Using the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD), we conducted a retrospective cohort study of patients undergoing elective lobectomy for lung cancer. Three separate multivariable logistic regression models were generated: the first included preoperative variables, the second added intraoperative variables, and the third added postoperative variables. The c statistic was calculated for each model.

RESULTS

There were 39,734 patients from 277 centers. The 30-day readmission rate was 8.2% (n = 3237). In the final model, postoperative complications had the greatest effect on readmission. Pulmonary embolus {odds ratio [OR] 12.34 [95% confidence interval (CI),7.94-19.18]} and empyema, [OR 11.66 (95% CI, 7.31-18.63)] were associated with the greatest odds of readmission, followed by pleural effusion [OR 7.52 (95% CI, 6.01-9.41)], pneumothorax [OR 5.08 (95% CI, 4.16-6.20)], central neurologic event [OR 3.67 (95% CI, 2.23-6.04)], pneumonia [OR 3.13 (95% CI, 2.43-4.05)], and myocardial infarction [OR 3.16 (95% CI, 1.71-5.82)]. The c statistic for the final model was 0.736.

CONCLUSIONS

Complications are the main driver of readmission after lobectomy for lung cancer. The highest risk was related to postoperative events requiring a procedure or medical therapy necessitating inpatient care.

Using Palliative Care Nurses in a Supportive Care Program to Reduce Hospital Utilization for Patients With Multiple Chronic Conditions

BACKGROUND

Health care organizations are designing comprehensive care programs to reduce hospital utilization by high-risk patients with multiple chronic illnesses.

LOCAL PROBLEM

A community hospital recognized patients with multiple chronic conditions had higher rates of inpatient stays and emergency department (ED) visits.

METHODS

Patients (n = 36) with multiple chronic conditions enrolled in a supportive care program. Researchers analyzed hospital utilization, inpatient stays, and ED visits preintervention and postgraduation for the participants enrolled. Palliative care nurses were assigned to patients enrolled in the supportive care program.

RESULTS

There was a statistically significant decrease in hospital utilization (Z = -2.540, P = .011) and inpatient stays (Z = -4.037, P < .001) following the implementation of the supportive care program.

CONCLUSIONS

The study met its aim of reducing hospital utilization and inpatient stays by creating a comprehensive approach to support high-risk patients in self-management of their chronic illnesses.

Impact of the integrated comprehensive care program post-thoracic surgery: A propensity score-matched study

OBJECTIVE

Thoracic surgery is associated with significant rates of postoperative morbidity and postdischarge return to the hospital or emergency department (ED). This study aims to assess the impact of a novel integrated patient-centered, hospital-based multidisciplinary community program (Integrated Comprehensive Care [ICC]) on postdischarge outcomes in patients undergoing thoracic surgery compared to routine care.

METHODS

This was a retrospective cohort study of patients who underwent surgical resection for lung malignancies at a tertiary care center from 2010 to 2014. Patients were divided into 2 cohorts based on their enrollment in the ICC program (intervention cohort; 2012-2014) or routine postoperative care (control cohort; 2010-2012). Propensity score matching was performed to match the 2 cohorts. The impact of the ICC program on postoperative length of stay (LOS), rate of ED visits, readmissions, and mortality within the first 60 days was assessed.

RESULTS

Of the 1288 patients included in this study, 658 (51.1%) were male patients with mean age of 64 years (standard deviation 14.1 years). After propensity score matching, 478 patients were enrolled in the ICC cohort and 592 were enrolled as controls. The ICC cohort had significantly shorter LOS (4 days, vs 5 days in controls, P = .001), lower rate of 60-day ED visits (9.8% vs 28.4% in controls, P < .001), and readmissions (6.9% vs 8.6% in controls, P < .001). The 60-day mortality was also significantly lower in the ICC cohort compared with the control group (0.6% vs 0.8% in controls, P < .001).

CONCLUSIONS

The ICC program is associated with shorter LOS, fewer ED visits and readmissions after discharge, and ultimately may decrease postoperative mortality.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Development of the IRIS-AR strategy: an intervention to improve rates of accrual and retention for the VTE-PRO randomized controlled trial

BACKGROUND

The Venous Thromboembolism Prophylaxis (VTE-PRO) randomized trial is a pilot study evaluating the impact of extended-duration prophylaxis on venous thromboembolic events in patients undergoing lung cancer resection. Enrolled VTE-PRO participants self-inject either low-molecular weight heparin or a saline placebo for 30 days postoperatively. Study outcomes include feasibility, incidence of venous thromboembolism, and venous thromboembolism-related morbidity and mortality. Initial analyses demonstrated low rates of accrual and retention for the VTE-PRO pilot. Therefore, the purpose of the current study was to develop a knowledge translation intervention to improve VTE-PRO pilot trial accrual and retention.

METHODS

Eligible participants were surveyed to identify the barriers to VTE-PRO participation. The Theoretical Domains Framework was used to categorize these barriers. Barriers were mapped to the capabilities, opportunities, and behavior (COM-B) behavioral change wheel to identify potential interventions to support trial accrual and retention. The resulting knowledge translation intervention was titled Inform, Remind, Involve and Support to improve Accrual and Retention (IRIS-AR). Key informant interviews with patients were held to refine and confirm the validity of identified barriers and perceived acceptability of the proposed IRIS-AR intervention. Institutional Review Board approval was granted for this study.

RESULTS

The resulting intervention included: information booklets and counseling sessions to identify unique participant challenges to trial participation (Inform); daily reminders to administer injections (Remind); involvement of family/caregivers in study processes (Involve); and leverage of an existing home-care nursing program to provide injection support when needed (Support). Twenty-six key informant participants were interviewed. The most common barriers to trial participation included lack of social support and fear of needle injection. Participants generally supported use of information booklets, involvement of family/caregivers, and support by a home-care nursing program; however, not all supported the use of daily reminders.

CONCLUSION

Developed using theory and integrated knowledge translation, the IRIS-AR presents a patient-centered intervention that leverages existing programs to promote trial engagement. The proposed strategy can likely be adapted to improve compliance with other patient-directed interventions.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02334007 . Registered on 8 January 2015.

Preliminary Results of the Adoption and Application of the Integrated Comprehensive Care Bundle Care Program When Treating Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

St. Joseph's Health System has implemented an integrated comprehensive care bundle care (ICC) program with the hopes that it would improve patients' care while reducing overall costs. The aim of this analysis was to evaluate the performance of the ICC program within patients admitted with chronic pulmonary obstructive disease (COPD).

METHODS

We conducted a retrospective observational cohort study comparing ICC patients to non-ICC patients admitted to St. Joseph's Healthcare Hamilton for COPD being discharged with support services between June 2012 and March 2015, using administrative data. Confounding adjustment was achieved through the use of propensity score matching. Medical resource utilizations during the initial hospitalization and within the 60 days following discharge were compared using regression models.

RESULTS

All 76 patients who entered the ICC program (100.0%) were matched 1 : 1 to 76 eligible non-ICC patients (28.4%). Length of stay (6.47 [7.29] versus 9.55 [10.21] days) and resource intensity weights (1.16 [0.80] versus 1.64 [1.69]) were lower in the ICC group within the initial hospitalization but, while favoring the ICC program, healthcare resource use tended not to differ statistically following discharge.

INTERPRETATION

The ICC program was able to reduce initial medical resource utilization without increasing subsequent medical resource use.

Results of Postdischarge Nursing Telephone Assessments: Persistent Symptoms Common Among Pulmonary Resection Patients

BACKGROUND

After hospital discharge, patients may have questions or complaints that surface or remain inadequately addressed. However, the dominant concerns and indications for further intervention among recently discharged patients after pulmonary resection have not been well described. The aims of this study were to characterize dominant concerns of pulmonary resection patients after discharge and to elucidate any relevant risk factors for their development.

METHODS

A single-institution, retrospective review was conducted of all patients who underwent pulmonary resection over a 12-month period and included records of standardized, nurse-initiated follow-up phone calls to discharged patients. Records of postdischarge telephone calls were reviewed, and data collected pertaining to complaints requiring counseling over the phone or escalation to higher care level. Demographic, operative, and hospital data were examined by multivariate analyses to assess predictors of need for counseling or escalation of care.

RESULTS

In all, 523 patients underwent pulmonary resection during the study, and 245 (46.8%) had nursing-documented telephone conversations at 4.6 days (±0.18) days after discharge. Among those reached, 81 (33.1%) had problems requiring counseling during the call; 31 (12.7%) reported concerns requiring escalation of care, handled by subsequent telephone call for 7 (22.6%), clinic appointment for 22 (71.0%), or emergency room referral for 2 (6.5%). Age, sex, race, and residential proximity to the hospital did not predict need for counseling nor escalation of care.

CONCLUSIONS

Patient complaints after pulmonary resection were frequent, with most problems resolved by telephone counseling. Despite highly prevalent concerns, predictors of need for counseling or care escalation were not identified, suggesting ongoing utility in the practice of telephoning all patients. Further, this study serves as a needs assessment, highlighting the importance of patient education and discharge planning.