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Ali H, Inayat F, Jahagirdar V, Jaber F, Afzal A, Patel P, Tahir H, Anwar MS, Rehman AU, Sarfraz M, Chaudhry A, Nawaz G, Dahiya DS, Sohail AH, Aziz M. Early versus delayed necrosectomy in pancreatic necrosis: A population-based cohort study on readmission, healthcare utilization, and in-hospital mortality. World J Methodol 2024; 14:91810. [PMID: 39310231 PMCID: PMC11230070 DOI: 10.5662/wjm.v14.i3.91810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Acute necrotizing pancreatitis is a severe and life-threatening condition. It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications. Several minimally invasive and open necrosectomy procedures have been developed. Despite advancements in treatment modalities, the optimal timing to perform necrosectomy lacks consensus. AIM To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States. METHODS A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database. Patients with non-elective admissions for pancreatic necrosis were identified. The participants were divided into two groups based on the necrosectomy timing: The early group received intervention within 48 hours, whereas the delayed group underwent the procedure after 48 hours. The various intervention techniques included endoscopic, percutaneous, or surgical necrosectomy. The major outcomes of interest were 30-day readmission rates, healthcare utilization, and inpatient mortality. RESULTS A total of 1309 patients with pancreatic necrosis were included. After propensity score matching, 349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention. The early cohort had a 30-day readmission rate of 8.6% compared to 4.8% in the delayed cohort (P = 0.040). Early necrosectomy had lower rates of mechanical ventilation (2.9% vs 10.9%, P < 0.001), septic shock (8% vs 19.5%, P < 0.001), and in-hospital mortality (1.1% vs 4.3%, P = 0.01). Patients in the early intervention group incurred lower healthcare costs, with median total charges of $52202 compared to $147418 in the delayed group. Participants in the early cohort also had a relatively shorter median length of stay (6 vs 16 days, P < 0.001). The timing of necrosectomy did not significantly influence the risk of 30-day readmission, with a hazard ratio of 0.56 (95% confidence interval: 0.31-1.02, P = 0.06). CONCLUSION Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs. Delayed intervention does not significantly alter the risk of 30-day readmission.
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Affiliation(s)
- Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Faisal Inayat
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Arslan Afzal
- Division of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Pratik Patel
- Division of Gastroenterology, Mather Hospital and Zucker School of Medicine at Hofstra University, Port Jefferson, NY 11777, United States
| | - Hamza Tahir
- Department of Internal Medicine, Jefferson Einstein Hospital, Philadelphia, PA 19141, United States
| | - Muhammad Sajeel Anwar
- Department of Internal Medicine, UHS Wilson Medical Center, Johnson City, NY 13790, United States
| | - Attiq Ur Rehman
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Muhammad Sarfraz
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Ahtshamullah Chaudhry
- Department of Internal Medicine, St. Dominic's Hospital, Jackson, MS 39216, United States
| | - Gul Nawaz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, United States
| | - Amir H Sohail
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, United States
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, The University of Toledo, Toledo, OH 43606, United States
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Chang ET, Huynh A, Yoo C, Yoon J, Zulman DM, Ong MK, Klein M, Eng J, Roy S, Stockdale SE, Jimenez EE, Denietolis A, Needleman J, Asch SM. Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis. J Gen Intern Med 2024:10.1007/s11606-024-08923-3. [PMID: 39075268 DOI: 10.1007/s11606-024-08923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/26/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. OBJECTIVE The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs. DESIGN Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. PARTICIPANTS Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. INTERVENTION PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. MAIN OUTCOMES AND MEASURES Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. KEY RESULTS Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM. CONCLUSIONS AND RELEVANCE VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes. TRIAL REGISTRATION PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.
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Affiliation(s)
- Evelyn T Chang
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA.
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Alexis Huynh
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
| | - Caroline Yoo
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
| | - Jean Yoon
- VHA Health Economics Resource Center (HERC), Menlo Park, CA, USA
- Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA
| | - Donna M Zulman
- VHA HSR Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael K Ong
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Medicine, VHA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Klein
- Department of Medicine, VHA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Jessica Eng
- On Lok Program of All-Inclusive Care for the Elderly (PACE), San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, CA, USA
| | - Sudip Roy
- VHA Salisbury Healthcare System, Salisbury, NC, USA
| | - Susan E Stockdale
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA
| | - Elvira E Jimenez
- VHA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA
- Behavioral Neurology, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Angela Denietolis
- VHA Office of Primary Care, 810 Vermont Ave, Washington, DC, 20420, USA
| | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven M Asch
- VHA HSR Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Jiang L, Austin PC, Wodchis WP, Kiran T, Guan J, Gershon AS. Timing of follow-up visits after hospital discharge for COPD: Application of a new method. PLoS One 2024; 19:e0302681. [PMID: 38985795 PMCID: PMC11236132 DOI: 10.1371/journal.pone.0302681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 04/07/2024] [Indexed: 07/12/2024] Open
Abstract
RATIONALE A common strategy to reduce COPD readmissions is to encourage patient follow-up with a physician within 1 to 2 weeks of discharge, yet evidence confirming its benefit is lacking. We used a new study design called target randomized trial emulation to determine the impact of follow-up visit timing on patient outcomes. METHODS All Ontario residents aged 35 or older discharged from a COPD hospitalization were identified using health administrative data and randomly assigned to those who received and did not receive physician visit follow-up by within seven days. They were followed to all-cause emergency department visits, readmissions or death. Targeted randomized trial emulation was used to adjust for differences between the groups. COPD emergency department visits, readmissions or death was also considered. RESULTS There were 94,034 patients hospitalized with COPD, of whom 73.5% had a physician visit within 30 days of discharge. Adjusted hazard ratio for all-cause readmission, emergency department visits or death for people with a visit within seven days post discharge was 1.03 (95% Confidence Interval [CI]: 1.01-1.05) and remained around 1 for subsequent days; adjusted hazard ratio for the composite COPD events was 0.97 (95% CI 0.95-1.00) and remained significantly lower than 1 for subsequent days. CONCLUSION While a physician visit after discharge was found to reduce COPD events, a specific time period when a physician visit was most beneficial was not found. This suggests that follow-up visits should not occur at a predetermined time but be based on factors such as anticipated medical need.
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Affiliation(s)
- Lili Jiang
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Peter C. Austin
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Walter P. Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health; Trillium Health Partners, Mississauga, Ontario, Canada
| | - Tara Kiran
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions and the Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Andrea S. Gershon
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Ali H, Inayat F, Rasheed W, Afzal A, Chaudhry A, Patel P, Rehman AU, Anwar MS, Nawaz G, Afzal MS, Sohail AH, Subramanium S, Dahiya DS, Budh D, Mohan BP, Adler DG. Association between acute peripancreatic fluid collections and early readmission in acute pancreatitis: A propensity-matched analysis. World J Exp Med 2024; 14:92052. [PMID: 38948418 PMCID: PMC11212740 DOI: 10.5493/wjem.v14.i2.92052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/15/2024] [Accepted: 04/09/2024] [Indexed: 06/19/2024] Open
Abstract
BACKGROUND Patients with acute pancreatitis (AP) frequently experience hospital readmissions, posing a significant burden to healthcare systems. Acute peripancreatic fluid collection (APFC) may negatively impact the clinical course of AP. It could worsen symptoms and potentially lead to additional complications. However, clinical evidence regarding the specific association between APFC and early readmission in AP remains scarce. Understanding the link between APFC and readmission may help improve clinical care for AP patients and reduce healthcare costs. AIM To evaluate the association between APFC and 30-day readmission in patients with AP. METHODS This retrospective cohort study is based on the Nationwide Readmission Database for 2016-2019. Patients with a primary diagnosis of AP were identified. Participants were categorized into those with and without APFC. A 1:1 propensity score matching for age, gender, and Elixhauser comorbidities was performed. The primary outcome was early readmission rates. Secondary outcomes included the incidence of inpatient complications and healthcare utilization. Unadjusted analyses used Mann-Whitney U and χ 2 tests, while Cox regression models assessed 30-day readmission risks and reported them as adjusted hazard ratios (aHR). Kaplan-Meier curves and log-rank tests verified readmission risks. RESULTS A total of 673059 patients with the principal diagnosis of AP were included. Of these, 5.1% had APFC on initial admission. After propensity score matching, each cohort consisted of 33914 patients. Those with APFC showed a higher incidence of inpatient complications, including septic shock (3.1% vs 1.3%, P < 0.001), portal venous thrombosis (4.4% vs 0.8%, P < 0.001), and mechanical ventilation (1.8% vs 0.9%, P < 0.001). The length of stay (LOS) was longer for APFC patients [4 (3-7) vs 3 (2-5) days, P < 0.001], as were hospital charges ($29451 vs $24418, P < 0.001). For 30-day readmissions, APFC patients had a higher rate (15.7% vs 6.5%, P < 0.001) and a longer median readmission LOS (4 vs 3 days, P < 0.001). The APFC group also had higher readmission charges ($28282 vs $22865, P < 0.001). The presence of APFC increased the risk of readmission twofold (aHR 2.52, 95% confidence interval: 2.40-2.65, P < 0.001). The independent risk factors for 30-day readmission included female gender, Elixhauser Comorbidity Index ≥ 3, chronic pulmonary diseases, chronic renal disease, protein-calorie malnutrition, substance use disorder, depression, portal and splenic venous thrombosis, and certain endoscopic procedures. CONCLUSION Developing APFC during index hospitalization for AP is linked to higher readmission rates, more inpatient complications, longer LOS, and increased healthcare costs. Knowing predictors of readmission can help target high-risk patients, reducing healthcare burdens.
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Affiliation(s)
- Hassam Ali
- Department of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Faisal Inayat
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Waqas Rasheed
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, United States
| | - Arslan Afzal
- Department of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Ahtshamullah Chaudhry
- Department of Internal Medicine, St. Dominic’s Hospital, Jackson, MS 39216, United States
| | - Pratik Patel
- Department of Gastroenterology, Mather Hospital and Hofstra University Zucker School of Medicine, Port Jefferson, NY 11777, United States
| | - Attiq Ur Rehman
- Department of Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Muhammad Sajeel Anwar
- Department of Internal Medicine, UHS Wilson Medical Center, Johnson City, NY 13790, United States
| | - Gul Nawaz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Muhammad Sohaib Afzal
- Department of Internal Medicine, Louisiana State University Health, Shreveport, LA 71103, United States
| | - Amir H Sohail
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, United States
| | - Subanandhini Subramanium
- Department of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas School of Medicine, Kansas City, KS 64108, United States
| | - Deepa Budh
- Department of Internal Medicine, St. Barnabas Hospital and Albert Einstein College of Medicine, Bronx, NY 10457, United States
| | - Babu P Mohan
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT 84132, United States
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Porter Adventist Hospital, Centura Health, Denver, CO 80210, United States
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Sheridan N, Love T, Kenealy T. Is there equity of patient health outcomes across models of general practice in Aotearoa New Zealand? A national cross-sectional study. Int J Equity Health 2023; 22:79. [PMID: 37143152 PMCID: PMC10157126 DOI: 10.1186/s12939-023-01893-8] [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] [Received: 11/24/2022] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Primary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Māori and non-Māori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Māori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care. METHODS We conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes. Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response. RESULTS The study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Māori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Māori, Pacific and Trust/NGO practices. There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Māori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes. CONCLUSIONS Model-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care.
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Grants
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- HRC 18/788 Health Research Council of New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
- 18/788 Ministry of Health, New Zealand
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Affiliation(s)
| | - Tom Love
- Sapere Research Group, Wellington, Aotearoa, New Zealand
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Boesing M, Gregoriano C, Minder AE, Abshagen C, Dahl S, Dieterle T, Eicher F, Leuppi-Taegtmeyer AB, Rageth L, Miedinger D, Wirz E, Leuppi JD. Predictors for Unplanned Readmissions within 18 Days after Hospital Discharge: a Retrospective Cohort Study. PRAXIS 2023; 112:57-63. [PMID: 36722113 DOI: 10.1024/1661-8157/a003985] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Since the introduction of the reimbursement system based on diagnosis-related groups (DRG) in Swiss hospitals in 2012, most readmissions occurring within 18 days and appertaining to the same major diagnostic category (MDC) are merged and thus often reimbursed to a lesser extent. While readmissions reflect increased distress for patients and their relatives, the causes are mainly patient-related and difficult to influence. However, it may be possible to identify cases at higher risk for readmission. Therefore, the aim of this study was to find predictors for early readmissions in the same MDC, to identify high-risk index hospitalizations and possibly prevent unnecessary readmissions. The data of all patients admitted to the Clinic of Internal Medicine at the University Hospital of Basel, Switzerland, hospitalized for longer than 24 hours during the pre-DRG period between October 2009 and September 2010 were retrospectively collected. Data were examined for predictors of unplanned readmission within 18 days under the same MDC ('relevant readmission') by means of logistic regression. 7479 patients (median age 67.8 years, 56% male) were admitted to the Clinic of Internal Medicine, with 232 patients (3.1%) being readmitted at least once. Logistic regression revealed male sex (p =0.035) and a high number of prescribed drugs at discharge (p <0.005) as patient-related predictors. The MDCs respiratory system, cardiovascular system, and gastrointestinal/hepatobiliary system were identified as high-risk categories (each p <0.005). Age and length of index hospital stay added no significant explanatory value to the regression model. Unplanned readmissions under the same MDC within 18 days were infrequent and not related to patients' age or length of hospital stay. Overall, multimorbid patients, and hospitalizations regarding the cardiovascular, respiratory, or gastrointestinal system appear to be most at risk and should therefore be specifically targeted in the prevention of early readmissions.
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Affiliation(s)
- Maria Boesing
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
- Contributed equally
| | - Claudia Gregoriano
- Medical University Department of Internal Medicine, Cantonal Hospital Aarau, Aarau, Switzerland
- Contributed equally
| | - Anna E Minder
- Division of Endocrinology, Diabetology, Porphyria, Stadtspital Waid and Triemli, Zurich, Switzerland
- Contributed equally
| | - Christian Abshagen
- Medical and financial controlling, University Hospital of Basel, Basel, Switzerland
| | - Sylwia Dahl
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Thomas Dieterle
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Cardiology, Klinik, Arlesheim, Switzerland
| | | | - Anne B Leuppi-Taegtmeyer
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland
| | - Luana Rageth
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - David Miedinger
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Elina Wirz
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Joerg D Leuppi
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Hydoub YM, Fischer KM, Hanson KT, Coons TJ, Wilshusen LL, Vista TL, Colbenson GA, Burton MC, Habermann EB, Dugani SB. Multisite analysis of patient experience scores and risk of hospital admission: a retrospective cohort study. Hosp Pract (1995) 2023; 51:35-43. [PMID: 36326005 PMCID: PMC9928911 DOI: 10.1080/21548331.2022.2144055] [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: 07/12/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Routinely collected patient experience scores may inform risk of patient outcomes. The objective of the study was to evaluate the risk of hospital admission within 30-days following third-party receipt of the patient experience survey and guide interventions. METHODS In this retrospective cohort study, we analyzed Hospital Consumer Assessment of Healthcare Providers and Systems surveys, January 2016-July 2019, from an institution's 20 hospitals in four U.S. states. Surveys were routinely sent to patients using census sampling. We analyzed surveys received ≤60 days following discharge from patients living ≤60 miles of any of the institution's hospitals. The exposures were 19 survey items. The outcome was hospital admission within 30 days after third-party receipt of the survey. We evaluated the association of favorable (top-box) vs unfavorable (non-top-box) score for survey items with risk of 30-day hospital admission in models including patient and hospitalization characteristics and reported adjusted odds ratios (aOR [95% confidence interval]). RESULTS Among 40,162 respondents (mean age ± standard deviation: 68.1 ± 14.0 years), 49.8% were women and 4.3% had 30-day hospital admission. Patients with 30-day hospital admission, compared to those not admitted, were more likely to be discharged from a medical service line (62.9% vs 42.3%; P < 0.001) and have a higher Elixhauser index. Favorable vs unfavorable score for hospital rating was associated with lower odds of 30-day hospital admission in the overall cohort (0.88 [0.77-0.99]; P = 0.04), medical service line (0.81 [0.70-0.94]; P = 0.007), and upper tertile of Elixhauser index (0.79 [0.67-0.92]; P = 0.003). Favorable score for recommend hospital was associated with lower odds of 30-day hospital admission in the medical service line (0.83 [0.71-0.97]; P = 0.02) but for others (e.g. cleanliness of hospital environment) showed no association. CONCLUSION In routinely collected patient experience scores, favorable hospital rating was associated with lower odds of 30-day hospital admission and may inform risk stratification and interventions. Evidence-based survey items linked to patient outcomes may also inform future surveys.
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Affiliation(s)
- Yousif M. Hydoub
- Division of Cardiology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Karen M. Fischer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristine T. Hanson
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Trevor J. Coons
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Tafi L. Vista
- Office of Patient Experience, Mayo Clinic, Rochester, MN, United States
| | | | - M. Caroline Burton
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Elizabeth B. Habermann
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Sagar B. Dugani
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, United States
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8
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McGinlay M, Straw S, Byrom-Goulthorp R, Relton SD, Gierula J, Cubbon RM, Kearney MT, Witte KK. Suboptimal Dosing of β-Blockers in Chronic Heart Failure: A Missed Opportunity? J Cardiovasc Nurs 2022; 37:589-594. [PMID: 34321430 PMCID: PMC7613698 DOI: 10.1097/jcn.0000000000000847] [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: 11/25/2022]
Abstract
BACKGROUND The evidence base for the benefits of β-blockers in heart failure with reduced ejection fraction (HFrEF) suggests that higher doses are associated with better outcomes. OBJECTIVES The aim of this study was to report the proportion of patients receiving optimized doses of β-blockers, outcomes, and factors associated with suboptimal dosing. METHODS This was a prospective cohort study of 390 patients with HFrEF undergoing clinical and echocardiography assessment at baseline and at 1 year. RESULTS Two hundred thirty-seven patients (61%) were receiving optimized doses (≥5-mg/d bisoprolol equivalent), 72 (18%) could not be up-titrated (because of heart rate < 60 beats/min or systolic blood pressure <100 mm Hg), and the remaining 81 (21%) should have been. Survival was similarly reduced in those who could not and should have been receiving 5 mg/d or greater, and patient factors did not explain the failure to attain optimized dosing. CONCLUSIONS Many patients with HFrEF are not receiving optimal dosing of β-blockers, and in around half, there was no clear contraindication in terms of heart rate or blood pressure.
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9
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Xu C, Shen P, Lu F, Chen X, Zhang J, Zhong J. The Impact of a Family Doctor Contract Service on Outcomes for Type 2 Diabetes Patients in Zhejiang Province. Asia Pac J Public Health 2022; 34:643-648. [PMID: 35950322 DOI: 10.1177/10105395221113778] [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: 11/17/2022]
Abstract
This study evaluated the effect of family doctor contract service on the health management in Chinese type 2 diabetes mellitus (T2DM) patients over a 24-month period. According to whether patients signing contracts with family doctors or not, the contracting status was divided into contracted and noncontracted. The analysis of covariance was used to examine changes in weight, body mass index, waist circumference, systolic blood pressure, fasting plasma glucose, and lipid parameters between the two groups. The hazard ratios for incident diabetes-related complications were calculated using a Cox proportional hazard model. Of the 2310 patients, 1155 were contracted. The contracted patients displayed the improved fasting blood glucose control and lower low-density lipoprotein cholesterol level than the noncontracted group. Patients signed up with family doctors had a lower risk of diabetes-related complications than those who did not. The data suggested that family doctor contract service might help to achieve better T2DM control.
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Affiliation(s)
- Chunxiao Xu
- Department of Chronic Non-Communicable Diseases Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, P.R. China
| | - Peng Shen
- Department of Chronic Diseases and Health Promotion, Yinzhou District Center for Disease Control and Prevention, Ningbo, P.R. China
| | - Feng Lu
- Department of Chronic Non-Communicable Diseases Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, P.R. China
| | - Xiangyu Chen
- Department of Chronic Non-Communicable Diseases Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, P.R. China
| | - Jie Zhang
- Department of Chronic Non-Communicable Diseases Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, P.R. China
| | - Jieming Zhong
- Department of Chronic Non-Communicable Diseases Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, P.R. China
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10
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Sahay A, Mittman BS, Gholami P, Lin S, Heidenreich PA. How successful was the use of a community of practice for the implementation of evidence-based practices for heart failure within the United States Department of Veterans Affairs: Insights from a formative evaluation. Health Res Policy Syst 2022; 20:79. [PMID: 35804413 PMCID: PMC9264639 DOI: 10.1186/s12961-022-00880-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/14/2022] [Indexed: 12/01/2022] Open
Abstract
Background Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). CoPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. This study describes the conceptualization, creation, capacity-building and dissemination of a CoP sustained over 9 years, and evaluates its value and impact on EBP. Methods In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established within the United States Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. We assessed (formative) the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual level, and its distal impacts (outcomes) at the site level including implementation of new/improved EBPs at the systemwide level. Results The HF Network membership grew steadily over the 9 years. The CoP has involved a total of 1341 multidisciplinary and multilevel members at all 144 VA Health Care Systems (sites). Most members were practising clinicians (n = 891, 66.4%), followed by administrators (n = 342, 25.5%), researchers (n = 70, 5.2%) and others (n = 38, 2.8%). Participation was assessed to be “active” for 70.6% versus “passive” for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership. Conclusions Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Strong evidence shows that these members, particularly those who considered themselves influential in improving quality of care, noted multiple benefits of membership, which included confirmation of their own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programmes. Such CoPs have strong impacts on the quality of care being delivered for both mandated and non-mandated initiatives.
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Affiliation(s)
- Anju Sahay
- United States Department of Veterans Affairs, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA.
| | - Brian S Mittman
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, 3rd Floor, Pasadena, CA, 91101, USA
| | - Parisa Gholami
- United States Department of Veterans Affairs, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA
| | - Shoutzu Lin
- United States Department of Veterans Affairs, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA
| | - Paul A Heidenreich
- United States Department of Veterans Affairs, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA.,Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
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11
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Griffith KN, Schwartzman DA, Pizer SD, Bor J, Kolachalama VB, Jack B, Garrido MM. Local Supply Of Postdischarge Care Options Tied To Hospital Readmission Rates. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:1036-1044. [PMID: 35787076 DOI: 10.1377/hlthaff.2021.01991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The extent to which patients' risk for readmission after a hospitalization is influenced by local availability of postdischarge care options is not currently known. We used national, hospital-level data to assess whether the supply of postdischarge care options in hospitals' catchment areas was associated with readmission rates for Medicare patients after hospitalizations for acute myocardial infarction, heart failure, or pneumonia. Overall, readmission rates were negatively associated with per capita supply of primary care physicians (-0.16 percentage points per standard deviation) and licensed nursing home beds (-0.09 percentage points per standard deviation). In contrast, readmission rates were positively associated with per capita supply of nurse practitioners (0.09 percentage points per standard deviation). Our results suggest potential modifications to the Hospital Readmissions Reduction Program to account for local health system characteristics when assigning penalties to hospitals.
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Affiliation(s)
- Kevin N Griffith
- Kevin N. Griffith , Vanderbilt University Medical Center, Nashville, Tennessee, and Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - David A Schwartzman
- David A. Schwartzman, Washington University in St. Louis, St. Louis, Missouri
| | - Steven D Pizer
- Steven D. Pizer, Veterans Affairs Boston Healthcare System and Boston University, Boston, Massachusetts
| | | | | | | | - Melissa M Garrido
- Melissa M. Garrido, Veterans Affairs Boston Healthcare System and Boston University
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12
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Hussein HM, Chrenka EA, Herrmann AA. Rate and Predictors of Acute Care Encounters in the First Month After Stroke. J Stroke Cerebrovasc Dis 2022; 31:106466. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/07/2021] [Accepted: 03/17/2022] [Indexed: 10/18/2022] Open
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13
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John G, Payrard L, Donzé J. Associations between post-discharge medical consultations and 30-day unplanned hospital readmission: A prospective observational cohort study. Eur J Intern Med 2022; 99:57-62. [PMID: 35034807 DOI: 10.1016/j.ejim.2022.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/20/2021] [Accepted: 01/03/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The period following hospital discharge is one of significant vulnerability. Little is known about the relationship between post-discharge healthcare use and the risk of readmission. OBJECTIVES To explore associations between medical consultations and other healthcare use parameters and the risk of 30-day unplanned hospital readmission. METHODS Between July 2017 and March 2018, we monitored all adult internal medicine patients for 30 days after their discharge from four mid-sized hospitals. Using follow-up telephone calls, we assessed their post-discharge healthcare use: consultations with general practitioners (GPs) and specialist physicians, emergency room (ER) visits, and home visits by nurses. The binary outcome was defined as any unplanned hospital readmission within 30 days of discharge, and this was analyzed using logistic regression. RESULTS Of 934 patients discharged, 111 (12%) experienced at least one unplanned hospital readmission within 30 days. Attending at least one GP consultation decreased the odds of readmission by half (adjusted OR: 0.5; 95%CI: 0.3-0.7), whereas attending at least one specialist consultation doubled those odds (aOR: 2.0; 95%CI: 1.2-3.3). GP consultations also reduced the odds of the combined risk of an ER visit or unplanned hospital readmission (aOR: 0.5; 95%CI: 0.3-0.7). ER visits were also associated with a higher readmission risk after adjusting for confounding factors (aOR: 10.0; 95%CI: 6.0-16.8). CONCLUSION GP consultations were associated with fewer ER visits and unplanned hospital readmissions.
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Affiliation(s)
- Gregor John
- Department of Internal Medicine, Neuchâtel Hospital Network, Rue de la Maladière 45, Neuchâtel CH-2000, Switzerland; Department of Internal Medicine, Geneva University Hospitals (HUG), Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland; University of Geneva, Rue Michel-Servet 1, Geneva CH-1211, Switzerland.
| | - Loïc Payrard
- Department of Medicine, Neuchâtel Hospital Network, Rue de la Maladière 45, Neuchâtel CH-2000, Switzerland.
| | - Jacques Donzé
- Department of Medicine, Neuchâtel Hospital Network, Neuchâtel, Switzerland; Department of Medicine, University of Lausanne, Switzerland, Division of Internal Medicine, Bern University Hospital, Bern, Switzerland; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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14
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Zhao Q, Li H, Ni Q, Dai Y, Zheng Q, Wang Y, Ke T, Li L, Zhao D, Dong Q, Ji B, Shi J, Peng Y, Zhang Y, Xu F, Wang W. Follow-up frequency and clinical outcomes in patients with type 2 diabetes: A prospective analysis based on multicenter real-world data. J Diabetes 2022; 14:306-314. [PMID: 35613850 PMCID: PMC9366569 DOI: 10.1111/1753-0407.13271] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/12/2022] [Accepted: 04/21/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND To determine whether the follow-up frequency for type 2 diabetes mellitus (T2DM) patients in the National Metabolic Management Centers (MMCs) leads to different clinical outcomes. METHODS A total of 19 908 T2DM patients with at least 6 months of facility-based follow-up were recruited in MMCs between June 2017 and April 2021 and divided into lower-frequency and higher-frequency follow-up (LFF and HFF) groups according to the median follow-up frequency of 2.0 (interquartile range 1.2) times per year. Metabolic parameters at baseline and at the last follow-up visit were analyzed. Multivariable linear regression models were performed to assess the relationship between follow-up frequency and between-group percentage changes, adjusting for the major covariables. Additional stratified analyses were conducted to evaluate the metabolic outcomes in the subgroups. RESULTS The characteristics of the participants in the LFF and HFF groups were significantly different at baseline. Participants had significant improvements in multiple metabolic parameters after follow-up. Patients with HFF showed significantly greater decrease in percentage changes of fasting blood glucose (-4.95% ± 37.96% vs -2.21% ± 43.08%, P < .0001) and glycosylated hemoglobin (HbA1c) (-12.14% ± 19.78% vs -9.67% ± 20.29%, P < .0001) after adjustments compared to those with LFF. Furthermore, stratification analyses showed that significant between-group percentage changes of HbA1c were observed in those with younger age (<55 years) and higher HbA1c (>9%) at baseline (P for interaction <.001). CONCLUSIONS HFF is associated with better metabolic outcomes. Participants, especially with younger age or worse HbA1c at baseline in the HFF group achieved better glycemic control than those in the LFF group.
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Affiliation(s)
- Qiubo Zhao
- Department of Endocrinology and Metabolism, Hebi Coal (group) LtdGeneral HospitalHebiChina
| | - Hongwei Li
- Department of Endocrinology and Metabolism, Hebi Coal (group) LtdGeneral HospitalHebiChina
| | - Qicheng Ni
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai National Clinical Research Center for metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yuancheng Dai
- Department of Internal Medicine of Traditional Chinese MedicineSheyang Diabetes HospitalYanchengChina
| | - Qidong Zheng
- Department of Internal MedicineThe Second People's Hospital of YuhuanYuhuanChina
| | - Yufan Wang
- Department of Endocrinology and Metabolism, Shanghai General HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Tingyu Ke
- Department of EndocrinologyThe Second Affiliated Hospital of Kunming Medical UniversityKunmingChina
| | - Li Li
- Department of EndocrinologyNingbo First HospitalChina
| | - Dong Zhao
- Center for Endocrine Metabolism and Immune Diseases, Beijing Luhe HospitalCapital Medical UniversityBeijingChina
| | - Qijuan Dong
- Department of Endocrinology and MetabolismPeople's Hospital of Zhengzhou Affiliated Henan University of Chinese MedicineZhengzhouChina
| | - Bangqun Ji
- Department of EndocrinologyXingyi People's HospitalXingyiChina
| | - Juan Shi
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai National Clinical Research Center for metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ying Peng
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai National Clinical Research Center for metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yifei Zhang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai National Clinical Research Center for metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Fengmei Xu
- Department of Endocrinology and Metabolism, Hebi Coal (group) LtdGeneral HospitalHebiChina
| | - Weiqing Wang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Shanghai National Clinical Research Center for metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
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15
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Merli G. Preventing re-admission: Are general practitioners the solution? Eur J Intern Med 2022; 99:28-29. [PMID: 35307246 DOI: 10.1016/j.ejim.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Geno Merli
- Professor of Medicine and Surgery, Director Division Vascular Medicine, Co-Director Jefferson Vascular Center, Thomas Jefferson University Hospitals, 111 South 11th Street, Suite 6210 Gibbon Building, Philadelphia, PA 19107.
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16
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Gilmartin HM, Warsavage T, Hines A, Leonard C, Kelley L, Wills A, Gaskin D, Ujano-De Motta L, Connelly B, Plomondon ME, Yang F, Kaboli P, Burke RE, Jones CD. Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study. J Hosp Med 2022; 17:149-157. [PMID: 35504490 DOI: 10.1002/jhm.12802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.
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Affiliation(s)
- Heather M Gilmartin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Theodore Warsavage
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Anne Hines
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Chelsea Leonard
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lynette Kelley
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Ashlea Wills
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - David Gaskin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lexus Ujano-De Motta
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Brigid Connelly
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Mary E Plomondon
- Clinical Assessment Reporting and Tracking Program, Office of Quality and Patient Safety, Veterans' Health Administration, Washington, District of Columbia, USA
| | - Fan Yang
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Peter Kaboli
- Research Department, Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Robert E Burke
- Research Department, Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Health Administration Medical Center, Philadelphia, Pennsylvania, USA
- Hospital Medicine Section - Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine D Jones
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Division of Hospital Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
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17
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Abstract
BACKGROUND Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review. OBJECTIVES To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text. MAIN RESULTS We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants; low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence). AUTHORS' CONCLUSIONS A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.
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Affiliation(s)
- Daniela C Gonçalves-Bradley
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Natasha A Lannin
- Brain Recovery and Rehabilitation Group, Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Lindy Clemson
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Sydney Medical School, Northern Clinical School, The University of Sydney, St Leonards, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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18
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He W. Effects of establishing a financing scheme for outpatient care on inpatient services: empirical evidence from a quasi-experiment in China. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:7-22. [PMID: 34224059 DOI: 10.1007/s10198-021-01340-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 06/22/2021] [Indexed: 06/13/2023]
Abstract
The relationship between outpatient and inpatient care is central to the current healthcare reform debate especially in developing countries. Despite the importance of this relationship to health policy makers, empirical evidence, particularly evidence that can be interpreted as causal is limited and inconclusive. This paper examines the effects of establishing a financing scheme for outpatient care on inpatient utilization and expenditure in China's Urban Employee Basic Medical Insurance scheme. Under a quasi-experimental design, we use a unique administrative insurance claim dataset and conduct a difference-in-differences analysis. Our results indicate that after the policy change, total number of admissions and total inpatient expenditure of the enrollees decreased by 0.47% and 6.05% respectively, which imply outpatient and inpatient care are substitutes, and the reduction in cost-sharing can release the underuse of the outpatient care, so as to reduce those excessive demands for inpatient care. Moreover, we present evidence that the effects on the admissions of Ambulatory Care Sensitive Conditions which should be sensitive to outpatient care intervention are relatively limited because of the lower reimbursement cap, inadequate capacity of the local primary care providers and stickiness in patients' healthcare-seeking behaviors. While the enrollees aged over 55 and retirees are more vulnerable to the medical prices, and the enrollees living in the central districts are more responsive because of the better and more accessible primary care.
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Affiliation(s)
- Wen He
- School of Public Administration, Hunan University, Lushan Road (S), Yuelu District, Changsha, 410082, China.
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19
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Yen HY, Lin SC, Chi MJ. Exploration of risk factors for high-risk adverse events in elderly patients after discharge and comparison of discharge planning screening tools. J Nurs Scholarsh 2021; 54:7-14. [PMID: 34841651 DOI: 10.1111/jnu.12705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 05/12/2021] [Accepted: 07/08/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Discharge planning is an effective strategy to prevent adverse health events and reduce medical expenditures. The high-risk target populations of discharged elderly patients and important predictors for the occurrence of adverse events are still not clear. Therefore, the purposes of this study were to examine the validity of discharge planning screening tools in sufficiently identifying high-risk adverse events to health after discharge and to compare two screening tools with our study model. DESIGN We conducted a prospective study and recruited elderly patients who had had no hospitalization within 3 months before admission to 13 general wards of a medical center in northern Taiwan from November 2018 to May 2020. METHODS Elderly patients were randomly selected during the study period. Within 24 h of admission, patients were asked to consent to join this study. After the patient was discharged, the patient's health and hospitalization for the next year were tracked by telephone interviews. RESULTS In total, 300 participants were recruited for this study. Incidences of high-risk adverse events within 30 days, 60 days, and 12 months after discharge were 20.3%, 25.7%, and 48.7% respectively. A logistic regression showed that an increased age, physical or mental disabilities or a major illness, a low body-mass index, and having been hospitalized in the past year were significantly related to the occurrence of high-risk events among elderly discharge patients. The pooled sensitivity of the Pra was 52% and the specificity was 72%; the pooled sensitivity of the LACE index was 67% and the specificity was 36%. The predictive model of this study had a higher discriminatory power than the Pra and LACE index for high-risk events after discharge. CONCLUSIONS Elderly patients are more vulnerable to high-risk adverse events after discharge. Both the LACE index and Pra are useful discharge planning screening tools to screen for high-risk adverse events after discharge. Elderly patients need more-active and complete continuity of care plans and discharge planning services to ensure that the overall quality of patient care can be improved and readmissions and mortality reduced. CLINICAL RELEVANCE The findings of this study can provide information for discharge planning managers to identify high-risk elderly patients during hospitalization and promptly offer care education or resources to improve care management.
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Affiliation(s)
- Hsin-Yen Yen
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Siou-Chun Lin
- Master Program in Long-term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan.,Department of Preventive and Community Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mei-Ju Chi
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan.,Master Program in Long-term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
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20
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Wong MS, Luger TM, Katz ML, Stockdale SE, Ewigman NL, Jackson JL, Zulman DM, Asch SM, Ong MK, Chang ET. Outcomes that Matter: High-Needs Patients' and Primary Care Leaders' Perspectives on an Intensive Primary Care Pilot. J Gen Intern Med 2021; 36:3366-3372. [PMID: 33987789 PMCID: PMC8606366 DOI: 10.1007/s11606-021-06869-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Quantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value. OBJECTIVE To understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients. DESIGN A total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation. PARTICIPANTS High-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites. APPROACH We used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects. KEY RESULTS Patients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization. CONCLUSIONS Patients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).
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Affiliation(s)
- Michelle S Wong
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.
| | - Tana M Luger
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Covenant Health Network, Phoenix, AZ, USA
| | - Marian L Katz
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Jeffrey L Jackson
- Department of Medicine, Zablocki VA Medical Center, Milwaukee, WI, USA.,Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Michael K Ong
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.,Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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21
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Chang ET, Yoon J, Esmaeili A, Zulman DM, Ong MK, Stockdale SE, Jimenez EE, Chu K, Atkins D, Denietolis A, Asch SM. Outcomes of a randomized quality improvement trial for high-risk Veterans in year two. Health Serv Res 2021; 56 Suppl 1:1045-1056. [PMID: 34145564 PMCID: PMC8515223 DOI: 10.1111/1475-6773.13674] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year. DATA SOURCES VHA administrative data for five demonstration sites from August 2013 to March 2019. DATA SOURCES Administrative data extracted from VHA's Corporate Data Warehouse. STUDY DESIGN Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences. PRINCIPAL FINDINGS Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73). CONCLUSIONS Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.
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Affiliation(s)
- Evelyn T. Chang
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Department of MedicineVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Department of MedicineDavid Geffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Jean Yoon
- VA Health Economics Resource Center (HERC)Menlo ParkCaliforniaUSA
- Department of General Internal MedicineUCSF School of MedicineSan FranciscoCaliforniaUSA
| | - Aryan Esmaeili
- VA Health Economics Resource Center (HERC)Menlo ParkCaliforniaUSA
| | - Donna M. Zulman
- VA HSR&D Center for Innovation to ImplementationMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineMenlo ParkCaliforniaUSA
| | - Michael K. Ong
- Department of MedicineVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Department of MedicineDavid Geffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
- Department of Health Policy and ManagementFielding School of Public Health, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Susan E. Stockdale
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Department of Psychiatry and Biobehavioral SciencesUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Elvira E. Jimenez
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
- Behavioral NeurologyGeffen School of Medicine, University of California at Los AngelesLos AngelesCaliforniaUSA
| | - Karen Chu
- VA Center for the Study of Healthcare InnovationImplementation and Policy (CSHIIP)Los AngelesCaliforniaUSA
| | - David Atkins
- VA Health Services Research and DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | - Steven M. Asch
- VA HSR&D Center for Innovation to ImplementationMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineMenlo ParkCaliforniaUSA
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22
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Pugh K, Granger D, Lusk J, Feaster W, Weiss M, Wright D, Ehwerhemuepha L. Targeted Clinical Interventions for Reducing Pediatric Readmissions. Hosp Pediatr 2021; 11:1151-1163. [PMID: 34535502 DOI: 10.1542/hpeds.2020-005786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In this interventional study, we addressed the selection and application of clinical interventions on pediatric patients identified as at risk by a predictive model for readmissions. METHODS A predictive model for readmissions was implemented, and a team of providers expanded corresponding clinical interventions for at-risk patients at a freestanding children's hospital. Interventions encompassed social determinants of health, outpatient care, medication reconciliation, inpatient and discharge planning, and postdischarge calls and/or follow-up. Statistical process control charts were used to compare readmission rates for the 3-year period preceding adoption of the model and clinical interventions with those for the 2-year period after adoption of the model and clinical interventions. Potential financial savings were estimated by using national estimates of the cost of pediatric inpatient readmissions. RESULTS The 30-day all-cause readmission rates during the periods before and after predictive modeling (and corresponding 95% confidence intervals [CI]) were 12.5% (95% CI: 12.2%-12.8%) and 11.1% (95% CI: 10.8%-11.5%), respectively. More modest but similar improvements were observed for 7-day readmissions. Statistical process control charts indicated nonrandom reductions in readmissions after predictive model adoption. The national estimate of the cost of pediatric readmissions indicates an associated health care savings due to reduced 30-day readmission during the 2-year predictive modeling period at $2 673 264 (95% CI: $2 612 431-$2 735 364). CONCLUSIONS A combination of predictive modeling and targeted clinical interventions to improve the management of pediatric patients at high risk for readmission was successful in reducing the rate of readmission and reducing overall health care costs. The continued prioritization of patients with potentially modifiable outcomes is key to improving patient outcomes.
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Affiliation(s)
- Karen Pugh
- Children's Health of Orange County, Orange, California
| | - David Granger
- Children's Health of Orange County, Orange, California
| | - Jennifer Lusk
- Children's Health of Orange County, Orange, California
| | | | - Michael Weiss
- Children's Health of Orange County, Orange, California
| | | | - Louis Ehwerhemuepha
- Children's Health of Orange County, Orange, California .,Schmid College of Science and Technology, Chapman University, Orange, California
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Jayakody A, Carey M, Bryant J, Ella S, Hussein P, Warren E, Bacon S, Field B, Sanson-Fisher R. Exploring experiences and perceptions of Aboriginal and Torres Strait Islander peoples readmitted to hospital with chronic disease in New South Wales, Australia: a qualitative study. AUST HEALTH REV 2021; 45:411-417. [PMID: 34334156 DOI: 10.1071/ah20342] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 06/21/2021] [Indexed: 11/23/2022]
Abstract
Objective This study explored the experiences and perceptions of unplanned hospital readmissions from the perspective of Aboriginal and Torres Strait Islander peoples with chronic disease. Method We conducted semi-structured interviews with Aboriginal and Torres Strait Islander patients readmitted to hospital with chronic disease. Interviews covered perceptions of avoidable readmissions, experiences of health care, medications and carer support. Inductive thematic analysis was used to code and analyse the data. Results Fifteen patients with multiple chronic diseases were interviewed. Several participants believed their readmission was unavoidable due to their poor health, while others considered their readmission was avoidable due to perceived health professional and system failures. Enablers to chronic disease management included the importance of continuity of care and strong family networks, although a few participants struggled with isolation. Four themes emerged as barriers: poor communication from health professionals; low levels of health literacy and adherence to chronic disease management; poor access to community services; and health risk behaviours. Conclusions The participants in our study identified complex and interacting patient-, environmental-, encounter- and organisational-level factors as contributing to chronic disease management and unplanned readmissions. Our findings suggest systemic failures remain in access to basic services and access to culturally appropriate care. Family support and continuity of care were valued by participants. What is known about the topic? Aboriginal and Torres Strait Islander peoples with chronic diseases are more likely to be readmitted to hospital compared with non-Aboriginal people. Unplanned readmissions are associated with high health system costs, as well as poorer quality of life and psychological distress for the patient. What does this paper add? This paper describes the experiences and perceptions of unplanned readmissions by Aboriginal and Torres Strait Islander peoples with chronic disease. Our findings suggest systemic failures exist in access to basic services for a safe and secure living environment, and access to culturally appropriate care that is delivered in a manner which promotes health literacy and self-management capacity. What are the implications for practitioners? Practitioners and policy makers should consider involving family members in discharge planning and other medical care, and funding for Aboriginal and Torres Strait Islander health and community services to enhance transport, care coordination, culturally appropriate disability and housing services, and health promotion.
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Affiliation(s)
- Amanda Jayakody
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia. ; ; ; and Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia; and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; and Corresponding author.
| | - Mariko Carey
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia. ; ; ; and Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia; and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia. ; ; ; and Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia; and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Stephen Ella
- Nunyara Aboriginal Health Unit, Central Coast Local Health District, Ward Street, Gosford, NSW, Australia. ;
| | - Paul Hussein
- Yerin Aboriginal Health Services Ltd, Suites 8 and 9, 36 Alison Road, Wyong, NSW, Australia. ; ;
| | - Eloise Warren
- Yerin Aboriginal Health Services Ltd, Suites 8 and 9, 36 Alison Road, Wyong, NSW, Australia. ; ;
| | - Shanell Bacon
- Nunyara Aboriginal Health Unit, Central Coast Local Health District, Ward Street, Gosford, NSW, Australia. ;
| | - Belinda Field
- Yerin Aboriginal Health Services Ltd, Suites 8 and 9, 36 Alison Road, Wyong, NSW, Australia. ; ;
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia. ; ; ; and Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia; and Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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24
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Reeves MJ, Fritz MC, Osunkwo I, Grudzen CR, Hsu LL, Li J, Lawrence RH, Bettger JP. Opening Pandora's Box: From Readmissions to Transitional Care Patient-Centered Outcome Measures. Med Care 2021; 59:S336-S343. [PMID: 34228015 PMCID: PMC8263140 DOI: 10.1097/mlr.0000000000001592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Measuring the effectiveness of transitional care interventions has historically relied on health care utilization as the primary outcome. Although the Care Transitions Measure was the first outcome measure specifically developed for transitional care, its applicability beyond the hospital-to-home transition is limited. There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings (ie, TC-PCOMs) to ensure that outcomes are both meaningful to patients and relevant to the particular care transition. The overall objective of this paper is to describe the opportunities and challenges of integrating TC-PCOMs into research and practice. METHODS AND RESULTS This narrative review was conducted by members of the Patient-Centered Outcomes Research Institute (PCORI) Transitional Care Evidence to Action Network. We define TC-PCOMs as outcomes that matter to patients because they account for their individual experiences, concerns, preferences, needs, and values during the transition period. The cardinal features of TC-PCOMs should be that they are developed following direct input from patients and stakeholders and reflect their lived experience during the transition in question. Although few TC-PCOMs are currently available, existing patient-reported outcome measures could be adapted to become TC-PCOMs if they incorporated input from patients and stakeholders and are validated for the relevant care transition. CONCLUSION Establishing validated TC-PCOMs is crucial for measuring the responsiveness of transitional care interventions and optimizing care that is meaningful to patients.
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Affiliation(s)
| | - Michele C. Fritz
- College of Veterinary Medicine, Michigan State University, East Lansing, MI
| | - Ifeyinwa Osunkwo
- Sickle Cell Disease Enterprise, Levine Cancer Institute, Department of Medicine & Pediatrics, Atrium Health, Charlotte, NC
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, NYU Grossman School of Medicine, New York, NY
| | - Lewis L. Hsu
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL
| | - Jing Li
- Department of Internal Medicine, Center for Health Services Research (CHSR), University of Kentucky, Lexington, KY
| | - Raymona H. Lawrence
- Jiann Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA
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25
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Income inequalities and risk of early rehospitalization for diabetes, hypertension, and heart failure in the Canadian working age population. Can J Diabetes 2021; 46:561-568. [DOI: 10.1016/j.jcjd.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 05/19/2021] [Accepted: 08/13/2021] [Indexed: 11/19/2022]
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Association of Post-discharge Service Types and Timing with 30-Day Readmissions, Length of Stay, and Costs. J Gen Intern Med 2021; 36:2197-2204. [PMID: 33987792 PMCID: PMC8342719 DOI: 10.1007/s11606-021-06708-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although early follow-up after discharge from an index admission (IA) has been postulated to reduce 30-day readmission, some researchers have questioned its efficacy, which may depend upon the likelihood of readmission at a given time and the health conditions contributing to readmissions. OBJECTIVE To investigate the relationship between post-discharge services utilization of different types and at different timepoints and unplanned 30-day readmission, length of stay (LOS), and inpatient costs. DESIGN, SETTING, AND PARTICIPANTS The study sample included 583,199 all-cause IAs among 2014 Medicare fee-for-service beneficiaries that met IA inclusion criteria. MAIN MEASURES The outcomes were probability of 30-day readmission, average readmission LOS per IA discharge, and average readmission inpatient cost per IA discharge. The primary independent variables were 7 post-discharge health services (institutional outpatient, primary care physician, specialist, non-physician provider, emergency department (ED), home health care, skilled nursing facility) utilized within 7 days, 14 days, and 30 days of IA discharge. To examine the association with post-discharge services utilization, we employed multivariable logistic regressions for 30-day readmissions and two-part models for LOS and inpatient costs. KEY RESULTS Among all IA discharges, the probability of unplanned 30-day readmission was 0.1176, the average readmission LOS per discharge was 0.67 days, and the average inpatient cost per discharge was $5648. Institutional outpatient, home health care, and primary care physician visits at all timepoints were associated with decreased readmission and resource utilization. Conversely, 7-day and 14-day specialist visits were positively associated with all three outcomes, while 30-day visits were negatively associated. ED visits were strongly associated with increases in all three outcomes at all timepoints. CONCLUSION Post-discharge services of different types and at different timepoints have varying impacts on 30-day readmission, LOS, and costs. These impacts should be considered when coordinating post-discharge follow-up, and their drivers should be further explored to reduce readmission throughout the health care system.
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Use of Web-Based Patient Portals in Patients With Atrial Fibrillation Is Associated With Higher Readmissions. Ochsner J 2021; 21:25-29. [PMID: 33828423 PMCID: PMC7993436 DOI: 10.31486/toj.19.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The impact of web-based patient portals on patient outcomes-specifically hospital readmissions in patients with atrial fibrillation (AF)-remains understudied. Methods: This single-center retrospective cohort study investigated the use of an online portal system (MyChart) by patients hospitalized from January 1, 2014 to June 30, 2017 for AF. During the study period, 11,334 unique AF admissions were identified; 50.3% were MyChart users and 49.7% were non-MyChart users. Patients who experienced inpatient mortality were excluded. The study groups were analyzed for demographic variables, comorbidities, readmission rates, and the frequency of MyChart use during the 3.5-year time frame. Results: MyChart users were younger (median age, 74 years, interquartile range [IQR] 66-82 vs 77 years, IQR 68-85; P<0.0001) and more likely to be white (91.9% vs 84.6%; P<0.0001), but the sex distribution was similar between groups, with 51.8% males in the MyChart group vs 53.2% in the non-MyChart group. MyChart users had a significantly higher rate of readmission compared to non-MyChart users at 1 year (43.0% vs 32.0%, respectively; P<0.0001). MyChart users who were readmitted had a higher median number of logins to MyChart (121 [IQR 32-270.5]) than MyChart users who were not readmitted (91 [IQR 26-205]; P<0.0001). Multivariable regression analysis demonstrated that MyChart use was associated with readmission (odds ratio 1.57, 95% CI 1.49-1.70; P<0.0001). Conclusion: Among patients with AF, MyChart use was associated with higher readmissions in this single-center cohort. Use and benefit of bespoke portals require further study.
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Hanlon JT. Perspectives on geriatrics by pioneers in aging: Reflections of a clinical pharmacist. J Am Geriatr Soc 2021; 69:896-899. [PMID: 33559891 DOI: 10.1111/jgs.17052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Geriatric Research Education and Clinical Center/Center for Health Equity Research and Promotion, VA Pittsburgh Health System, Pittsburgh, Pennsylvania, USA
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Dalal HM, Taylor RS, Wingham J, Greaves CJ, Jolly K, Lang CC, Davis RC, Smith KM, Doherty PJ, Miles J, van Lingen R, Warren FC, Sadler S, Abraham C, Britten N, Frost J, Hillsdon M, Singh S, Hayward C, Eyre V, Paul K. A facilitated home-based cardiac rehabilitation intervention for people with heart failure and their caregivers: a research programme including the REACH-HF RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background
Rates of participation in centre (hospital)-cardiac rehabilitation by patients with heart failure are suboptimal. Heart failure has two main phenotypes differing in underlying pathophysiology: heart failure with reduced ejection fraction is characterised by depressed left ventricular systolic function (‘reduced ejection fraction’), whereas heart failure with preserved ejection fraction is diagnosed after excluding other causes of dyspnoea with normal ejection fraction. This programme aimed to develop and evaluate a facilitated home-based cardiac rehabilitation intervention that could increase the uptake of cardiac rehabilitation while delivering the clinical benefits of centre-based cardiac rehabilitation.
Objectives
To develop an evidence-informed, home-based, self-care cardiac rehabilitation programme for patients with heart failure and their caregivers [the REACH-HF (Rehabilitation Enablement in Chronic Heart Failure) intervention]. To conduct a pilot randomised controlled trial to assess the feasibility of a full trial of the clinical effectiveness and cost-effectiveness of the REACH-HF intervention in addition to usual care in patients with heart failure with preserved ejection fraction. To assess the short- and long-term clinical effectiveness and cost-effectiveness of the REACH-HF intervention in addition to usual care in patients with heart failure with reduced ejection fraction and their caregivers.
Design
Intervention mapping to develop the REACH-HF intervention; uncontrolled feasibility study; pilot randomised controlled trial in those with heart failure with preserved ejection fraction; randomised controlled trial with a trial-based cost-effectiveness analysis in those with heart failure with reduced ejection fraction; qualitative studies including process evaluation; systematic review of cardiac rehabilitation in heart failure; and modelling to assess long-term cost-effectiveness (in those with heart failure with reduced ejection fraction).
Setting
Four centres in England and Wales (Birmingham, Cornwall, Gwent and York); one centre in Scotland (Dundee) for a pilot randomised controlled trial.
Participants
Adults aged ≥ 18 years with heart failure with reduced ejection fraction (left ventricular ejection fraction < 45%) for the main randomised controlled trial (n = 216), and those with heart failure with preserved ejection fraction (left ventricular ejection fraction ≥ 45%) for the pilot randomised controlled trial (n = 50).
Intervention
A self-care, facilitated cardiac rehabilitation manual was offered to patients (and participating caregivers) at home over 12 weeks by trained health-care professionals in addition to usual care or usual care alone.
Main outcome measures
The primary outcome was disease-specific health-related quality of life measured using the Minnesota Living with Heart Failure Questionnaire at 12 months. Secondary outcomes included deaths and hospitalisations.
Results
The main randomised controlled trial recruited 216 participants with heart failure with reduced ejection fraction and 97 caregivers. A significant and clinically meaningful between-group difference in the Minnesota Living with Heart Failure Questionnaire score (primary outcome) at 12 months (–5.7 points, 95% confidence interval –10.6 to –0.7 points) favoured the REACH-HF intervention (p = 0.025). Eight (4%) patients (four in each group) had died at 12 months. There was no significant difference in hospital admissions, at 12 months, with 19 participants in the REACH-HF intervention group having at least one hospital admission, compared with 24 participants in the control group (odds ratio 0.72, 95% confidence interval 0.35 to 1.51; p = 0.386). The mean cost of the intervention was £418 per participant with heart failure with reduced ejection fraction. The costs at 12 months were, on average, £401 higher in the intervention group than in the usual care alone group. Model-based economic evaluation, extrapolating from the main randomised controlled trial in those with heart failure with reduced ejection fraction over 4 years, found that adding the REACH-HF intervention to usual care had an estimated mean cost per participant of £15,452 (95% confidence interval £14,240 to £16,780) and a mean quality-adjusted life-year gain of 4.47 (95% confidence interval 3.83 to 4.91) years, compared with £15,051 (95% confidence interval £13,844 to £16,289) and 4.24 (95% confidence interval 4.05 to 4.43) years, respectively, for usual care alone. This gave an incremental cost per quality-adjusted life-year of £1721. The probabilistic sensitivity analysis indicated 78% probability that the intervention plus usual care versus usual care alone has a cost-effectiveness below the willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained. The intervention was well received by participants with heart failure with reduced ejection fraction and those with heart failure with preserved ejection fraction, as well as their caregivers. Both randomised controlled trials recruited to target, with > 85% retention at follow-up.
Limitations
Key limitations included (1) lack of blinding – given the nature of the intervention and the control we could not mask participants to treatments, so our results may reflect participant expectation bias; (2) that we were not able to capture consistent participant-level data on level of intervention adherence; (3) that there may be an impact on the generalisability of findings due to the demographics of the trial patients, as most were male (78%) and we recruited only seven people from ethnic minorities.
Conclusions
Evaluation of the comprehensive, facilitated, home-based REACH-HF intervention for participants with heart failure with reduced ejection fraction and caregivers indicated clinical effectiveness in terms of health-related quality of life and patient self-care but no other secondary outcomes. Although the economic analysis conducted alongside the full randomised controlled trial did not produce significant differences on the EuroQol-5 Dimensions or in quality-adjusted life-years, economic modelling suggested greater cost-effectiveness of the intervention than usual care. Our REACH-HF intervention offers a new evidence-based cardiac rehabilitation option that could increase uptake of cardiac rehabilitation in patients with heart failure not attracted to or able to access hospital-based programmes.
Future work
Systematic collection of real-world data would track future changes in uptake of and adherence to alternative cardiac rehabilitation interventions in heart failure with reduced ejection fraction and increase understanding of how changes in service delivery might affect clinical and health economic outcomes. The findings of our pilot randomised controlled trial in patients with heart failure with preserved ejection fraction support progression to a full multicentre randomised controlled trial.
Trial registration
Current Controlled Trials ISRCTN86234930 and ISRCTN78539530.
Funding details
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hasnain M Dalal
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Research and Development, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Professor of Population, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jennifer Wingham
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Colin J Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Chim C Lang
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Russell C Davis
- Cardiology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Karen M Smith
- Cardiac Rehabilitation Office, Ninewells Hospital, Dundee, UK
| | | | - Jackie Miles
- Research and Development, Aneurin Bevan University Health Board, St Woolos Hospital, Newport, UK
| | | | - Fiona C Warren
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Susannah Sadler
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Charles Abraham
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- School of Psychological Sciences, University of Melbourne, Victoria, VIC, Australia
| | - Nicky Britten
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Julia Frost
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | | | - Sally Singh
- Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | | | | | - Kevin Paul
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
- Research and Development, Royal Cornwall Hospitals NHS Trust, Truro, UK
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Longman J, Johnston J, Ewald D, Gilliland A, Burke M, Mutonga T, Passey M. What could prevent chronic condition admissions assessed as preventable in rural and metropolitan contexts? An analysis of clinicians' perspectives from the DaPPHne study. PLoS One 2021; 16:e0244313. [PMID: 33411717 PMCID: PMC7790391 DOI: 10.1371/journal.pone.0244313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/07/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Reducing potentially preventable hospitalisations (PPH) is a priority for health services. This paper describes the factors that clinicians perceived contributed to preventable admissions for angina, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), and what they considered might have been done in the three months leading up to an admission to prevent it. METHODS The study was conducted in a rural and a metropolitan health district in NSW, Australia. Expert Panels reviewed detailed case reports to assess preventability. For those admissions identified as preventable, comments from clinicians indicating what they perceived could have made a difference and/or been done differently to prevent each of the preventable admissions were analysed qualitatively. RESULTS 148 (46%) of 323 admissions were assessed as preventable. Across the two districts, the most commonly identified groups of contributing factors to preventable admissions were: 'Systems issues: Community based services missing or inadequate or not referred to'; 'Patient issues: Problems with adherence/self-management'; and 'Clinician issues: GP care inadequate'. In some instances, important differences drove these groups of factors. For example, in the rural district 'Systems issues: Community based services missing or inadequate or not referred to' was largely driven by social and welfare support services missing/inadequate/not referred to, whereas in the metropolitan district it was largely driven by community nursing, allied health, care coordination or integrated care services missing/inadequate/not referred to. Analyses revealed the complexity of system, clinician and patient factors contributing to each admission. Admissions for COPD (rural) and CHF (metropolitan) admissions showed greatest complexity. DISCUSSION AND CONCLUSION These findings suggest preventability of individual admissions is complex and context specific. There is no single, simple solution likely to reduce PPH. Rather, an approach addressing multiple factors is required. This need for comprehensiveness may explain why many programs seeking to reduce PPH have been unsuccessful.
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Affiliation(s)
- Jo Longman
- University Centre for Rural Health, The University of Sydney, Lismore, NSW, Australia
- * E-mail:
| | - Jennifer Johnston
- University Centre for Rural Health, The University of Sydney, Lismore, NSW, Australia
| | - Dan Ewald
- University Centre for Rural Health, The University of Sydney, Lismore, NSW, Australia
- North Coast Primary Health Network, Ballina, NSW, Australia
| | | | - Michael Burke
- School of Medicine, The University of Sydney, Sydney, NSW, Australia
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Tabeth Mutonga
- Mt Druitt Community Health Centre, Western Sydney Local Health District, Mt Druitt, NSW, Australia
| | - Megan Passey
- University Centre for Rural Health, The University of Sydney, Lismore, NSW, Australia
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Practices to support relational coordination in care transitions: Observations from the VA rural Transitions Nurse Program. Health Care Manage Rev 2020; 47:109-114. [PMID: 33181554 DOI: 10.1097/hmr.0000000000000300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ensuring safe transitions of care around hospital discharge requires effective relationships and communication between health care teams. Relational coordination (RC) is a process of communicating and relating for the purpose of task integration that predicts desirable outcomes for patients and providers. RC can be measured using a validated survey. PURPOSE The aim of the study was to demonstrate the application of RC practices within the rural Transitions Nurse Program (TNP), a nationwide transitions of care intervention for Veterans, and assess relationships and mechanisms for developing RC in teams. METHODOLOGY/APPROACH TNP implemented practices expected to support RC. These included creation of a transition nurse role, preimplementation site visits, process mapping to understand workflow, creation of standardized communication templates and protocols, and inclusion of teamwork and shared accountability in job descriptions and annual reviews. We used the RC Survey to measure RC for TNP health care teams. Associations between the months each site participated in TNP, number of Veterans enrolled, and adherence to the TNP intervention were assessed as possible mechanisms for developing high RC using Spearman (rs) correlations. RESULTS The RC Survey was completed by 44 providers from 11 Veterans Health Administration medical centers. RC scores were high across sites (mean = 4.19; 1-5 Likert scale) and were positively correlated with months participating in TNP (rs = .66) and number of enrollees (rs = .63), but not with adherence to the TNP intervention (rs = .12). PRACTICE IMPLICATIONS The impact of practices to support RC can be assessed using the RC Survey. Our findings suggest scale-up time is a likely mechanism to the development of high-quality relationships and communication within teams.
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Sanjeevan V, Rajagopal P, Venkitachalam R, Aras M. Efficiency of simplified versus traditional denture fabrication methods: A systematic review and meta-analysis. J Prosthet Dent 2020; 126:377-385. [PMID: 32891402 DOI: 10.1016/j.prosdent.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 11/27/2022]
Abstract
STATEMENT OF PROBLEM Conventional techniques (CTs) for complete denture fabrication involve a series of clinical and laboratory steps. A simplification of this process has been advocated, but whether simplified techniques result in acceptable treatment outcomes is unclear. PURPOSE The purpose of this systematic review and meta-analysis was to evaluate the efficiency of simplified denture fabrication techniques in comparison with CTs. MATERIAL AND METHODS The standard methodological procedures prescribed by the Cochrane Collaboration for systematic review and meta-analysis were used. An electronic search (MEDLINE through PubMed, Cochrane trial registry, and Scopus) and a manual search up to February 2020 were made to identify studies. Only randomized controlled trials involving edentulous adults requiring complete denture treatment were included. RESULTS Nineteen studies met the inclusion criteria. The pooled estimate of the included studies for patient satisfaction at 6 months marginally favored the simplified method of denture fabrication (standardized mean difference=0.02 [95% confidence interval {CI} -0.22 to 0.27]). The pooled estimate of the included studies for clinical time and cost of fabrication favored the simplified method (mean difference=-77.34 [95% CI -122.45 to -32.24] and mean difference=-85.89 [95% CI -170.02 to -1.77] respectively). CONCLUSIONS Simplified techniques were cost effective and less time consuming than the CT, with no significant difference in patient satisfaction or oral health-related quality of life. The high risk of bias and heterogeneity among studies requires that the results be considered cautiously.
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Affiliation(s)
- Vinita Sanjeevan
- Senior Lecturer, Department of Public Health Dentistry, Goa Dental College and Hospital, Bambolim, North Goa, Goa, India
| | - Praveen Rajagopal
- Assistant Professor, Department of Prosthodontics, Goa Dental College and Hospital, Bambolim, North Goa, Goa, India.
| | - Ramanarayanan Venkitachalam
- Assistant Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Ponekkara, Kochi, Kerala, India
| | - Meena Aras
- Professor and Head of Department, Department of Prosthodontics, Goa Dental College and Hospital, Bambolim, North Goa, Goa, India
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McGinn T, Best P, Wilson J, Chereni A, Kamndaya M, Shlonsky A. Family group decision-making for children at risk of abuse or neglect: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2020; 16:e1088. [PMID: 37131917 PMCID: PMC8356301 DOI: 10.1002/cl2.1088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Capturing the scale of child maltreatment is difficult, but few would argue that it is anything less than a global problem which can affect victims' health and well-being throughout their life. Systems of detection, investigation and intervention for maltreated children are the subject of continued review and debate. Objectives To assess the effectiveness of the formal use of family group decision-making (FGDM) in terms of child safety, permanence (of child's living situation), child and family well-being, and client satisfaction with the decision-making process. Search Methods Both published and unpublished manuscripts were considered eligible for this review. Library staff from Scholarly Information (Brownless Biomedical Library) University of Melbourne, conducted 14 systematic bibliographic searches. Reviewers also checked the reference lists of all relevant articles obtained, and reference lists from previously published reviews. Researchers also hand-searched 10 relevant journals. Selection Criteria Study samples of children and young people, aged 0-18 years, who have been the subject of a child maltreatment investigation, were eligible for this review. Studies had to have used random assignment to create treatment and control groups; or, parallel cohorts in which groups were assessed at the same point in time. Any form of FGDM, used in the course of a child maltreatment investigation or service, was considered an eligible intervention if it involved: a concerted effort to convene family, extended family, and community members; and professionals; and involved a planned meeting with the intention of working collaboratively to develop a plan for the safety well-being of children; with a focus on family-centred decision-making. Data Collection and Analysis Two review authors independently extracted the necessary data from each study report, using the software application Covidence. Covidence highlighted discrepancies between data extracted by separate reviewers, further analysis was conducted until a consensus was reached on what data were to be included in the review. Two authors also independently conducted analyses of study bias. Main Results Eighteen eligible study reports were found, providing findings from 15 studies, involving 18 study samples. Four were randomised controlled trials (RCTs; N = 941) the remainder employed quasi-experimental designs with parallel cohorts. Three of the quasi-experimental studies used prospective evaluations of nonrandomly assigned comparison groups (N = 4,368); the rest analysed pre-existing survey data, child protection case files or court data (N = 91,786). The total number of children studied was 97,095. The longest postintervention follow-up period was 3 years. Only four studies were conducted outside the United States; two in Canada and one in Sweden and one in the Netherlands. The review authors judged there to be a moderate or high risk of bias, in most of the bias categories considered. Only one study referenced a study protocol. Eleven of the fifteen studies were found to have a high likelihood of selection bias (73%). Baseline imbalance bias was deemed to be unlikely in just two studies, and highly likely in nine (60%). Confounding variables were judged to be highly likely in four studies (27%), and contamination bias was judged highly likely in five studies (33%). Researcher allegiance was rated as a high risk in three studies (20%) where the authors argued for the benefits of FGDM within the article, but without supporting references to an appropriate evidence base. Bias from differential diagnostic activity, and funding source bias, were less evident across the evidence reviewed. This review combines findings for eight FGDM outcome measures. Findings from RCTs were available for four outcomes, but none of these, combined in meta-analysis or otherwise, were statistically significant. Combining findings from the quasi-experimental studies provided one statistically significant finding, for the reunification of families, favouring FGDM. Ten effect sizes, from nine quasi-experimental studies, were synthesised to examine effects on the reunification of children with their family or the effect on maintaining in-home care; in short, the effect FGDM has on keeping families together. There was a high level of heterogeneity between the studies (I 2 = 92%). The overall effect, based on the combination of these studies was positive, small, but statistically significant: odds ratio (OR), 1.69 (confidence interval [CI], 1.03, 2.78). Holinshead's (2017) RCT also measured the maintenance on in-home care and reported a similar result: OR, 1.54 (CI, -0.19, 0.66) not statistically significant. The overall effect for continued maltreatment from meta-analysis of five quasi-experimental studies, favoured the FGDM group, but was not statistically significant: OR, 0.73 (CI, 0.48, 1.11). The overall combined effect for continued maltreatment, reported in RCTs, favoured the control group. But it was not statistically significant: OR, 1.29 (CI, 0.85, 1.98). Five effect sizes, from nonrandomised studies, were synthesised to examine the effect of FGDM on the number of kinship placements. The overall positive effect based on the combination of these studies was negligible: OR, 1.31 (CI, 0.94, 1.82). Meta-analysis was not possible with other outcomes. FGDM's role in expediting case processing and case closures was investigated in six studies, three of which reported findings favouring FGDM, and three which favoured the comparison group. Children's placement stability was reported in two studies: an RCT's findings favoured the control, while a quasi-experimental study's findings favoured FGDM. Three studies reported findings for service user satisfaction: one had only 30 participants, one reported a statistically significant positive effect for FGDM, the other found no difference between FGDM and a control. Engagement with support services was reported in two studies; neither reported statistically significant findings. Authors' Conclusions The current evidence base, in this field, is insufficient to draw conclusions about the effectiveness of FGDM. These models of child protection decision-making may help bring about better outcomes for children at risk, or they may increase the risk of further maltreatment. Further research of rigour, designed to avoid the potential biases of previous evaluations, is needed.
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Affiliation(s)
- Tony McGinn
- School of Sociology and Applied Social StudiesUlster UniversityDerry/LondonderryUK
| | - Paul Best
- School of Social Sciences, Education and Social WorkQueens UniversityBelfastUK
| | - Jason Wilson
- School of Health SciencesUlster UniversityN. IrelandUK
| | - Admire Chereni
- Department of Anthropology and Development StudiesJohannesburgSouth Africa
| | | | - Aron Shlonsky
- Department of Social WorkMonash UniversityMelbourneAustralia
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Sturt J, Huxley C, Ajana B, Gainty C, Gibbons C, Graham T, Khadjesari Z, Lucivero F, Rogers R, Smol A, Watkins JA, Griffiths F. How does the use of digital consulting change the meaning of being a patient and/or a health professional? Lessons from the Long-term Conditions Young People Networked Communication study. Digit Health 2020; 6:2055207620942359. [PMID: 32742716 PMCID: PMC7375714 DOI: 10.1177/2055207620942359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 06/22/2020] [Indexed: 11/16/2022] Open
Abstract
Background While studies have examined the impact of digital communication technology on healthcare, there is little exploration of how new models of digital care change the roles and identities of the health professional and patient. The purpose of the current study is to generate multidisciplinary reflections and questions around the use of digital consulting and the way it changes the meaning of being a patient and/or a health professional. Method We used a large pre-existing qualitative dataset from the Long-term Conditions Young People Networked Communication (LYNC) study which involved interviews with healthcare professionals and a group of 16-24 years patients with long-term physical and mental health conditions. We conducted a three-stage mixed methods analysis. First, using a small sample of interview data from the LYNC study, we identified three key themes to explore in the data and relevant academic literature. Second, in small groups we conducted secondary analysis of samples of patient and health professional LYNC interview data. Third, we ran a series of rapid evidence reviews. Findings We identified three key themes: workload/flow, impact of increased access to healthcare and vulnerabilities. Both health professionals and patients were 'on duty' in their role more often. Increased access to healthcare introduced more responsibilities to both patients and health professionals. Traditional concepts in medical ethics, confidentiality, empathy, empowerment/power, efficiency and mutual responsibilities are reframed in the context of digital consulting. Conclusions Our collaboration identified conflicts and constraints in the construction of digital patients and digital clinicians. There is evidence that digital technologies change the nature of a medical consultation and with it the identities and the roles of clinicians and patients which, in turn, calls for a redefinition of traditional concepts of medical ethics. Overall, digital consulting has the potential to significantly reduce costs while maintaining or improving patient care and clinical outcomes. Timely study of digital engagement in the National Health Service is a matter of critical importance.
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Affiliation(s)
- Jackie Sturt
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | - Caroline Huxley
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | - Btihaj Ajana
- Department of Digital Humanities, King's College London, UK
| | | | | | - Tanya Graham
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | | | | | - Rebecca Rogers
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
| | | | | | - Frances Griffiths
- Warwick Medical School, University of Warwick, UK.,Centre for Health Policy, University of the Witwatersrand, South Africa
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Song W, Intrator O, Twersky J, Davagnino J, Kinosian B, Wieland D. Utilization and Cost Effects of the VHA Caring for Older Adults and Caregivers at Home (COACH) Program. Med Care Res Rev 2020; 78:736-746. [PMID: 32646276 DOI: 10.1177/1077558720929592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since 2010, the Veterans Health Administration has initiated a home-based Caring for Older Adults and Caregivers at Home (COACH) program to provide clinical support to dementia patients and family caregivers. But its impact on health care utilization and costs is unknown. We compared 354 COACH care recipients with a propensity score weighted comparison group of 9,857 community-dwelling Veterans during fiscal years 2010-2015. In 1-year follow-up, COACH program was associated with a lower rate of long-term nursing home placement (average treatment effect on the treated [ATT] -3%; p = .01). The program increased utilization of emergency services (ATT 6%; p = .01), hospitals (ATT 10%; p < .001), and personal care services (ATT 31%; p < .001). Health care costs were also significantly increased. Improved access to services may have enabled COACH Veterans to stay at home longer. As one of Veterans Health Administration's top priorities to expand caregiver assistance programs, COACH seems to be a promising model for a nationwide implementation.
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Affiliation(s)
- Wei Song
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
| | - Jack Twersky
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
| | - Judith Davagnino
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
| | - Bruce Kinosian
- Geriatrics and Extended Care Data Analysis Center and Center for Health Equity Research and Promotion, Cpl. Michael J Crescenz VA Medical Center, Philadelphia, USA.,Department of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Darryl Wieland
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
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Vasan A, Morgan JW, Mitra N, Xu C, Long JA, Asch DA, Kangovi S. Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: A pooled analysis of three clinical trials. Health Serv Res 2020; 55 Suppl 2:894-901. [PMID: 32643163 PMCID: PMC7518822 DOI: 10.1111/1475-6773.13321] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. DATA SOURCES/STUDY SETTING Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016. STUDY DESIGN The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high-poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices. DATA COLLECTION/EXTRACTION METHODS The primary outcome for this study was all-cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3. PRINCIPAL FINDINGS Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023). CONCLUSIONS Data from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.
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Affiliation(s)
- Aditi Vasan
- National Clinician Scholars Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,PolicyLab and Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John W Morgan
- National Clinician Scholars Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chang Xu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judith A Long
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Corporal Michael J Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania
| | - David A Asch
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Corporal Michael J Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania
| | - Shreya Kangovi
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Corporal Michael J Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania.,Penn Center for Community Health Workers, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Toms R, Feng X, Mayne DJ, Bonney A. Role of Area-Level Access to Primary Care on the Geographic Variation of Cardiometabolic Risk Factor Distribution: A Multilevel Analysis of the Adult Residents in the Illawarra-Shoalhaven Region of NSW, Australia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4297. [PMID: 32560149 PMCID: PMC7344656 DOI: 10.3390/ijerph17124297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/13/2020] [Accepted: 06/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Access to primary care is important for the identification, control and management of cardiometabolic risk factors (CMRFs). This study investigated whether differences in geographic access to primary care explained area-level variation in CMRFs. METHODS Multilevel logistic regression models were used to derive the association between area-level access to primary care and seven discrete CMRFs after adjusting for individual and area-level co-variates. Two-step floating catchment area method was used to calculate the geographic access to primary care for the small areas within the study region. RESULTS Geographic access to primary care was inversely associated with low high density lipoprotein (OR 0.94, CI 0.91-0.96) and obesity (OR 0.91, CI 0.88-0.93), after adjusting for age, sex and area-level disadvantage. The intra-cluster correlation coefficient (ICCs) of all the fully adjusted models ranged between 0.4-1.8%, indicating low general contextual effects of the areas on CMRF distribution. The area-level variation in CMRFs explained by primary care access was ≤10.5%. CONCLUSION The findings of the study support proportionate universal interventions for the prevention and control of CMRFs, rather than any area specific interventions based on their primary care access, as the contextual influence of areas on all the analysed CMRFs were found to be minimal. The findings also call for future research that includes other aspects of primary care access, such as road-network access, financial affordability and individual-level acceptance of the services in order to gain an overall picture of the area-level contributing role of primary care on CMRFs in the study region.
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Affiliation(s)
- Renin Toms
- School of Medicine, University of Wollongong, Wollongong NSW 2522, Australia; (D.J.M.); (A.B.)
- Illawarra Health and Medical Research Institute, Wollongong NSW 2522, Australia;
| | - Xiaoqi Feng
- Illawarra Health and Medical Research Institute, Wollongong NSW 2522, Australia;
- Population Wellbeing and Environment Research Lab (PowerLab), School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong NSW 2500, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2033, Australia
| | - Darren J Mayne
- School of Medicine, University of Wollongong, Wollongong NSW 2522, Australia; (D.J.M.); (A.B.)
- Illawarra Health and Medical Research Institute, Wollongong NSW 2522, Australia;
- Illawarra Shoalhaven Local Health District, Public Health Unit, Warrawong NSW 2502, Australia
- School of Public Health, The University of Sydney, Sydney NSW 2006, Australia
| | - Andrew Bonney
- School of Medicine, University of Wollongong, Wollongong NSW 2522, Australia; (D.J.M.); (A.B.)
- Illawarra Health and Medical Research Institute, Wollongong NSW 2522, Australia;
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Basu J. Multilevel Risk Factors for Hospital Readmission Among Patients With Opioid Use Disorder in Selected US States: Role of Socioeconomic Characteristics of Patients and Their Community. Health Serv Res Manag Epidemiol 2020; 7:2333392820904240. [PMID: 32529001 PMCID: PMC7265081 DOI: 10.1177/2333392820904240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Research Objective Using a multilevel framework, the study examines the association of socioeconomic characteristics of the individual and the community with all-cause 30-day readmission risks for patients hospitalized with a principal diagnosis of opioid use disorder (OUD). Study Design The study uses hospital discharge data of adult (18+) patients in 5 US states for 2014 from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, linked to community and hospital characteristics using data from Health Resources and Services Administration and American Hospital Association, respectively. A multilevel logistic regression model is applied on data pooled over 5 states adjusting for patient, hospital, and community characteristics. Principal Findings Higher primary care access, as measured by density of primary care providers, is associated with reduced readmission risks among patients with OUD. Medicare is associated with the highest readmission risk (odds ratio [OR] = 2.0, P < .01) compared to private coverage, while Medicaid coverage is also associated with elevated risk (OR = 1.71, P < .01). Being self-pay or covered by other payers carried a similar risk to private coverage. Urban patients had higher readmission rates than rural patients. Conclusions Patients' risk of readmission following hospitalization for OUD varies according to availability of primary care providers, expected payer, and geographic location. Understanding which patients are most at risk may allow policy makers to design interventions to prevent readmissions and improve patient outcomes. Future studies may wish to focus on understanding when a decreased readmission rate represents better patient outcomes and when it represents difficulty accessing health care.
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Affiliation(s)
- Jayasree Basu
- Agency for Healthcare Research and Quality, Rockville, MD, USA
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Daliri S, Boujarfi S, El Mokaddam A, Scholte Op Reimer WJM, Ter Riet G, den Haan C, Buurman BM, Karapinar-Çarkit F. Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis. BMJ Qual Saf 2020; 30:146-156. [PMID: 32434936 DOI: 10.1136/bmjqs-2020-010927] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Harm due to medications is common during the transition from hospital to home. Approaches that seek to prevent harm often involve isolated medication-related interventions and show conflicting results. However, until now, no review has focused on the effect of intervention components delivered both in hospital and following discharge from hospital to home. OBJECTIVE To examine effects of medication-related interventions on hospital readmissions, medication-related problems (MRPs), medication adherence and mortality. METHODS For this systematic review and meta-analysis, we searched the PubMed, Embase, CINAHL and CENTRAL databases without language restrictions. Citations of included articles were checked through Web of Science and Scopus from inception to 20 June 2019. We included prospective studies that examined effects of medication-related interventions delivered both in hospital and following discharge from hospital to home compared with usual care. Three authors independently extracted data and assessed study quality in pairs. RESULTS Fourteen original studies were included, comprising 8182 patients. Interventions consisted mainly of patient education and medication reconciliation in the hospital, and patient education following discharge. Nine studies were included in the meta-analysis; compared with usual care (n=3376 patients), medication-related interventions (n=1820 patients) reduced hospital readmissions by 3.8 percentage points within 30 days of discharge (number needed to treat=27, risk ratio (RR) 0.79 (95% CI 0.65 to 0.96)). Meta-regression analysis suggested that readmission rates were reduced by 17% per additional intervention component (RR 0.83 (95% Cl 0.75 to 0.91)). Medication adherence and MRPs may be improved. Effects on mortality were unclear. CONCLUSIONS Studied medication-related interventions reduce all-cause hospital readmissions within 30 days. The treatment effect appears to increase with higher intervention intensities. More evidence is needed for recommendations on adherence, mortality and MRPs.
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Affiliation(s)
- Sara Daliri
- Department of Clinical Pharmacy, OLVG, Amsterdam, North-Holland, The Netherlands
| | - Samira Boujarfi
- Department of Clinical Pharmacy, OLVG, Amsterdam, North-Holland, The Netherlands
| | - Asma El Mokaddam
- Department of Clinical Pharmacy, OLVG, Amsterdam, North-Holland, The Netherlands
| | - Wilma J M Scholte Op Reimer
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, North-Holland, The Netherlands.,ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, North-Holland, The Netherlands
| | - Gerben Ter Riet
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, North-Holland, The Netherlands.,ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, North-Holland, The Netherlands
| | - Chantal den Haan
- Department of Research and Education, Medical Library, OLVG, Amsterdam, North-Holland, The Netherlands
| | - Bianca M Buurman
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC location AMC, Amsterdam, North-Holland, The Netherlands
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40
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Affiliation(s)
- Samuel W Terman
- From the Department of Neurology (S.W.T., J.F.B.), Institute for Healthcare Policy and Innovation (S.W.T., J.F.B.), and Department of Neurology Stroke Program (J.F.B.), University of Michigan, Ann Arbor.
| | - James F Burke
- From the Department of Neurology (S.W.T., J.F.B.), Institute for Healthcare Policy and Innovation (S.W.T., J.F.B.), and Department of Neurology Stroke Program (J.F.B.), University of Michigan, Ann Arbor
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Tran BX, Nguyen LH, Pham NM, Vu HTT, Nguyen HT, Phan DH, Ha GH, Pham HQ, Nguyen TP, Latkin CA, Ho CS, Ho RC. Global Mapping of Interventions to Improve Quality of Life of People with Diabetes in 1990-2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1597. [PMID: 32121642 PMCID: PMC7084501 DOI: 10.3390/ijerph17051597] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 12/18/2022]
Abstract
Improving the quality of life (QOL) of people living with diabetes is the ultimate goal of diabetes care. This study provides a quantitative overview of global research on interventions aiming to improve QOL among people with diabetes. A total of 700 English peer-reviewed papers published during 1990-2018 were collected and extracted from the Web of Science databases. Latent Dirichlet Allocation (LDA) analysis was undertaken to categorize papers by topic or theme. Results showed an increase in interventions to improve the QOL of patients with diabetes across the time period, with major contributions from high-income countries. Community- and family-based interventions, including those focused on lifestyle and utilizing digital technologies, were common approaches. Interventions that addressed comorbidities in people with diabetes also increased. Our findings emphasize the necessity of translating the evidence from clinical interventions to community interventions. In addition, they underline the importance of developing collaborative research between developed and developing countries.
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Affiliation(s)
- Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi 100000, Vietnam
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA;
| | - Long Hoang Nguyen
- Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden;
| | - Ngoc Minh Pham
- School of Public Health, Faculty of Health Sciences, Curtin University, Perth, WA 2605, Australia;
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen 250000, Vietnam
| | - Huyen Thanh Thi Vu
- Department of Gerontology and Geriatrics, Hanoi Medical University, Hanoi 100000, Vietnam;
- Scientific Research Department, National Geriatric Hospital, Hanoi 100000, Vietnam
| | - Hung Trong Nguyen
- Clinical Nutrition and Dietetics Department, National Institute of Nutrition, Hanoi 100000, Vietnam;
| | | | - Giang Hai Ha
- Institute for Global Health Innovations, Duy Tan University, Da Nang 550000, Vietnam; (G.H.H.); (H.Q.P.)
- Faculty of Pharmacy, Duy Tan University, Danang 550000, Vietnam
| | - Hai Quang Pham
- Institute for Global Health Innovations, Duy Tan University, Da Nang 550000, Vietnam; (G.H.H.); (H.Q.P.)
- Faculty of Medicine, Duy Tan University, Danang 550000, Vietnam
| | - Thao Phuong Nguyen
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 700000, Vietnam;
| | - Carl A. Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA;
| | - Cyrus S.H. Ho
- Department of Psychological Medicine, National University Hospital, Singapore 119074, Singapore;
| | - Roger C.M. Ho
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 700000, Vietnam;
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore 119077, Singapore
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Papadopoulos A, Stark RB. Does Home Health Care Increase the Probability of 30-Day Hospital Readmissions? Interpreting Coefficient Sign Reversals, or Their Absence, in Binary Logistic Regression Analysis. AM STAT 2020. [DOI: 10.1080/00031305.2019.1704873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Alecos Papadopoulos
- Department of Economics, Athens University of Economics and Business, Athens, Greece
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McAlister FA, Tonelli M, Wiebe N, Lin M, Svenson LW, Dean S. The ecology of medical care for adults in Alberta, 2002/03 to 2016/17: a retrospective cohort study. CMAJ Open 2020; 8:E169-E177. [PMID: 32184280 PMCID: PMC7082108 DOI: 10.9778/cmajo.20190188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND If we are to improve the patient experience, knowing where and with whom people receive professional health advice and treatment (the ecology of medical care) is the first step. We designed this study to define the ecology of medical care in Alberta and to examine whether province-wide implementation of 5 policy changes between 2003 and 2012 changed patterns of care among adults in the province. METHODS This was a retrospective cohort study of adults (age ≥ 18 yr) in Alberta using routinely collected data from 6 linked administrative health databases, the 2016 Canadian Community Health Survey and the Alberta Health Link teletriage system. We collected data on all encounters with pharmacists, primary care physicians, specialists, emergency departments and hospitals in 2002/03, 2009/10 and 2016/17. RESULTS Between 2002/03 and 2016/17, the community-dwelling adult population of Alberta increased from 2.66 million to 3.84 million; the median age increased from 41 to 43 years, and the proportion with at least 1 ambulatory-care-sensitive condition increased from 20.6% to 27.8%. The proportion who saw a primary care physician decreased significantly (from 70.8% to 68.2%, p < 0.001), as did the proportion who visited an emergency department (from 20.6% to 19.2%, p < 0.001); the declines were seen in all subgroups examined. The proportion who saw a specialist as an outpatient increased from 31.9% to 33.2% (p < 0.001), and the proportion who received at least 1 medication dispensation increased from 54.9% to 60.2% (p < 0.001). The proportion admitted to an acute care hospital (5.6%-6.5%) or academic hospital (1.2%) was relatively stable over time. INTERPRETATION Despite implementation of 5 system-wide changes designed to affect the delivery of primary and specialty medical care as well as the use of pharmacist and nursing services in Alberta, patterns of health care delivery changed little between 2002/03 and 2016/17. Rather than searching for a policy "magic bullet," health care planners may be better served by focusing on upscaling and implementing interventions proven to be efficacious.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta.
| | - Marcello Tonelli
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Natasha Wiebe
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Meng Lin
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Lawrence W Svenson
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Stafford Dean
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
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Costa AP, Schumacher C, Jones A, Dash D, Campbell G, Junek M, Agarwal G, Bell CM, Boscart V, Bronskill SE, Feeny D, Hébert PC, Heckman GA, Hirdes JP, Lee L, McKelvie RS, Mitchell L, Sinha SK, Davis J, Priddle T, Rose J, Gillan R, Mills D, Haughton D. DIVERT-Collaboration Action Research and Evaluation (CARE) Trial Protocol: a multiprovincial pragmatic cluster randomised trial of cardiorespiratory management in home care. BMJ Open 2019; 9:e030301. [PMID: 31843821 PMCID: PMC6924743 DOI: 10.1136/bmjopen-2019-030301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 11/06/2019] [Accepted: 11/19/2019] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Home care clients are increasingly medically complex, have limited access to effective chronic disease management and have very high emergency department (ED) visitation rates. There is a need for more appropriate and targeted supportive chronic disease management for home care clients. We aim to evaluate the effectiveness and preliminary cost effectiveness of a targeted, person-centred cardiorespiratory management model. METHODS AND ANALYSIS The Detection of Indicators and Vulnerabilities of Emergency Room Trips (DIVERT) - Collaboration Action Research and Evaluation (CARE) trial is a pragmatic, cluster-randomised, multicentre superiority trial of a flexible multicomponent cardiorespiratory management model based on the best practice guidelines. The trial will be conducted in partnership with three regional, public-sector, home care providers across Canada. The primary outcome of the trial is the difference in time to first unplanned ED visit (hazard rate) within 6 months. Additional secondary outcomes are to identify changes in patient activation, changes in cardiorespiratory symptom frequencies and cost effectiveness over 6 months. We will also investigate the difference in the number of unplanned ED visits, number of inpatient hospitalisations and changes in health-related quality of life. Multilevel proportional hazard and generalised linear models will be used to test the primary and secondary hypotheses. Sample size simulations indicate that enrolling 1100 home care clients across 36 clusters (home care caseloads) will yield a power of 81% given an HR of 0.75. ETHICS AND DISSEMINATION Ethics approval was obtained from the Hamilton Integrated Research Ethics Board as well as each participating site's ethics board. Results will be submitted for publication in peer-reviewed journals and for presentation at relevant conferences. Home care service partners will also be informed of the study's results. The results will be used to inform future support strategies for older adults receiving home care services. TRIAL REGISTRATION NUMBER NCT03012256.
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Affiliation(s)
- Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Schlegel Chair in Clinical Epidemiology and Aging, McMaster University, Hamilton, Ontario, Canada
| | - Connie Schumacher
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Hamilton Niagara Haldimand Brant Local Health Integration Network, Hamilton, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Graham Campbell
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Mats Junek
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gina Agarwal
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Chaim M Bell
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Veronique Boscart
- Schlegel Centre for Advancing Seniors Care, Conestoga College Institute of Technology and Advanced Learning, Kitchener, Ontario, Canada
| | - Susan E Bronskill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - David Feeny
- Department of Economics, McMaster University, Hamilton, Ontario, Canada
| | - Paul C Hébert
- Department of Medicine, Universite de Montreal, Montreal, Québec, Canada
| | - George A Heckman
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - John P Hirdes
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Linda Lee
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Lori Mitchell
- Home Care, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
| | - Samir K Sinha
- Departments of Medicine, Family and Community Medicine, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Joy Davis
- Information Management, Western Health Care Corp, Corner Brook, Newfoundland, Canada
| | - Tammy Priddle
- Community Support, Western Health Care Corp, Corner Brook, Newfoundland, Canada
| | - Joanne Rose
- Department of Health and Community Services, Government of Newfoundland and Labrador, Saint John's, Newfoundland, Canada
| | - Roslyn Gillan
- Community Health Services, Island Health, Victoria, British Columbia, Canada
| | - Deborah Mills
- Community Health Services, Island Health, Victoria, British Columbia, Canada
| | - Dilys Haughton
- Hamilton Niagara Haldimand Brant Local Health Integration Network, Hamilton, Ontario, Canada
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Abstract
Purpose
The purpose of this paper is to provide a summary of some of the lessons about implementing different types of integrated care.
Design/methodology/approach
The author used evidence from the author’s own evaluations and the findings of other researchers to identify some important lessons for policy makers and practitioners.
Findings
The author identifies eight high-level lessons which may be of interest to policy makers and practitioners working in the field.
Research limitations/implications
The lessons outlined in the paper provide only a starting point for those designing interventions or evaluation.
Practical implications
The changes required to implement integrated care are complex and are embedded in a complex context. Change of this type is difficult and generally takes longer to deliver than expected. The evaluation of these models often requires longer than is often available and needs to focus on the impact on the whole system rather than narrow measures, e.g. hospital utilisation.
Originality/value
This is a viewpoint paper synthesising evidence from the English pilot programmes in integrated care.
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Abstract
BACKGROUND While there has been ample interest and literature published regarding craniosynostosis surgical technique, there are few reports on adverse hospital and health system outcomes. The purpose of this study was to describe rate of and risk factors for complications, and adverse outcomes following craniosynostosis reconstruction. METHODS This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database and identified all patients undergoing craniosynostosis repair from 2012 to 2016. Univariate logistic regression analysis was used to identify significant associations between preoperative risk factors and adverse outcomes. Multivariate logistic regression analysis was then used to identify independent risk factors and causes of prolonged operative times, transfusions, reoperation, prolonged length of hospital stays, and readmission. RESULTS There were 3924 patients included who underwent craniosynostosis repair, of whom 1732 underwent frontoorbital advancement and 2192 underwent cranial vault remodeling. Transfusion was the most common NSQIP reportable outcome, occurring for 66.5% of all patients. The incidence of reoperation was 2.4% and readmission was 3.0%. CONCLUSION This study provides a large descriptive analysis of craniosynostosis repair throughout the United States. Largely nonmodifiable patient risk factors lead to worse health system metrics, with young age, gastrointestinal comorbidities, American Society of Anesthesiologist scores of 3 and greater, reoperation, and a prolonged length of stay as independent risk factors for readmission. This analysis can be used to identify the standard of practice in synostosis care and enhance the implementation of ancillary care services to provide safe and cost-effective care for patients undergoing craniosynostosis repair.
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Chen J, van den Berghe E, Kaestner R. Is Primary Care A Substitute or Complement for Other Medical Care? Evidence from Medicaid. Forum Health Econ Policy 2019; 22:/j/fhep.2019.22.issue-1/fhep-2018-0032/fhep-2018-0032.xml. [PMID: 31618174 DOI: 10.1515/fhep-2018-0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It is widely believed that Medicaid reimbursement for primary care is too low and that these low fees adversely affect access to healthcare for Medicaid recipients. In this article, we exploit changes in Medicaid physician fees for primary care to study the response of primary care visits and services that are complements/substitutes with primary care, including emergency department, hospitalization, prescription drugs, and imaging. Results from our study indicate that higher Medicaid fees for primary care have modest effects. Among non-blind and non-disabled adults, we find that a 25% (or $10) increase in Medicaid fees for primary care is associated with approximately a 5% of a standard deviation increase in the number of primary care visits. For the same group, we also find that the fee increase is associated with an increase in the probability of having any primary care visits of approximately 3 percentage points. For children, changes in Medicaid fees are not significantly related to the number of primary care visits. In terms of other types of care, we find some evidence that Medicaid fees for primary care are associated with prescription drug use, and no evidence that primary care fees are associated with the use of emergency department, inpatient services, or imaging. Overall, our evidence provides, at best, limited support for the large effects of Medicaid fees on service provision sometimes asserted in policy discussions.
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Affiliation(s)
- Jiajia Chen
- Department of Economics, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Robert Kaestner
- Harris School of Public Policy, University of Chicago, Chicago, IL, USA
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Post-Discharge Services for Different Diagnoses Than Index Hospitalization Predict Decreased 30-Day Readmissions Among Medicare Beneficiaries. J Gen Intern Med 2019; 34:1766-1774. [PMID: 31228052 PMCID: PMC6712241 DOI: 10.1007/s11606-019-05115-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/05/2018] [Accepted: 05/01/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Efforts to reduce hospital readmissions include post-discharge interventions related to the illness treated during the index hospitalization (IH). These efforts may be inadequate because readmissions are precipitated by a wide range of health conditions unrelated to the primary diagnosis of the IH. OBJECTIVE To investigate the relationship between post-discharge health services utilization for the same or a different diagnosis than the IH and unplanned 30-day readmission. DESIGN AND PARTICIPANTS The study sample included 583,199 all-cause IHs among 2014 Medicare fee-for-service beneficiaries. For all-cause IH, as well as individually for heart failure, myocardial infarction, and pneumonia IH, we used multivariable logistic regressions to investigate the association between post-discharge services utilization and readmission. MAIN MEASURES The outcome was unplanned 30-day readmission. Primary independent variables were post-discharge services utilization, including institutional outpatient, office-based primary care, office-based specialist, office-based non-physician practitioner, emergency department, home health care, and skilled nursing facility providers. KEY RESULTS Among all-cause IH, 11.7% resulted in unplanned 30-day readmissions, and only 18.1% of readmissions occurred for the same primary diagnosis as IH. A substantial majority of post-discharge health services were utilized for a primary diagnosis differing from IH. Compared with no visit, institutional outpatient visits for the same primary diagnosis as IH (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.31-0.34) and for a different primary diagnosis than IH (OR, 0.36; 95% CI, 0.35-0.37) were similarly strongly associated with decreased unplanned 30-day readmission. Primary care physician, specialist, non-physician practitioner, and home health care showed similar patterns. IH for heart failure, myocardial infarction, and pneumonia manifested similar patterns to all-cause IH both in terms of post-discharge services utilization and in terms of its impact on readmission. CONCLUSIONS To reduce unplanned 30-day readmission more effectively, discharge planning should include post-discharge services to address health conditions beyond the primary cause of the IH.
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Francesconi P, Ballo P, Profili F, Policardo L, Roti L, Zuppiroli A. Chronic Care Model for the Management of Patients with Heart Failure in Primary Care. Health Serv Insights 2019; 12:1178632919866200. [PMID: 31456642 PMCID: PMC6702766 DOI: 10.1177/1178632919866200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 04/18/2019] [Indexed: 11/26/2022] Open
Abstract
We recently investigated the prognostic impact of a Chronic Care Model (CCM)-based healthcare program applied in primary care in Tuscany Region mainly run by multidisciplinary teams composed of general practitioners (GPs) and nurses. The project included proactively planned follow-up visits for each patient, individualized counselling to optimize lifestyle modifications and adherence to appropriate diagnostic and therapeutic pathways. 1761 patients with Chronic heart failure (CHF) directly enrolled by the GPs were matched with 3522 CHF controls not involved in the project. Over a 4-year follow-up in the CCM group a higher CHF hospitalization rate was found (12.1 vs 10.3 events/100 patient-years; incidence rate ratio [IRR] 1.15, p=0.0030), whereas mortality was lower (10.8 vs 12.6 events/100 patient-years; IRR 0.82, p<0.0001). The CCM status was independently associated with a 34% increase in the risk of CHF hospitalization and a 18% reduction in the risk of death (p<0.0001 for both). The CCM status was associated with a 50% increase in the rate of planned Heart failure (HF) hospitalizations whereas the rate of 1-month CHF readmissions showed no differences. Such a divergent trend could be explained by the direct involvement of GPs in the CCM program, leading them to a better awareness of patients’ clinical status, and then to a more frequent use of clinical pathways and facilities, including hospitalization. It is reasonable to argue that not all hospitalizations must necessarily be considered as a poor outcome, as they often provide additional opportunities to improve therapies, optimize patient education, or define follow-up strategies. The evidence of a divergent trend between mortality and hospitalization in our population might support the clinical importance of a multidisciplinary approach for the management of patients with HF.
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Affiliation(s)
- Paolo Francesconi
- Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy
| | - Piercarlo Ballo
- Cardiology Unit, S. Maria Annunziata Hospital, Florence, Italy
| | - Francesco Profili
- Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy
| | - Laura Policardo
- Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy
| | - Lorenzo Roti
- Primary Healthcare Unit, Regional Health Authority, Florence, Italy
| | - Alfredo Zuppiroli
- Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy
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Nieto-Martín MD, De la Higuera-Vila L, Bernabeu-Wittel M, González-Benitez MA, Alfaro-Lara ER, Barón-Ramos MA, Montero-Aparicio E, Aparicio-Santos R, Baturone MO. A multidisciplinary approach for patients with multiple chronic conditions: IMPACTO study. Med Clin (Barc) 2019; 153:93-99. [PMID: 30857796 DOI: 10.1016/j.medcli.2019.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective of the study was to evaluate the effects of a multidisciplinary intervention on the outcomes of polypathological patients (PP). METHODS A multicenter quasi-experimental pre-post study with a 12-month follow up was performed. In-hospital, at discharge and outpatient clinics patients who met criteria of PP between March 2012 and October 2013 were included. The multidisciplinary approach was defined by 11 interventions performed by general practitioners, internal medicine physicians, team care nurses and hospital pharmacists. The primary outcome was reduction in the number of hospital admissions and days of hospitalization. Secondary outcomes included mortality and the effects of 11 interventions on mortality. RESULTS 420 patients were included. Mean patient age was 77.3 (SD: 8.90) and average number of PP defining categories was 2.99 (SD: 1.00). Number of hospital admissions and days of hospitalization decreased significantly after intervention: 1.52 (SD: 1.35) versus 0.82 (SD: 1.29), p<0.001, and 13.77 (SD: 15.20) versus 7.21 (SD: 12.90), p<0.001 respectively. 12-month mortality was 37.7%. PP who failed to receive a structured medical visit from the internal medicine physician and educational workshops from the team care nurses had a higher risk of exitus in the next 12 months, HR: 1.68; 95% CI: 1.15-2.46, p=0.007 and HR: 2.86; 95% CI: 1.92-4.27, p<0.001, respectively. CONCLUSIONS This multidisciplinary intervention reduced the risk of PP hospital admission and days of hospitalization. Educational workshop programs for PP and their caregivers and structured IM medical visits were associated with improvements of survival.
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Affiliation(s)
- Maria Dolores Nieto-Martín
- Internal Medicine Department, University Hospital Virgen del Rocío, Avd. Manuel Siurot, s/n, 41013 Seville, Spain.
| | - Laura De la Higuera-Vila
- Internal Medicine Department, Bidasoa Hospital, Barrio Mendelu s/n, 20280 Hondarribia, Guipúzcoa, Spain
| | - Maximo Bernabeu-Wittel
- Internal Medicine Department, University Hospital Virgen del Rocío, Avd. Manuel Siurot, s/n, 41013 Seville, Spain
| | | | - Eva Rocío Alfaro-Lara
- Andalusian Agency for Health Technology Assessment, Avda de la Innovación, Edificio ARENA 1, 41020 Seville, Spain
| | - Miguel Angel Barón-Ramos
- Internal Medicine Department, Hospital Serranía de Ronda, Carretera del Burgo, Km 1, 29400 Ronda, Málaga, Spain
| | | | - Reyes Aparicio-Santos
- Internal Medicine Department, Hospital San Juan De Dios del Aljarafe, Avd. San Juan de Dios s/n, 41930 Seville, Spain
| | - Manuel Ollero Baturone
- Internal Medicine Department, University Hospital Virgen del Rocío, Avd. Manuel Siurot, s/n, 41013 Seville, Spain
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