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Leung CK, Walton NC, Kheder E, Zalpour A, Wang J, Zavgorodnyaya D, Kondody S, Zhao C, Lin H, Bruera E, Manzano JGM. Understanding Potentially Preventable 7-day Readmission Rates in Hospital Medicine Patients at a Comprehensive Cancer Center. Am J Med Qual 2024; 39:14-20. [PMID: 38127668 PMCID: PMC10841441 DOI: 10.1097/jmq.0000000000000157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
This study aimed to describe the potentially preventable 7-day unplanned readmission (PPR) rate in medical oncology patients. A retrospective analysis of all unplanned 7-day readmissions within Hospital Medicine at MD Anderson Cancer Center from September 1, 2020 to February 28, 2021, was performed. Readmissions were independently analyzed by 2 randomly selected individuals to determine preventability. Discordant reviews were resolved by a third reviewer to reach a consensus. Statistical analysis included 138 unplanned readmissions. The estimated PPR rate was 15.94%. The median age was 62.50 years; 52.90% were female. The most common type of cancer was noncolon GI malignancy (34.06%). Most patients had stage 4 cancer (69.57%) and were discharged home (64.93%). Premature discharge followed by missed opportunities for goals of care discussions were the most cited reasons for potential preventability. These findings highlight areas where care delivery can be improved to mitigate the risk of readmission within the medical oncology population.
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Affiliation(s)
- Cerena K. Leung
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Natalie C. Walton
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Ed Kheder
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Ali Zalpour
- Department of Pharmacy Clinical Programs, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Justine Wang
- Department of Pharmacy Clinical Programs, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sonia Kondody
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Christina Zhao
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Joanna-Grace M. Manzano
- Department of Hospital Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Leung C, Andersen CR, Wilson K, Nortje N, George M, Flowers C, Bruera E, Hui D. The impact of a multidisciplinary goals-of-care program on unplanned readmission rates at a comprehensive cancer center. Support Care Cancer 2023; 32:66. [PMID: 38150077 DOI: 10.1007/s00520-023-08265-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/17/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE This study examined the 30-day unplanned readmission rate in the medical oncology population before and after the implementation of an institution-wide multicomponent interdisciplinary goals of care (myGOC) program. METHODS This retrospective study compared the 30-day unplanned readmission rates in consecutive medical patients during the pre-implementation period (May 1, 2019, to December 31, 2019) and the post-implementation period (May 1, 2020, to December 31, 2020). Secondary outcomes included 7-day unplanned readmission rates, inpatient do-not-resuscitate (DNR) orders, and palliative care consults. We randomly selected a hospitalization encounter for each unique patient during each study period for statistical analysis. A multivariate analysis model was used to examine the association between 30-day unplanned readmission rates and implementation of the myGOC program. RESULTS There were 7028 and 5982 unique medical patients during the pre- and post-implementation period, respectively. The overall 30-day unplanned readmission rate decreased from 24.0 to 21.3% after implementation of the myGOC program. After adjusting for covariates, the myGOC program implementation remained significantly associated with a reduction in 30-day unplanned readmission rates (OR [95% CI] 0.85 [0.77, 0.95], p = 0.003). Other factors significantly associated with a decreased likelihood of a 30-day unplanned readmission were an inpatient DNR order, advanced care planning documentation, and an emergent admission type. We also observed a significant decrease in 7-day unplanned readmission rates (OR [95% CI] 0.75 [0.64, 0.89]) after implementation of the myGOC program. CONCLUSION The 30-day and 7-day unplanned readmission rates decreased in our hospital after implementation of a system-wide multicomponent GOC intervention.
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Affiliation(s)
- Cerena Leung
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaycee Wilson
- Department of Inpatient Analytics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nico Nortje
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina George
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher Flowers
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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James J, Tan S, Stretton B, Kovoor JG, Gupta AK, Gluck S, Gilbert T, Sharma Y, Bacchi S. Why do we evaluate 30-day readmissions in general medicine? A historical perspective and contemporary data. Intern Med J 2023; 53:1070-1075. [PMID: 37278138 DOI: 10.1111/imj.16115] [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] [Received: 02/03/2023] [Accepted: 04/11/2023] [Indexed: 06/07/2023]
Abstract
Reducing preventable readmissions is important to help manage current strains on healthcare systems. The metric of 30-day readmissions is commonly cited in discussions regarding this topic. While such thresholds have contemporary funding implications, the rationale for individual cut-off points is partially historical in nature. Through the examination of the basis for the analysis of 30-day readmissions, greater insight into the possible benefits and limitations of such a metric may be obtained.
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Affiliation(s)
- Jonathan James
- Flinders University, Adelaide, South Australia, Australia
| | - Sheryn Tan
- University of Adelaide, Adelaide, South Australia, Australia
| | - Brandon Stretton
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Samuel Gluck
- University of Adelaide, Adelaide, South Australia, Australia
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Toby Gilbert
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Yogesh Sharma
- Flinders University, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Flinders University, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Riman KA, Doupnik SK, Kutney-Lee AM, Lake ET. Nurse Education and Hospital Readmissions for Children With and Without a Mental Health Condition. Hosp Pediatr 2023; 13:72-79. [PMID: 36477797 PMCID: PMC9808724 DOI: 10.1542/hpeds.2022-006602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES In adults, receiving care in a hospital with more baccalaureate-prepared nurses improves outcomes. This relationship is magnified in adults with serious mental illness or cognitive impairment. Whether the same is true in children with and without a mental health condition is unknown. The study purposes were to determine 1) whether the proportion of baccalaureate-prepared nurses affected the odds of readmission in children; and 2) whether this relationship differed for children with a mental health condition. PATIENTS AND METHODS We linked cross-sectional data from the 2016 Healthcare Cost and Utilization Project State Inpatient Databases, the RN4CAST-US nurse survey in Florida, and the American Hospital Association. Inclusion criteria were ages 3 to 21 years. Mental health conditions were defined as psychiatric or developmental/behavioral diagnoses. These were identified using the Child and Adolescent Mental Health Disorders Classification System. We used multivariable, hierarchical logistic regression models to assess the relationship between nurse training and readmissions. RESULTS In 35 081 patients admitted to 122 hospitals with 4440 nurses, 21.0% of patients had a mental health condition and 4.2% had a 7-day readmission. For individuals without a mental health condition, each 10% increase in the proportion of baccalaureate-prepared nurses was associated with 8.0% lower odds of readmission (odds ratio = 0.92, 95% confidence interval = 0.87-0.97). For those with a mental health condition, each 10% increase in the proportion of baccalaureate-prepared nurses was associated with 16.0% lower odds of readmission (odds ratio = 0.84, 95% confidence interval = 0.78-0.91). CONCLUSIONS A higher proportion of baccalaureate-educated nurses is associated with lower odds of readmission for pediatric patients. This association has a larger magnitude in patients with a mental health condition.
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Affiliation(s)
- Kathryn A. Riman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie K. Doupnik
- University of Pennsylvania School of Medicine & Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ann M. Kutney-Lee
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Eileen T. Lake
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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Morrison JM, Casey B, Sochet AA, Dudas RA, Rehman M, Goldenberg NA, Ahumada L, Dees P. Performance Characteristics of a Machine-Learning Tool to Predict 7-Day Hospital Readmissions. Hosp Pediatr 2022; 12:824-832. [PMID: 36004542 DOI: 10.1542/hpeds.2022-006527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To develop an institutional machine-learning (ML) tool that utilizes demographic, socioeconomic, and medical information to stratify risk for 7-day readmission after hospital discharge; assess the validity and reliability of the tool; and demonstrate its discriminatory capacity to predict readmissions. PATIENTS AND METHODS We performed a combined single-center, cross-sectional, and prospective study of pediatric hospitalists assessing the face and content validity of the developed readmission ML tool. The cross-sectional analyses used data from questionnaire Likert scale responses regarding face and content validity. Prospectively, we compared the discriminatory capacity of provider readmission risk versus the ML tool to predict 7-day readmissions assessed via area under the receiver operating characteristic curve analyses. RESULTS Overall, 80% (15 of 20) of hospitalists reported being somewhat to very confident with their ability to accurately predict readmission risk; 53% reported that an ML tool would influence clinical decision-making (face validity). The ML tool variable exhibiting the highest content validity was history of previous 7-day readmission. Prospective provider assessment of risk of 413 discharges showed minimal agreement with the ML tool (κ = 0.104 [95% confidence interval 0.028-0.179]). Both provider gestalt and ML calculations poorly predicted 7-day readmissions (area under the receiver operating characteristic curve: 0.67 vs 0.52; P = .11). CONCLUSIONS An ML tool for predicting 7-day hospital readmissions after discharge from the general pediatric ward had limited face and content validity among pediatric hospitalists. Both provider and ML-based determinations of readmission risk were of limited discriminatory value. Before incorporating similar tools into real-time discharge planning, model calibration efforts are needed.
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Affiliation(s)
- John M Morrison
- Departments of Pediatrics.,Divisions of Pediatric Hospital Medicine
| | | | - Anthony A Sochet
- Anesthesia and Critical Care Medicine, Division of Pediatric Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Pediatric Critical Care
| | - Robert A Dudas
- Departments of Pediatrics.,Divisions of Pediatric Hospital Medicine
| | - Mohamed Rehman
- Departments of Anesthesia, Pain, and Perioperative Medicine.,Pediatric Critical Care
| | - Neil A Goldenberg
- Departments of Pediatrics.,Pediatric Hematology, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | | | - Paola Dees
- Divisions of Pediatric Hospital Medicine
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Short SS, Rollins MD, Zobell S, Torres H, Guthery S. Decreased ER visits and readmissions after implementation of a standardized perioperative toolkit for children with IBD. J Pediatr Surg 2022; 57:604-609. [PMID: 34583832 DOI: 10.1016/j.jpedsurg.2021.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric inflammatory bowel disease (IBD) carries significant morbidity and requires extensive medical and often surgical intervention. The aim of this study was to evaluate the impact of a dedicated Multidisciplinary clinic on the outcomes of children with IBD. METHODS A retrospective review of a prospective database, established to track quality and outcomes of children undergoing an abdominal operation for IBD, was performed. Children who were managed before (09/2017-03/2019) and after (04/2019-06/2020) establishment of the multidisciplinary clinic were examined. The clinic instituted several care process protocols including early recovery (ERAS) and garnered additional resources for patients (wound ostomy, nutrition, social work, etc.) Primary outcomes were unanticipated return to the operating room, length of stay, ER visits within 30 days of surgery and hospital readmissions within 30 days of surgery. RESULTS We identified 41 children who underwent a total of 80 major abdominal operations; 46.3% of procedures occurred before and 53.7% occurred after instituting our clinic. There were no notable changes in disease distribution (e.g., ulcerative colitis vs. Crohn's), disease severity, medication exposure, or case urgency (elective vs. emergent). ER visits within 30 days of surgery decreased (4 (9.3%) vs. 10 (27%), p = 0.04) as did readmissions within 30 days of surgery (1 (2.3%) vs. 9 (24.3%), p = 0.005). CONCLUSIONS Implementation of a dedicated multidisciplinary clinic for IBD and its attendant focus on protocols and appropriate use of adjunctive resources was associated with decreased emergency department visits and hospital readmissions in the post-operative setting. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Scott S Short
- Department of Surgery, Division of Pediatric Surgery, and Primary Children's Hospital, University of Utah, 100N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, United States.
| | - Michael D Rollins
- Department of Surgery, Division of Pediatric Surgery, and Primary Children's Hospital, University of Utah, 100N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, United States
| | - Sarah Zobell
- Department of Surgery, Division of Pediatric Surgery, and Primary Children's Hospital, University of Utah, 100N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, United States
| | - Hillary Torres
- Department of Surgery, Division of Pediatric Surgery, and Primary Children's Hospital, University of Utah, 100N. Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84108, United States
| | - Stephen Guthery
- Department of Pediatrics, Division of Gastroenterology, and Primary Children's Hospital, University of Utah, Salt Lake City, UT, United States
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Racial Disparities in 7-Day Readmissions from an Adult Hospital Medicine Service. J Racial Ethn Health Disparities 2021; 9:1500-1505. [PMID: 34181237 PMCID: PMC9249686 DOI: 10.1007/s40615-021-01088-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 11/09/2022]
Abstract
Background Health systems have targeted hospital readmissions to promote health equity as there may be racial and ethnic disparities across different patient groups. However, 7-day readmissions have been understudied in adult hospital medicine. Design This is a retrospective study. We performed multivariable logistic regression between patient race/ethnicity and 7-day readmission. Mediation analysis was performed for limited English proficiency (LEP) status. Subgroup analyses were performed for patients with initial admissions for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and cancer. Patients We identified all adults discharged from the adult hospital medicine service at UCSF Medical Center between July 2016 and June 2019. Main Measures The primary outcome was 7-day all-cause readmission back to the discharging hospital. Results There were 18,808 patients in our dataset who were discharged between July 2016 and June 2019. A total of 1,297 (6.9%) patients were readmitted within 7 days. Following multivariable regression, patients who identified as Black (OR 1.35, 95% CI 1.15–1.58, p <0.001) and patients who identified as Asian (OR 1.26, 95% CI 1.06–1.50, p = 0.008) had higher odds of readmission compared to white patients. Multivariable regression at the subgroup level for CHF, COPD, and cancer readmissions did not demonstrate significant differences between the racial and ethnic groups. Conclusions Black patients and Asian patients experienced higher rates of 7-day readmission than patients who identified as white, confirmed on adjusted analysis.
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Vaz LE, Wagner DV, Jungbauer RM, Ramsey KL, Jenisch C, Koskela-Staples N, Everist S, Austin JP, Harris MA, Zuckerman KE. The Role of Caregiver-Reported Risks in Predicting Adverse Pediatric Outcomes. J Pediatr Psychol 2020; 45:957-970. [PMID: 32815539 PMCID: PMC8312731 DOI: 10.1093/jpepsy/jsaa067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Certain social risk factors (e.g., housing instability, food insecurity) have been shown to directly and indirectly influence pediatric health outcomes; however, there is limited understanding of which social factors are most salient for children admitted to the hospital. This study examines how caregiver-reported social and medical characteristics of children experiencing an inpatient admission are associated with the presence of future health complications. METHODS Caregivers of children experiencing an inpatient admission (N = 249) completed a predischarge questionnaire designed to capture medical and social risk factors across systems (e.g., patient, caregiver, family, community, healthcare environment). Electronic health record (EHR) data were reviewed for child demographic data, chronic disease status, and subsequent emergency department visits or readmissions (i.e., acute events) 90 days postindex hospitalization. Associations between risk factors and event presence were estimated using odds ratios (ORs) and confidence intervals (CI), both unadjusted and adjusted OR (aOR) for chronic disease and age. RESULTS Thirty-three percent (N = 82) of children experienced at least one event. After accounting for child age and chronic disease status, caregiver perceptions of child's health being generally "poor" or "not good" prior to discharge (aOR = 4.7, 95% CI = 2.3, 9.7), having high care coordination needs (aOR = 3.2, 95% CI = 1.6, 6.1), and experiencing difficulty accessing care coordination (aOR = 2.5, 95% CI = 1.4, 4.7) were significantly associated with return events. CONCLUSIONS Caregiver report of risks may provide valuable information above and beyond EHR records to both determine risk of future health problems and inform intervention development.
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Affiliation(s)
- Louise E Vaz
- Department of Pediatrics, Doernbecher Children’s Hospital
| | - David V Wagner
- Department of Pediatrics, Doernbecher Children’s Hospital
| | - Rebecca M Jungbauer
- Pacific Northwest Evidence-Based Practice Center, Oregon Health
& Science University
| | - Katrina L Ramsey
- Biostatistics and Design Program, Oregon Health & Science
University
| | | | | | - Steven Everist
- Department of Pediatrics, Doernbecher Children’s Hospital
- BUILD EXITO Program, Portland State University
| | - Jared P Austin
- Department of Pediatrics, Doernbecher Children’s Hospital
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Chiu CY, Oria D, Yangga P, Kang D. Quality assessment of weekend discharge: a systematic review and meta-analysis. Int J Qual Health Care 2020; 32:347-355. [PMID: 32453404 DOI: 10.1093/intqhc/mzaa060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/13/2020] [Accepted: 05/07/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Hospital bed utility and length of stay affect the healthcare budget and quality of patient care. Prior studies already show admission and operation on weekends have higher mortality rates compared with weekdays, which has been identified as the 'weekend effect.' However, discharges on weekends are also linked with quality of care, and have been evaluated in the recent decade with different dimensions. This meta-analysis aims to discuss weekend discharges associated with 30-day readmission, 30-day mortality, 30-day emergency department visits and 14-day follow-up visits compared with weekday discharges. DATA SOURCES PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov were searched from January 2000 to November 2019. STUDY SELECTION Preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Only studies published in English were reviewed. The random-effects model was applied to assess the effects of heterogeneity among the selected studies. DATA EXTRACTION Year of publication, country, sample size, number of weekday/weekend discharges, 30-day readmission, 30-day mortality, 30-day ED visits and 14-day appointment follow-up rate. RESULTS OF DATA SYNTHESIS There are 20 studies from seven countries, including 13 articles from America, in the present meta-analysis. There was no significant difference in odds ratio (OR) in 30-day readmission, 30-day mortality, 30-day ED visit, and 14-day follow-up between weekday and weekend. However, the OR for 30-day readmission was significantly higher among patients in the USA, including studies with high heterogeneity. CONCLUSION In the USA, the 30-day readmission rate was higher in patients who had been discharged on the weekend compared with the weekday. However, interpretation should be cautious because of data limitation and high heterogeneity. Further intervention should be conducted to eliminate any healthcare inequality within the healthcare system and to improve the quality of patient care.
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Affiliation(s)
- Chia-Yu Chiu
- Department of Internal Medicine, Lincoln Medical Center, Room 8-20, 234 E 149th St, New York, NY 10451, USA
| | - David Oria
- Department of Internal Medicine, Lincoln Medical Center, Room 8-20, 234 E 149th St, New York, NY 10451, USA
| | - Peter Yangga
- Department of Internal Medicine, Lincoln Medical Center, Room 8-20, 234 E 149th St, New York, NY 10451, USA
| | - Dasol Kang
- Department of Internal Medicine, Lincoln Medical Center, Room 8-20, 234 E 149th St, New York, NY 10451, USA
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