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Makam AN, Burnfield J, Prettyman E, Nguyen OK, Wu N, Espejo E, Blat C, Boscardin WJ, Ely EW, Jackson JC, Covinsky KE, Votto J. One-Year Recovery Among Survivors of Prolonged Severe COVID-19: A National Multicenter Cohort. Crit Care Med 2024:00003246-990000000-00325. [PMID: 38597793 DOI: 10.1097/ccm.0000000000006258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
OBJECTIVES Understanding the long-term effects of severe COVID-19 illness on survivors is essential for effective pandemic recovery planning. Therefore, we investigated impairments among hospitalized adults discharged to long-term acute care hospitals (LTACHs) for prolonged severe COVID-19 illness who survived 1 year. DESIGN The Recovery After Transfer to an LTACH for COVID-19 (RAFT COVID) study was a national, multicenter, prospective longitudinal cohort study. SETTING AND PATIENTS We included hospitalized English-speaking adults transferred to one of nine LTACHs in the United States between March 2020 and February 2021 and completed a survey. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Validated instruments for impairments and free response questions about recovering. Among 282 potentially eligible participants who provided permission to be contacted, 156 (55.3%) participated (median age, 65; 38.5% female; 61.3% in good prior health; median length of stay of 57 d; 77% mechanically ventilated for a median of 26 d; 42% had a tracheostomy). Approximately two-thirds (64%) had a persistent impairment, including physical (57%), respiratory (49%; 19% on supplemental oxygen), psychiatric (24%), and cognitive impairments (15%). Nearly half (47%) had two or more impairment types. Participants also experienced persistent debility from hospital-acquired complications, including mononeuropathies and pressure ulcers. Participants described protracted recovery, attributing improvements to exercise/rehabilitation, support, and time. While considered life-altering with 78.7% not returning to their usual health, participants expressed gratitude for recovering; 99% returned home and 60% of previously employed individuals returned to work. CONCLUSIONS Nearly two-thirds of survivors of among the most prolonged severe COVID-19 illness had persistent impairments at 1 year that resembled post-intensive care syndrome after critical illness plus debility from hospital-acquired complications.
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Affiliation(s)
- Anil N Makam
- Division of Hospital Medicine, UCSF at San Francisco General Hospital, San Francisco, CA
| | - Judith Burnfield
- Institute for Rehabilitation Science and Engineering, Madonna Rehabilitation Hospitals, Lincoln, NE
| | - Ed Prettyman
- Texas NeuroRehab Center, Austin, TX
- National Association of Long Term Hospitals, North Bethesda, MD
| | - Oanh Kieu Nguyen
- Division of Hospital Medicine, UCSF at San Francisco General Hospital, San Francisco, CA
| | - Nancy Wu
- Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Edie Espejo
- Division of Geriatrics, UCSF, San Francisco, CA
- Northern California Center for Research and Education, San Francisco, CA
| | - Cinthia Blat
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UCSF, San Francisco, CA
| | - W John Boscardin
- Division of Geriatrics, UCSF, San Francisco, CA
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University, Medical Center, Nashville, TN
| | - James C Jackson
- Critical Illness, Brain Dysfunction and Survivorship Center, Vanderbilt University, Medical Center, Nashville, TN
| | | | - John Votto
- National Association of Long Term Hospitals, North Bethesda, MD
- Hospital for Special Care, New Britain, CT
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Fraimow-Wong L, Martín M, Thomas L, Giuliano R, Nguyen OK, Knight K, Suen LW. Patient and Staff Perspectives on the Impacts and Challenges of Hospital-Based Harm Reduction. JAMA Netw Open 2024; 7:e240229. [PMID: 38386317 PMCID: PMC10884877 DOI: 10.1001/jamanetworkopen.2024.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
Importance Harm reduction is associated with improved health outcomes among people who use substances. As overdose deaths persist, hospitals are recognizing the need for harm reduction services; however, little is known about the outcomes of hospital-based harm reduction for patients and staff. Objective To evaluate patient and staff perspectives on the impact and challenges of a hospital-based harm reduction program offering safer use education and supplies at discharge. Design, Setting, and Participants This qualitative study consisted of 40-minute semistructured interviews with hospitalized patients receiving harm reduction services and hospital staff at an urban, safety-net hospital in California from October 2022 to March 2023. Purposive sampling allowed inclusion of diverse patient racial and ethnic identities, substance use disorders (SUDs), and staff roles. Exposure Receipt of harm reduction education and/or supplies (eg, syringes, pipes, naloxone, and test strips) from an addiction consult team, or providing care for patients receiving these services. Main Outcomes and Measures Interviews were analyzed using thematic analysis to identify key themes. Results A total of 40 participants completed interviews, including 20 patients (mean [SD] age, 43 [13] years; 1 American Indian or Alaska Native [5%], 1 Asian and Pacific Islander [5%], 6 Black [30%]; 6 Latine [30%]; and 6 White [30%]) and 20 staff (mean [SD] age 37 [8] years). Patients were diagnosed with a variety of SUDs (7 patients with opioid and stimulant use disorder [35%]; 7 patients with stimulant use disorder [35%]; 3 patients with opioid use disorder [15%]; and 3 patients with alcohol use disorder [15%]). A total of 3 themes were identified; respondents reported that harm reduction programs (1) expanded access to harm reduction education and supplies, particularly for ethnically and racially minoritized populations; (2) built trust by improving the patient care experience and increasing engagement; and (3) catalyzed culture change by helping destigmatize care for individuals who planned to continue using substances and increasing staff fulfillment. Black and Latine patients, those who primarily used stimulants, and those with limited English proficiency (LEP) reported learning new harm reduction strategies. Program challenges included hesitancy regarding regulations, limited SUD education among staff, remaining stigma, and the need for careful assessment of patient goals. Conclusions and Relevance In this qualitative study, patients and staff believed that integrating harm reduction services into hospital care increased access for populations unfamiliar with harm reduction, improved trust, and reduced stigma. These findings suggest that efforts to increase access to harm reduction services for Black, Latine, and LEP populations, including those who use stimulants, are especially needed.
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Affiliation(s)
| | - Marlene Martín
- University of California, San Francisco, School of Medicine
- Division of Hospital Medicine at San Francisco General Hospital, University of California, San Francisco
| | - Laura Thomas
- San Francisco AIDS Foundation, San Francisco, California
| | - Ro Giuliano
- San Francisco AIDS Foundation, San Francisco, California
| | - Oanh Kieu Nguyen
- University of California, San Francisco, School of Medicine
- Division of Hospital Medicine at San Francisco General Hospital, University of California, San Francisco
| | - Kelly Knight
- University of California, San Francisco, School of Medicine
- Department of Humanities and Social Sciences, University of California San Francisco
| | - Leslie W Suen
- University of California, San Francisco, School of Medicine
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco
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Abstract
Current digital health approaches have not engaged diverse end users or reduced health or health care inequities, despite their promise to deliver more tailored and personalized support to individuals at the right time and the right place. To achieve digital health equity, we must refocus our attention on the current state of digital health uptake and use across the policy, system, community, individual, and intervention levels. We focus here on (a) outlining a multilevel framework underlying digital health equity; (b) summarizingfive types of interventions/programs (with example studies) that hold promise for advancing digital health equity; and (c) recommending future steps for improving policy, practice, and research in this space.
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Affiliation(s)
- Courtney R Lyles
- Department of Medicine, Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, California, USA;
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
- Center for Vulnerable Populations, University of California-San Francisco, San Francisco, California, USA
- School of Public Health, University of California-Berkeley, Berkeley, California, USA
| | - Oanh Kieu Nguyen
- Center for Vulnerable Populations, University of California-San Francisco, San Francisco, California, USA
- Department of Medicine, Division of Hospital Medicine at Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, California, USA
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Elaine C Khoong
- Department of Medicine, Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, California, USA;
- Center for Vulnerable Populations, University of California-San Francisco, San Francisco, California, USA
| | - Adrian Aguilera
- Center for Vulnerable Populations, University of California-San Francisco, San Francisco, California, USA
- School of Social Welfare, University of California-Berkeley, Berkeley, California, USA
- Department of Psychiatry, University of California-San Francisco, San Francisco, California, USA
| | - Urmimala Sarkar
- Department of Medicine, Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, University of California-San Francisco, San Francisco, California, USA;
- Center for Vulnerable Populations, University of California-San Francisco, San Francisco, California, USA
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Martin M, Clement J, Defries T, Makam AN, Nguyen OK. Prevalence and Characteristics of Hospitalizations with Unhealthy Alcohol Use in a Safety-Net Hospital from 2016 to 2018. J Gen Intern Med 2022; 37:3211-3213. [PMID: 35060005 PMCID: PMC9485374 DOI: 10.1007/s11606-021-07357-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/15/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Marlene Martin
- Division of Hospital Medicine, San Francisco General Hospital, San Francisco, CA, USA.
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Joseph Clement
- Department of Nursing, San Francisco General Hospital, San Francisco, CA, USA
| | - Triveni Defries
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Division of General Internal Medicine, San Francisco General Hospital, San Francisco, CA, USA
| | - Anil N Makam
- Division of Hospital Medicine, San Francisco General Hospital, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, USA
- Center for Vulnerable Populations, University of California, San Francisco, San Francisco, USA
| | - Oanh Kieu Nguyen
- Division of Hospital Medicine, San Francisco General Hospital, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, USA
- Center for Vulnerable Populations, University of California, San Francisco, San Francisco, USA
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Suen LW, Makam AN, Snyder HR, Repplinger D, Kushel MB, Martin M, Nguyen OK. National Prevalence of Alcohol and Other Substance Use Disorders Among Emergency Department Visits and Hospitalizations: NHAMCS 2014-2018. J Gen Intern Med 2022; 37:2420-2428. [PMID: 34518978 PMCID: PMC8436853 DOI: 10.1007/s11606-021-07069-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/21/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Acute healthcare utilization attributed to alcohol use disorders (AUD) and other substance use disorders (SUD) is rising. OBJECTIVE To describe the prevalence and characteristics of emergency department (ED) visits and hospitalizations made by adults with AUD or SUD. DESIGN, SETTING, AND PARTICIPANTS Observational study with retrospective analysis of the National Hospital Ambulatory Medical Care Survey (2014 to 2018), a nationally representative survey of acute care visits with information on the presence of AUD or SUD abstracted from the medical chart. MAIN MEASURES Outcome measured as the presence of AUD or SUD. KEY RESULTS From 2014 to 2018, the annual average prevalence of AUD or SUD was 9.4% of ED visits (9.3 million visits) and 11.9% hospitalizations (1.4 million hospitalizations). Both estimates increased over time (30% and 57% relative increase for ED visits and hospitalizations, respectively, from 2014 to 2018). ED visits and hospitalizations from individuals with AUD or SUD, compared to individuals with neither AUD nor SUD, had higher percentages of Medicaid insurance (ED visits: AUD: 33.1%, SUD: 35.0%, neither: 24.4%; hospitalizations: AUD: 30.7%, SUD: 36.3%, neither: 14.8%); homelessness (ED visits: AUD: 6.2%, SUD 4.4%, neither 0.4%; hospitalizations: AUD: 5.9%, SUD 7.3%, neither: 0.4%); coexisting depression (ED visits: AUD: 26.3%, SUD 24.7%, neither 10.5%; hospitalizations: AUD: 33.5%, SUD 35.3%, neither: 13.9%); and injury/trauma (ED visits: AUD: 51.3%, SUD 36.3%, neither: 26.4%; hospitalizations: AUD: 31.8%, SUD: 23.8%, neither: 15.0%). CONCLUSIONS In this nationally representative study, 1 in 11 ED visits and 1 in 9 hospitalizations were made by adults with AUD or SUD, and both increased over time. These estimates are higher or similar than previous national estimates using claims data. This highlights the importance of identifying opportunities to address AUD and SUD in acute care settings in tandem with other medical concerns, particularly among visits presenting with injury, trauma, or coexisting depression.
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Affiliation(s)
- Leslie W Suen
- National Clinician Scholars Program, Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA. .,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Anil N Makam
- Division of Hospital Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA.,University of California, San Francisco Center for Vulnerable Populations, San Francisco, CA, USA.,Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Hannah R Snyder
- Department of Family and Community Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Repplinger
- Department of Emergency Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Margot B Kushel
- University of California, San Francisco Center for Vulnerable Populations, San Francisco, CA, USA
| | - Marlene Martin
- Division of Hospital Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Oanh Kieu Nguyen
- Division of Hospital Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA.,University of California, San Francisco Center for Vulnerable Populations, San Francisco, CA, USA
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Wray CM, Tang J, Shah S, Nguyen OK, Keyhani S. Sociodemographics, Social Vulnerabilities, and Health Factors Associated with Telemedicine Unreadiness Among US Adults. J Gen Intern Med 2022; 37:1811-1813. [PMID: 34331214 PMCID: PMC8324431 DOI: 10.1007/s11606-021-07051-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/15/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Charlie M Wray
- Department of Medicine, University of California, San Francisco, San Francisco, USA.
- Section of Hospital Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
- Section of Hospital Medicine, San Francisco VA Medical Center, CA, San Francisco, USA.
| | - Janet Tang
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Sachin Shah
- Department of Medicine, University of California, San Francisco, San Francisco, USA
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Oanh Kieu Nguyen
- Department of Medicine, University of California, San Francisco, San Francisco, USA
- Division of Hospital Medicine, San Francisco General Hospital, San Francisco, USA
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, San Francisco, USA
- Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, USA
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Bepo L, Makam AN, Nguyen OK. Sodium-Glucose Cotransporter-2 Inhibitors Versus Glucagon-like Peptide-1 Receptor Agonists and the Risk for Cardiovascular Outcomes in Routine Care Patients With Diabetes Across Categories of Cardiovascular Disease. Ann Intern Med 2022; 175:W3. [PMID: 35038403 DOI: 10.7326/l21-0707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Lurit Bepo
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, California
| | - Anil N Makam
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, California
| | - Oanh Kieu Nguyen
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, California
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Sekar DR, Siropaides CH, Smith LN, Nguyen OK. Adapting Existing Resources for Serious Illness Communication Skills Training for Internal Medicine Residents. South Med J 2021; 114:283-287. [PMID: 33942112 DOI: 10.14423/smj.0000000000001247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Goals of care discussions are a vital component of patient care, but Internal Medicine residents receive limited training in these skills. Existing curricula often require simulated patients or faculty development, limiting implementation in many residency programs. Thus, we developed and implemented a curriculum leveraging existing educational resources with the goal of improving resident attitudes and confidence in conducting goals of care discussions in training settings. METHODS We developed cases and a detailed faculty guide for small-group discussion with three exercises to standardize the learner experience and minimize the need for faculty development. Exercises introduced established communication skill frameworks including SPIKES (setting, perception, invitation, knowledge, empathy, summary) and REMAP (reframe, emotion, map, align, propose a plan) for how to break bad news, respond to strong emotions, and conduct a goals of care discussion. Participants were 163 Internal Medicine postgraduate year 1, -2, and -3 residents at a large urban academic institution, where residency-wide curriculum is delivered in weekly half-day didactic sessions during the course of 5 weeks. Primary outcomes were resident self-reported confidence with goals of care communication skills. RESULTS A total of 109 (response rate 67%) of residents reported improvement in overall confidence in goals of care discussion skills (3.6 ± 0.9 vs 4.1 ± 0.6, P < 0.001), responding to emotions (3.5 ± 0.9 vs 3.9 ± 0.6, P = 0.004), making care recommendations (3.5 ± 1.0 vs 3.9 ± 0.7, P < 0.001), and quickly conducting a code status discussion (3.6 ± 1.0 vs 4.0 ± 0.7, P < 0.001). Residents also expressed an increased desire for supervision and feedback to further develop these skills. CONCLUSIONS This goals of care communication curriculum improves resident confidence and requires minimal resources. It may be ideal for programs that have limited access to simulated patients and/or faculty trained in communication skill simulation, but desire enhanced education on this important aspect of patient-doctor communication and high-quality patient care. Future studies measuring clinical outcomes and changes in learner behavior as a result of this intervention are needed. Ongoing observation and feedback on these skills will be important to solidify learning and sustain impact.
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Affiliation(s)
- Dheepa R Sekar
- From the Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, the Division of General Internal Medicine, Section of Palliative Care, University of Texas Southwestern Medical Center, Dallas, the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, and the Division of Hospital Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco
| | - Caitlin H Siropaides
- From the Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, the Division of General Internal Medicine, Section of Palliative Care, University of Texas Southwestern Medical Center, Dallas, the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, and the Division of Hospital Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco
| | - Lauren N Smith
- From the Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, the Division of General Internal Medicine, Section of Palliative Care, University of Texas Southwestern Medical Center, Dallas, the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, and the Division of Hospital Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco
| | - Oanh Kieu Nguyen
- From the Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, the Division of General Internal Medicine, Section of Palliative Care, University of Texas Southwestern Medical Center, Dallas, the Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, and the Division of Hospital Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco
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Makam AN, Nguyen OK, Miller ME, Shah SJ, Kapinos KA, Halm EA. Comparative effectiveness of long-term acute care hospital versus skilled nursing facility transfer. BMC Health Serv Res 2020; 20:1032. [PMID: 33176767 PMCID: PMC7656509 DOI: 10.1186/s12913-020-05847-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background Long-term acute care hospital (LTACH) use varies considerably across the U.S., which may reflect uncertainty about the effectiveness of LTACHs vs. skilled nursing facilities (SNF), the principal post-acute care alternative. Given that LTACHs provide more intensive care and thus receive over triple the reimbursement of SNFs for comparable diagnoses, we sought to compare outcomes and spending between LTACH versus SNF transfer. Methods Using Medicare claims linked to electronic health record (EHR) data from six Texas Hospitals between 2009 and 2010, we conducted a retrospective cohort study of patients hospitalized on a medicine service in a high-LTACH use region and discharged to either an LTACH or SNF and followed for one year. The primary outcomes included mortality, 60-day recovery without inpatient care, days at home, and healthcare spending Results Of 3503 patients, 18% were transferred to an LTACH. Patients transferred to LTACHs were younger (median 71 vs. 82 years), less likely to be female (50.5 vs 66.6%) and white (69.0 vs. 84.1%), but were sicker (24.3 vs. 14.2% for prolonged intensive care unit stay; median diagnosis resource intensity weight of 2.03 vs. 1.38). In unadjusted analyses, patients transferred to an LTACH vs. SNF were less likely to survive (59.1 vs. 65.0%) or recover (62.5 vs 66.0%), and spent fewer days at home (186 vs. 200). Adjusting for demographic and clinical confounders available in Medicare claims and EHR data, LTACH transfer was not significantly associated with differences in mortality (HR, 1.12, 95% CI, 0.94–1.33), recovery (SHR, 1.07, 0.93–1.23), and days spent at home (IRR, 0.96, 0.83–1.10), but was associated with greater Medicare spending ($16,689 for one year, 95% CI, $12,216–$21,162). Conclusion LTACH transfer for Medicare beneficiaries is associated with similar clinical outcomes but with higher healthcare spending compared to SNF transfer. LTACH use should be reserved for patients who require complex inpatient care and cannot be cared for in SNFs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05847-6.
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Affiliation(s)
- Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA. .,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA. .,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, San Francisco, USA.
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, San Francisco, USA.,Division of Hospital Medicine, University Hospital of UCSF, San Francisco, USA
| | - Michael E Miller
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sachin J Shah
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
| | - Kandice A Kapinos
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,RAND Corporation, Arlington, VA, USA
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA
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Saleh SN, Makam AN, Halm EA, Nguyen OK. Can we predict early 7-day readmissions using a standard 30-day hospital readmission risk prediction model? BMC Med Inform Decis Mak 2020; 20:227. [PMID: 32933505 PMCID: PMC7493907 DOI: 10.1186/s12911-020-01248-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite focus on preventing 30-day readmissions, early readmissions (within 7 days of discharge) may be more preventable than later readmissions (8-30 days). We assessed how well a previously validated 30-day EHR-based readmission prediction model predicts 7-day readmissions and compared differences in strength of predictors. METHODS We conducted an observational study on adult hospitalizations from 6 diverse hospitals in North Texas using a 50-50 split-sample derivation and validation approach. We re-derived model coefficients for the same predictors as in the original 30-day model to optimize prediction of 7-day readmissions. We then compared the discrimination and calibration of the 7-day model to the 30-day model to assess model performance. To examine the changes in the point estimates between the two models, we evaluated the percent changes in coefficients. RESULTS Of 32,922 index hospitalizations among unique patients, 4.4% had a 7-day admission and 12.7% had a 30-day readmission. Our original 30-day model had modestly lower discrimination for predicting 7-day vs. any 30-day readmission (C-statistic of 0.66 vs. 0.69, p ≤ 0.001). Our re-derived 7-day model had similar discrimination (C-statistic of 0.66, p = 0.38), but improved calibration. For the re-derived 7-day model, discharge day factors were more predictive of early readmissions, while baseline characteristics were less predictive. CONCLUSION A previously validated 30-day readmission model can also be used as a stopgap to predict 7-day readmissions as model performance did not substantially change. However, strength of predictors differed between the 7-day and 30-day model; characteristics at discharge were more predictive of 7-day readmissions, while baseline characteristics were less predictive. Improvements in predicting early 7-day readmissions will likely require new risk factors proximal to day of discharge.
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Affiliation(s)
- Sameh N. Saleh
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Anil N. Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, USA
- Division of Hospital Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Ethan A. Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, USA
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, USA
- Division of Hospital Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, USA
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Makam AN, Nguyen OK, Halm EA. Reply to Comment on: The Clinical Course After Long-Term Acute Care Hospital Admission Among Older Medicare Beneficiaries. J Am Geriatr Soc 2020; 68:667-668. [PMID: 31903543 DOI: 10.1111/jgs.16317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/12/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Anil N Makam
- Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Oanh Kieu Nguyen
- Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Ethan A Halm
- Department of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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12
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Abstract
Respiratory rate (RR) is a predictor of adverse outcomes. However, RRs are inaccurately measured in the hospital. We conducted a quality improvement (QI) initiative using plan-do-study-act methodology on one inpatient unit of a safety-net hospital to improve RR accuracy. We added time-keeping devices to vital sign carts and retrained patient-care assistants on a newly modified workflow that included concomitant RR measurement during automated blood pressure measurement. The median RR was 18 (interquartile range [IQR] 18-20) preintervention versus 14 (IQR 15-20) postintervention. RR accuracy, defined as ±2 breaths of gold-standard measurements, increased from 36% preintervention to 58% postintervention (P < .01). The median time for vital signs decreased from 2:36 minutes (IQR, 2:04-3:20) to 1:55 minutes (IQR, 1:40-2:22; P < .01). The intervention was associated with a 7.8% reduced incidence of tachypnea-specific systemic inflammatory response syndrome (SIRS = 2 points with RR > 20; 95% CI, -13.5% to -2.2%). Our interdisciplinary, low-cost, low-tech QI initiative improved the accuracy and efficiency of RR measurement.
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Affiliation(s)
- Neil Keshvani
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Corresponding Author: Neil Keshvani, MD; E-mail: ; Telephone: 214-648-2287; Twitter:@NeilKeshvani
| | - Kimberly Berger
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Arjun Gupta
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Sheila DePaola
- Department of Nursing, Parkland Health and Hospital System, Dallas, Texas
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Medicine, Chan Zuckerberg San Francisco General Hospital, University of California, San Francisco, California
| | - Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Medicine, Chan Zuckerberg San Francisco General Hospital, University of California, San Francisco, California
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13
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Makam AN, Tran T, Miller ME, Xuan L, Nguyen OK, Halm EA. The Clinical Course after Long-Term Acute Care Hospital Admission among Older Medicare Beneficiaries. J Am Geriatr Soc 2019; 67:2282-2288. [PMID: 31449686 DOI: 10.1111/jgs.16106] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Long-term acute care (LTAC) hospitals provide extended complex post-acute care to more than 120 000 Medicare beneficiaries annually, with the goal of helping patients to regain independence and recover. Because little is known about patients' long-term outcomes, we sought to examine the clinical course after LTAC admission. DESIGN Nationally representative 5-year cohort study using 5% Medicare data from 2009 to 2013. SETTING LTAC hospitals. PARTICIPANTS Hospitalized Medicare fee-for-service beneficiaries 65 years of age or older who were transferred to an LTAC hospital. MEASUREMENTS Mortality, recovery (defined as achieving 60 consecutive days alive without inpatient care), time spent in an inpatient facility following LTAC hospital admission, receipt of an artificial life-prolonging procedure (feeding tube, tracheostomy, hemodialysis), and palliative care physician consultation. RESULTS Of 14 072 hospitalized older adults transferred to an LTAC hospital, median survival was 8.3 months, and 1- and 5-year survival rates were 45% and 18%, respectively. Following LTAC admission, 53% never achieved a 60-day recovery. The median time of their remaining life a patient spent as an inpatient after LTAC admission was 65.6% (interquartile range = 21.4%-100%). More than one-third (36.9%) died in an inpatient setting, never returning home after the LTAC admission. During the preceding hospitalization and index LTAC admission, 30.9% received an artificial life-prolonging procedure, and 1% had a palliative care physician consultation. CONCLUSION Hospitalized older adults transferred to LTAC hospitals have poor survival, spend most of their remaining life as an inpatient, and frequently undergo life-prolonging procedures. This prognostic understanding is essential to inform goals of care discussions and prioritize healthcare needs for hospitalized older adults admitted to LTAC hospitals. Given the exceedingly low rates of palliative care consultations, future research is needed to examine unmet palliative care needs in this population. J Am Geriatr Soc 67:2282-2288, 2019.
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Affiliation(s)
- Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California San Francisco, Dallas, Texas
| | - Thu Tran
- UT Southwestern Medical School, Dallas, Texas
| | - Michael E Miller
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Lei Xuan
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California San Francisco, Dallas, Texas
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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14
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Smith LN, Makam AN, Darden D, Mayo H, Das SR, Halm EA, Nguyen OK. Acute Myocardial Infarction Readmission Risk Prediction Models: A Systematic Review of Model Performance. Circ Cardiovasc Qual Outcomes 2019; 11:e003885. [PMID: 29321135 DOI: 10.1161/circoutcomes.117.003885] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 12/08/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospitals are subject to federal financial penalties for excessive 30-day hospital readmissions for acute myocardial infarction (AMI). Prospectively identifying patients hospitalized with AMI at high risk for readmission could help prevent 30-day readmissions by enabling targeted interventions. However, the performance of AMI-specific readmission risk prediction models is unknown. METHODS AND RESULTS We systematically searched the published literature through March 2017 for studies of risk prediction models for 30-day hospital readmission among adults with AMI. We identified 11 studies of 18 unique risk prediction models across diverse settings primarily in the United States, of which 16 models were specific to AMI. The median overall observed all-cause 30-day readmission rate across studies was 16.3% (range, 10.6%-21.0%). Six models were based on administrative data; 4 on electronic health record data; 3 on clinical hospital data; and 5 on cardiac registry data. Models included 7 to 37 predictors, of which demographics, comorbidities, and utilization metrics were the most frequently included domains. Most models, including the Centers for Medicare and Medicaid Services AMI administrative model, had modest discrimination (median C statistic, 0.65; range, 0.53-0.79). Of the 16 reported AMI-specific models, only 8 models were assessed in a validation cohort, limiting generalizability. Observed risk-stratified readmission rates ranged from 3.0% among the lowest-risk individuals to 43.0% among the highest-risk individuals, suggesting good risk stratification across all models. CONCLUSIONS Current AMI-specific readmission risk prediction models have modest predictive ability and uncertain generalizability given methodological limitations. No existing models provide actionable information in real time to enable early identification and risk-stratification of patients with AMI before hospital discharge, a functionality needed to optimize the potential effectiveness of readmission reduction interventions.
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Affiliation(s)
- Lauren N Smith
- From the Department of Internal Medicine (L.N.S., A.N.M., S.R.D., E.A.H., O.K.N.), Department of Clinical Sciences (A.N.M., E.A.H., O.K.N.), and Health Sciences Digital Library and Learning Center (H.M.), UT Southwestern Medical Center, Dallas, TX; and Department of Internal Medicine, University of California San Diego, La Jolla (D.D.)
| | - Anil N Makam
- From the Department of Internal Medicine (L.N.S., A.N.M., S.R.D., E.A.H., O.K.N.), Department of Clinical Sciences (A.N.M., E.A.H., O.K.N.), and Health Sciences Digital Library and Learning Center (H.M.), UT Southwestern Medical Center, Dallas, TX; and Department of Internal Medicine, University of California San Diego, La Jolla (D.D.)
| | - Douglas Darden
- From the Department of Internal Medicine (L.N.S., A.N.M., S.R.D., E.A.H., O.K.N.), Department of Clinical Sciences (A.N.M., E.A.H., O.K.N.), and Health Sciences Digital Library and Learning Center (H.M.), UT Southwestern Medical Center, Dallas, TX; and Department of Internal Medicine, University of California San Diego, La Jolla (D.D.)
| | - Helen Mayo
- From the Department of Internal Medicine (L.N.S., A.N.M., S.R.D., E.A.H., O.K.N.), Department of Clinical Sciences (A.N.M., E.A.H., O.K.N.), and Health Sciences Digital Library and Learning Center (H.M.), UT Southwestern Medical Center, Dallas, TX; and Department of Internal Medicine, University of California San Diego, La Jolla (D.D.)
| | - Sandeep R Das
- From the Department of Internal Medicine (L.N.S., A.N.M., S.R.D., E.A.H., O.K.N.), Department of Clinical Sciences (A.N.M., E.A.H., O.K.N.), and Health Sciences Digital Library and Learning Center (H.M.), UT Southwestern Medical Center, Dallas, TX; and Department of Internal Medicine, University of California San Diego, La Jolla (D.D.)
| | - Ethan A Halm
- From the Department of Internal Medicine (L.N.S., A.N.M., S.R.D., E.A.H., O.K.N.), Department of Clinical Sciences (A.N.M., E.A.H., O.K.N.), and Health Sciences Digital Library and Learning Center (H.M.), UT Southwestern Medical Center, Dallas, TX; and Department of Internal Medicine, University of California San Diego, La Jolla (D.D.)
| | - Oanh Kieu Nguyen
- From the Department of Internal Medicine (L.N.S., A.N.M., S.R.D., E.A.H., O.K.N.), Department of Clinical Sciences (A.N.M., E.A.H., O.K.N.), and Health Sciences Digital Library and Learning Center (H.M.), UT Southwestern Medical Center, Dallas, TX; and Department of Internal Medicine, University of California San Diego, La Jolla (D.D.).
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15
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Affiliation(s)
- Ross C Schumacher
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Oanh Kieu Nguyen
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Anil N Makam
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
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16
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas.,Department of Medicine, University of California, San Francisco, San Francisco
| | - Anil N Makam
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas.,Department of Medicine, University of California, San Francisco, San Francisco
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17
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Abstract
This study assesses whether American Thoracic Society clinical practice guidelines are substantiated by high-quality evidence and can be used to promote evidence-based medicine.
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Affiliation(s)
- Ross C Schumacher
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas.,Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Kaivalya Deshpande
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Anil N Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas.,Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
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18
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Nguyen OK, Vazquez MA, Charles L, Berger JR, Quiñones H, Fuquay R, Sanders JM, Kapinos KA, Halm EA, Makam AN. Association of Scheduled vs Emergency-Only Dialysis With Health Outcomes and Costs in Undocumented Immigrants With End-stage Renal Disease. JAMA Intern Med 2019; 179:175-183. [PMID: 30575859 PMCID: PMC6439652 DOI: 10.1001/jamainternmed.2018.5866] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In 40 of 50 US states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease (ESRD); instead, they receive intermittent emergency-only dialysis to treat life-threatening manifestations of ESRD. However, the comparative effectiveness of scheduled dialysis vs emergency-only dialysis and the influence of treatment on health outcomes, utilization, and costs is uncertain. OBJECTIVE To compare the effectiveness of scheduled vs emergency-only dialysis with regard to health outcomes, utilization, and costs in undocumented immigrants with ESRD. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of 181 eligible adults with ESRD receiving emergency-only dialysis in Dallas, Texas, who became newly eligible and applied for private commercial health insurance in February 2015; 105 received coverage and were enrolled in scheduled dialysis; 76 were not enrolled in insurance for nonclinical reasons (eg, lack of capacity at a participating outpatient dialysis center) and remained uninsured, receiving emergency-only dialysis. We examined data on eligible persons during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015) until 12 months after enrollment (follow-up period, March 1, 2015-February 29, 2016), with an intervening 1-month washout period (February 2015). All participants were undocumented immigrants; self-reported data on immigration status was collected from Parkland Hospital electronic health records. EXPOSURES Enrollment in private health insurance coverage and scheduled dialysis. MAIN OUTCOMES AND MEASURES We used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score-adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs. RESULTS Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis. Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P = .001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P = .03), adjusted emergency department visits (-5.2 vs +1.1 visits/mo; DiD, -6.2; P < .001), adjusted hospitalizations (-2.1 vs -0.5 hospitalizations/6 months; DiD, -1.6; P < .001), adjusted hospital days (-9.2 vs +0.8 days/6 months; DiD, -9.9; P = .007), and adjusted costs (-$4316 vs +$1452 per person per month; DiD, -$5768; P < .001). CONCLUSIONS AND RELEVANCE In this study, scheduled dialysis was significantly associated with reduced 1-year mortality, health care utilization, and costs compared with emergency-only dialysis. Scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Miguel A Vazquez
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | - Joseph R Berger
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Henry Quiñones
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | - Joanne M Sanders
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | | | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Anil N Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
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Makam AN, Nguyen OK, Kirby B, Miller ME, Xuan L, Halm EA. Effect of Site-Neutral Payment Policy on Long-Term Acute Care Hospital Use. J Am Geriatr Soc 2018; 66:2104-2111. [PMID: 30281783 DOI: 10.1111/jgs.15539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/20/2018] [Accepted: 06/27/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the projected effect of the Centers for Medicare and Medicaid Services new site-neutral payment policy, which aims to decrease unnecessary long-term acute care hospital (LTACH) admissions by reducing reimbursements for less-ill individuals by 2020. DESIGN Observational. SETTING National 5% Medicare data (2011-12). MEASUREMENTS We examined the proportion of site-neutral LTACH admissions. Regional LTACH market supply was defined as LTACH beds per 100,000 residents, categorized according to tertile. We conducted a hospital-level analysis to compare the projected effect of site-neutral payment on "propensity score" matched high- and low-LTACH-use hospitals. RESULTS Forty-one percent of LTACH admissions would be subjected to site-neutral payment. The proportion of site-neutral admissions was large, varied considerably according to LTACH (median 40%, interquartile range 22-60%), and was only modestly greater with greater market supply (Pearson correlation coefficient=0.23, p<.001; coefficient of determination=0.10). The site-neutral payment policy would affect 47% of admissions from the highest-supply regions, versus 30% from the lowest-supply regions (p<.001); and 43% from high-use hospitals versus 36% from propensity score-matched low-use hospitals (p<.001). CONCLUSION A considerable proportion of LTACH admissions will be subjected to lower site-neutral payments. Although the policy will disproportionately affect high-use regions and hospitals, it will also affect nearly one-third of the current LTACH population from low-use hospitals and regions. As such, the site-neutral payment policy may limit LTACH access in existing LTAC-scarce markets, with potential adverse implications for recovery of hospitalized older adults. J Am Geriatr Soc 66:2104-2111, 2018.
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Affiliation(s)
- Anil N Makam
- Departments of Internal Medicine, Dallas, Texas.,Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Oanh Kieu Nguyen
- Departments of Internal Medicine, Dallas, Texas.,Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Benjamin Kirby
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Michael E Miller
- Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lei Xuan
- Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ethan A Halm
- Departments of Internal Medicine, Dallas, Texas.,Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
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20
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Makam AN, Nguyen OK, Xuan L, Miller ME, Halm EA. Long-Term Acute Care Hospital Use of Non-Mechanically Ventilated Hospitalized Older Adults. J Am Geriatr Soc 2018; 66:2112-2119. [PMID: 30295927 DOI: 10.1111/jgs.15564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To determine why non-mechanically ventilated hospitalized older adults are transferred to long-term acute care (LTAC) hospitals rather than remaining in the hospital. DESIGN Observational cohort. SETTING National Medicare data. PARTICIPANTS Non-mechanically ventilated hospitalized adults aged 65 and older with fee-for-service Medicare in 2012 who were transferred to an LTAC hospital (n=1,831) or had a prolonged hospitalization without transfer (average hospital length of stay or longer of those transferred to an LTAC hospital) and had one of the 50 most common hospital diagnoses leading to LTAC transfer (N=12,875). MEASUREMENTS We assessed predictors of transfer using a multilevel model, adjusting for patient-, hospital-, and hospital referral region (HRR)-level factors. We estimated proportions of variance at each level and adjusted hospital- and HRR-specific LTAC transfer rates using sequential models. RESULTS The strongest predictor of transfer was being hospitalized near an LTAC hospital (<1.4 vs > 33.6 miles, adjusted odds ratio=6.2, 95% confidence interval (CI)=4.2-9.1). After adjusting for case mix, differences between hospitals explained 15.4% of the variation in LTAC use and differences between regions explained 27.8%. Case mix-adjusted LTAC use was high in the South, where many HRRs had rates between 20.3% and 53.1%, whereas many HRRs were less than 5.4% in the Pacific Northwest, North, and New England. From our fully adjusted model, the median adjusted hospital LTAC transfer rate was 7.2% (interquartile range 2.8-17.5%), with substantial within-region variation (intraclass coefficient=0.25, 95% CI=0.21-0.30). CONCLUSIONS Nearly half of the variation in LTAC use is independent of illness severity and is explained by which hospital and what region the individual was hospitalized in. Because of the greater fragmentation of care and Medicare spending with LTAC transfers (because LTAC hospitals generate a separate bundled payment from the hospital), greater attention is needed to define the optimal role of LTAC hospitals in caring for older adults. J Am Geriatr Soc 66:2112-2119, 2018.
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Affiliation(s)
- Anil N Makam
- Departments of Internal Medicine.,Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Oanh Kieu Nguyen
- Departments of Internal Medicine.,Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lei Xuan
- Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael E Miller
- Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ethan A Halm
- Departments of Internal Medicine.,Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
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21
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Affiliation(s)
- Anil N Makam
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Oanh Kieu Nguyen
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Ethan A Halm
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
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22
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Nguyen OK, Makam AN, Clark C, Zhang S, Das SR, Halm EA. Predicting 30-Day Hospital Readmissions in Acute Myocardial Infarction: The AMI "READMITS" (Renal Function, Elevated Brain Natriuretic Peptide, Age, Diabetes Mellitus , Nonmale Sex , Intervention with Timely Percutaneous Coronary Intervention, and Low Systolic Blood Pressure) Score. J Am Heart Assoc 2018; 7:e008882. [PMID: 29666065 PMCID: PMC6015397 DOI: 10.1161/jaha.118.008882] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/19/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Readmissions after hospitalization for acute myocardial infarction (AMI) are common. However, the few currently available AMI readmission risk prediction models have poor-to-modest predictive ability and are not readily actionable in real time. We sought to develop an actionable and accurate AMI readmission risk prediction model to identify high-risk patients as early as possible during hospitalization. METHODS AND RESULTS We used electronic health record data from consecutive AMI hospitalizations from 6 hospitals in north Texas from 2009 to 2010 to derive and validate models predicting all-cause nonelective 30-day readmissions, using stepwise backward selection and 5-fold cross-validation. Of 826 patients hospitalized with AMI, 13% had a 30-day readmission. The first-day AMI model (the AMI "READMITS" score) included 7 predictors: renal function, elevated brain natriuretic peptide, age, diabetes mellitus, nonmale sex, intervention with timely percutaneous coronary intervention, and low systolic blood pressure, had an optimism-corrected C-statistic of 0.73 (95% confidence interval, 0.71-0.74) and was well calibrated. The full-stay AMI model, which included 3 additional predictors (use of intravenous diuretics, anemia on discharge, and discharge to postacute care), had an optimism-corrected C-statistic of 0.75 (95% confidence interval, 0.74-0.76) with minimally improved net reclassification and calibration. Both AMI models outperformed corresponding multicondition readmission models. CONCLUSIONS The parsimonious AMI READMITS score enables early prospective identification of high-risk AMI patients for targeted readmissions reduction interventions within the first 24 hours of hospitalization. A full-stay AMI readmission model only modestly outperformed the AMI READMITS score in terms of discrimination, but surprisingly did not meaningfully improve reclassification.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Christopher Clark
- Office of Research Administration, Parkland Health & Hospital System, Dallas, TX
| | - Song Zhang
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Sandeep R Das
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
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23
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA. .,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA. .,, 5323 Harry Hines Blvd., Dallas, TX, 75390-9169, USA.
| | - Robin T Higashi
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Juan C Mijares
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Simon Craddock Lee
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
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Makam AN, Nguyen OK, Xuan L, Miller ME, Goodwin JS, Halm EA. Factors Associated With Variation in Long-term Acute Care Hospital vs Skilled Nursing Facility Use Among Hospitalized Older Adults. JAMA Intern Med 2018; 178:399-405. [PMID: 29404575 PMCID: PMC5840036 DOI: 10.1001/jamainternmed.2017.8467] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Despite providing an overlapping level of care, it is unknown why hospitalized older adults are transferred to long-term acute care hospitals (LTACs) vs less costly skilled nursing facilities (SNFs) for postacute care. OBJECTIVE To examine factors associated with variation in LTAC vs SNF transfer among hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS We conducted this retrospective observational cohort study of hospitalized older adults (≥65 years) transferred to an LTAC vs SNF during fiscal year 2012 using national 5% Medicare data. MAIN OUTCOMES AND MEASURES Predictors of LTAC transfer were assessed using a multilevel mixed-effects model adjusting for patient-, hospital-, and region-level factors. We estimated variation partition coefficients and adjusted hospital- and region-specific LTAC transfer rates using sequential models. RESULTS Among 65 525 hospitalized older adults (42 461 [64.8%] women; 39 908 [60.9%] ≥85 years) transferred to an LTAC or SNF, 3093 (4.7%) were transferred to an LTAC. We identified 29 patient-, 3 hospital-, and 5 region-level independent predictors. The strongest predictors of LTAC transfer were receiving a tracheostomy (adjusted odds ration [aOR], 23.8; 95% CI, 15.8-35.9) and being hospitalized in close proximity to an LTAC (0-2 vs >42 miles; aOR, 8.4, 95% CI, 6.1-11.5). After adjusting for case-mix, differences between patients explained 52.1% (95% CI, 47.7%-56.5%) of the variation in LTAC use. The remainder was attributable to hospital (15.0%; 95% CI, 12.3%-17.6%), and regional differences (32.9%; 95% CI, 27.6%-38.3%). Case-mix adjusted LTAC use was very high in the South (17%-37%) compared with the Pacific Northwest, North, and Northeast (<2.2%). From the full multilevel model, the median adjusted hospital LTAC transfer rate was 2.1% (10th-90th percentile, 0.24%-10.8%). Even within a region, adjusted hospital LTAC transfer rates varied substantially (intraclass correlation coefficient [ICC], 0.26; 95% CI, 0.23-0.30). CONCLUSIONS AND RELEVANCE Although many patient-level factors were associated with LTAC use, half of the variation in LTAC vs SNF transfer is independent of patients' illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region, with far greater use in the South. Even among hospitals in regions with similar LTAC access, there was considerable variation in LTAC use. Given the higher expense associated with LTACs vs SNFs, greater attention is needed to define the optimal role of LTACs in the postacute care of older adults.
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Affiliation(s)
- Anil N Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Lei Xuan
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Michael E Miller
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - James S Goodwin
- Department of Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
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Nguyen OK, Makam AN. What Are the Opportunity Costs of Self-Financing Medical Education? Acad Med 2017; 92:1655. [PMID: 29210740 DOI: 10.1097/acm.0000000000001974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Oanh Kieu Nguyen
- Assistant professor, Departments of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas; ORCID: http://orcid.org/0000-0002-4614-0215; . Assistant professor, Departments of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas; ORCID: http://orcid.org/0000-0001-7072-9946
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Keshvani N, Berger K, Nguyen OK, Makam AN. Roadmap for improving the accuracy of respiratory rate measurements. BMJ Qual Saf 2017; 27:e5. [PMID: 29122976 DOI: 10.1136/bmjqs-2017-007516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Neil Keshvani
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kimberly Berger
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Anil N Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Badawy J, Nguyen OK, Clark C, Halm EA, Makam AN. Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults. BMJ Qual Saf 2017; 26:832-836. [PMID: 28652259 DOI: 10.1136/bmjqs-2017-006671] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/16/2017] [Accepted: 05/21/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Respiratory rate (RR) is an independent predictor of adverse outcomes and an integral component of many risk prediction scores for hospitalised adults. Yet, it is unclear if RR is recorded accurately. We sought to assess the potential accuracy of RR by analysing the distribution and variation as a proxy, since RR should be normally distributed if recorded accurately. METHODS We conducted a descriptive observational study of electronic health record data from consecutive hospitalisations from 2009 to 2010 from six diverse hospitals. We assessed the distribution of the maximum RR on admission, using heart rate (HR) as a comparison since this is objectively measured. We assessed RR patterns among selected subgroups expected to have greater physiological variation using the coefficient of variation (CV=SD/mean). RESULTS Among 36 966 hospitalisations, recorded RR was not normally distributed (p<0.001), but right skewed (skewness=3.99) with values clustered at 18 and 20 (kurtosis=23.9). In contrast, HR was relatively normally distributed. Patients with a cardiopulmonary diagnosis or hypoxia only had modestly greater variation (CV increase of 2%-6%). Among 1318 patients transferred from the ward to the intensive care unit (n=1318), RR variation the day preceding transfer was similar to that observed on admission (CV 0.24 vs 0.26), even for those transferred with respiratory failure (CV 0.25). CONCLUSIONS The observed patterns suggest that RR is inaccurately recorded, even among those with cardiopulmonary compromise, and represents a 'spot' estimate with values of 18 and 20 breaths per minute representing 'normal.' While spot estimates may potentially be adequate to indicate clinical stability, inaccurate RR may alternatively lead to misclassification of disease severity, potentially jeopardising patient safety. Thus, we recommend greater training for hospital personnel to accurately record RR.
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Affiliation(s)
- Jack Badawy
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Anil N Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Abstract
BACKGROUND Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the electronic health record (EHR) may improve prediction. OBJECTIVE To develop pneumonia-specific readmission risk-prediction models using EHR data from the first day and from the entire hospital stay ("full stay"). DESIGN Observational cohort study using stepwise-backward selection and cross-validation. SUBJECTS Consecutive pneumonia hospitalizations from 6 diverse hospitals in north Texas from 2009-2010. MEASURES All-cause nonelective 30-day readmissions, ascertained from 75 regional hospitals. RESULTS Of 1463 patients, 13.6% were readmitted. The first-day pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index; the full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay pneumonia-specific model outperformed the first-day model (C statistic 0.731 vs 0.695; P = 0.02; net reclassification index = 0.08). Compared to a validated multi-condition readmission model, the Centers for Medicare and Medicaid Services pneumonia model, and 2 commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C statistic range 0.604-0.681; P < 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18). CONCLUSIONS EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day pneumonia-specific model, the Centers for Medicare and Medicaid Services pneumonia model, and 2 commonly used pneumonia severity of illness scores. Journal of Hospital Medicine 2017;12:209-216.
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Affiliation(s)
- Anil N. Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- Address for correspondence and reprint requests: Anil N. Makam, MD, MAS; 5323 Harry Hines Blvd., Dallas, TX, 75390-9169; Telephone: 214-648-3272; Fax: 214-648-3232;
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Clark
- Office of Research Administration, Parkland Health and Hospital System, Dallas, Texas
| | - Song Zhang
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bin Xie
- Parkland Center for Clinical Innovation, Dallas, Texas
| | - Mark Weinreich
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric M. Mortensen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- VA North Texas Health Care System, Dallas, Texas
| | - Ethan A. Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
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Pruitt SL, Leonard T, Xuan L, Amory R, Higashi RT, Nguyen OK, Pezzia C, Swales S. Who Is Food Insecure? Implications for Targeted Recruitment and Outreach, National Health and Nutrition Examination Survey, 2005-2010. Prev Chronic Dis 2016; 13:E143. [PMID: 27736055 PMCID: PMC5063607 DOI: 10.5888/pcd13.160103] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Food insecurity is negatively associated with health; however, health needs may differ among people participating in food assistance programs. Our objectives were to characterize differences in health among people receiving different types of food assistance and summarize strategies for targeted recruitment and outreach of various food insecure populations. Methods We examined health status, behaviors, and health care access associated with food insecurity and receipt of food assistance among US adults aged 20 years or older using data from participants (N = 16,934) of the National Health and Nutrition Examination Survey from 2005 through 2010. Results Food insecurity affected 19.3% of US adults (95% confidence interval, 17.9%–20.7%). People who were food insecure reported poorer health and less health care access than those who were food secure (P < .001 for all). Among those who were food insecure, 58.0% received no assistance, 20.3% received only Supplemental Nutrition Assistance Program (SNAP) benefits, 9.7% received only food bank assistance, and 12.0% received both SNAP and food bank assistance. We observed an inverse relationship between receipt of food assistance and health and health behaviors among the food insecure. Receipt of both (SNAP and food bank assistance) was associated with the poorest health; receiving no assistance was associated with the best health. For example, functional limitations were twice as prevalent among people receiving both types of food assistance than among those receiving none. Conclusion Receipt of food assistance is an overlooked factor associated with health and has the potential to shape future chronic disease prevention efforts among the food insecure.
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Affiliation(s)
- Sandi L Pruitt
- Department of Clinical Sciences, University of Texas Southwestern Medical Center and Harold C. Simmons Cancer Center, 5323 Harry Hines Blvd, Dallas, TX 75390.
| | | | - Lei Xuan
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Richard Amory
- The Hunger Center, North Texas Food Bank, Dallas, Texas
| | - Robin T Higashi
- University of Texas Southwestern Medical Center, Dallas, Texas
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas2Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas2Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas2Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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Affiliation(s)
- Anil N Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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Nguyen OK, Makam AN, Clark C, Zhang S, Xie B, Velasco F, Amarasingham R, Halm EA. Predicting all-cause readmissions using electronic health record data from the entire hospitalization: Model development and comparison. J Hosp Med 2016; 11:473-80. [PMID: 26929062 PMCID: PMC5365027 DOI: 10.1002/jhm.2568] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/15/2016] [Accepted: 01/28/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Incorporating clinical information from the full hospital course may improve prediction of 30-day readmissions. OBJECTIVE To develop an all-cause readmissions risk-prediction model incorporating electronic health record (EHR) data from the full hospital stay, and to compare "full-stay" model performance to a "first day" and 2 other validated models, LACE (includes Length of stay, Acute [nonelective] admission status, Charlson Comorbidity Index, and Emergency department visits in the past year), and HOSPITAL (includes Hemoglobin at discharge, discharge from Oncology service, Sodium level at discharge, Procedure during index hospitalization, Index hospitalization Type [nonelective], number of Admissions in the past year, and Length of stay). DESIGN Observational cohort study. SUBJECTS All medicine discharges between November 2009 and October 2010 from 6 hospitals in North Texas, including safety net, teaching, and nonteaching sites. MEASURES Thirty-day nonelective readmissions were ascertained from 75 regional hospitals. RESULTS Among 32,922 admissions (validation = 16,430), 12.7% were readmitted. In addition to many first-day factors, we identified hospital-acquired Clostridium difficile infection (adjusted odds ratio [AOR]: 2.03, 95% confidence interval [CI]: 1.18-3.48), vital sign instability on discharge (AOR: 1.25, 95% CI: 1.15-1.36), hyponatremia on discharge (AOR: 1.34, 95% CI: 1.18-1.51), and length of stay (AOR: 1.06, 95% CI: 1.04-1.07) as significant predictors. The full-stay model had better discrimination than other models though the improvement was modest (C statistic 0.69 vs 0.64-0.67). It was also modestly better in identifying patients at highest risk for readmission (likelihood ratio +2.4 vs. 1.8-2.1) and in reclassifying individuals (net reclassification index 0.02-0.06). CONCLUSIONS Incorporating clinically granular EHR data from the full hospital stay modestly improves prediction of 30-day readmissions. Given limited improvement in prediction despite incorporation of data on hospital complications, clinical instabilities, and trajectory, our findings suggest that many factors influencing readmissions remain unaccounted for. Further improvements in readmission models will likely require accounting for psychosocial and behavioral factors not currently captured by EHRs. Journal of Hospital Medicine 2016;11:473-480. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Oanh Kieu Nguyen
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Anil N Makam
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | | | - Song Zhang
- Division of Biostatistics, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Bin Xie
- Parkland Center for Clinical Innovation (PCCI), Dallas, Texas
| | | | - Ruben Amarasingham
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
- Parkland Center for Clinical Innovation (PCCI), Dallas, Texas
| | - Ethan A Halm
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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Nguyen OK, Halm EA, Makam AN. Relationship between hospital financial performance and publicly reported outcomes. J Hosp Med 2016; 11:481-8. [PMID: 26929094 PMCID: PMC5362822 DOI: 10.1002/jhm.2570] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/13/2016] [Accepted: 02/03/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hospitals that have robust financial performance may have improved publicly reported outcomes. OBJECTIVES To assess the relationship between hospital financial performance and publicly reported outcomes of care, and to assess whether improved outcome metrics affect subsequent hospital financial performance. DESIGN Observational cohort study. SETTING AND PATIENTS Hospital financial data from the Office of Statewide Health Planning and Development in California in 2008 and 2012 were linked to data from the Centers for Medicare and Medicaid Services Hospital Compare website. MEASUREMENTS Hospital financial performance was measured by net revenue by operations, operating margin, and total margin. Outcomes were 30-day risk-standardized mortality and readmission rates for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PNA). RESULTS Among 279 hospitals, there was no consistent relationship between measures of financial performance in 2008 and publicly reported outcomes from 2008 to 2011 for AMI and PNA. However, improved hospital financial performance (by any of the 3 measures) was associated with a modest increase in CHF mortality rates (ie, 0.26% increase in CHF mortality rate for every 10% increase in operating margin [95% confidence interval: 0.07%-0.45%]). Conversely, there were no significant associations between outcomes from 2008 to 2011 and subsequent financial performance in 2012 (P > 0.05 for all). CONCLUSIONS Robust financial performance is not associated with improved publicly reported outcomes for AMI, CHF, and PNA. Financial incentives in addition to public reporting, such as readmissions penalties, may help motivate hospitals with robust financial performance to further improve publicly reported outcomes. Reassuringly, improved mortality and readmission rates do not necessarily lead to loss of revenue. Journal of Hospital Medicine 2016;11:481-488. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
- Address for correspondence and reprint requests: Oanh Kieu Nguyen, MD, 5323 Harry Hines Blvd., Dallas, Texas 75390-9169; Telephone: 214-648-3135; Fax: 214-648-3232;
| | - Ethan A. Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Anil N. Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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Fontil V, Bibbins-Domingo K, Nguyen OK, Guzman D, Goldman LE. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians' Offices. Health Serv Res 2016; 52:807-825. [PMID: 27283354 DOI: 10.1111/1475-6773.12516] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To examine adherence to guideline-concordant hypertension treatment practices at community health centers (CHCs) compared with private physicians' offices. DATA SOURCES/STUDY SETTING National Ambulatory Medical Care Survey from 2006 to 2010. STUDY DESIGN We examined four guideline-concordant treatment practices: initiation of a new medication for uncontrolled hypertension, use of fixed-dose combination drugs for patients on multiple antihypertensive medications, use of thiazide diuretics among patients with uncontrolled hypertension on ≥3 antihypertensive medications, and use of aldosterone antagonist for resistant hypertension, comparing use at CHC with private physicians' offices overall and by payer group. DATA COLLECTION/EXTRACTION METHODS We identified visits of nonpregnant adults with hypertension at CHCs and private physicians' offices. PRINCIPAL FINDINGS Medicaid patients at CHCs were as likely as privately insured individuals to receive a new medication for uncontrolled hypertension (AOR 1.0, 95 percent CI: 0.6-1.9), whereas Medicaid patients at private physicians' offices were less likely to receive a new medication (AOR 0.3, 95 percent CI: 0.1-0.6). Use of fixed-dose combination drugs was lower at CHCs (AOR 0.6, 95 percent CI: 0.4-0.9). Thiazide use for patients was similar in both settings (AOR 0.8, 95 percent CI: 0.4-1.7). Use of aldosterone antagonists was too rare (2.1 percent at CHCs and 1.5 percent at private clinics) to allow for statistically reliable comparisons. CONCLUSIONS Increasing physician use of fixed-dose combination drugs may be particularly helpful in improving hypertension control at CHCs where there are higher rates of uncontrolled hypertension.
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Affiliation(s)
- Valy Fontil
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA.,UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA
| | - Kirsten Bibbins-Domingo
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA.,UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Oanh Kieu Nguyen
- Divisions of General Internal Medicine and Outcomes and Health Services Research, UT Southwestern, Dallas, TX
| | - David Guzman
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Lauren Elizabeth Goldman
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
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Nguyen OK, Makam AN, Halm EA. National Use of Safety-Net Clinics for Primary Care among Adults with Non-Medicaid Insurance in the United States. PLoS One 2016; 11:e0151610. [PMID: 27027617 PMCID: PMC4814117 DOI: 10.1371/journal.pone.0151610] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 03/01/2016] [Indexed: 11/19/2022] Open
Abstract
Objective To describe the prevalence, characteristics, and predictors of safety-net use for primary care among non-Medicaid insured adults (i.e., those with private insurance or Medicare). Methods Cross-sectional analysis using the 2006–2010 National Ambulatory Medical Care Surveys, annual probability samples of outpatient visits in the U.S. We estimated national prevalence of safety-net visits using weighted percentages to account for the complex survey design. We conducted bivariate and multivariate logistic regression analyses to examine characteristics associated with safety-net clinic use. Results More than one-third (35.0%) of all primary care safety-net clinic visits were among adults with non-Medicaid primary insurance, representing 6,642,000 annual visits nationally. The strongest predictors of safety-net use among non-Medicaid insured adults were: being from a high-poverty neighborhood (AOR 9.53, 95% CI 4.65–19.53), being dually eligible for Medicare and Medicaid (AOR 2.13, 95% CI 1.38–3.30), and being black (AOR 1.97, 95% CI 1.06–3.66) or Hispanic (AOR 2.28, 95% CI 1.32–3.93). Compared to non-safety-net users, non-Medicaid insured adults who used safety-net clinics had a higher prevalence of diabetes (23.5% vs. 15.0%, p<0.001), hypertension (49.4% vs. 36.0%, p<0.001), multimorbidity (≥2 chronic conditions; 53.5% vs. 40.9%, p<0.001) and polypharmacy (≥4 medications; 48.8% vs. 34.0%, p<0.001). Nearly one-third (28.9%) of Medicare beneficiaries in the safety-net were dual eligibles, compared to only 6.8% of Medicare beneficiaries in non-safety-net clinics (p<0.001). Conclusions Safety net clinics are important primary care delivery sites for non-Medicaid insured minority and low-income populations with a high burden of chronic illness. The critical role of safety-net clinics in care delivery is likely to persist despite expanded insurance coverage under the Affordable Care Act.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, United States of America
- * E-mail:
| | - Anil N. Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, United States of America
| | - Ethan A. Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, United States of America
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Affiliation(s)
- Purav Mody
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas2Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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Nguyen OK, Chan CV, Makam A, Stieglitz H, Amarasingham R. Envisioning a social-health information exchange as a platform to support a patient-centered medical neighborhood: a feasibility study. J Gen Intern Med 2015; 30:60-7. [PMID: 25092009 PMCID: PMC4284262 DOI: 10.1007/s11606-014-2969-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 06/26/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Social determinants directly contribute to poorer health, and coordination between healthcare and community-based resources is pivotal to addressing these needs. However, our healthcare system remains poorly equipped to address social determinants of health. The potential of health information technology to bridge this gap across the delivery of healthcare and social services remains unrealized. OBJECTIVE, DESIGN, AND PARTICIPANTS We conducted in-depth, in-person interviews with 50 healthcare and social service providers to determine the feasibility of a social-health information exchange (S-HIE) in an urban safety-net setting in Dallas County, Texas. After completion of interviews, we conducted a town hall meeting to identify desired functionalities for a S-HIE. APPROACH We conducted thematic analysis of interview responses using the constant comparative method to explore perceptions about current communication and coordination across sectors, and barriers and enablers to S-HIE implementation. We sought participant confirmation of findings and conducted a forced-rank vote during the town hall to prioritize potential S-HIE functionalities. KEY RESULTS We found that healthcare and social service providers perceived a need for improved information sharing, communication, and care coordination across sectors and were enthusiastic about the potential of a S-HIE, but shared many technical, legal, and ethical concerns around cross-sector information sharing. Desired technical S-HIE functionalities encompassed fairly simple transactional operations such as the ability to view basic demographic information, visit and referral data, and medical history from both healthcare and social service settings. CONCLUSIONS A S-HIE is an innovative and feasible approach to enabling better linkages between healthcare and social service providers. However, to develop S-HIEs in communities across the country, policy interventions are needed to standardize regulatory requirements, to foster increased IT capability and uptake among social service agencies, and to align healthcare and social service priorities to enable dissemination and broader adoption of this and similar IT initiatives.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 9169, Dallas, TX, 75390-9169, USA,
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Nguyen OK, Kruger J, Greysen SR, Lyndon A, Goldman LE. Understanding how to improve collaboration between hospitals and primary care in postdischarge care transitions: a qualitative study of primary care leaders' perspectives. J Hosp Med 2014; 9:700-6. [PMID: 25211608 DOI: 10.1002/jhm.2257] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 08/13/2014] [Accepted: 08/25/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND There is limited collaboration between hospitals and primary care despite parallel efforts to improve postdischarge care transitions. OBJECTIVE To understand what primary care leaders perceived as barriers and facilitators to collaboration with hospitals. METHODS Qualitative study with in-depth, semistructured interviews of 22 primary care leaders in 2012 from California safety-net clinics. RESULTS Major barriers to collaboration included lack of institutional financial incentives for collaboration, competing priorities (e.g., regulatory requirements, strained clinic capacity, financial strain) and mismatched expectations about role and capacity of primary care to improve care transitions. Facilitators included relationship building through interpersonal networking and improving communication and information transfer via electronic health record (EHR) implementation. CONCLUSIONS Efforts to improve care transitions should focus on aligning financial incentives, standardizing regulations around EHR interoperability and data sharing, and enhancing opportunities for interpersonal networking.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Nguyen OK, Tang N, Hillman JM, Gonzales R. What's cost got to do with it? Association between hospital costs and frequency of admissions among "high users" of hospital care. J Hosp Med 2013; 8:665-71. [PMID: 24173680 DOI: 10.1002/jhm.2096] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 09/12/2013] [Accepted: 09/25/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Efforts to curb healthcare spending have included interventions that target frequently hospitalized individuals. It is unclear the extent to which the most frequently hospitalized individuals also represent the costliest individuals. OBJECTIVE To examine the relationship between 2 types of "high users" commonly targeted in cost-containment interventions-those incurring the highest hospital costs ("high cost") and those incurring the highest number of hospitalizations ("high admit"). DESIGN, SETTING, AND PATIENTS Cross-sectional study of 2566 individuals with a primary care physician and at least 1 hospitalization within an academic health system from 2010 to 2011. MEASUREMENTS Overlap between the population constituting the top decile of hospital costs and the population constituting the top decile of hospitalizations; characteristics of the 3 resulting high user subgroups. RESULTS Only 48% of individuals who were high cost (>$65,000) were also high admit (≥ 3 hospitalizations). Compared to hospitalizations incurred by high cost-high admit individuals (n = 605), hospitalizations incurred by high cost-low admit individuals (n = 206) were more likely to be for surgical procedures (58 vs 22%, P < 0.001), had a higher cost ($68,000 vs $28,000, P < 0.001), longer length of stay (10 vs 5 days, P < 0.001), and were less likely to be a 30-day readmission (17 vs 47%, P < 0.001). CONCLUSIONS Stratifying high admit individuals by costs and high cost individuals by hospitalizations yields 3 distinct high user subgroups with important differences in clinical characteristics and utilization patterns. Consideration of these distinct subgroups may lead to better-tailored interventions and achieve greater cost savings.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
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Cepeda C, André VM, Flores-Hernández J, Nguyen OK, Wu N, Klapstein GJ, Nguyen S, Koh S, Vinters HV, Levine MS, Mathern GW. Pediatric Cortical Dysplasia: Correlations between Neuroimaging, Electrophysiology and Location of Cytomegalic Neurons and Balloon Cells and Glutamate/GABA Synaptic Circuits. Dev Neurosci 2005; 27:59-76. [PMID: 15886485 DOI: 10.1159/000084533] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2004] [Accepted: 11/08/2004] [Indexed: 11/19/2022] Open
Abstract
Seizures in cortical dysplasia (CD) could be from cytomegalic neurons and balloon cells acting as epileptic 'pacemakers', or abnormal neurotransmission. This study examined these hypotheses using in vitro electrophysiological techniques to determine intrinsic membrane properties and spontaneous glutamatergic and GABAergic synaptic activity for normal-pyramidal neurons, cytomegalic neurons and balloon cells from 67 neocortical sites originating from 43 CD patients (ages 0.2-14 years). Magnetic resonance imaging (MRI), (18)fluoro-2-deoxyglucose positron emission tomography (FDG-PET) and electrocorticography graded cortical sample sites from least to worst CD abnormality. Results found that cytomegalic neurons and balloon cells were observed more frequently in areas of severe CD compared with mild or normal CD regions as assessed by FDG-PET/MRI. Cytomegalic neurons (but not balloon cells) correlated with the worst electrocorticography scores. Electrophysiological recordings demonstrated that cytomegalic and normal-pyramidal neurons displayed similar firing properties without intrinsic bursting. By contrast, balloon cells were electrically silent. Normal-pyramidal and cytomegalic neurons displayed decreased spontaneous glutamatergic synaptic activity in areas of severe FDG-PET/MRI abnormalities compared with normal regions, while GABAergic activity was unaltered. In CD, these findings indicate that cytomegalic neurons (but not balloon cells) might contribute to epileptogenesis, but are not likely to be 'pacemaker' cells capable of spontaneous paroxysmal depolarizations. Furthermore, there was more GABA relative to glutamate synaptic neurotransmission in areas of severe CD. Thus, in CD tissue alternate mechanisms of epileptogenesis should be considered, and we suggest that GABAergic synaptic circuits interacting with cytomegalic and normal-pyramidal neurons with immature receptor properties might contribute to seizure generation.
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Affiliation(s)
- C Cepeda
- Division of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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