The Seamless Transfer-of-Care Protocol: a randomized controlled trial assessing the efficacy of an electronic transfer-of-care communication tool

Community Paramedicine Intervention Reduces Hospital Readmission and Emergency Department Utilization for Patients with Cardiopulmonary Conditions

OBJECTIVE

Patients discharged from the hospital with diagnoses of myocardial infarction, congestive heart failure or acute exacerbation of chronic obstructive pulmonary disease (COPD) have high rates of readmission. We sought to quantify the impact of a community paramedicine (CP) intervention on hospital readmission and emergency department (ED) and clinic utilization for patients discharged with these conditions and to calculate the difference in healthcare costs.

METHODS

This was a prospective, observational cohort study with a matched historical control. The groups were matched for qualifying diagnosis, age, gender, and ZIP code. The intervention group received 1-2 home visits per week by a community paramedic for 30 days. We calculated the number of all-cause hospital readmissions and ED and clinic visits, and used descriptive statistics to compare cohorts.

RESULTS

Included in the study were 78 intervention patients and 78 controls. Compared to controls, fewer subjects in the CP cohort had experienced a readmission at 120 days (34.6% vs 64.1%, P < 0.001) and 210 days (43.6% vs 75.6%, P < 0.001) after discharge. At 210 days the CP cohort had 40.9% fewer total hospital admissions, saving 218 bed days and $410,428 in healthcare costs. The CP cohort had 40.7% fewer total ED visits.

CONCLUSION

Patients who received a post-hospital community paramedic intervention had fewer hospital readmissions and ED visits, which resulted in saving 218 bed days and decreasing healthcare costs by $410,428. Incorporation of a home CP intervention of 30 days in this patient population has the potential to benefit payors, hospitals, and patients.

Prospective economic evaluation of an electronic discharge communication tool: analysis of a randomised controlled trial

OBJECTIVE

To complete an economic evaluation within a randomised controlled trial (RCT) comparing the use of an electronic discharge communication tool (eDCT) compared with usual care.

SETTING

Patients being discharged from a single tertiary care centre's internal medicine Medical Teaching Units.

PARTICIPANTS

Between January 2012 and December 2013, 1399 patients were randomised to a discharge mechanism. Forty-five patients were excluded from the economic evaluation as they did not have data for the index hospitalisation cost; 1354 patients contributed to the economic evaluation.

INTERVENTION

eDCT generated at discharge containing structured content on reason for admission, details of the hospital stay, treatments received and follow-up care required. The control group was discharged via traditional dictation methods.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary economic outcome was the cost per quality-adjusted life year (QALY) gained. Secondary outcomes included the cost per death avoided and the cost per readmission avoided.

RESULTS

The average transcription cost was $C22.28 per patient, whereas the estimated cost of the eDCT was $C13.33 per patient. The cost per QALY gained was $C239 933 in the eDCT arm compared with usual care due to the very small gains in effectiveness and approximately $C800difference in resource utilisation costs. The bootstrap analyses resulted in eDCT being more effective and more costly in 29.2% of samples, less costly and more effective in 29.2% of samples, less effective and more costly in 23.9% of samples and finally, less costly and less effective in 17.7% of samples.

CONCLUSIONS

The eDCT reduced per patient costs of the generation of discharge summaries. The bootstrap estimates demonstrate considerable uncertainty supporting the finding of neutrality reported in the clinical component of the RCT. The immediate transcription cost savings and previously documented provider and patient satisfaction may increase the impetus for organisations to invest in such systems, provided they have a foundation of eHealth infrastructure and readiness.

TRIAL REGISTRATION NUMBER

NCT01402609.

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission

OBJECTIVE

To assess the efficacy of an electronic discharge communication tool (e-DCT) for preventing death or hospital readmission, as well as reducing patient-reported adverse events after hospital discharge. The e-DCT assessed has already been shown to yield high-quality discharge summaries with high levels of patient and physician satisfaction.

METHODS

This two-arm randomised controlled trial was conducted in a Canadian tertiary care centre's internal medicine medical teaching units. Out of the 1953 patients approached and screened for inclusion, 1399 were randomised and available for data linkage for determination of the primary outcome. Participants were randomly assigned to e-DCT versus usual care (traditional discharge communication generated by dictation). The primary outcome was a composite of death or readmission within 90 days. The secondary outcome included any patient-reported adverse events within 30 days of discharge.

RESULTS

Among 1399 randomised participants, 230 of 701 participants (32.8%) in the e-DCT group experienced the primary composite outcome of death or readmission within 90 days vs 205 of 698 participants (29.4%) in the usual care group (p=0.166). The incidence at 30 days of patient-reported adverse outcomes (35% for e-DCT vs 34% for usual care) and adverse events (2.1% for e-DCT vs 1.8% for usual care) also did not differ significantly between groups.

CONCLUSIONS

The e-DCT tested did not reduce the composite endpoint of death or readmission at 90 days, nor the incidence of patient-reported adverse events at 30 days. This neutral finding for hard clinical endpoints needs to be considered in the context of high patient and physician satisfaction, and high quality of discharge summaries.

A framework to assess patient-reported adverse outcomes arising during hospitalization

BACKGROUND

The assessment of adverse events from a patient-centered view includes patient-reported adverse outcomes. An adverse outcome refers to any suboptimal outcome experienced by the patient; when adverse outcomes are identified through a patient interview these are called patient-reported adverse outcomes. An adverse event is an adverse outcome that is more likely due to the processes of medical care rather than to the mere progression of disease. In the context of a large-scale study assessing post-hospitalization adverse events, we developed a conceptual framework to assess patient-reported adverse outcomes (PRAOs). This methodological manuscript describes this conceptual framework.

METHODS

The PRAO framework builds on a validated adverse event ascertainment method including three phases: Phase 1 involves an inquiry to ascertain the occurrence of any patient-reported adverse outcome. It is completed by a structured telephone interview to obtain details - from a patient perspective - on symptoms that developed and/or worsened after hospitalization. Phase 2 involves the classification of PRAOs by physicians not involved in the patient care. Physician-reviewers then rate the PRAOs using well-adopted scales to determine whether the occurrence was the natural progression of the underlying illness or due to medical care. When the PRAO is rated as "due to medical care", it is then classified as an "adverse event". Phase 3 involves the classification of adverse events as preventable or ameliorable.

RESULTS

Out of the 1347 patients contacted at 1-month post-discharge, 469 reported AOs and after reviewing 369 cases, 29 were classified as AEs. Observed agreement levels between raters were 87.3, 85.5, and 85.2 % respectively displaying a good agreement (k > 0.60).

CONCLUSION

The framework incorporates PRAOs as a way to identify cases that need to be evaluated for adverse events. Further validation of this framework is warrant with the final aim of implementation at larger scale. The implementation of this framework will enable clinicians, researchers and healthcare institutions to compare outcome rates across providers and over time.

Medical teleconsultation to general practitioners reduces the medical error vulnerability of internal medicine patients

BACKGROUND

e-Health strategies are supposed to improve the performance of national health systems. Medical teleconsultation (MT) is an important component of such e-Health strategies.

OBJECTIVES

The outcome of MT was evaluated with regard to the impact on the medical error vulnerability (MEV) of internal medicine patients.

METHODS

A team of internal medicine doctors plus a network of forty specialists was set-up in one health district belonging to a unified and universal national health system of a country of Western Europe, in order to provide free-of-charge MT to support general practitioners in solving internal medicine cases. In this observational study, the case series of 2013 is reviewed.

RESULTS

a) Only 21% of the MT fell short to the general practitioner's expectations about the case solving focus; b) throughout the medical care process of the patient, 49% of the cases met with one or more of the five MEVs, namely: 1) clinical test mishandling; 2) inaccurate differential diagnosis; 3) inadequate information flow between health providers at different levels of care (transition care); 4) poor coordination between health providers; and 5) poor reconciliation of medications or hazardous therapies. c) MT canceled or prevented MEVs in 56% and mitigate MEVs in 15% of the cases; d) MT canceled or prevented 85% of MEV caused by poor information exchange in transition care, therefore improving patient referral and counter-referral.

CONCLUSIONS

MT reduces MEV and therefore, whenever implemented to a large extent, may improve the quality of health care delivery and the performance of national health systems.

Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers' perceptions

BACKGROUND

The complex process of discharging patients from acute care to community care requires a multifaceted interaction between all health care providers and patients. Poor communication in a patient's discharge can result in post hospital adverse events, readmission, and mortality. Because of the gravity of these problems, discharge planning has been emphasized as a potential solution. The purpose of this paper is to identify communication barriers to effective discharge planning in an acute care unit of a tertiary care center and to suggest solutions to these barriers.

METHODS

Health care providers provided comments to a single open-ended question: "What are the communication barriers between the different health care providers that limit an effective discharge of patients from Unit 36?" We conducted qualitative thematic analysis by identifying themes related to communication barriers affecting a successful discharge process.

RESULTS

Three broad themes related to barriers to the discharge process were identified: communication, lack of role clarity and lack of resources. We also identified two themes for opportunities for improvement, ie, structure and function of the medical team and need for leadership.

CONCLUSION

While it was evident that poor communication was an overarching barrier identified by health care providers, other themes emerged. In an effort to increase inter-team communication, "bullet rounds", a condensed form of discharge rounds, were introduced to the medical teaching unit and occurred on a daily basis between the multidisciplinary team. To help facilitate provider-patient communication, electronic transfer of care summaries were suggested as a potential solution. To help role clarity, a discharge coordinator and/or liaison was suggested. Communication can be enhanced through use of electronic discharge summaries, bullet rounds, and implementation of a discharge coordinator(s). The findings from this study can be used to aid future researchers in devising appropriate discharging strategies that are focused around the patient and inter-health care provider communication.

Physicians' experience adopting the electronic transfer of care communication tool: barriers and opportunities

PURPOSE

The purpose of this study was to assess physicians' perceptions on a newly developed electronic transfer of care (e-TOC) communication tool and identify barriers and opportunities toward its adoption.

PARTICIPANTS AND METHODS

The study was conducted in a tertiary care teaching center as part of a randomized controlled trial assessing the efficacy of an e-TOC communication tool. The e-TOC technology was developed through iterative consultation with stakeholders. This e-TOC summary was populated by acute care physicians (AcPs) and communicated electronically to community care physicians (CcPs). The AcPs consisted of attending physicians, resident trainees, and medical students rotating through the Medical Teaching Unit. The CcPs were health care providers caring for patients discharged from hospital to the community. AcPs and CcPs completed validated surveys assessing their experience with the newly developed e-TOC tool. Free text questions were added to gather general comments from both groups of physicians. Units of analysis were individual physicians. Data from the surveys were analyzed using mixed methods.

RESULTS

AcPs completed 138 linked pre- and post-rotation surveys. At post-rotation, each AcP completed an average of six e-TOC summaries, taking an average of 37 minutes per e-TOC summary. Over 100 CcPs assessed the quality of the TOC summaries, with an overall rating of 8.3 (standard deviation: 1.48; on a scale of 1-10). Thematic analyses revealed barriers and opportunities encountered by physicians toward the adoption of the e-TOC tool. While the AcPs highlighted issues with timeliness, usability, and presentation, the CcPs identified barriers accessing the web-based TOC summaries, emphasizing that the summaries were timely and the quality of information supported continuity of care.

CONCLUSION

Despite the barriers identified by both groups of physicians, the e-TOC communication tool was well received. Our experience can serve as a template for other health research teams considering the implementation of e-health technologies into health care systems.