A transition care coordinator model reduces hospital readmissions and costs

BACKGROUND

The optimal structure and intensity of interventions to reduce hospital readmission remains uncertain, due in part to lack of head-to-head comparison. To address this gap, we evaluated two forms of an evidence-based, multi-component transitional care intervention.

METHODS

A quasi-experimental evaluation design compared outcomes of Transition Care Coordinator (TCC) Care to Usual Care, while controlling for sociodemographic characteristics, comorbidities, readmission risk, and administrative factors. The study was conducted between January 1, 2013 and April 30, 2015 as a quality improvement initiative. Eligible adults (N = 7038) hospitalized with pneumonia, congestive heart failure, or chronic obstructive pulmonary disease were identified for program evaluation via an electronic health record algorithm. Nurse TCCs provided either a full intervention (delivered in-hospital and by post-discharge phone call) or a partial intervention (phone call only).

RESULTS

A total of 762 hospitalizations with TCC Care (460 full intervention and 302 partial intervention) and 6276 with Usual Care was examined. In multivariable models, hospitalizations with TCC Care had significantly lower odds of readmission at 30 days (OR = 0.512, 95% CI 0.392 to 0.668) and 90 days (OR = 0.591, 95% CI 0.483 to 0.723). Adjusted costs were significantly lower at 30 days (difference = $3969, 95% CI $5099 to $2691) and 90 days (difference = $5684, 95% CI $7602 to $3627). The effect was similar whether patients received the full or partial intervention.

CONCLUSION

An evidence-based multi-component intervention delivered by nurse TCCs reduced 30- and 90-day readmissions and associated health care costs. Lower intensity interventions delivered by telephone after discharge may have similar effectiveness to in-hospital programs.

A Multidisciplinary Housestaff-Led Initiative to Safely Reduce Daily Laboratory Testing

PURPOSE

Provision of high-value care is a milestone in physician training. The authors evaluated the effect of a housestaff-led initiative on laboratory testing rates.

METHOD

Vanderbilt University Medical Center's Choosing Wisely steering committee, led by housestaff with faculty advisors, sought to reduce unnecessary daily basic metabolic panel (BMP) and complete blood count (CBC) testing on inpatient general medicine and surgical services. Intervention services received a didactic session followed by regular data feedback with goal rates and peer comparison. Testing rates during January 1, 2013-February 9, 2015, were compared on intervention services and control services using a difference-in-differences analysis and an interrupted time-series analysis with segmented linear regression.

RESULTS

Compared with concurrent controls, the mean number of BMP tests per patient day decreased by an additional 0.23 (95% CI 0.17-0.29) on medical housestaff and 0.15 (95% CI 0.09-0.21) on hospitalist intervention services. Daily CBC tests decreased by an additional 0.28 (95% CI 0.23-0.33) on medical housestaff, 0.08 (95% CI 0.03-0.13) on hospitalist, and 0.12 (95% CI 0.05-0.20) on surgical housestaff intervention services. Patients with lab-free days (0 labs ordered in 24 hours) increased by an additional 4.1 percentage points (95% CI 2.1-6.1) on medical housestaff and 9.7 percentage points (95% CI 6.6-12.8) on hospitalist intervention services. There were no adverse changes in length of stay or intensive care unit transfer, in-hospital mortality, or 30-day readmission rates.

CONCLUSIONS

A housestaff-led intervention utilizing education and data feedback with goal setting and peer comparison resulted in safe, significant reductions in daily laboratory testing rates.

Effect of Health Literacy on Research Follow-Up

Previous research has not examined the effect of health literacy on research subjects' completion of scheduled research follow-up. This article evaluates patient factors associated with incomplete research follow-up at three time points after enrollment in a large, hospital-based prospective cohort study. Predictor variables included health literacy, age, race, gender, education, employment status, difficulty paying bills, hospital diagnosis, length of stay, self-reported global health status, depression, perceived health competence, medication adherence, and health care system distrust. In a sample of 2,042 patients, multivariable models demonstrated that lower health literacy and younger age were significantly associated with a lower likelihood of completing research follow-up interviews at 2-3 days, 30 days, and 90 days after hospital discharge. In addition, patients who had less education, were currently employed, and had moderate financial stress were less likely to complete 90-day follow-up. This study is the first to demonstrate that lower health literacy is a significant predictor of incomplete research follow-up.

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial

BACKGROUND

Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs).

OBJECTIVE

To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge.

DESIGN

Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021)

SETTING

Two tertiary care academic hospitals.

PATIENTS

Adults hospitalized with acute coronary syndromes or acute decompensated heart failure.

INTERVENTION

Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge.

MEASUREMENTS

The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs.

RESULTS

Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]).

LIMITATION

The characteristics of the study hospitals and participants may limit generalizability.

CONCLUSION

Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Risk prediction models for hospital readmission: a systematic review

CONTEXT

Predicting hospital readmission risk is of great interest to identify which patients would benefit most from care transition interventions, as well as to risk-adjust readmission rates for the purposes of hospital comparison.

OBJECTIVE

To summarize validated readmission risk prediction models, describe their performance, and assess suitability for clinical or administrative use.

DATA SOURCES AND STUDY SELECTION

The databases of MEDLINE, CINAHL, and the Cochrane Library were searched from inception through March 2011, the EMBASE database was searched through August 2011, and hand searches were performed of the retrieved reference lists. Dual review was conducted to identify studies published in the English language of prediction models tested with medical patients in both derivation and validation cohorts.

DATA EXTRACTION

Data were extracted on the population, setting, sample size, follow-up interval, readmission rate, model discrimination and calibration, type of data used, and timing of data collection.

DATA SYNTHESIS

Of 7843 citations reviewed, 30 studies of 26 unique models met the inclusion criteria. The most common outcome used was 30-day readmission; only 1 model specifically addressed preventable readmissions. Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large US populations and had poor discriminative ability (c statistic range: 0.55-0.65). Seven models could potentially be used to identify high-risk patients for intervention early during a hospitalization (c statistic range: 0.56-0.72), and 5 could be used at hospital discharge (c statistic range: 0.68-0.83). Six studies compared different models in the same population and 2 of these found that functional and social variables improved model discrimination. Although most models incorporated variables for medical comorbidity and use of prior medical services, few examined variables associated with overall health and function, illness severity, or social determinants of health.

CONCLUSIONS

Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly. Although in certain settings such models may prove useful, efforts to improve their performance are needed as use becomes more widespread.

Phenyl propenoic side chain degradation of ferulic acid by Pycnoporus cinnabarinus - elucidation of metabolic pathways using [5-2H]-ferulic acid

The white-rot fungus Pycnoporous cinnabarinus (DMS-1184) was submerged cultured for 22 days under controlled conditions in a bioreactor. After 6, 9, and 15 days of culture the growth medium was supplemented with [5-2H]-labelled ferulic acid (I). The major phenolic compounds identified labelled were four lignans, the methyl esters of ferulic (I) and vanillic acid (VIII), (E)-coniferyl aldehyde (II), (E)-coniferyl alcohol (III), vanillic acid (VIII), vanillin (IX) and vanillyl alcohol (X). The detection of considerable amounts of labelled 4-hydroxy-3-methoxyacetophenone (VII) in the late growth phase suggested the increasing formation and decarboxylation of free 4-hydroxy-3-methoxybenzoylacetic acid (VI) and, thus, a beta-oxidation-like degradation of ferulic acid (I) or its methyl ester to vanillic acid (VIII). 4-Hydroxy-3-methoxybenzoylacetic acid methyl ester (VI) and 3-hydroxy-(4-hydroxy-3-methoxyphenyl)-propanoic acid methyl ester (V) were synthesised and then identified as metabolites in the culture medium. The fungal degradation of the phenyl propenoic side chain of ferulic acid (I), a principal key step of lignin decomposition, appeared to proceed analogous to fatty acids.

Mechanism of inhibition of LDL phospholipase A2 by monocyclic-beta-lactams. Burst kinetics and the effect of stereochemistry

Investigation of the inhibition of LDL-associated phospholipase A2 by monocyclic beta-lactams has shown that LDL phospholipase A2 is capable of hydrolyzing monocyclic-beta-lactams by a mechanism which shares many similarities to the hydrolysis of beta-lactams by beta-lactamases. We believe that this is the first demonstration of a serine-dependent lipase being able to hydrolyze an amide bond. Although 4-(phenylthio)-N-(4-phenyl-2-oxobutyl)azetidin-2-one, SB-216477, and its enantiomers are relatively modest covalent inactivators with kobs/[I] = 46 M-1 s-1 for the R enantiomer, analysis of the kinetics of inactivation and reactivation shows that these compounds act as slow-turnover substrates, presumably via an acylation-deacylation mechanism. The detection of a suprastoichiometric burst indicates that the pathway must be branched with the branching giving rise to the slow reactivation via a more stable covalent intermediate. Study of the two enantiomers of SB-216477 shows that LDL-associated phospholipase A2 is sensitive to the beta-lactam stereochemistry at C4. However, a common achiral intermediate is formed along the turnover pathway, and this must be at or immediately prior to the branch point.