Soft Skills: The Work of Communication and Persuasion Among Nurse Navigators in Hospital at Home Programs

OBJECTIVE

To assess the role of soft skills in the work of Hospital at Home (HaH) nurse navigators.

BACKGROUND

In HaH programs that employ them, nurse navigators are often responsible for identifying, assessing, referring, and educating potential HaH patients. The experiences of these navigators have gone understudied.

METHODS

Researchers conducted semistructured interviews and observations with nurse navigators (n = 7) who collectively cover 14 North Carolina-based HaH sites. Navigators were asked to keep diaries of responses to directed questions.

RESULTS

In their capacity as navigators, interviewees said they served several roles: intermediaries between hospital and HaH staff, interpreters of clinical knowledge for patients, and champions of, and educators for, the home-based program. The navigators noted that the interpersonal soft skills of building rapport, clear communication, and gentle persuasion were of the utmost importance in this work.

CONCLUSIONS

The job descriptions of nurse navigators in HaH programs should fully reflect the breadth of their responsibilities, including time performing soft skilled labor. Also, training for these roles should include techniques to develop and refine these skills.

Evaluating Racial/Ethnic Differences in Care Escalation Among COVID-19 Patients in a Home-Based Hospital

The novel coronavirus disease 2019 (COVID-19) has infected over 414 million people worldwide with 5.8 million deaths, as of February 2022. Telemedicine-based interventions to expand healthcare systems' capacity and reduce infection risk have rapidly increased during the pandemic, despite concerns regarding equitable access. Atrium Health Hospital at Home (AH-HaH) is a home-based program that provides advanced, hospital-level medical care and monitoring for patients who would otherwise be hospitalized in a traditional setting. Our retrospective cohort study of positive COVID-19 patients who were admitted to AH-HaH aims to investigate whether the rate of care escalation from AH-HaH to traditional hospitalization differed based on patients' racial/ethnic backgrounds. Logistic regression was used to examine the association between care escalation within 14 days from index AH-HaH admission and race/ethnicity. We found approximately one in five patients receiving care for COVID-19 in AH-HaH required care escalation within 14 days. Odds of care escalation were not significantly different for Hispanic or non-Hispanic Blacks compared to non-Hispanic Whites. However, secondary analyses showed that both Hispanic and non-Hispanic Black patients were younger and with fewer comorbidities than non-Hispanic Whites. The study highlights the need for new care models to vigilantly monitor for disparities, so that timely and tailored adaptations can be implemented for vulnerable populations.

Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic

BACKGROUND

Pandemics disrupt traditional health care operations by overwhelming system resource capacity but also create opportunities for care innovation.

OBJECTIVE

To describe the development and rapid deployment of a virtual hospital program, Atrium Health hospital at home (AH-HaH), within a large health care system.

DESIGN

Prospective case series.

SETTING

Atrium Health, a large integrated health care organization in the southeastern United States.

PATIENTS

1477 patients diagnosed with coronavirus disease 2019 (COVID-19) from 23 March to 7 May 2020 who received care via AH-HaH.

INTERVENTION

A virtual hospital model providing proactive home monitoring and hospital-level care through a virtual observation unit (VOU) and a virtual acute care unit (VACU) in the home setting for eligible patients with COVID-19.

MEASUREMENTS

Patient demographic characteristics, comorbid conditions, treatments administered (intravenous fluids, antibiotics, supplemental oxygen, and respiratory medications), transfer to inpatient care, and hospital outcomes (length of stay, intensive care unit [ICU] admission, mechanical ventilation, and death) were collected from electronic health record data.

RESULTS

1477 patients received care in either the AH-HaH VOU or VACU or both settings, with a median length of stay of 11 days. Of these, 1293 (88%) patients received care in the VOU only, with 40 (3%) requiring inpatient hospitalization. Of these 40 patients, 16 (40%) spent time in the ICU, 7 (18%) required ventilator support, and 2 (5%) died during their hospital admission. In total, 184 (12%) patients were ever admitted to the VACU, during which 21 patients (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required respiratory inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted as an inpatient to a conventional hospital. Of these 24 patients, 10 (42%) required ICU admission, 1 (3%) required a ventilator, and none died during their hospital admission.

LIMITATION

Generalizability is limited to patients with a working telephone and the ability to comply with the monitoring protocols.

CONCLUSION

Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond.

PRIMARY FUNDING SOURCE

Atrium Health.

Trends in Costs and Risk Factors of 30-Day Readmissions for Transcatheter Aortic Valve Implantation

As transcatheter aortic valve implantation (TAVI) continues its rapid growth as a treatment approach for aortic stenosis, costs associated with TAVI, and its burden to healthcare systems will assume greater importance. Patients undergoing TAVI between January 2012 and November 2017 in the Nationwide Readmission Database were identified. Trends in cause-specific readmissions were assessed using Poisson regression. Thirty-day TAVI cost burden (cost of index TAVI hospitalization plus total 30-day readmissions cost) was adjusted to 2017 U.S. dollars and trended over year from 2012 to 2017. Overall, 47,255 TAVI were included and 30-day readmissions declined from 20% to 12% (p <0.0001). Most common causes of readmission (heart failure, infection/sepsis, gastrointestinal causes, and respiratory) declined as well, except arrhythmia/heart block which increased (1.0% to 1.4%, p <0.0001). Cost of TAVI hospitalization ($52,024 to $44,110, p <0.0001) and 30-day cost burden ($54,122 to $45,252, p <0.0001) declined. Whereas costs of an average readmission did not change ($9,734 to $10,068, p = 0.06), cost burden of readmissions (per every TAVI performed) declined ($4,061 to $1,883, p <0.0001), including reductions in each of the top 5 causes except arrhythmia/heart block ($171 to $263, p = 0.04). Index TAVI hospitalizations complicated by acute kidney injury, length of stay ≥5 days, low hospital procedural volume, and skilled nursing facility discharge were associated with increased odds of 30-day readmissions. In conclusion, the costs of index hospitalizations and 30-day cost burden for TAVI in the U.S. significantly declined from 2012 to 2017. However, readmissions due to arrhythmia/heart block and their associated costs increased. Continued strategies to prevent readmissions, especially those for conduction disturbances, are crucial in the efforts to optimize outcomes and costs with the ongoing expansion of TAVI.

Cause and risk factors for readmissions after transcatheter aortic valve replacement

Background

Hospital readmissions following transcatheter aortic valve replacement (TAVR) are associated with higher costs and worse outcomes.

Purpose

Identify causes and risk factors for readmissions after TAVR

Methods

Hospitalizations of adults aged ≥50, with aortic stenosis and undergoing elective TAVR between 2012 and 2016 in the National Readmission Database were analyzed. Multivariable generalized logistic regression, adjusting for age, sex, Charleson Comorbidity Index, primary insurance type, median household income, hospital type and size, were used to assess the effect of inpatient complications, length of stay (LOS), discharge disposition, and TAVR hospital volume on 30-day cardiovascular (CV) and non-cardiovascular (non-CV) readmission.

Results

Between January 2012 and November 2016, 56,858 weighted TAVR hospitalizations were included. The most common causes of readmissions after TAVR were heart failure (23%), infection (17%), gastrointestinal (11%), respiratory (8%), and “other” non-CV causes (8%). The adjusted odds of both CV and non-CV readmissions were significantly higher in patients with acute kidney injury, inpatient LOS ≥5 days, those discharged to skilled nursing facility (SNF) and those treated at medium volume compared with high volume hospitals, Table 1.

Conclusion

Heart failure is the most common cause of readmissions after TAVR. Inpatient incidence of acute kidney injury, as well as longer LOS, SNF discharge and lower hospital TAVR volume were associated with higher odds of 30-day readmissions.

Funding Acknowledgement

Type of funding source: None

Nationwide Trends in Prevalent Cardiovascular Risk Factors and Diseases in Young Adults: Differences by Sex and Race and In-Hospital Outcomes

OBJECTIVES

Prevalence and trends in all cardiovascular disease (CVD) risk factors among young adults (18-39 years) have not been evaluated on a large scale stratified by sex and race. The aim of this study was to establish the prevalence and temporal trend of CVD risk factors in US inpatients younger than 40 years of age from 2007 through 2014 with racial and sex-based distinctions. In addition, the impact of these risk factors on inpatient outcomes and healthcare resource utilization was explored.

METHODS

A cross-sectional nationwide analysis of all hospitalizations, comorbidities, and complications among young adults from 2007 to 2014 was performed. The primary outcomes were frequency, trends, and race- and sex-based differences in coexisting CVD risk factors. Coprimary outcomes were trends in all-cause mortality, acute myocardial infarction, arrhythmia, stroke, and venous thromboembolism in young adults with CVD risk factors. Secondary outcomes were demographics and resource utilization in young adults with versus without CVD risk factors.

RESULTS

Of 63 million hospitalizations (mean 30.5 [standard deviation 5.9] years), 27% had at least one coexisting CVD risk factor. From 2007 to 2014, admission frequency with CVD risk factors increased from 42.8% to 55.1% in males and from 16.2% to 24.6% in females. Admissions with CVD risk were higher in male (41.4% vs 15.9%) and white (58.4% vs 53.8%) or African American (22.6% vs 15.9%) patients compared with those without CVD risk. Young adults in the Midwest (23.9% vs 21.1%) and South (40.8% vs 37.9%) documented comparatively higher hospitalizations rates with CVD risk. Young adults with CVD risk had higher all-cause in-hospital mortality (0.4% vs. 0.3%) with a higher average length of stay (4.3 vs 3.2 days) and charges per admission ($30,074 vs $20,124).

CONCLUSIONS

Despite modern advances in screening, management, and interventional measures for CVD, rising trends in CVD risk factors across all sex and race/ethnic groups call for attention by preventive cardiologists.

Impact of paroxysmal versus non-paroxysmal atrial fibrillation on outcomes in patients undergoing transcatheter mitral valve repair

Background

To study the impact of type of atrial fibrillation on outcomes following transcatheter mitral valve repair. The development of atrial fibrillation (AF) in degenerative mitral regurgitation (MR) can be a sign of progression of MR and associated with adverse outcomes. However, the impact of type of AF in patients undergoing transcatheter mitral valve (MV) repair remains uncertain.

Methods

Patients 18 years or older who underwent TMVR procedure in 2016 and had a concurrent ICD-10 diagnosis of either paroxysmal or non-paroxysmal AF were included from Nationwide Readmission Database (NRD). The association between type of AF and mortality, stroke, readmission (cardiovascular and non-cardiovascular readmissions) and composite outcome (mortality, inpatient stroke or 30-day readmissions) was analyzed using multivariable logistic regression. Statistical Analysis System (SAS) software 9.4 was used to conduct the analysis.

Results

A total of 913 (weighted N=1,750) TMVR hospitalizations from NRD for year 2016 were included. Of these, 510 (weighted N=995) patients had non-paroxysmal AF and 403 (weighted N=755) had paroxysmal AF. Patients with non-paroxysmal AF were older than paroxysmal AF (82.53 vs. 81.27; P=0.0004). As compared to paroxysmal AF, those with non-paroxysmal AF had comparable odds of composite outcome of stroke, readmission, or mortality (OR 1.31; 95% CI: 0.77-2.23), as well as stroke (OR 0.43; 95% CI: 0.10-1.78), or mortality (OR 0.54; 95% CI: 0.21-1.37), in patients undergoing TMVR. Similarly, no differences were noted in the odds of cardiac readmissions (OR 1.38; 95% CI: 0.83-2.28), non-cardiac readmissions (OR 0.80; 95% CI: 0.49-1.32) and discharge to skilled nursing/short term care (OR 1.24; 95% CI: 0.66-2.36) in those with non-paroxysmal vs. paroxysmal AF.

Conclusions

Inpatient outcomes and readmissions were similar in patient with paroxysmal and non-paroxysmal atrial fibrillation in this study. Future studies exploring the effect of type of atrial fibrillation on long term outcomes are needed.

In-Hospital Outcomes After Transcatheter Versus Surgical Aortic Valve Replacement in Octogenarians

Background

Octogenarians have low physiologic reserve and may benefit more from transcatheter aortic valve replacement (TAVR) than surgical aortic valve replacement (SAVR).

Methods and Results

This retrospective cohort study based on the National Inpatient Sample included octogenarians who underwent TAVR or SAVR from 2012 to 2015. Crude and standardized‐morbidity‐ratio‐weighted regression models were used to compare in‐hospital outcomes. Among 19 145 TAVR and 9815 SAVR hospitalizations, TAVR patients had higher Charlson Comorbidity Index (CCI) scores (2.0 versus 0.8, P<0.0001) than SAVR patients. Before weighting, TAVR was associated with significantly shorter length of stay, more home discharges, and lower incidences of acute kidney injury, bleeding, and cardiogenic shock. Associations were consistent across Charlson Comorbidity Index, except for TAVR being associated with greater length of stay reductions among patients with Charlson Comorbidity Index ≥2, compared with Charlson Comorbidity Index <2 (change in estimate −3.56 versus −2.61 days, P=0.004). After weighting, TAVR patients had significantly shorter length of stay (change in estimate −3.29 days, 95% CI −3.82, −2.75) and lower odds of transfer to skilled nursing facility (odds ratio 0.34, 95% CI 0.29, 0.41), acute kidney injury (odds ratio 0.55, 95% CI 0.45, 0.68), bleeding (odds ratio 0.44, 95% CI 0.37, 0.53), and cardiogenic shock (odds ratio 0.55, 95% CI 0.33, 0.92), compared with SAVR patients. Odds of permanent pacemaker implantation, transient ischemic attack/stroke, vascular complications, and in‐hospital mortality were not significantly different.

Conclusions

TAVR may be preferred over SAVR in high‐risk octogenarians because of shorter length of stay, better discharge disposition, and less acute kidney injury, and bleeding. All octogenarians may benefit more from TAVR, irrespective of comorbidity burden, but additional research is needed to confirm our findings.

See Editorial by Himbert et al

Differences in Inpatient Outcomes After Surgical Aortic Valve Replacement at Transcatheter Aortic Valve Replacement (TAVR) and Non-TAVR Centers

Background Transcatheter aortic valve replacement (TAVR) has solidified the importance of a heart team and revolutionized patient selection for surgical aortic valve replacement (SAVR). It is unknown if hospital ability to offer TAVR impacts SAVR outcomes. We investigated outcomes after SAVR between TAVR and non-TAVR centers. Methods and Results Hospitalizations of patients aged ≥50 years, undergoing elective SAVR between January 2012 and September 2015, in the National Readmission Database (NRD) were included. Multivariable logistic, linear, and generalized logistic regression models were used to adjust for patient and hospital characteristics and estimate association between undergoing SAVR at a TAVR center, compared with a non-TAVR center. The association between TAVR volumes and these outcomes were also assessed. SAVR hospitalizations (n = 32 198) were identified; 22 066 (69%) at TAVR and 10 132 (31%) at non-TAVR centers. SAVRs at TAVR centers had lower odds of inpatient mortality (odds ratio 0.67, 95% CI 0.55-0.82) and discharge to skilled nursing facility (odds ratio 0.92, 95% CI 0.85-0.99), compared with non-TAVR centers. There was no difference in LOS (change in estimate -0.09, 95% CI -0.26 to 0.08) or 30-day re-admission (odds ratio 0.95, 95% CI 0.88-1.03). SAVRs performed at the highest TAVR volume centers had the lowest inpatient mortality, compared with non-TAVR centers (odds ratio 0.43 95% CI 0.29-0.63). Conclusions Patients undergoing SAVR at TAVR centers are more likely to survive and have better discharge disposition than patients undergoing SAVR at non-TAVR centers. Whether this represents benefits of a heart-team approach to care or differences in patient selection for SAVR when TAVR is unavailable requires further study.

Rising Trends in Medication Non-compliance and Associated Worsening Cardiovascular and Cerebrovascular Outcomes Among Hospitalized Adults Across the United States

Introduction

Small-scale studies have described concerning rates of non-compliance/nonadherence towards groups of medications for primary and secondary prevention. Trends in cardiovascular and cerebrovascular events (CCE) among hospitalized patients with a non-compliant behavior towards medication, on the whole, remains unexplored on a large scale.

Methods

Using the National Inpatient Sample databases (2007-2014), we sought to assess the prevalence and trends in all-cause mortality and CCE in adult patients hospitalized with medication non-compliance. We compared baseline characteristics and comorbidities in the non-compliant patients with and without concomitant in-hospital CCE.

Results

We identified 7,453,831 adult hospitalizations with medication non-compliance from 2007 to 2014, of which 867,997 (11.6%) patients demonstrated in-hospital CCE. Non-compliant patients with CCE consisted of a higher number of older, white, male patients having greater comorbid risk factors. Non-compliant patients with CCE had higher all-cause in-hospital mortality (3% vs. 0.7%), frequent transfers [4.4% vs. 1.8% transfers to short-term hospitals, and 17.6% vs. 11.6% other transfers (skilled nursing or intermediate care facilities)], lower routine discharges (59.4% vs. 71.1%), and higher mean hospital charges ($52,740 vs. $30,748) compared to non-compliant patients without CCE. Remarkably, this study demonstrates the rising trend in medication non-compliance across all age, sex, and race groups, and related in-hospital mortality, CCE, transfers to other facilities, and the health care cost from 2007 to 2014.

Conclusions

We observed rising trends in the prevalence of medication non-compliance and subsequent in-hospital mortality in hospitalizations among adults from 2007 to 2014. Non-compliant patients with inpatient CCE demonstrated rising trends in all-cause mortality, complications, health care utilization, and cost from 2007 to 2014.

Does transendocardial injection of mesenchymal stem cells improve myocardial function locally or globally?: An analysis from the Percutaneous Stem Cell Injection Delivery Effects on Neomyogenesis (POSEIDON) randomized trial

RATIONALE

Transendocardial stem cell injection (TESI) with mesenchymal stem cells improves remodeling in chronic ischemic cardiomyopathy, but the effect of the injection site remains unknown.

OBJECTIVE

To address whether TESI exerts its effects at the site of injection only or also in remote areas, we hypothesized that segmental myocardial scar and segmental ejection fraction improve to a greater extent in injected than in noninjected segments.

METHODS AND RESULTS

Biplane ventriculographic and endocardial tracings were recorded. TESI was guided to 10 sites in infarct-border zones. Sites were mapped according to the 17-myocardial segment model. As a result, 510 segments were analyzed in 30 patients before and 13 months after TESI. Segmental early enhancement defect (a measure of scar size) was reduced by TESI in both injected (-43.7 ± 4.4%; n=95; P<0.01) and noninjected segments (-25.1 ± 7.8%; n=148; P<0.001; between-group comparison P<0.05). Conversely, segmental ejection fraction (a measure of contractile performance) improved in injected scar segments (19.9 ± 3.3-26.3 ± 3.5%; P=0.003) but not in noninjected scar segments (21.3 ± 2.6-23.5 ± 3.2%; P=0.20; between-group comparison P<0.05). Furthermore, segmental ejection fraction in injected scar segments improved to a greater degree in patients with baseline segmental ejection fraction <20% (12.1 ± 1.2-19.9 ± 2.7%; n=18; P=0.003), versus <20% (31.7 ± 3.4-35.5 ± 3.3%; n=12; P=0.33, between-group comparison P<0.0001).

CONCLUSIONS

These findings illustrate a dichotomy in regional responses to TESI. Although scar size reduction was evident in all scar segments, scar size reduction and ventricular functional responses preferentially occurred at the sites of TESI versus non-TESI sites. Furthermore, improvement was greatest when segmental left ventricular dysfunction was severe.