Patient and caregiver perspectives on care coordination during transitions of surgical care

Pharmacy Integrated Transitions (PIT) trial: a protocol for a pragmatic cluster-randomised crossover trial

INTRODUCTION

Ineffective coordination during care transitions from hospitals to skilled nursing facilities (SNFs) costs Medicare US$2.8-US$3.4 billion annually and results in avoidable adverse events. Approximately 70% of patients experience medication errors during these transitions, resulting in downstream consequences such as medication-related problems and unplanned readmissions. Patients and caregivers report significant emotional distress and concerns, particularly regarding medication management. Current protocols often fail to ensure effective medication management and communication between hospital and SNF teams. Developed with input from multiple interest holders, the Pharmacy Integrated Transitions (PIT) programme enhances these transitions by improving medication safety and communication. The programme includes a pharmacist who reconciles patients' medications during transitions from hospitals to SNFs, and a structured handoff between hospital and SNF clinical teams. A rigorous, pragmatic trial is needed to assess the programme's effectiveness in enhancing care transitions compared with standard practices.The PIT trial aims to evaluate the effectiveness of the PIT programme in improving patients' care transitions from hospitals to SNFs compared with usual care, and to characterise multiple interest holders' perspectives on its implementation fidelity, effectiveness and needed support for sustainment.

METHODS AND ANALYSIS

The PIT trial is a parallel cluster-randomised controlled crossover trial design, with randomisation occurring at the SNF cluster level. The trial is conducted across 4 hospitals and 14 independent SNFs in Washington State. SNFs are stratified by patient volume before being randomly assigned to either the PIT programme or usual care. The trial aims to include a diverse patient population transitioning from hospitals to SNFs. The primary outcome is medication-related problems within 30 days posthospital discharge. Clinical adverse events, readmission rates and emergency department visits will be compared. Additionally, we will conduct a mixed-methods summative evaluation to assess multiple interest holders' perspectives on the PIT programme's implementation fidelity, effectiveness and the support required for its sustainment.

ETHICS AND DISSEMINATION

This trial was approved by the University of Washington's Human Subjects Division on 9 September 2020 (STUDY00011018_PIT). The trial was reviewed by the University of Washington Institutional Review Board (IRB) and was issued a waiver of consent. The University of Washington serves as the IRB for all 14 of the Post Acute Care Skilled Nursing Facility study sites. Results from this trial will be published in peer-reviewed journals. Results may also be presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT05241951.

Inter-Specialty Communication for Older and High-Risk Surgical Patients: "A Huge Opportunity to Really Impact Our Patients' Care"

Older adults benefit from a multidisciplinary approach to perioperative care, with reductions in length of stay and postoperative readmission. To explore perioperative communication, we conducted in-depth, semi-structured interviews with anesthesia, surgery, and primary care providers caring for older patients in northern New England. Communication barriers included cumbersome health information exchange with system fragmentation across and within electronic health records resulting in clinician and administrative burden and unnecessary duplication of services. Clinicians expressed the value of preoperative communication across specialties but described a lack of timely communication with colleagues caring for shared patients and uncertainty about specialty roles and responsibilities. Preferences and use patterns of communication modalities varied across specialties, but the need for direct, secure communication linked to the patient chart was consistent. Clinicians emphasized the importance of communication for efficiency and patient safety and suggested strengthening perioperative care pathways through improvements in technological and organizational infrastructure and interprofessional relationships.

Synthesis of existing literature on the colorectal surgery patients' challenges during hospital-to-home transitions: a scoping review protocol

INTRODUCTION

Despite advances in innovation to improve patients' transition experiences, it is unclear-in the context of colorectal surgery-what elements of patient education and care could provide the greatest benefit to patient experiences and clinical outcomes. Thus, this scoping review protocol aims to outline a plan to synthesise the existing literature from countries with publicly funded health systems (ie, Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, the United Kingdom and the USA) on the challenges experienced by colorectal surgery patients' when transitioning home from the hospital.

METHODS AND ANALYSIS

This is a protocol for a scoping review to identify literature relating to adult patient challenges experienced when transitioning from hospital to home following colorectal surgery. We will search the following databases for studies published between 2012 and present: Ovid MEDLINE; Ovid Embase; Cochrane Database of Systematic Reviews (Ovid) and Cochrane Central Register of Controlled Trials (Ovid). Title, abstract and full-text review will be conducted independently by at least two reviewers. Data will be extracted, collated, summarised and reported numerically (eg, frequency counts) and presented using descriptive summaries. In addition, data related to the challenges reported by colorectal surgery patients during their transition home from the hospital will be descriptively analysed using deductive content analysis. The extracted challenges will be categorised according to the International Classification of Functioning, Disability and Health and the surgical transition trajectory (eg, predischarge, during discharge and postdischarge) to identify when in the patient journey is the best point to implement improved practices and achieve patient-centred care.

ETHICS AND DISSEMINATION

This protocol does not require ethics approval as data have not been collected or analysed. The findings will highlight insights into patient care transitions following colorectal surgery, which will be disseminated via publications and presentations.

Experiences with hospital-to-home transitions: perspectives from patients, family members and healthcare professionals. A systematic review and meta-synthesis of qualitative studies

PURPOSE

Multiple studies have explored the needs and experiences of patients, family members, and healthcare professionals regarding hospital-to-home transitions. Our study aimed to identify, critically appraise, and summarize these studies in a qualitative meta-synthesis.

MATERIALS AND METHODS

Medline, CINAHL and Embase were systematically searched to identify eligible articles from inception to June 2024. Qualitative studies were included and critically appraised using the Critical Appraisal Skills Program. Insufficient-quality papers were excluded. We performed a meta-synthesis following (1) open coding by two independent researchers and (2) discussing codes during reflexivity meetings.

RESULTS

Ninety-eight studies were appraised, of which 53 were included. We reached thematic saturation, four themes were constructed: (1) care coordination and continuity, (2) communication, (3) patient and family involvement, and (4) individualized support and information exchange. For patients and families, tailored information and support are prerequisites for a seamless transition and an optimal recovery trajectory after hospital discharge. It is imperative that healthcare professionals communicate effectively within and across care settings to ensure multidisciplinary collaboration and care continuity.

CONCLUSIONS

This study identifies essential elements of optimal transitional care. These findings could be supportive to researchers and healthcare professionals when (re)designing transitional care interventions to ensure care continuity after hospital discharge.

A qualitative study evaluating the discharge process for vascular surgery patients to identify significant themes for organizational improvement

OBJECTIVE

Transition from the hospital to an outpatient setting is a multifaceted process requiring coordination among a variety of services and providers to ensure a high-quality discharge. Vascular surgery patients comprise a complex population that experiences high unplanned readmission rates. We performed a qualitative study to identify themes for process improvement for vascular surgery patients. A validated discharge process, RED (Re-Engineered Discharge), was used to identify additional actionable themes to create a more efficient discharge process tailored specifically to the vascular surgery population.

METHODS

A prospective, qualitative analysis at a tertiary center using a semi-structured focus group interview guide was performed to evaluate the current discharge process and identify opportunities for improvement. Focus groups were Zoom recorded, transcribed into electronic text files, and were loaded into Dedoose qualitative software for analysis using a directed content analysis approach. Two researchers independently thematically coded each transcript, starting with accepted discharge components to identify new thematic categories. Prior to analysis, all redundancy of codes was resolved, and all team members agreed on text categorization and coding.

RESULTS

Eight focus groups with a total of 38 participants were conducted. Participants included physicians (n = 13), nursing/ancillary staff (n = 14), advanced nurse practitioners (n = 2), social worker/dietitian/pharmacist (n = 3), and patients (n = 6). Transcript analyses revealed facilitators and barriers to the discharge process. In addition to traditional RED components, unique concepts pertinent to vascular surgery patients included patient complexity, social determinants of health, technology literacy, complexity of ancillary services, discharge appropriateness, and use of advanced nurse practitioners for continuity.

CONCLUSIONS

Specific themes were identified to target and enhance the future vRED (vascular Re-Engineered Discharge) bundle. Thematic targets for improvement include increased planning, organization, and communication prior to discharge to address vascular surgery patients' multiple comorbidities, extensive medication lists, and need for complex ancillary services at the time of discharge. Other thematic barriers discovered to improve include provider awareness of patient health literacy, patient understanding of complex discharge instructions, patient technology barriers, and intrinsic social determinants of health in this population. To address these discovered barriers, organizational targets to improve include enhanced social support, the use of advanced nurse practitioners for education reinforcement, and increased coordination. These results provide a framework for future quality improvement targeting the vascular surgery discharge process.

Promoting Disposal of Left-Over Opioids After Surgery in Rural Communities: A Qualitative Description Study

BACKGROUND

Patients rarely dispose of left-over opioids after surgery. Disposal serves as a primary prevention against misuse, overdose, and diversion. However, current interventions promoting disposal have mixed efficacy. Increasing disposal in rural communities could prevent or reduce the harms caused by prescription opioids.

AIMS

Identify barriers and facilitators to disposal in the rural communities of the United States Mountain West region.

METHODS

We conducted a qualitative description study with 30 participants from Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. We used a phronetic iterative approach combining inductive content and thematic analysis with deductive interpretation through the Precaution Adoption Process Model (PAPM).

RESULTS

We identified four broad themes: (a) awareness, engagement, and education; (b) low perceived risk associated with nondisposal; (c) deciding to keep left-over opioids for future use; and (d) converting decisions into action. Most participants were aware of the importance of disposal but perceived the risks of nondisposal as low. Participants kept opioids for future use due to uncertainty about their recovery and future treatments, breakdowns in the patient-provider relationship, chronic illness or pain, or potential future injury. The rural context, particularly convenience, cost, and environmental contamination, contributes to decisional burden.

CONCLUSIONS

We identified PAPM stage-specific barriers to disposal of left-over opioids. Future interventions should account for where patients are along the spectrum of deciding to dispose or not dispose as well as promoting harm-reduction strategies for those who choose not to dispose.

Discharge process challenges of an academic vascular surgery service: A qualitative study

Vascular surgery patients have a high incidence of unplanned hospital readmissions and complications. Previous research has not fully examined specific elements of the hospital discharge process for vascular surgery patients to identify issues that may contribute to readmissions. The objective of this qualitative descriptive study was to explore challenges identified by healthcare providers and patients regarding the discharge process from an academic vascular surgery service. Data were collected from eight focus group interviews and analyzed for relevant themes. Patients and healthcare providers identified several challenges within the standard discharge process, including ineffective communication, insufficient time for discharge education, and limitations accessing providers with post-discharge concerns. These obstacles may be ameliorated in part by specialized coordinators, caregiver support, and use of adaptive strategies outside of the current discharge process. The discharge challenges described by study participants likely contribute to adverse post-hospitalization outcomes, including unplanned hospital readmissions. A multifaceted approach that incorporates standardized discharge processes, as well as informal problem-solving strategies, is recommended to improve hospital discharge and outcomes for vascular surgery patients.

Factors Influencing Patient Satisfaction With Care and Surgical Outcomes for Total Hip and Knee Replacement

INTRODUCTION

Although patient satisfaction with total joint arthroplasty has been a well-measured outcome, little is known about how preadmission and post-discharge care experiences affect patients' rating of satisfaction.

OBJECTIVE

This work aimed to identify actionable factors associated with better ratings of overall care and surgical results.

METHODS

A 36-item survey assessing care in the preoperative, perioperative, and post-discharge phases of care and across all phases was mailed to 7,031 patients who underwent primary unilateral elective total hip arthroplasty and total knee arthroplasty in 2018. Exploratory factor analysis identified 7 actionable domains. Stepwise logistic regression models identified domains associated with ratings of overall care and satisfaction with surgical outcome.

RESULTS

Of the 3,026 (43%) patients who returned the survey; 2,814 (93%) rated their overall experience of care as very good or excellent and satisfaction with surgical results as ≥ 7 on a 10-point scale. In exploratory factor analysis, four factors predicted higher ratings of both overall care and surgical outcome: knowing what to do with symptoms and pain during recovery (factor 1), self-reported health (factor 3), knowing what to expect before surgery (factor 4), and shared decision making (factor 6). Coordinated information among providers (factor 2), home health experience (factor 5), and patient-provider relationships (factor 7) also predicted overall care ratings.

CONCLUSION

Patient-centered quality improvement in total joint replacement care requires thinking of care across the entire episode, including before and after the hospital stay for surgery, in addition to perioperative care. The actionable factors identified from this study can be incorporated into total joint replacement care to improve patients' satisfaction with overall care and surgical results.

Barriers to the Delivery of Timely, Guideline-Adherent Adjuvant Therapy Among Patients With Head and Neck Cancer

PURPOSE

Delays initiating guideline-adherent postoperative radiation therapy (PORT) in head and neck squamous cell carcinoma (HNSCC) are common, contribute to excess mortality, and are a modifiable target for improving survival. However, the barriers that prevent the delivery of timely, guideline-adherent PORT remain unknown. This study aims to identify the multilevel barriers to timely, guideline-adherent PORT and organize them into a conceptual model.

MATERIALS AND METHODS

Semi-structured interviews with key informants were conducted with a purposive sample of patients with HNSCC and oncology providers across diverse practice settings until thematic saturation (n = 45). Thematic analysis was performed to identify the themes that explain barriers to timely PORT and to develop a conceptual model.

RESULTS

In all, 27 patients with HNSCC undergoing surgery and PORT were included, of whom 41% were African American, and 37% had surgery and PORT at different facilities. Eighteen clinicians representing a diverse mix of provider types from 7 oncology practices participated in key informant interviews. Five key themes representing barriers to timely PORT were identified across 5 health care delivery levels: (1) inadequate education about timely PORT, (2) postsurgical sequelae that interrupt the tight treatment timeline (both intrapersonal level), (3) insufficient coordination and communication during care transitions (interpersonal and health care team levels), (4) fragmentation of care across health care organizations (organizational level), and (5) travel burden for socioeconomically disadvantaged patients (community level).

CONCLUSION

This study provides a novel description of the multilevel barriers that contribute to delayed PORT. Interventions targeting these multilevel barriers could improve the delivery of timely, guideline-adherent PORT and decrease mortality for patients with HNSCC.

Measurement of nonbillable service value activities by nurse practitioners, physician assistants, and clinical nurse specialists in ambulatory specialty care

BACKGROUND

Revenue-generating health care activities, generally accepted as a measure of productivity, do not account for the full range of health care activities that enhance patient care.

PURPOSE

We analyzed the quantity, duration, and type of "service value activities" performed by nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs), which are nonbillable service activities that contribute to billable service provision, quality of care, and value of care.

METHODS

Data were obtained from ambulatory specialties at one health care institution over a 13-month period. First, descriptive statistics were calculated by time-based code for each category of provider (medical, surgical, transplant, hematology/oncology, and anesthesia). Then qualitative comments were analyzed for frequency of key words.

RESULTS

Each provider spent an estimated average of between 3.7 and 36.5 hours per month on service value activities, with the greatest number of these activities related to orders, chart review, and documentation.

IMPLICATIONS FOR PRACTICE

More thorough exploration of the quantity and type of service value activities performed may lead to a better understanding of the role and contribution of NPs, PAs, CNSs, and other health care professionals to patient care.