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Knees M, Keniston A, Yu A, Sakumoto M, Westergaard S, Schwatka N, Peterson R, Kochar A, Auerbach A, Lee T, Burden M. Academic hospitalist perspectives on the benefits and challenges of secure messaging: A mixed methods analysis. J Hosp Med 2024. [PMID: 39358988 DOI: 10.1002/jhm.13522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 09/13/2024] [Accepted: 09/19/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND Hospitals and patients rely on effective clinician communication. Asynchronous electronic secure messaging (SM) systems are a common way for hospitalists to communicate, but few studies have evaluated how hospitalists are navigating the adoption of SM and the benefits and challenges they are encountering. OBJECTIVES The objective of this study is to assess academic hospitalist perspectives on SM to guide future research and quality improvement initiatives. METHODS This was a mixed methods study utilizing an embedded REDCap survey and six virtual semistructured focus groups. It took place during a Hospital Medicine ReEngineering Network Zoom meeting on October 13, 2023. Rapid qualitative methods were used to define major themes. RESULTS There were 28 hospitalists and one patient representative across 24 separate academic institutions. There was a 71% survey completion rate (N = 20). SM was felt to be an effective and efficient communication modality but was associated with a large amount of multitasking and interruptions. Perspectives around SM clustered around three main themes: SM has been widely but variably adopted; there is a lack of institutional guidance about how to best engage with SM; and SM is changing the landscape of hospitalist work by increasing ease but decreasing depth of communication, increasing cognitive load, and changing interpersonal relationships. Recommendations for SM improvements included the need for institutions to work with frontline workers to develop and implement clear usage guidelines. CONCLUSION SM is likely contributing to both positive and negative effects for clinicians and patients. Understanding hospitalist perspectives on SM will help guide future research and quality improvement initiatives.
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Affiliation(s)
- Michelle Knees
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angela Keniston
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy Yu
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Matthew Sakumoto
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sara Westergaard
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Natalie Schwatka
- Department of Environmental and Occupational Health, Colorado School of Public Health, Center for Health, Work and Environment, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rachel Peterson
- Department of Medicine, Division of Hospital Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Aveena Kochar
- Department of Medicine, Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew Auerbach
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Tiffany Lee
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Marisha Burden
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Burden M, Astik G, Auerbach A, Bowling G, Kangelaris KN, Keniston A, Kochar A, Leykum LK, Linker AS, Sakumoto M, Rogers K, Schwatka N, Westergaard S. Identifying and Measuring Administrative Harms Experienced by Hospitalists and Administrative Leaders. JAMA Intern Med 2024; 184:1014-1023. [PMID: 38913371 PMCID: PMC11197021 DOI: 10.1001/jamainternmed.2024.1890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/25/2024] [Indexed: 06/25/2024]
Abstract
Importance Administrative harm (AH), defined as the adverse consequences of administrative decisions within health care that impact work structure, processes, and programs, is pervasive in medicine, yet poorly understood and described. Objective To explore common AHs experienced by hospitalist clinicians and administrative leaders, understand the challenges that exist in identifying and measuring AH, and identify potential approaches to mitigate AH. Design, Setting, and Participants A qualitative study using a mixed-methods approach with a 12-question survey and semistructured virtual focus groups was held on June 13 and August 11, 2023. Rapid qualitative methods including templated summaries and matrix analysis were applied. The participants included 2 consortiums comprising hospitalist clinicians, researchers, administrative leaders, and members of a patient and family advisory council. Main Outcomes and Measures Quantitative data from the survey on specific aspects of experiences related to AH were collected. Focus groups were conducted using a semistructured focus group guide. Themes and subthemes were identified. Results Forty-one individuals from 32 different organizations participated in the focus groups, with 32 participants (78%) responding to a brief survey. Survey participants included physicians (91%), administrative professionals (6%), an advanced practice clinician (3%), and those in leadership roles (44%), with participants able to select more than one role. Only 6% of participants were familiar with the term administrative harm to a great extent, 100% felt that collaboration between administrators and clinicians is crucial for reducing AH, and 81% had personally participated in a decision that led to AH to some degree. Three main themes were identified: (1) AH is pervasive and comes from all levels of leadership, and the phenomenon was felt to be widespread and arose from multiple sources within health care systems; (2) organizations lack mechanisms for identification, measurement, and feedback, and these challenges stem from a lack of psychological safety, workplace cultures, and ambiguity in who owns a decision; and (3) organizational pressures were recognized as contributors to AHs. Many ideas were proposed as solutions. Conclusions and Relevance The findings of this study suggest that AH is widespread with wide-reaching impact, yet organizations do not have mechanisms to identify or address it.
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Affiliation(s)
- Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora
| | - Gopi Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California, San Francisco
| | - Greg Bowling
- Division of Hospital Medicine, University of Texas Health, San Antonio
| | | | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora
| | - Aveena Kochar
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Luci K. Leykum
- Medicine Service, South Texas Veterans Health Care System, Department of Veterans Affairs, San Antonio
- Department of Medicine, Dell Medical School, The University of Texas at Austin
| | - Anne S. Linker
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Matthew Sakumoto
- Division of Hospital Medicine, University of California, San Francisco
| | - Kendall Rogers
- Division of Hospital Medicine, University of New Mexico, Albuquerque
| | - Natalie Schwatka
- Center for Health, Work & Environment, Department of Environmental & Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Sara Westergaard
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison
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Badawy J, Sakumoto M, Murphy E, Schmit D, Davis C, Segon A, Auerbach A, Burden M. Breaking barriers, building faculty: A qualitative analysis to exploring faculty development in academic hospital medicine. J Hosp Med 2024; 19:787-793. [PMID: 38751331 DOI: 10.1002/jhm.13406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/20/2024] [Accepted: 04/30/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Hospital medicine (HM) continues to be primarily composed of junior hospitalists and research has highlighted a paucity of mentors and academic output. Faculty advancement programs have been identified as a means to support junior hospitalists in their career trajectories and to advance the field. The optimal approach to supporting faculty development (FD) efforts is not known. OBJECTIVE To understand hospitalist groups' approaches to FD, including efforts that were perceived to be effective, and to identify barriers as well as potential future directions for FD. DESIGN Rapid qualitative methods were utilized including templated summaries and matrix analysis to identify major themes. SETTING AND PARTICIPANTS Virtual focus groups with hospitalists in the Hospital Medicine Reengineering Network (HOMERuN). MAIN OUTCOME AND MEASURES Qualitative themes. RESULTS Nineteen individuals from 17 unique institutions from across the United States in May 2022 participated in seven focus groups. Four key themes emerged from the study and included (1) academic hospitalist programs face multifaceted challenges and barriers to FD in HM, (2) groups have embraced a diversity of structures and frameworks, (3) due to clinical volumes, FD programs have had to adapt and evolve to meet FD needs, and (4) participants identified multiple areas for improvement, including defining tangible outcomes of FD programs and creating a repository of FD material which can be shared widely.
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Affiliation(s)
- Jack Badawy
- Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Matthew Sakumoto
- Division of Hospital Medicine, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Murphy
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - David Schmit
- Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Christine Davis
- Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Ankur Segon
- Division of Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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4
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Sakumoto M, Knees M, Rogers K, Segon A, Westergaard S, Yu A, Keniston A, Burden M. Virtual hospital care development and deployment: A rapid qualitative study of frontline clinicians and leaders. J Hosp Med 2024; 19:685-692. [PMID: 38664935 DOI: 10.1002/jhm.13380] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND Virtual hospitalist programs are rapidly growing in popularity due to worsening clinician shortages and increased pressure for flexible work options. These programs also have the potential to establish sustainable staffing models across multiple hospitals optimizing cost. We aimed to explore the current state of virtual hospitalist services at various health systems, challenges and opportunities that exist in providing virtual care, and future opportunities for these types of services. OBJECTIVES To identify perspectives on design and implementation of virtual hospitalist programs from academic hospitalist leaders. METHODS We conducted focus groups with United States academic hospitalist leaders. Semistructured interviews explored experiences with virtual hospitalist programs. Using rapid qualitative methods including templated summaries and matrix analysis, focus group recordings were analyzed to identify key themes. RESULTS We conducted four focus groups with 13 participants representing nine hospital systems across six geographic regions and range of experience with virtual hospital medicine care. Thematic analysis identified three themes: (1) a broad spectrum of virtual care delivery; (2) adoption and acceptance of virtual care models followed the stages of diffusion of innovation; and (3) sustainability and scalability of programs were affected by unclear finances. CONCLUSIONS Hospitalist leader perspectives revealed complex factors influencing virtual care adoption and implementation. Addressing concerns about care quality, financing, and training may accelerate adoption. Further research should clarify the best practices for sustainable models optimized for access, hospitalist experience, patient safety, and financial viability.
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Affiliation(s)
| | - Michelle Knees
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kendall Rogers
- Division of Hospital Medicine, University of New Mexico Health Sciences Center, Albuquerque, Mexico, USA
| | - Ankur Segon
- Division of Hospital Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Sara Westergaard
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Amy Yu
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Linker AS, Astik GJ, Bowling G, Kangelaris KN, Kara A, Keniston A, Kulkarni SA, Sakumoto M, Schwatka N, Westergaard S, Leykum LK, Auerbach A, Burden M. Collaborative research: The power of multiorganizational affinity groups and adaptive research methods. J Hosp Med 2024. [PMID: 38862414 DOI: 10.1002/jhm.13424] [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: 01/28/2024] [Revised: 05/13/2024] [Accepted: 05/19/2024] [Indexed: 06/13/2024]
Affiliation(s)
- Anne S Linker
- Division of Hospital Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Gopi J Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Kirsten N Kangelaris
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Areeba Kara
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Shradha A Kulkarni
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Matthew Sakumoto
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Natalie Schwatka
- Center for Health, Work & Environment, Department of Environmental & Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sara Westergaard
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Luci K Leykum
- Department of Veterans Affairs, South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA
- Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Westergaard S, Bowden K, Astik GJ, Bowling G, Keniston A, Linker A, Sakumoto M, Schwatka N, Auerbach A, Burden M. Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study. J Hosp Med 2024; 19:486-494. [PMID: 38598752 DOI: 10.1002/jhm.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit. OBJECTIVE To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization. DESIGN, SETTING AND PARTICIPANTS We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups. RESULTS Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction. CONCLUSIONS Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse.
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Affiliation(s)
- Sara Westergaard
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kasey Bowden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Gopi J Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Greg Bowling
- University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anne Linker
- Division of Hospital Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Matthew Sakumoto
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Natalie Schwatka
- Center for Health, Work & Environment, Department of Environmental & Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Nguyen KT, Lee TM, Mueller SK. Multi-Institution Survey of Accepting Physicians' Perception of Appropriate Reasons for Interhospital Transfer: A Mixed-Methods Evaluation. J Patient Saf 2024; 20:216-221. [PMID: 38345409 DOI: 10.1097/pts.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
OBJECTIVES There is a lack of evidence-based guidelines to direct best practices in interhospital transfers (IHTs). We aimed to identify frontline physicians' current and ideal reasons for accepting IHT patients to inform future IHT research and guidelines. METHODS We conducted a cross-sectional survey of hospitalist physicians across 11 geographically diverse hospitals. The survey asked respondents how frequently they currently consider and should consider various factors when triaging IHT requests. Responses were dichotomized into "highly considered" and "less considered" factors. Frequencies of the "highly considered" factors (current and ideal) were analyzed. Write-in responses were coded into themes within a priori domains in a qualitative analysis. RESULTS Of the 666 hospitalists surveyed, 238 (36%) responded. Respondents most frequently identified the need for specialty procedural and nonprocedural care and bed capacity as factors that should be considered when triaging IHT patients in current and ideal practice, whereas the least frequently considered factors were COVID-related care, insurance/financial considerations, and patient/family preference. More experienced respondents considered patient/family preference more frequently in current and ideal practice compared with less experienced respondents (33% versus 11% [ P = 0.0001] and 26% versus 9% [ P = 0.01], respectively). Qualitative analysis identified several themes in the domains of Criteria for Acceptance, Threshold for Acceptance, and Indications for Physician-to-Physician Communication. CONCLUSIONS This geographically diverse sample of hospitalist physicians responsible for accepting IHT patients showed general agreement between primary factors that are currently and that should be considered for IHT acceptance, with greatest weight placed on patients' need for specialty care.
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Affiliation(s)
- Khanh T Nguyen
- From the Section of Hospital Medicine, University of Chicago, Chicago, Illinois
| | - Tiffany M Lee
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California
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Dalal AK, Schnipper JL, Raffel K, Ranji S, Lee T, Auerbach A. Identifying and classifying diagnostic errors in acute care across hospitals: Early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study. J Hosp Med 2024; 19:140-145. [PMID: 37211760 DOI: 10.1002/jhm.13136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/23/2023]
Affiliation(s)
- Anuj K Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katie Raffel
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Sumant Ranji
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
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Auerbach AD, Lee TM, Hubbard CC, Ranji SR, Raffel K, Valdes G, Boscardin J, Dalal AK, Harris A, Flynn E, Schnipper JL. Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care. JAMA Intern Med 2024; 184:164-173. [PMID: 38190122 PMCID: PMC10775080 DOI: 10.1001/jamainternmed.2023.7347] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/07/2023] [Indexed: 01/09/2024]
Abstract
Importance Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients. Objective To determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalized adults transferred to an intensive care unit (ICU) or who died. Design, Setting, and Participants Retrospective cohort study conducted at 29 academic medical centers in the US in a random sample of adults hospitalized with general medical conditions and who were transferred to an ICU, died, or both from January 1 to December 31, 2019. Each record was reviewed by 2 trained clinicians to determine whether a diagnostic error occurred (ie, missed or delayed diagnosis), identify diagnostic process faults, and classify harms. Multivariable models estimated association between process faults and diagnostic error. Opportunity for diagnostic error reduction associated with each fault was estimated using the adjusted proportion attributable fraction (aPAF). Data analysis was performed from April through September 2023. Main Outcomes and Measures Whether or not a diagnostic error took place, the frequency of underlying causes of errors, and harms associated with those errors. Results Of 2428 patient records at 29 hospitals that underwent review (mean [SD] patient age, 63.9 [17.0] years; 1107 [45.6%] female and 1321 male individuals [54.4%]), 550 patients (23.0%; 95% CI, 20.9%-25.3%) had experienced a diagnostic error. Errors were judged to have contributed to temporary harm, permanent harm, or death in 436 patients (17.8%; 95% CI, 15.9%-19.8%); among the 1863 patients who died, diagnostic error was judged to have contributed to death in 121 (6.6%; 95% CI, 5.3%-8.2%). In multivariable models examining process faults associated with any diagnostic error, patient assessment problems (aPAF, 21.4%; 95% CI, 16.4%-26.4%) and problems with test ordering and interpretation (aPAF, 19.9%; 95% CI, 14.7%-25.1%) had the highest opportunity to reduce diagnostic errors; similar ranking was seen in multivariable models examining harmful diagnostic errors. Conclusions and Relevance In this cohort study, diagnostic errors in hospitalized adults who died or were transferred to the ICU were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.
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Affiliation(s)
- Andrew D. Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Tiffany M. Lee
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Colin C. Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Sumant R. Ranji
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Katie Raffel
- Department of Medicine, University of Colorado School of Medicine, Denver
| | - Gilmer Valdes
- Department of Radiation Oncology, University of California San Francisco
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California San Francisco
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | | | | | - Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
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Kulkarni SA, Wachter RM. The Hospitalist Movement 25 Years Later. Annu Rev Med 2024; 75:381-390. [PMID: 37802086 DOI: 10.1146/annurev-med-051022-043301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Hospitalists are generalists who specialize in the care of hospitalized patients. In the 25 years since the term hospitalist was coined, the field of hospital medicine has grown exponentially and established a substantial footprint in the medical community. There are now more hospitalists than practicing physicians in any other internal medicine subspecialty. Several key forces catalyzed the growth in the field of hospital medicine, including the quality, safety, and value movements; residency duty hour restrictions; the emergence of electronic health records; and the COVID-19 pandemic. Looking ahead, we see new opportunities in the realms of technology and telemedicine, and challenges persist in regard to balancing financial considerations with increasing workload and burnout. Hospitalists must remain nimble and seize emerging opportunities to continue supporting the field's prominence and growth.
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Affiliation(s)
- Shradha A Kulkarni
- Department of Medicine, University of California, San Francisco, California, USA; ,
| | - Robert M Wachter
- Department of Medicine, University of California, San Francisco, California, USA; ,
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11
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Mueller SK, Garabedian P, Goralnick E, Bates DW, Samal L. Advancing health information during interhospital transfer: An interrupted time series. J Hosp Med 2023; 18:1063-1071. [PMID: 37846028 DOI: 10.1002/jhm.13221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Although the transfer of patients between acute care hospitals (interhospital transfer, IHT) is common, health information exchange (HIE) during IHT remains inadequate, with fragmented communication and unreliable access to clinical information. This study aims to design, implement, and rigorously evaluate the implementation of a HIE platform to improve data access during IHT. METHODS AND ANALYSIS Study subjects include patients aged >18 transferred to the medical, cardiology, oncology, or intensive care unit (ICU) services at an 800-bed quaternary care hospital; and healthcare workers involved in their care. The first aim of this study is to optimize clinician workflow, data visualization, and interoperability through user-centered design sessions for HIE platform development. The second aim is to evaluate the impact of the intervention on clinician-reported medical errors among 500 pre- and 500 postintervention IHT patients using interrupted time series methodology, adjusting for confounding variables and temporal trends. The third aim is to evaluate intervention fidelity, use and perceived usability of the platform, and barriers and facilitators of implementation from interprofessional stakeholder input, using mixed-methods evaluation. The fourth aim is to consolidate key findings to create a toolkit for spread and sustainability. ETHICS AND DISSEMINATION We will track patient safety endpoints and clinician workflow burdens and ensure the protection of patient data throughout the study. We will disseminate our findings via the creation of a toolkit for spread and sustainability, partnering with our funder (AHRQ) for dissemination, and communicating our results via abstracts and publications.
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Affiliation(s)
- Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Eric Goralnick
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lipika Samal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Prusaczyk B, Burke RE. It's time for the field of geriatrics to invest in implementation science. BMJ Qual Saf 2023; 32:700-703. [PMID: 37479476 DOI: 10.1136/bmjqs-2023-016263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Beth Prusaczyk
- Department of Medicine, Division of General Medical Sciences, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Institute for Informatics, Data Science, and Biostatistics, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Divisions of General Internal Medicine and Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Schnipper JL, Raffel KE, Keniston A, Burden M, Glasheen J, Ranji S, Hubbard C, Barish P, Kantor M, Adler-Milstein J, Boscardin WJ, Harrison JD, Dalal AK, Lee T, Auerbach A. Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: A multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients. J Hosp Med 2023; 18:1072-1081. [PMID: 37888951 PMCID: PMC10964432 DOI: 10.1002/jhm.13230] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/29/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Few hospitals have built surveillance for diagnostic errors into usual care or used comparative quantitative and qualitative data to understand their diagnostic processes and implement interventions designed to reduce these errors. OBJECTIVES To build surveillance for diagnostic errors into usual care, benchmark diagnostic performance across sites, pilot test interventions, and evaluate the program's impact on diagnostic error rates. METHODS AND ANALYSIS Achieving diagnostic excellence through prevention and teamwork (ADEPT) is a multicenter, real-world quality and safety program utilizing interrupted time-series techniques to evaluate outcomes. Study subjects will be a randomly sampled population of medical patients hospitalized at 16 US hospitals who died, were transferred to intensive care, or had a rapid response during the hospitalization. Surveillance for diagnostic errors will occur on 10 events per month per site using a previously established two-person adjudication process. Concurrent reviews of patients who had a qualifying event in the previous week will allow for surveys of clinicians to better understand contributors to diagnostic error, or conversely, examples of diagnostic excellence, which cannot be gleaned from medical record review alone. With guidance from national experts in quality and safety, sites will report and benchmark diagnostic error rates, share lessons regarding underlying causes, and design, implement, and pilot test interventions using both Safety I and Safety II approaches aimed at patients, providers, and health systems. Safety II approaches will focus on cases where diagnostic error did not occur, applying theories of how people and systems are able to succeed under varying conditions. The primary outcome will be the number of diagnostic errors per patient, using segmented multivariable regression to evaluate change in y-intercept and change in slope after initiation of the program. ETHICS AND DISSEMINATION The study has been approved by the University of California, San Francisco Institutional Review Board (IRB), which is serving as the single IRB. Intervention toolkits and study findings will be disseminated through partners including Vizient, The Joint Commission, and Press-Ganey, and through national meetings, scientific journals, and publications aimed at the general public.
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Affiliation(s)
- Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Katie E. Raffel
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Institute for Healthcare Quality, Safety, and Efficiency, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angela Keniston
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marisha Burden
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jeffrey Glasheen
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Institute for Healthcare Quality, Safety, and Efficiency, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumant Ranji
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Colin Hubbard
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
| | - Peter Barish
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
| | - Molly Kantor
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
| | - Julia Adler-Milstein
- Center for Clinical Informatics and Improvement Research (CLIIR), University of California, San Francisco, California, USA
| | - W. John Boscardin
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - James D. Harrison
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tiffany Lee
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
| | - Andrew Auerbach
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
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14
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Busch JI, Keniston A, Astik GJ, Auerbach A, Kangelaris KN, Kulkarni SA, Leykum LK, Linker AS, Nieto K, Pierce RG, Sakumoto M, Burden M. Exploring the Impact of COVID-19 on Women Hospitalists: A Mixed-Gender Qualitative Analysis. J Gen Intern Med 2023; 38:3180-3187. [PMID: 37653202 PMCID: PMC10651559 DOI: 10.1007/s11606-023-08371-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 08/04/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Women physicians have faced persistent challenges, including gender bias, salary inequities, a disproportionate share of caregiving and domestic responsibilities, and limited representation in leadership. Data indicate the COVID-19 pandemic further highlighted and exacerbated these inequities. OBJECTIVE To understand the pandemic's impact on women physicians and to brainstorm solutions to better support women physicians. DESIGN Mixed-gender semi-structured focus groups. PARTICIPANTS Hospitalists in the Hospital Medicine Reengineering Network (HOMERuN). APPROACH Six semi-structured virtual focus groups were held with 22 individuals from 13 institutions comprised primarily of academic hospitalist physicians. Rapid qualitative methods including templated summaries and matrix analysis were applied to identify major themes and subthemes. KEY RESULTS Four key themes emerged: (1) the pandemic exacerbated perceived gender inequities, (2) women's academic productivity and career development were negatively impacted, (3) women held disproportionate roles as caregivers and household managers, and (4) institutional pandemic responses were often misaligned with workforce needs, especially those of women hospitalists. Multiple interventions were proposed including: creating targeted workforce solutions and benefits to address the disproportionate caregiving burden placed on women, addressing hospitalist scheduling and leave practices, ensuring promotion pathways value clinical and COVID-19 contributions, creating transparency around salary and non-clinical time allocation, and ensuring women are better represented in leadership roles. CONCLUSIONS Hospitalists perceived and experienced that women physicians faced negative impacts from the pandemic in multiple domains including leadership opportunities and scholarship, while also shouldering larger caregiving duties than men. There are many opportunities to improve workplace conditions for women; however, current institutional efforts were perceived as misaligned to actual needs. Thus, policy and programmatic changes, such as those proposed by this cohort of hospitalists, are needed to advance equity in the workplace.
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Affiliation(s)
- Johanna I Busch
- Division of Hospital Medicine, Dell Medical School, The University of Texas at Austin, 1500 Red River Street, Austin, TX, 78701, USA.
| | | | - Gopi J Astik
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew Auerbach
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Kirsten N Kangelaris
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Shradha A Kulkarni
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Luci K Leykum
- Division of Hospital Medicine, Dell Medical School, The University of Texas at Austin, 1500 Red River Street, Austin, TX, 78701, USA
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Anne S Linker
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kirsten Nieto
- Division of Hospital Medicine, Dell Medical School, The University of Texas at Austin, 1500 Red River Street, Austin, TX, 78701, USA
| | | | - Matthew Sakumoto
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Marisha Burden
- University of Colorado School of Medicine, Aurora, CO, USA
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15
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Murphy EA, White K, Meltzer D, Martin SK. Developing hospitalist educators when teaching time is scarce: The Passport model as a professional development approach. J Hosp Med 2023; 18:860-864. [PMID: 36635876 DOI: 10.1002/jhm.13042] [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: 09/26/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Elizabeth A Murphy
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Kara White
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - David Meltzer
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Shannon K Martin
- Department of Medicine, Section of Hospital Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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16
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Auerbach AD, Astik GJ, O'Leary KJ, Barish PN, Kantor MA, Raffel KR, Ranji SR, Mueller SK, Burney SN, Galinsky J, Gershanik EF, Goyal A, Chitneni PR, Rastegar S, Esmaili AM, Fenton C, Virapongse A, Ngov LK, Burden M, Keniston A, Patel H, Gupta AB, Rohde J, Marr R, Greysen SR, Fang M, Shah P, Mao F, Kaiksow F, Sterken D, Choi JJ, Contractor J, Karwa A, Chia D, Lee T, Hubbard CC, Maselli J, Dalal AK, Schnipper JL. Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19. J Gen Intern Med 2023; 38:1902-1910. [PMID: 36952085 PMCID: PMC10035474 DOI: 10.1007/s11606-023-08176-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN Retrospective cohort. SETTING Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.
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Affiliation(s)
- Andrew D Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Gopi J Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter N Barish
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Molly A Kantor
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Katie R Raffel
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sumant R Ranji
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Stephanie K Mueller
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | | | | | - Esteban F Gershanik
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Abhishek Goyal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pooja R Chitneni
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | | | - Armond M Esmaili
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Cynthia Fenton
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Anunta Virapongse
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Li-Kheng Ngov
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marisha Burden
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Angela Keniston
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hemali Patel
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ashwin B Gupta
- Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jeff Rohde
- Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ruby Marr
- Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - S Ryan Greysen
- Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michele Fang
- Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pranav Shah
- Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances Mao
- Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Farah Kaiksow
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, WI, Madison, USA
| | - David Sterken
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, WI, Madison, USA
| | - Justin J Choi
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jigar Contractor
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Abhishek Karwa
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - David Chia
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Tiffany Lee
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Colin C Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Judith Maselli
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Anuj K Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
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17
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Linker AS, Jones CD, Ruhnke GW. Can we build the plane while flying? Creative approaches to expand the research community in hospital medicine. J Hosp Med 2023. [PMID: 37129425 DOI: 10.1002/jhm.13115] [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: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/03/2023]
Affiliation(s)
- Anne S Linker
- Icahn School of Medicine at Mount Sinai, Division of Hospital Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Christine D Jones
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Division of Geriatrics and Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Gregory W Ruhnke
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, Illinois, USA
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18
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Kulkarni SA, Keniston A, Linker AS, Astik GJ, Kangelaris KN, Leykum LK, Sakumoto M, Auerbach A, Burden M. Building a thriving academic hospitalist workforce: A rapid qualitative analysis identifying key areas of focus in the field. J Hosp Med 2023; 18:329-336. [PMID: 36876949 DOI: 10.1002/jhm.13074] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/14/2023] [Accepted: 02/20/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND The hospitalist workforce has been at the forefront of the pandemic and has been stretched in both clinical and nonclinical domains. We aimed to understand current and future workforce concerns, as well as strategies to cultivate a thriving hospital medicine workforce. DESIGN, SETTING, AND PARTICIPANTS We conducted qualitative, semistructured focus groups with practicing hospitalists via video conferencing (Zoom). Utilizing components from the Brainwriting Premortem Approach, attendees were split into small focus groups and listed their thoughts about workforce issues that hospitalists may encounter in the next 3 years, identifying the highest priority workforce issues for the hospital medicine community. Each small group discussed the most pressing workforce issues. These ideas were then shared across the entire group and ranked. We used rapid qualitative analysis to guide a structured exploration of themes and subthemes. RESULTS Five focus groups were held with 18 participants from 13 academic institutions. We identified five key areas: (1) support for workforce wellness; (2) staffing and pipeline development to maintain an adequate workforce to match clinical growth; (3) scope of work, including how hospitalist work is defined and whether the clinical skillset should be expanded; (4) commitment to the academic mission in the setting of rapid and unpredictable clinical growth; and (5) alignment between the duties of hospitalists and resources of hospitals. Hospitalists voiced numerous concerns about the future of our workforce. Several domains were identified as high-priority areas of focus to address current and future challenges.
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Affiliation(s)
- Shradha A Kulkarni
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anne S Linker
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, Division of Hospital Medicine, New York, New York, USA
| | - Gopi J Astik
- Northwestern University Feinberg School of Medicine, Division of Hospital Medicine, Chicago, Illinois, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Luci K Leykum
- Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
- South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Matthew Sakumoto
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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19
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Murphy E, Chokshi K, Niranjan-Azadi A, Schram A, Clements J, Pasha O, Mueller S. Looking Back While Thinking Forward: Institutional Best Practices to Address Hospitalist Well-being During COVID-19. J Gen Intern Med 2023; 38:1326-1328. [PMID: 36759441 PMCID: PMC9910768 DOI: 10.1007/s11606-023-08073-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Affiliation(s)
- Elizabeth Murphy
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA.
| | - Krishna Chokshi
- Department of Medicine, Division of Hospital Medicine, Mount Sinai School of Medicine, Mew York, NY, USA
| | - Ashwini Niranjan-Azadi
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Andrew Schram
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | - James Clements
- Department of Medicine, Division of Hospital Medicine, Oregon Health Sciences Univeristy, Portland, OR, USA
| | - Omrana Pasha
- Department of Medicine, Division of Hospital Medicine, Penn State Health, Hershey, PA, USA
| | - Stephanie Mueller
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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20
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Practical Applications of Rapid Qualitative Analysis for Operations, Quality Improvement, and Research in Dynamically Changing Hospital Environments. Jt Comm J Qual Patient Saf 2023; 49:98-104. [PMID: 36585315 DOI: 10.1016/j.jcjq.2022.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Health care systems are in a constant state of change. As such, methods to quickly acquire and analyze data are essential to effectively evaluate current processes and improvement projects. Rapid qualitative analysis offers an expeditious approach to evaluate complex, dynamic, and time-sensitive issues. METHODS We used rapid data acquisition and qualitative methods to assess six real-world problems the hospitalist field faced during the COVID-19 pandemic. We iteratively modified and applied a six-step framework for conducting rapid qualitative analysis, including determining if rapid methods are appropriate, creating a team, selecting a data collection approach, data analysis, and synthesis and dissemination. Virtual platforms were used for focus groups and interviews; templated summaries and matrix analyses were then applied to allow for rapid qualitative analyses. RESULTS We conducted six projects using rapid data acquisition and rapid qualitative analysis from December 4, 2020, to January 14, 2022, each of which included 23 to 33 participants. One project involved participants from a single institution; the remainder included participants from 15 to 24 institutions. These projects led to the refinement of an adapted rapid qualitative method for evaluation of hospitalist-driven operational, research, and quality improvement efforts. We describe how we used these methods and disseminated our results. We also discuss situations for which rapid qualitative methods are well-suited and strengths and weaknesses of the methods. CONCLUSION Rapid qualitative methods paired with rapid data acquisition can be employed for prompt turnaround assessments of quality, operational, and research projects in complex health care environments. Although rapid qualitative analysis is not meant to replace more traditional qualitative methods, it may be appropriate in certain situations. Application of a framework to guide projects using a rapid qualitative approach can help provide structure to the analysis and instill confidence in the findings.
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21
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Keniston A, Sakumoto M, Astik GJ, Auerbach A, Eid SM, Kangelaris KN, Kulkarni SA, Lee T, Leykum LK, Linker AS, Worster DT, Burden M. Adaptability on Shifting Ground: a Rapid Qualitative Assessment of Multi-institutional Inpatient Surge Planning and Workforce Deployment During the COVID-19 Pandemic. J Gen Intern Med 2022; 37:3956-3964. [PMID: 35319085 PMCID: PMC8939495 DOI: 10.1007/s11606-022-07480-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND During the initial wave of COVID-19 hospitalizations, care delivery and workforce adaptations were rapidly implemented. In response to subsequent surges of patients, institutions have deployed, modified, and/or discontinued their workforce plans. OBJECTIVE Using rapid qualitative methods, we sought to explore hospitalists' experiences with workforce deployment, types of clinicians deployed, and challenges encountered with subsequent iterations of surge planning during the COVID-19 pandemic across a collaborative of hospital medicine groups. APPROACH Using rapid qualitative methods, focus groups were conducted in partnership with the Hospital Medicine Reengineering Network (HOMERuN). We interviewed physicians, advanced practice providers (APP), and physician researchers about (1) ongoing adaptations to the workforce as a result of the COVID-19 pandemic, (2) current struggles with workforce planning, and (3) evolution of workforce planning. KEY RESULTS We conducted five focus groups with 33 individuals from 24 institutions, representing 52% of HOMERuN sites. A variety of adaptations was described by participants, some common across institutions and others specific to the institution's location and context. Adaptations implemented shifted from the first waves of COVID patients to subsequent waves. Three global themes also emerged: (1) adaptability and comfort with dynamic change, (2) the importance of the unique hospitalist skillset for effective surge planning and redeployment, and (3) the lack of universal solutions. CONCLUSIONS Hospital workforce adaptations to the COVID pandemic continued to evolve. While few approaches were universally effective in managing surges of patients, and successful adaptations were highly context dependent, the ability to navigate a complex system, adaptability, and comfort in a chaotic, dynamic environment were themes considered most critical to successful surge management. However, resource constraints and sustained high workload levels raised issues of burnout.
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Affiliation(s)
- Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, 12401 E. 17th Avenue, Mail Stop F782, Aurora, CO, 80045, USA.
| | - Matthew Sakumoto
- Division of General Internal Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Gopi J Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew Auerbach
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Shaker M Eid
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Shradha A Kulkarni
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Tiffany Lee
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Luci K Leykum
- The University of Texas at Austin, Dell Medical School, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Anne S Linker
- Division of Hospital Medicine, Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Devin T Worster
- Section of Hospital Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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22
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Walters JK, Sharma A, Harrison R. Driving Efficiency Improvement (EI): Exploratory Analysis of a Centralised Model in New South Wales. Healthc Policy 2022; 15:1887-1894. [PMID: 36254223 PMCID: PMC9569157 DOI: 10.2147/rmhp.s383107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Public healthcare systems face rising demand coupled with reducing funding growth rates, necessitating ongoing approaches to efficiency improvement (EI). Centrally coordinated EI approaches l may support EI leaders, yet few such approaches exist internationally. This study provides evidence to inform system-wide EI by harnessing understanding of the perceptions, role demands and support requirements of key EI stakeholders in the centralised EI model implemented in New South Wales. Methods A purposive sample of key informants within NSW Health with responsibility for EI in their organisation were invited to participate. Semi-structured interviews were conducted, recorded and transcribed. A thematic analysis was undertaken using a theoretical deductive approach. Results Seventeen respondents participated who occupied EI leadership roles in metro (8) and rural (6) health services as well as non-clinical support (3) services. Four primary themes emerged on the perceptions and experiences of participants in 1. holding a unique skillset which enables them to undertake EI; 2. inheriting EI accountabilities as additional duties rather than holding dedicated EI roles; 3. the importance of senior support for EI success; and 4. feelings of isolation in undertaking EI. An additional underpinning theme that EI is not well conceptualized in public health systems also emerged, whereby EI planners felt that frontline staff generally do not consider efficiency as a component of their duties. Conclusion EI leaders provide points of authority, experience and influence across organisations within public health systems. This study finds that EI planners possess a unique skillset, can feel isolated both within their health organisation and within the broader public health system and believe that EI is poorly conceptualized amongst health staff. Centralised support for EI stakeholders across a public health system can promote knowledge sharing and capability development. Addressing the role and support requirements of key EI stakeholders is essential.
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Affiliation(s)
- James Kenneth Walters
- Patient Experience and System Performance Division, NSW Health, St Leonards, NSW, Australia,Correspondence: James Kenneth Walters, NSW Health, Level 9, 1 Reserve Road, St Leonards, NSW, Australia, Email
| | - Anurag Sharma
- School of Population Health, UNSW, Kensington, NSW, Australia
| | - Reema Harrison
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie Park, NSW, Australia
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23
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Parks AL, Auerbach AD, Schnipper JL, Bertram A, Jeon SY, Boyle B, Fang MC, Gadrey SM, Siddiqui ZK, Brotman DJ. Venous thromboembolism (VTE) prevention and diagnosis in COVID-19: Practice patterns and outcomes at 33 hospitals. PLoS One 2022; 17:e0266944. [PMID: 35511940 PMCID: PMC9071149 DOI: 10.1371/journal.pone.0266944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/31/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Early reports of increased thrombosis risk with SARS-CoV-2 infection led to changes in venous thromboembolism (VTE) management. Real-world data on the prevalence, efficacy and harms of these changes informs best practices. OBJECTIVE Define practice patterns and clinical outcomes related to VTE diagnosis, prevention, and management in hospitalized patients with coronavirus disease-19 (COVID-19) using a multi-hospital US sample. METHODS In this retrospective cross-sectional study of 1121 patients admitted to 33 hospitals, exposure was dose of anticoagulant prescribed for VTE prophylaxis (standard, intensified, therapeutic), and primary outcome was VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]); secondary outcomes were PE, DVT, arterial thromboembolism (ATE), and bleeding events. Multivariable logistic regression models accounting for clustering by site and adjusted for risk factors were used to estimate odds ratios (ORs). Inverse probability weighting was used to account for confounding by indication. RESULTS 1121 patients (mean age 60 ± 18, 47% female) admitted with COVID-19 between February 2, 2020 and December 31, 2020 to 33 US hospitals were included. Pharmacologic VTE prophylaxis was prescribed in 86%. Forty-seven patients (4.2%) had PE, 51 (4.6%) had DVT, and 23 (2.1%) had ATE. Forty-six patients (4.1%) had major bleeding and 46 (4.1%) had clinically relevant non-major bleeding. Compared to standard prophylaxis, adjusted odds of VTE were 0.67 (95% CI 0.21-2.1) with no prophylaxis, 1.0 (95% CI 0.06-17) with intensified, and 3.0 (95% CI 0.89-10) with therapeutic. Adjusted odds of bleeding with no prophylaxis were 5.6 (95% CI 3.0-11) and 5.3 (95% CI 3.0-10) with therapeutic (no events on intensified dosing). CONCLUSIONS Therapeutic anticoagulation was associated with a 3-fold increased odds of VTE and 5-fold increased odds of bleeding. While higher bleeding rates with high-intensity prophylaxis were likely due to full-dose anticoagulation, we conclude that high thrombosis rates were due to clinical concern for thrombosis before formal diagnosis.
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Affiliation(s)
- Anna L. Parks
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah, Salt Lake City, UT, United States of America
| | - Andrew D. Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Jeffrey L. Schnipper
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Amanda Bertram
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Sun Y. Jeon
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA, United States of America
| | - Bridget Boyle
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Margaret C. Fang
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Shrirang M. Gadrey
- Division of General, Geriatric, Palliative and Hospital Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Zishan K. Siddiqui
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Daniel J. Brotman
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
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24
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Evans P, Rogers B, Symczak G, Ziegler G, Wurst M, Carnie MB, Holmes D, Banta J, Cunningham M, Alikhaani J, Hanson C, Harrison JD. Earn our trust: The perspectives of patients and caregivers. J Hosp Med 2022; 17:313-315. [PMID: 35535930 PMCID: PMC9096919 DOI: 10.1002/jhm.12796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Patricia Evans
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Beverly Rogers
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Gina Symczak
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Georgiann Ziegler
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Melissa Wurst
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Martha B Carnie
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - D'Anna Holmes
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Jim Banta
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Melissa Cunningham
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Jacqueline Alikhaani
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - Catherine Hanson
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Franisco, California, USA
| | - James D Harrison
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
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25
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Berger AC, Simchoni N, Auerbach A, Brode WM, Kuperman E, Raffel K, Kubey A. Implementation of Clinical Practice Guidelines for Hospitalized Patients With COVID-19 in Academic Medical Centers. JAMA Netw Open 2022; 5:e225657. [PMID: 35377428 PMCID: PMC8980917 DOI: 10.1001/jamanetworkopen.2022.5657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 01/16/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Amy Chang Berger
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Noa Simchoni
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Andrew Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - W Michael Brode
- Division of Hospital Medicine, Department of Internal Medicine, Dell Medical School at University of Texas at Austin, Austin
| | - Ethan Kuperman
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Katie Raffel
- Division of Hospital Internal Medicine, Department of Internal Medicine, Denver Health, Denver, Colorado
| | - Alan Kubey
- Division of Hospital Medicine, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
- Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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26
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Walters JK, Sharma A, Malica E, Harrison R. Supporting efficiency improvement in public health systems: a rapid evidence synthesis. BMC Health Serv Res 2022; 22:293. [PMID: 35241066 PMCID: PMC8892107 DOI: 10.1186/s12913-022-07694-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/23/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Public health systems internationally are under pressure to meet increasing demand for healthcare in the context of increasing financial resource constraint. There is therefore a need to maximise health outcomes achieved with public healthcare expenditure. This paper aims to establish and synthesize the contemporary evidence base for approaches taken at a system management level to improve efficiency. METHODS Rapid Evidence Assessment (REA) methodology was employed. A search strategy was developed and applied (PUBMED, MEDLINE) returning 5,377 unique titles. 172 full-text articles were screened to determine relevance with 82 publications included in the final review. Data regarding country, study design, key findings and approaches to efficiency improvement were extracted and a narrative synthesis produced. Publications covering health systems from developed countries were included. RESULTS Identified study designs included policy reviews, qualitative reviews, mixed methods reviews, systematic reviews, literature reviews, retrospective analyses, scoping reviews, narrative papers, regression analyses and opinion papers. While findings revealed no comprehensive frameworks for system-wide efficiency improvement, a range of specific centrally led improvement approaches were identified. Elements associated with success in current approaches included dedicated central functions to drive system-wide efficiency improvement, managing efficiency in tandem with quality and value, and inclusive stakeholder engagement. CONCLUSIONS The requirement for public health systems to improve efficiency is likely to continue to increase. Reactive cost-cutting measures and short-term initiatives aimed only at reducing expenditure are unlikely to deliver sustainable efficiency improvement. By providing dedicated central system-wide efficiency improvement support, public health system management entities can deliver improved financial, health service and stakeholder outcomes.
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Affiliation(s)
| | | | - Emma Malica
- New South Wales Ministry of Health, St Leonards, Australia
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27
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Shannon EM, Cauley M, Vitale M, Wines L, Chopra V, Greysen SR, Herzig SJ, Kripalani S, O'Leary KJ, Vasilevskis EE, Williams MV, Auerbach AD, Mueller SK, Schnipper JL. Patterns of utilization and evaluation of advanced practice providers on academic hospital medicine teams: A national survey. J Hosp Med 2022; 17:186-191. [PMID: 35504577 DOI: 10.1002/jhm.12788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/09/2022]
Abstract
This survey study aimed to provide a contemporary appraisal of advanced practice provider (APP) practice and to summarize perceptions of the benefits and challenges of integrating APPs into adult academic hospital medicine (HM) groups. We surveyed leaders of academic HM groups. We received responses from 43 of 86 groups (50%) surveyed. Thirty-four (79%) reported that they employed APPs. In most groups (85%), APPs were reported to perform daily tasks of patient care, including rounding and documentation. Less than half of the groups reported that APPs had completed HM-specific postgraduate training. The reported benefits of APPs included improved perceived quality of care and greater volume of patients that could be seen. Reported challenges included training requirements and support for new hires. Further investigation is needed to determine which APP team structures deliver the highest quality care. There may be a role for expanding standardized competency-based postgraduate training for APPs planning to practice HM.
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Affiliation(s)
- Evan M Shannon
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, California, USA
| | - Marissa Cauley
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Matthew Vitale
- Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Leanne Wines
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vineet Chopra
- Department of Medicine, Division of Hospital Medicine, University of Denver, Denver, Colorado, USA
| | - S Ryan Greysen
- Section of Hospital Medicine, Perelman School of Medicine at the University of Pennsylvania, Division of General Internal Medicine, Philadelphia, Pennsylvania, USA
- The Wharton School at the University of Pennsylvania, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Shoshana J Herzig
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Division of General Medicine, Boston, Massachusetts, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt University Medical Center, Division of General Internal Medicine and Public Health, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin J O'Leary
- Department of Medicine, Northwestern University Feinberg School of Medicine, Division of Hospital Medicine, Chicago, Illinois, USA
| | - Eduard E Vasilevskis
- Section of Hospital Medicine, Vanderbilt University Medical Center, Division of General Internal Medicine and Public Health, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley, Nashville, Tennessee, USA
| | - Mark V Williams
- Washington University School of Medicine, Division of Hospital Medicine, St. Louis, Missouri, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Stephanie K Mueller
- Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
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28
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Bracing for the Wave: a Multi-Institutional Survey Analysis of Inpatient Workforce Adaptations in the First Phase of COVID-19. J Gen Intern Med 2021; 36:3456-3461. [PMID: 34047919 PMCID: PMC8161717 DOI: 10.1007/s11606-021-06697-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/03/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Medical centers across the country have had to rapidly adapt clinician staffing strategies to accommodate large influxes of patients with the coronavirus disease 2019 (COVID-19). OBJECTIVE We sought to understand the adaptations and staffing strategies that US academic medical centers employed in the inpatient setting early in the spread of COVID-19, and to assess whether those changes were sustained during the first phase of the pandemic. DESIGN Cross-sectional survey assessing organization-level, team-level, and clinician-level inpatient workforce adaptations. PARTICIPANTS Hospital medicine leadership at 27 academic medical centers in the USA. KEY RESULTS Twenty-seven of 36 centers responded to the survey (75%). Widespread practices included frequent staffing reassessment, organization-level changes such as geographic cohorting and redeployment of non-hospitalists, and exempting high-risk healthcare workers from direct care of patients with COVID-19. Several practices were implemented but discontinued, such as reduction of non-essential services, indicating that they were less sustainable for large centers. CONCLUSION These findings provide guidance for inpatient leaders seeking to identify sustainable practices for COVID-19 inpatient workforce planning.
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29
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Harrison JD, Weiss R, Radhakrishnan NS, Hanson C, Carnie MB, Evans P, Banta J, Symczak G, Ziegler G, Holmes D, Michel-Leconte SJ, Rogers B, Wurst M, Alikhaani J, Davis C, Lee T, Schnipper JL, Auerbach AD, Romond J. A Patient-Centered Environmental Scan of Inpatient Visitor Policies During the COVID-19 Pandemic. J Patient Exp 2021; 8:23743735211049646. [PMID: 34712784 PMCID: PMC8547154 DOI: 10.1177/23743735211049646] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Researchers and patients conducted an environmental scan of policy documents and public-facing websites and abstracted data to describe COVID-19 adult inpatient visitor restrictions at 70 academic medical centers. We identified variations in how centers described and operationalized visitor policies. Then, we used the nominal group technique process to identify patient-centered information gaps in visitor policies and provide key recommendations for improvement. Recommendations were categorized into the following domains: 1) provision of comprehensive, consistent, and clear information; 2) accessible information for patients with limited English proficiency and health literacy; 3) COVID-19 related considerations; and 4) care team member methods of communication.
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Affiliation(s)
- James D Harrison
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rachel Weiss
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Catherine Hanson
- Office of Patient Experience, University of Miami Health System, Miami, FL, USA.,Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - Martha B Carnie
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA.,Center for Patient & Families, Brigham and Women's Hospital, Boston, MA, USA
| | - Patricia Evans
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - Jim Banta
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - Gina Symczak
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - Georgiann Ziegler
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - D'Anna Holmes
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA.,Astellas Pharma Inc, Northbrook, IL, USA
| | - Safia J Michel-Leconte
- Office of Patient Experience, University of Miami Health System, Miami, FL, USA.,Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - Beverly Rogers
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - Melissa Wurst
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - Jacqueline Alikhaani
- Hospital Medicine Reengineering Network (HOMERuN) Patient & Family Advisory Council (PFAC), San Francisco, CA, USA
| | - Clark Davis
- Brigham Health Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School, Boston, MA, USA
| | - Tiffany Lee
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey L Schnipper
- Brigham Health Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School, Boston, MA, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA, USA
| | - John Romond
- University of Kentucky College of Medicine, Lexington, KY, USA
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30
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Valverde PA, Ayele R, Leonard C, Cumbler E, Allyn R, Burke RE. Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives. J Gen Intern Med 2021; 36:2251-2258. [PMID: 33532965 PMCID: PMC8342702 DOI: 10.1007/s11606-020-06511-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions. OBJECTIVE We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions. DESIGN Semi-structured interviews with interdisciplinary hospital and SNF providers. PARTICIPANTS Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6). APPROACH Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs. KEY RESULTS Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge. CONCLUSIONS As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.
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Affiliation(s)
- Patricia A Valverde
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA. .,Department of Community and Behavioral Health, Colorado School of Public Health, Aurora, CO, 80045, USA.
| | - Roman Ayele
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA.,Health Systems, Management and Policy Department, Colorado School of Public Health, Aurora, CO, USA
| | - Chelsea Leonard
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA
| | - Ethan Cumbler
- Division of Hospital Medicine, Departments of Medicine and Surgery, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Rebecca Allyn
- Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Robert E Burke
- VA Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Section of Hospital Medicine, Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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31
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Greysen SR, Auerbach AD, Mitchell MD, Goldstein JN, Weiss R, Esmaili A, Kuye I, Manjarrez E, Bann M, Schnipper JL. Discharge Practices for COVID-19 Patients: Rapid Review of Published Guidance and Synthesis of Documents and Practices at 22 US Academic Medical Centers. J Gen Intern Med 2021; 36:1715-1721. [PMID: 33835314 PMCID: PMC8034037 DOI: 10.1007/s11606-021-06711-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND There are currently no evidence-based guidelines that provide standardized criteria for the discharge of COVID-19 patients from the hospital. OBJECTIVE To address this gap in practice guidance, we reviewed published guidance and collected discharge protocols and procedures to identify and synthesize common practices. DESIGN Rapid review of existing guidance from US and non-US public health organizations and professional societies and qualitative review using content analysis of discharge documents collected from a national sample of US academic medical centers with follow-up survey of hospital leaders SETTING AND PARTICIPANTS: We reviewed 65 websites for major professional societies and public health organizations and collected documents from 22 Academic Medical Centers (AMCs) in the US participating in the HOspital MEdicine Reengineering Network (HOMERuN). RESULTS We synthesized data regarding common practices around 5 major domains: (1) isolation and transmission mitigation; (2) criteria for discharge to non-home settings including skilled nursing, assisted living, or homeless; (3) clinical criteria for discharge including oxygenation levels, fever, and symptom improvement; (4) social support and ability to perform activities of daily living; (5) post-discharge instructions, monitoring, and follow-up. LIMITATIONS We used streamlined methods for rapid review of published guidance and collected discharge documents only in a focused sample of US academic medical centers. CONCLUSION AMCs studied showed strong consensus on discharge practices for COVID-19 patients related to post-discharge isolation and transmission mitigation for home and non-home settings. There was high concordance among AMCs that discharge practices should address COVID-19-specific factors in clinical, functional, and post-discharge monitoring domains although definitions and details varied.
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Affiliation(s)
- S Ryan Greysen
- Penn Medicine Center for Evidence-based Practice, Section of Hospital Medicine, Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, USA.
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
| | - Matthew D Mitchell
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, USA
| | | | - Rachel Weiss
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
- University of Virginia, Charlottesville, VA, USA
| | - Armond Esmaili
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
| | - Ifedayo Kuye
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Maralyssa Bann
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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32
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Shannon EM, Chopra V, Greysen SR, Herzig SJ, Kripalani S, O’Leary KJ, Vasilevskis EE, Williams MV, Mueller SK, Auerbach AD, Schnipper JL. Dearth of Hospitalist Investigators in Academic Medicine: A Call to Action. J Hosp Med 2021; 16:189-191. [PMID: 33617444 PMCID: PMC7929609 DOI: 10.12788/jhm.3536] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/15/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Evan Michael Shannon
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Corresponding Author: Evan Michael Shannon, MD, MPH; ; Twitter: @EMShan_MD
| | - Vineet Chopra
- Division of Hospital Medicine, University of Michigan Medicine, Ann Arbor, Michigan
| | - S Ryan Greysen
- Section of Hospital Medicine, Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, The Wharton School at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shoshana J Herzig
- Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Kevin J O’Leary
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Eduard E Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, VA Tennessee Valley, Nashville, Tennessee
| | - Mark V Williams
- Center for Health Services Research, University of Kentucky, Lexington, Kentucky
| | - Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Austin EJ, Neukirch J, Ong TD, Simpson L, Berger GN, Keller CS, Flum DR, Giusti E, Azen J, Davidson GH. Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care. J Gen Intern Med 2021; 36:358-365. [PMID: 32869191 PMCID: PMC7878619 DOI: 10.1007/s11606-020-06140-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 08/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Failure of effective transitions of care following hospitalization can lead to excess days in the hospital, readmissions, and adverse events. Evidence identifies both patient and system factors that influence poor care transitions, yet health systems struggle to translate evidence into complex interventions that have a meaningful impact on care transitions. OBJECTIVE We report on our experience developing, pilot testing, and evaluating a complex intervention (Addressing Complex Transitions program, or ACT program) that aims to improve care transitions for complex patients. DESIGN Following the Medical Research Council (MRC) framework, we engaged in iterative, stakeholder-driven work to develop a complex care intervention, assess feasibility and pilot methods, evaluate the intervention in practice, and facilitate ongoing implementation monitoring and dissemination. PARTICIPANTS Patients receiving care from UW Medicine's health system including 4 hospitals and 20-site Post-Acute Care network. INTERVENTION Literature review and prospective data collection activities informed ACT program design. ACT program components include a tailored risk calculator that provides real-time scoring of transitions of care risk factors, a multidisciplinary team with the capacity to address complex barriers to safe transitions, and enhanced discharge workflows to improve care transitions for complex patients. KEY MEASURES Program evaluation metrics included estimated hospital days saved and program acceptance by care team members. KEY RESULTS During the 6-month pilot, 565 patients were screened and 97 enrolled in the ACT program. An estimated 664 hospital days were saved for the index admission of ACT program participants. Analysis of pre/post-hospital utilization for ACT program participants showed an estimated 3227 fewer hospital days after ACT program enrollment. CONCLUSIONS Health systems need to address increasingly difficult challenges in care delivery. The use of evidence-based frameworks, such as the MRC framework, can guide systems to design complex interventions that respond to their local context and stakeholder needs.
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Affiliation(s)
- Elizabeth J. Austin
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Jen Neukirch
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
| | - Thuan D. Ong
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, WA USA
| | - Louise Simpson
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
| | - Gabrielle N. Berger
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - Carolyn Sy Keller
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - David R Flum
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Elaine Giusti
- Center for Clinical Excellence, University of Washington, Seattle, WA USA
| | - Jennifer Azen
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - Giana H. Davidson
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
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COVID-19 coagulopathy and thrombosis: Analysis of hospital protocols in response to the rapidly evolving pandemic. Thromb Res 2020; 196:355-358. [PMID: 32977136 PMCID: PMC7492800 DOI: 10.1016/j.thromres.2020.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/12/2020] [Accepted: 09/14/2020] [Indexed: 02/08/2023]
Abstract
As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines.
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Auerbach A, O’Leary KJ, Greysen SR, Harrison JD, Kripalani S, Ruhnke GW, Vasilevskis EE, Maselli J, Fang MC, Herzig SJ, Lee T, Schnipper J. Hospital Ward Adaptation During the COVID-19 Pandemic: A National Survey of Academic Medical Centers. J Hosp Med 2020; 15:483-488. [PMID: 32804610 PMCID: PMC7518133 DOI: 10.12788/jhm.3476] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/21/2020] [Indexed: 11/20/2022]
Abstract
IMPORTANCE Although intensive care unit (ICU) adaptations to the coronavirus disease of 2019 (COVID-19) pandemic have received substantial attention , most patients hospitalized with COVID-19 have been in general medical units. OBJECTIVE To characterize inpatient adaptations to care for non-ICU COVID-19 patients. DESIGN Cross-sectional survey. SETTING A network of 72 hospital medicine groups at US academic centers. MAIN OUTCOME MEASURES COVID-19 testing, approaches to personal protective equipment (PPE), and features of respiratory isolation units (RIUs). RESULTS Fifty-one of 72 sites responded (71%) between April 3 and April 5, 2020. At the time of our survey, only 15 (30%) reported COVID-19 test results being available in less than 6 hours. Half of sites with PPE data available reported PPE stockpiles of 2 weeks or less. Nearly all sites (90%) reported implementation of RIUs. RIUs primarily utilized attending physicians, with few incorporating residents and none incorporating students. Isolation and room-entry policies focused on grouping care activities and utilizing technology (such as video visits) to communicate with and evaluate patients. The vast majority of sites reported decreases in frequency of in-room encounters across provider or team types. Forty-six percent of respondents reported initially unrecognized non-COVID-19 diagnoses in patients admitted for COVID-19 evaluation; a similar number reported delayed identification of COVID-19 in patients admitted for other reasons. CONCLUSION The COVID-19 pandemic has required medical wards to rapidly adapt with expanding use of RIUs and use of technology emerging as critical approaches. Reports of unrecognized or delayed diagnoses highlight how such adaptations may produce potential adverse effects on care.
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Affiliation(s)
- Andrew Auerbach
- University of California, San Francisco School of Medicine, San Francisco, California
- Corresponding Author: Andrew Auerbach, MD, MPH; Twitter: @ADAuerbach
| | - Kevin J O’Leary
- Northwestern University Medical Center, Feinberg School of Medicine, Chicago, Illinois
| | - S Ryan Greysen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Harrison
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Sunil Kripalani
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Judith Maselli
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Margaret C Fang
- University of California, San Francisco School of Medicine, San Francisco, California
| | | | - Tiffany Lee
- University of California, San Francisco School of Medicine, San Francisco, California
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Mueller S, Zheng J, Orav EJ, Schnipper JL. Inter-hospital transfer and patient outcomes: a retrospective cohort study. BMJ Qual Saf 2019; 28:e1. [PMID: 30257883 PMCID: PMC11128274 DOI: 10.1136/bmjqs-2018-008087] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied. OBJECTIVE To evaluate the association between IHT and healthcare utilisation and clinical outcomes. DESIGN Retrospective cohort. SETTING CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data. PARTICIPANTS Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories. MAIN OUTCOME MEASURES Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients. RESULTS The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease). CONCLUSIONS In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients' disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.
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Affiliation(s)
- Stephanie Mueller
- Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts, USA
| | - Jie Zheng
- Harvard School of Public Health, Department of Health Policy and Management, Boston, Massachusetts, USA
| | - Endel John Orav
- Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts, USA
- Harvard School of Public Health, Department of Health Policy and Management, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts, USA
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Harrison JD, Anderson WG, Fagan M, Robinson E, Schnipper J, Symczak G, Carnie MB, Hanson C, Banta J, Chen S, Duong J, Wong C, Auerbach AD. Patient and Family Advisory Councils for Research: Recruiting and Supporting Members From Diverse and Hard-to-Reach Communities. J Nurs Adm 2019; 49:473-479. [PMID: 31490796 PMCID: PMC10985779 DOI: 10.1097/nna.0000000000000790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe strategies to recruit and support members from hard-to-reach groups on research-focused Patient and Family Advisory Councils (PFACs). BACKGROUND Ensuring diverse representation of members of research PFACs is challenging, and few studies have given attention to addressing this problem. METHODS A qualitative study was conducted using 8 focus groups and 19 interviews with 80 PFAC members and leaders, hospital leaders, and researchers. RESULTS Recruitment recommendations were: 1) utilizing existing networks; 2) going out to the community; 3) accessing outpatient clinics; and 4) using social media. Strategies to support inclusion were: 1) culturally appropriate communication methods; 2) building a sense of community between PFAC members; 3) equalizing roles between community members/leaders; 4) having a diverse PFAC leadership team; and 5) setting transparent expectations for PFAC membership. CONCLUSION Increasing the diversity of research PFACs is a priority, and it is important to determine how best to engage groups that have been traditionally underrepresented.
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Affiliation(s)
- James D Harrison
- Author Affiliations: Assistant Professors (Drs Harrison and Duong), Associate Professor (Dr Anderson), Professor (Dr Auerbach), and Project Manager (Ms Chen), Division of Hospital Medicine, University of California San Francisco; Chief Experience Officer (Dr Fagan) and Director of Patient and Family Advisory Councils (Ms Hanson), University of Miami Health System, Florida; Chief Transformation Officer and Vice President (Dr Robinson), Christiana Care Health System, Wilmington, Delaware; Associate Professor (Dr Schnipper), Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts; Patient and Family Advisory Council Members (Ms Symczak and Mr Banta), Intensive Care Unit Patient & Family Advisory Council, University of California San Francisco; and Senior Patient Advisor (Ms Carnie) and Project Manager (Ms Wong), Center for Patients and Families, Brigham & Women's Hospital, Boston, Massachusetts
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Brega AG, Hamer MK, Albright K, Brach C, Saliba D, Abbey D, Gritz RM. Organizational Health Literacy: Quality Improvement Measures with Expert Consensus. Health Lit Res Pract 2019; 3:e127-e146. [PMID: 31294314 PMCID: PMC6610031 DOI: 10.3928/24748307-20190503-01] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/30/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Organizational health literacy (OHL) is the degree to which health care organizations implement strategies to make it easier for patients to understand health information, navigate the health care system, engage in the health care process, and manage their health. Although resources exist to guide OHL-related quality improvement (QI) initiatives, little work has been done to establish measures that organizations can use to monitor their improvement efforts. OBJECTIVE We sought to identify and evaluate existing OHL-related QI measures. To complement prior efforts to develop measures based on patient-reported data, we sought to identify measures computed from clinical, administrative, QI, or staff-reported data. Our goal was to develop a set of measures that experts agree are valuable for informing OHL-related QI activities. METHODS We used four methods to identify relevant measures computed from clinical, administrative, QI, or staff-reported data. We convened a Technical Expert Panel, published a request for measures, conducted a literature review, and interviewed 20 organizations working to improve OHL. From the comprehensive list of measures identified, we selected a set of high-priority measures for review by a second expert panel. Using a modified Delphi review process, panelists rated measures on four evaluation criteria, participated in a teleconference to discuss areas of disagreement among panelists, and rerated all measures. KEY RESULTS Across all methods, we identified 233 measures. Seventy measures underwent Delphi Panel review. For 22 measures, there was consensus among panelists that the measures were useful, meaningful, feasible, and had face validity. Five additional measures received strong ratings for usefulness, meaningfulness, and face validity, but failed to show consensus among panelists regarding feasibility. CONCLUSIONS We identified OHL-related QI measures that have the support of experts in the field. Although additional measure development and testing is recommended, the Consensus OHL QI Measures are appropriate for immediate use. [HLRP: Health Literacy Research and Practice. 2019;3(2):e127-e146.]. PLAIN LANGUAGE SUMMARY The health care system is complex. Health care organizations can make things easier for patients by making changes to improve communication and to help patients find their way around, become engaged in the health care process, and manage their health. We identify 22 measures that organizations can use to monitor their efforts to improve communication with and support for patients.
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Affiliation(s)
- Angela G. Brega
- Address correspondence to Angela G. Brega, PhD, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Mail Stop F800, 13055 East 17th Avenue, Aurora, CO 80045;
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Harrison JD, Anderson WG, Fagan M, Robinson E, Schnipper J, Symczak G, Hanson C, Carnie MB, Banta J, Chen S, Duong J, Wong C, Auerbach AD. Patient and Family Advisory Councils (PFACs): Identifying Challenges and Solutions to Support Engagement in Research. THE PATIENT 2018; 11:413-423. [PMID: 29392529 PMCID: PMC11034744 DOI: 10.1007/s40271-018-0298-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The aim was to describe barriers to patient and family advisory council (PFAC) member engagement in research and strategies to support engagement in this context. METHODS We formed a study team comprising patient advisors, researchers, physicians, and nurses. We then undertook a qualitative study using focus groups and interviews. We invited PFAC members, PFAC leaders, hospital leaders, and researchers from nine academic medical centers that are part of a hospital medicine research network to participate. All participants were asked a standard set of questions exploring the study question. We used content analysis to analyze data. RESULTS Eighty PFAC members and other stakeholders (45 patient/caregiver members of PFACs, 12 PFAC leaders, 12 hospital leaders, 11 researchers) participated in eight focus and 19 individual interviews. We identified ten barriers to PFAC member engagement in research. Codes were organized into three categories: (1) individual PFAC member reluctance; (2) lack of skills and training; and (3) problems connecting with the right person at the right time. We identified ten strategies to support engagement. These were organized into four categories: (1) creating an environment where the PFAC members are making a genuine and unique contribution; (2) building community between PFAC members and researchers; (3) best practice activities for researchers to facilitate engagement; and (4) tools and training. CONCLUSION Barriers to engaging PFAC members in research include patients' negative perceptions of research and researchers' lack of training. Building community between PFAC members and researchers is a foundation for partnerships. There are shared training opportunities for PFAC members and researchers to build skills about research and research engagement.
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Affiliation(s)
- James D Harrison
- Division of Hospital Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Wendy G Anderson
- Division of Hospital Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Maureen Fagan
- Center for Patients and Families, Brigham and Women's Hospital, Boston, MA, USA
| | - Edmondo Robinson
- Department of Medicine, Christiana Care Health System, Wilmington, DE, USA
| | - Jeffrey Schnipper
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Gina Symczak
- Intensive Care Unit Patient and Family Advisory Council, University of California San Francisco, San Francisco, CA, USA
| | - Catherine Hanson
- University of Michigan Local Patient and Stakeholder Council, Ann Arbor, MI, USA
| | - Martha B Carnie
- Center for Patients and Families, Brigham and Women's Hospital, Boston, MA, USA
| | - Jim Banta
- Intensive Care Unit Patient and Family Advisory Council, University of California San Francisco, San Francisco, CA, USA
| | - Sherry Chen
- Division of Hospital Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Jonathan Duong
- Division of Hospital Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Celene Wong
- Center for Patients and Families, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA, 94143, USA
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Hernández C, Aibar J, Seijas N, Puig I, Alonso A, Garcia-Aymerich J, Roca J. Implementation of Home Hospitalization and Early Discharge as an Integrated Care Service: A Ten Years Pragmatic Assessment. Int J Integr Care 2018; 18:12. [PMID: 30127696 PMCID: PMC6095082 DOI: 10.5334/ijic.3431] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 04/18/2018] [Indexed: 11/20/2022] Open
Abstract
Home Hospitalization has proven efficacy, but its effectiveness and potential as an Integrated Care Service in a real world setting deserves to be explored. OBJECTIVE To evaluate implementation and 10 years follow-up of Home Hospitalization and Early Discharge as an Integrated Care Service in an urban healthcare district in Barcelona. METHODS Prospective study with pragmatic assessment. Patients: Surgical and medical acute and exacerbated chronic patients requiring admission into a highly specialized hospital, from 2006 to 2015. Intervention: Home-based individualized care plan, administered as a hospital-based outreach service, aiming at substituting hospitalization and implementing a transitional care strategy for optimal discharge. Main measurements: Emergency Department, readmissions and mortality. Patients' and professionals' perspectives, technologies and costs were evaluated. RESULTS 4,165 admissions (71 ± 15 yrs; Charlson Index 4 ± 3). In-hospital stay was 1 (0-3) days and the length of home-based stay was 6 (5-7) days. The 30-day readmission rate was 11% and mortality was 2%. Patients, careers and health professionals expressed high levels of satisfaction (98%). At the start, the service was reimbursed at a flat rate of 918€ per patient discharged, significantly lower than conventional hospitalization (2,879€) but still allowing the hospital to keep a balanced budget. At present, there is no difference in the payment schemes for both types of services. CONCLUSIONS The service freed an average of 6 in-hospital days per patient. The program showed health value generation, as well as potential for synergies with community-based Integrated Care Services.
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Affiliation(s)
- Carme Hernández
- Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en red, Enfermedades Respiratorias, University of Barcelona, Catalonia, ES
| | - Jesus Aibar
- Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, ES
| | - Nuria Seijas
- Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, ES
| | - Imma Puig
- Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, ES
- Hospital Clinic, Barcelona, Catalonia, ES
| | - Albert Alonso
- Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en red, Enfermedades Respiratorias, University of Barcelona, Catalonia, ES
| | - Judith Garcia-Aymerich
- Centre de Recerca en Epidemiologia Ambiental. Centro de Investigación Biomédica en red de Epidemiologia y Salud Pública, Universitat Pompeu Fabra, Barcelona, Catalonia, ES
| | - Josep Roca
- Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en red, Enfermedades Respiratorias, University of Barcelona, Catalonia, ES
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Gundersen EC, Sehgal MM, Ouslander JG. Into the Great Unknown Our Patients Go. J Am Geriatr Soc 2017; 65:2452-2454. [DOI: 10.1111/jgs.15010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Mandi M. Sehgal
- Charles E. Schmidt College of Medicine; Florida Atlantic University; Boca Raton Florida
| | - Joseph G. Ouslander
- Charles E. Schmidt College of Medicine; Florida Atlantic University; Boca Raton Florida
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Evaluation of the Yale New Haven Readmission Risk Score for Pneumonia in a General Hospital Population. Am J Med 2017; 130:1107-1111.e1. [PMID: 28545885 DOI: 10.1016/j.amjmed.2017.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Yale New Haven Readmission Risk Score (YNHRRS) for pneumonia is a clinical prediction tool developed to assess risk for 30-day readmission. This tool was validated in a cohort of Medicare patients; generalizability to a broader patient population has not been evaluated. In addition, it lacks indicators of functional status or social support, which have been shown in other studies to be predictors of readmission. The objective of this study was to evaluate the generalizability of the YNHRRS for pneumonia in a general population of hospitalized patients, and assess the impact of incorporating measures of functional status and social support on its predictive value. METHODS This retrospective chart review comprised all patients admitted to a 563-bed academic medical center with a primary diagnosis of pneumonia between March 2014 and March 2015. Abstraction of clinical variables allowed calculation of the YNHRRS and additional indicators of functional status and social support. The primary outcome was 30-day readmission rate. We created a logistic regression model to predict readmission using the YNHRRS, functional status, and social support as covariates. RESULTS Among 270 discharges with pneumonia, the observed readmission rate was 23%. The YNHRRS was a significant predictor of readmission in our multivariate model, with an odds ratio of 2.20 (95% confidence interval, 1.29-3.73) for each 10% increase in calculated risk. Indicators of functional status and social support were not significant predictors of readmission. CONCLUSIONS The YNHRRS can be applied to an unselected population as a tool to predict patients with pneumonia at risk for readmission.
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Allen-Dicker J, Auerbach A, Herzig SJ. Perceived Safety and Value of Inpatient "Very Important Person" Services. J Hosp Med 2017; 12:177-179. [PMID: 28272595 DOI: 10.12788/jhm.2701] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Providing care to "very important person" (VIP) patients can pose unique moral and value-based challenges for providers. No studies have examined VIP services in the inpatient setting. Through a multi-institutional survey of hospitalists, we assessed physician viewpoints and behavior surrounding the care of VIP patients. A significant proportion of respondents reported feeling pressured by patients, family members, and hospital representatives to provide unnecessary care to VIP patients. Based on self-reported perceptions, as well as case-based questions, we also found that the VIP status of a patient may impact physician clinical decision-making related to unnecessary medical care. Additional studies to quantify the use of VIP services and its effect on cost, resource availability, and patient-specific outcomes are needed. Journal of Hospital Medicine 2017;12:177-179.
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Affiliation(s)
- Joshua Allen-Dicker
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Shoshana J Herzig
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Vasilevskis EE, Ouslander JG, Mixon AS, Bell SP, Jacobsen JML, Saraf AA, Markley D, Sponsler K, Shutes J, Long E, Kripalani S, Simmons SF, Schnelle JF. Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff. J Am Geriatr Soc 2017; 65:269-276. [PMID: 27981557 PMCID: PMC5311021 DOI: 10.1111/jgs.14557] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. OBJECTIVES To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives. DESIGN Prospective cohort study. SETTING One academic medical center and 23 SNFs. PARTICIPANTS We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. MEASUREMENTS Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions. RESULTS The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively. CONCLUSION A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
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Affiliation(s)
- Eduard E. Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Joseph G. Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | - Amanda S. Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN
| | - Susan P. Bell
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - J. Mary Lou Jacobsen
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Avantika A. Saraf
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Daniel Markley
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly Sponsler
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jill Shutes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | - Emily Long
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - S. Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN
| | - Sandra F. Simmons
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - John F. Schnelle
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Greysen SR, Harrison JD, Kripalani S, Vasilevskis E, Robinson E, Metlay J, Schnipper JL, Meltzer D, Sehgal N, Ruhnke GW, Williams MV, Auerbach AD. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf 2017; 26:33-41. [PMID: 26769841 DOI: 10.1136/bmjqs-2015-004570] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 12/04/2015] [Accepted: 12/19/2015] [Indexed: 11/03/2022]
Abstract
IMPORTANCE Patient concerns at or before discharge inform many transitional care interventions; few studies examine patients' perceptions of self-care and other factors related to readmission. OBJECTIVES To characterise patient-reported or caregiver-reported factors contributing to readmission. DESIGN, SETTING AND PARTICIPANTS Cross-sectional, national study of general medicine patients readmitted within 30 days at 12 US hospitals. Interviews included multiple-choice survey and open-ended survey questions of patients or their caregivers. MEASUREMENTS Multiple-choice survey quantified post-discharge difficulty in seven domains of self-care: medication use, contacting providers, transportation, basic needs (eg, food and shelter), diet, social support and substance abuse. Open-ended responses were coded into themes that added depth to the domains above or captured additional patient-centred concerns. RESULTS We interviewed 1066 readmitted patients. 91% reported understanding their discharge plan; however, only 37% reported that providers asked about barriers to carrying out the plan. 52% reported experiencing difficulty in ≥1 self-care domains ranging in frequency from 22% (diet) to 7% (substance use); 26% experienced difficulty in two or more domains. Among 508 patients (48% overall) who reported no difficulties in these domains, two-thirds either could not attribute their readmission to any specific difficulty (34%) or attributed their readmission to progression or persistence of their disease despite following their discharge plan (31%). Only 20% attributed their readmission to early discharge (8%), poor-quality hospital care (6%) or issues such as inadequate discharge instructions or follow-up care (6%). LIMITATIONS The study population included only patients readmitted at academic medical centres and may not be representative of community-based care. CONCLUSION Patients readmitted within 30 days reported understanding their discharge plans, but frequent difficulties in self-care and low anticipatory guidance for resolving these issues after discharge.
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Affiliation(s)
- S Ryan Greysen
- Division of Hospital Medicine, University of California, San Francisco, CA, USA
| | - James D Harrison
- Division of Hospital Medicine, University of California, San Francisco, CA, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt University, Nashville, TN, USA
| | | | | | - Joshua Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffery L Schnipper
- Division of General Internal Medicine, Brigham and Womens Hospital, Boston, MA, USA
| | - David Meltzer
- Section of Hospital Medicine, University of Chicago, IL, USA
| | - Neil Sehgal
- School of Public Health, University of California, Berkeley, CA, USA
| | | | - Mark V Williams
- Division of Hospital Medicine, University of Kentucky, Louisville, KY, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California, San Francisco, CA, USA
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Auerbach AD. The next 20 years of hospital medicine: Continuing to foster the mind, heart, and soul of our field. J Hosp Med 2016; 11:892-893. [PMID: 27373963 DOI: 10.1002/jhm.2631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 06/03/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew D Auerbach
- Department of Medicine, UCSF School of Medicine, San Francisco, California
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Physician Perspectives on Factors Contributing to Readmissions and Potential Prevention Strategies: A Multicenter Survey. J Gen Intern Med 2016; 31:1287-1293. [PMID: 27282857 PMCID: PMC5071281 DOI: 10.1007/s11606-016-3764-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 05/02/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The transition out of the hospital is a vulnerable time for patients, relying heavily on communication and coordination of resources across care settings. Understanding the perspectives of inpatient and outpatient physicians regarding factors contributing to readmission and potential preventive strategies is crucial in designing appropriately targeted readmission prevention efforts. OBJECTIVE To examine and compare inpatient and outpatient physician opinions regarding reasons for readmission and interventions that might have prevented readmission. DESIGN Cross-sectional multicenter study. PARTICIPANTS We identified patients readmitted to general medicine services within 30 days of discharge at 12 US academic medical centers, and surveyed the primary care physician (PCP), discharging physician from the index admission, and admitting physician from the readmission regarding their endorsement of pre-specified factors contributing to the readmission and potential preventive strategies. MAIN MEASURES We calculated kappa statistics to gauge agreement between physician dyads (PCP-discharging physician, PCP-admitting physician, and admitting-discharging physician). KEY RESULTS We evaluated 993 readmission events, which generated responses from 356 PCPs (36 % of readmissions), 675 discharging physicians (68 % of readmissions), and 737 admitting physicians (74 % of readmissions). The most commonly endorsed contributing factors by both PCPs and inpatient physicians related to patient understanding and ability to self-manage. The most commonly endorsed preventive strategies involved providing patients with enhanced post-discharge instructions and/or support. Although PCPs and inpatient physicians endorsed contributing factors and potential preventive strategies with similar frequencies, agreement among the three physicians on the specific factors and/or strategies that applied to individual readmission events was poor (maximum kappa 0.30). CONCLUSIONS Differing opinions among physicians on factors contributing to individual readmissions highlights the importance of communication between inpatient and outpatient providers at discharge to share their different perspectives, and suggests that multi-faceted, broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors.
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48
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Vasilevskis EE, Kripalani S, Ong MK, Rosenthal JT, Longnecker DE, Harmon B, Hohmann SF, Wright K, Black JT. Variability in Implementation of Interventions Aimed at Reducing Readmissions Among Patients With Heart Failure: A Survey of Teaching Hospitals. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:522-9. [PMID: 26579793 PMCID: PMC4811742 DOI: 10.1097/acm.0000000000000994] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
PURPOSE To highlight teaching hospitals' efforts to reduce readmissions by describing interventions implemented to improve care transitions for heart failure (HF) patients and the variability in implemented HF-specific and care transition interventions. METHOD In 2012, the authors surveyed a network of 17 teaching hospitals to capture information about the number, type, stage of implementation, and structure of 4 HF-specific and 21 care transition (predischarge, bridging, and postdischarge) interventions implemented to reduce readmissions among patients with HF. The authors summarized data using descriptive statistics, including the mean number of interventions implemented and the frequency and stage of specific interventions, and descriptive plots of the structure of two common interventions (multidisciplinary rounds and follow-up telephone calls). RESULTS Sixteen hospitals (94%) responded. The number and stage of implementation of the HF-specific and care transition interventions implemented varied across institutions. The mean number of interventions at an advanced stage of implementation (i.e., implemented for ≥ 75% of HF patients on the cardiology service or on all services) was 10.9 (standard deviation = 4.3). Overall, predischarge interventions were more common than bridging or postdischarge interventions. There was variability in the personnel involved in multidisciplinary rounds and in the processes/content of follow-up telephone calls. CONCLUSIONS Teaching hospitals have implemented a wide range of interventions aimed at reducing hospital readmissions, but there is substantial variability in the types, stages, and structure of their interventions. This heterogeneity highlights the need for collaborative efforts to improve understanding of intervention effectiveness.
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Affiliation(s)
- Eduard E Vasilevskis
- E.E. Vasilevskis is assistant professor of medicine, Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, and staff physician, Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Health Care System, Nashville, Tennessee. S. Kripalani is associate professor, Center for Clinical Quality and Implementation Research, Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee. M.K. Ong is associate professor of medicine, Department of Medicine, University of California, Los Angeles, and the VA Greater Los Angeles Health Care System, Los Angeles, California. J.T. Rosenthal is chief medical officer, University of California, Los Angeles Health System, Los Angeles, California. D.E. Longnecker is professor of anesthesiology and critical care emeritus, University of Pennsylvania, Philadelphia, Pennsylvania, and executive director, Coalition to Transform Advanced Care, Washington, DC. B. Harmon is a quality and safety data consultant, Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota. S.F. Hohmann is a principal consultant for comparative data and informatics research, University HealthSystem Consortium, and assistant professor, Department of Health Systems Management, Rush University, Chicago, Illinois. K. Wright is program coordinator, Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee. J.T. Black is manager, Health Policy and Program Evaluation, Cedars-Sinai Health System, Los Angeles, California
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49
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Auerbach AD, Kripalani S, Vasilevskis EE, Sehgal N, Lindenauer PK, Metlay JP, Fletcher G, Ruhnke GW, Flanders SA, Kim C, Williams MV, Thomas L, Giang V, Herzig SJ, Patel K, Boscardin WJ, Robinson EJ, Schnipper JL. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med 2016; 176:484-93. [PMID: 26954564 PMCID: PMC6900926 DOI: 10.1001/jamainternmed.2015.7863] [Citation(s) in RCA: 258] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement. OBJECTIVES To determine preventability of readmissions and to use these estimates to prioritize areas for improvement. DESIGN, SETTING, AND PARTICIPANTS An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors. MAIN OUTCOME AND MEASURE Likelihood that a readmission could have been prevented. RESULTS The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%). CONCLUSIONS AND RELEVANCE Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management.
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Affiliation(s)
- Andrew D Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Sunil Kripalani
- Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Neil Sehgal
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Joshua P Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Grant Fletcher
- Division of General Internal Medicine, Harborview Medical Center, Seattle, Washington
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Scott A Flanders
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Christopher Kim
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mark V Williams
- Center for Health Services Research, University of Kentucky College of Medicine, Louisville
| | - Larissa Thomas
- Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California
| | - Vernon Giang
- Department of Medicine, California Pacific Medical Center, San Francisco
| | - Shoshana J Herzig
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - W John Boscardin
- Department of Medicine, University of California, San Francisco15Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Edmondo J Robinson
- Value Institute and Department of Medicine, Christiana Care Health System, Wilmington, Delaware
| | - Jeffrey L Schnipper
- Hospital Medicine Service, Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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50
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Lavenberg JG, Leas B, Umscheid CA, Williams K, Goldmann DR, Kripalani S. Assessing preventability in the quest to reduce hospital readmissions. J Hosp Med 2014; 9:598-603. [PMID: 24961204 PMCID: PMC4234107 DOI: 10.1002/jhm.2226] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/14/2014] [Accepted: 05/22/2014] [Indexed: 11/09/2022]
Abstract
Hospitals devote significant human and capital resources to eliminate hospital readmissions, prompted most recently by the Centers for Medicare and Medicaid Services (CMS) financial penalties for higher-than-expected readmission rates. Implicit in these efforts are assumptions that a significant proportion of readmissions are preventable, and preventable readmissions can be identified. Yet, no consensus exists in the literature regarding methods to determine which readmissions are reasonably preventable. In this article, we examine strengths and limitations of the CMS readmission metric, explore how preventable readmissions have been defined and measured, and discuss implications for readmission reduction efforts. Drawing on our clinical, research and operational experiences, we offer suggestions to address the key challenges in moving forward to measure and reduce preventable readmissions.
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Affiliation(s)
- Julia G. Lavenberg
- Center for Evidence-based Practice, University of Pennsylvania, Philadelphia, PA
| | - Brian Leas
- Center for Evidence-based Practice, University of Pennsylvania, Philadelphia, PA
| | - Craig A. Umscheid
- Center for Evidence-based Practice, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania, Philadelphia, PA
| | - Kendal Williams
- Center for Evidence-based Practice, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David R. Goldmann
- Center for Evidence-based Practice, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University
- Center for Clinical Quality and Implementation Research, Vanderbilt University
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