Reduction in pediatric gastroenterology ED visits can be sustained through physician accountability and financial incentives

OBJECTIVE

There have been various interventions to reduce ED utilization. Little is known about the sustainability of outcomes of interventions to reduce ED overcrowding. We sought to investigate whether the outcomes from one of successful interventions to reduce ED utilization, specialist physician level reporting were sustained over time and how this practice change was sustained over time.

METHOD

This study is a longitudinal analysis of the pre and post intervention ED utilization data collected on ED pediatric patients who were followed by pediatric gastroenterologists in an urban, academic hospital. The primary outcome was the mean rate of ED visits per 1000 office visits from January, 2013 to June, 2017 using a u control chart with three sigma limits.

RESULTS

There were continuous leadership's support, physicians' engagement and communications among different members involved in the intervention. The rate of gastrointestinal (GI)-related ED visits after an intervention decreased by 54% from 4.89 to 2.23 during all hours and by 59% from 2.19 to 0.91 during office hours.

DISCUSSION

Physician-level reporting reduced ED utilization over a four year period. The outcomes could be sustained over time with sustained leadership and physicians' engagement.

Optimizing the Use of Electronic Health Records to Identify High-Risk Psychosocial Determinants of Health

BACKGROUND

Care coordination programs have traditionally focused on medically complex patients, identifying patients that qualify by analyzing formatted clinical data and claims data. However, not all clinically relevant data reside in claims and formatted data. Recently, there has been increasing interest in including patients with complex psychosocial determinants of health in care coordination programs. Psychosocial risk factors, including social determinants of health, mental health disorders, and substance abuse disorders, are less amenable to rapid and systematic data analyses, as these data are often not collected or stored as formatted data, and due to US Health Insurance Portability and Accountability Act (HIPAA) regulations are often not available as claims data.

OBJECTIVE

The objective of our study was to develop a systematic approach using word recognition software to identifying psychosocial risk factors within any part of a patient's electronic health record (EHR).

METHODS

We used QPID (Queriable Patient Inference Dossier), an ontology-driven word recognition software, to scan adult patients' EHRs to identify terms predicting a high-risk patient suitable to be followed in a care coordination program in Massachusetts, USA. Search terms identified high-risk conditions in patients known to be enrolled in a care coordination program, and were then tested against control patients. We calculated precision, recall, and balanced F-measure for the search terms.

RESULTS

We identified 22 EHR-available search terms to define psychosocial high-risk status; the presence of 9 or more of these terms predicted that a patient would meet inclusion criteria for a care coordination program. Precision was .80, recall .98, and balanced F-measure .88 for the identified terms. For adult patients insured by Medicaid and enrolled in the program, a mean of 14 terms (interquartile range [IQR] 11-18) were present as identified by the search tool, ranging from 2 to 22 terms. For patients enrolled in the program but not insured by Medicaid, a mean of 6 terms (IQR 3-8) were present as identified by the search tool, ranging from 1 to 21.

CONCLUSIONS

Selected informatics tools such as word recognition software can be leveraged to improve health care delivery, such as an EHR-based protocol that identifies psychosocially complex patients eligible for enrollment in a care coordination program.

Abstract 047: Variation by Provider in Echocardiographic Surveillance of Mitral Regurgitation

Clinical outcomes after surgical treatment of mitral regurgitation (MR) are worse if intervention occurs after deterioration of left ventricular (LV) size and function. Echocardiographic surveillance of patients with MR is therefore indicated to avoid ventricular remodeling that could worsen patient outcomes. However, overly frequent trans-thoracic echocardiograms (TTEs) can impair access for other patients and reduce value in the delivery of care. Given the balance between timeliness of surveillance and possible over-utilization of TTE in valvular disease, we sought to investigate patient and provider factors contributing to variation in TTE utilization. We hypothesized that there was variation attributable to provider practice even after adjustment for patient characteristics.

We obtained records of all TTEs from 2001-2016 ordered at a large echocardiography laboratory. For each TTE, we linked to patient demographic data from hospital administrative records. To control for both clinical and demographic predictors of frequency of echocardiography, we constructed a hierarchical mixed-effects linear regression model with the individual physician as the random effect in the model. The outcome variable was time interval between TTEs. Intra-class correlation coefficient (ICC) was used to assess the proportion of total variation in the outcome variable due to provider practice, and shrinkage estimates were used to measure the contribution of individual providers.

After application of exclusion criteria, 79,194 TTEs corresponding to 55,663 TTE intervals remained. The mean interval between TTEs was 11.9 months for severe MR, 15.4 months for moderate MR, and 17.6 and 17.7 months for mild and trace MR respectively. After multivariate adjustment, male gender (Rate Ratio (RR) 0.96; 95% CI 0.94-0.98) was associated with shorter follow up, and Hispanic race (RR 1.11; 95% CI 1.01-1.21) was associated with longer follow-up intervals. Eight hundred and sixty-seven physicians were included in the analysis. After adjustment for patient factors, 31% of the variation in intervals was associated with provider practice and 19% of providers (161 of 867) were over-utilizers of TTEs and 24% (210 of 867) were under-utilizers.

We conclude that substantial variation exists in follow up intervals for TTE assessment of MR even after risk-adjustment for clinical and demographic variables, likely due to provider factors including specialty and experience. The association of TTE interval with race and gender warrants further investigation. Improving standardization of follow-up intervals may offer opportunity to reduce both overutilization and underutilization of echocardiography.

Face time versus test ordering: is there a trade-off?

BACKGROUND

As clinician-patient face time comes under pressure, clinicians might consider substituting testing for time spent in diagnostic reasoning, history, and physical exam.

OBJECTIVES

To explore the relationship between clinician-patient time and medical resource utilization.

METHODS

In the Massachusetts General Hospital/Massachusetts General Physician Organization outpatient radio frequency identification project, clinicians and patients wore real-time location system (RTLS) tags. "Face time" was defined as the duration patients and clinicians were colocated. Radiology testing was used as a proxy for medical resource use. A radiology test was determined to be associated with a clinical encounter if it involved the same patient and clinician and occurred less than 3 months after the index encounter. Radiologic data were derived from the electronic health record and test appropriateness proxy score from the radiology order entry system. Data were synthesized and analyzed using standard structured query language and statistical analysis.

RESULTS

From July 2008 to October 2010, 2086 clinical encounter medical records and RTLSmeasured face times could be associated: 1957 for primary care (PC) and 129 for urgent care (UC). Of these, 471 met study criteria. In PC, shorter face time was associated with more testing, but shorter wait times and flow times. In UC, testing was not associated with shorter face times, but was associated with shorter wait times and longer flow times.

CONCLUSION

Our pilot suggests RTLS can capture face time and trade-offs between face time and testing. Ongoing studies will elucidate how these trade-offs affect patients, clinicians, and healthcare systems.

Neuropsychiatric side effects related to treatment with felbamate

Seven patients with refractory seizure disorders and neuropsychiatric symptoms believed secondary to felbamate are presented. Five were on concomitant valproic acid (and other agents). Anergia, apathy, bradyphrenia, and increased irritability were prominent. One patient on felbamate monotherapy had a new-onset psychosis. Felbamate's NMDA receptor antagonism and GABA potentiation (perhaps enhanced by valproic acid use) are discussed as possible mechanisms of these side effects.