A Fully Integrated Infectious Diseases and Antimicrobial Stewardship Telehealth Service Improves Staphylococcus aureus Bacteremia Bundle Adherence and Outcomes in 16 Small Community Hospitals.

Background: Infectious diseases (ID) and antimicrobial stewardship (AS) improve Staphylococcus aureus bacteremia (SAB) outcomes. However, many small community hospitals (SCHs) lack on-site access to these services, and it is not known if ID telehealth (IDt) offers the same benefit for SAB. We evaluated the impact of an integrated IDt service on SAB outcomes in 16 SCHs. Methods: An IDt service offering IDt physician consultation plus IDt pharmacist surveillance was implemented in October 2016. Patients treated for SAB in 16 SCHs between January 2009 and August 2019 were identified for review. We compared SAB bundle adherence and outcomes between patients with and without an IDt consult (IDt group and control group, respectively). Results: A total of 423 patients met inclusion criteria: 157 in the IDt group and 266 in the control group. Baseline characteristics were similar between groups. Among patients completing their admission at an SCH, IDt consultation increased SAB bundle adherence (79% vs 23%; odds ratio [OR], 16.9; 95% CI, 9.2-31.0). Thirty-day mortality and 90-day SAB recurrence favored the IDt group, but the differences were not statistically significant (5% vs 9%; P = .2; and 2% vs 6%; P = .09; respectively). IDt consultation significantly decreased 30-day SAB-related readmissions (9% vs 17%; P = .045) and increased length of stay (median [IQR], 5 [5-8] days vs 5 [3-7] days; P = .04). In a subgroup of SAB patients with a controllable source, IDt appeared to have a mortality benefit (2% vs 9%; OR, 0.12; 95% CI, 0.01-0.98). Conclusions: An integrated ID/AS telehealth service improved SAB management and outcomes at 16 SCHs. These findings provide important insights for other IDt programs.

Video Teleconferencing for Disease Prevention, Diagnosis, and Treatment : A Rapid Review.

BACKGROUND: Video teleconferencing (VTC) as a substitute for in-person health care or as an adjunct to usual care has increased in recent years. PURPOSE: To assess the benefits and harms of VTC visits for disease prevention, diagnosis, and treatment and to develop an evidence map describing gaps in the evidence. DATA SOURCES: Systematically searched PubMed, EMBASE, Web of Science, and the Cochrane Library from 1 January 2013 to 3 March 2021. STUDY SELECTION: Two investigators independently screened the literature and identified 38 randomized controlled trials (RCTs) meeting inclusion criteria. DATA EXTRACTION: Data abstraction by a single investigator was confirmed by a second investigator; 2 investigators independently rated risk of bias. DATA SYNTHESIS: Results from 20 RCTs rated low risk of bias or some concerns of bias show that the use of VTC for the treatment and management of specific diseases produces largely similar outcomes when used to replace or augment usual care. Nine of 12 studies where VTC was intended to replace usual care and 5 of 8 studies where VTC was intended to augment usual care found similar effects between the intervention and control groups. The remaining 6 included studies (3 intended to replace usual care and 3 intended to augment usual care) found 1 or more primary outcomes that favored the VTC group over the usual care group. Studies comparing VTC with usual care that did not involve in-person care were more likely to favor the VTC group. No studies evaluated the use of VTC for diagnosis or prevention of disease. Studies that reported harms found no differences between the intervention and control groups; however, many studies did not report harms. No studies evaluated the effect of VTC on health equity or disparities. LIMITATIONS: Studies that focused on mental health, substance use disorders, maternal care, and weight management were excluded. Included studies were limited to RCTs with sample sizes of 50 patients or greater. Component analyses were not conducted in the studies. CONCLUSION: Replacing or augmenting aspects of usual care with VTC generally results in similar clinical effectiveness, health care use, patient satisfaction, and quality of life as usual care for areas studied. However, included trials were limited to a handful of disease categories, with patients seeking care for a limited set of purposes. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Implementation and Outcomes of a Telehealth Neonatology Program in a Single Healthcare System.

Background: Intermountain Healthcare, an early adopter and champion for newborn video-assisted resuscitation (VAR), identified a reduction in facility-level transfers and an estimated savings of $1. 2 million in potentially avoided transfers in a 2018 study. This study was conducted to increase understanding of VAR at the individual, newborn level. Study Aim: To compare transfers to a newborn intensive care unit (NICU), length of stay (LOS), and days of life on oxygen between newborns managed by neonatal VAR and those receiving standard care (SC). Methods: This retrospective, nonequivalent group study includes infants born in an Intermountain hospital between 2013 and 2017, 34 weeks gestation or greater, and requiring oxygen support in the first 15 minutes of life. Data came from billing and clinical records from Intermountain's enterprise data warehouse and chart reviews. We used logistic regression to estimate neonatal VAR's impact on transfers. Negative binomial regression estimated the impact on LOS and days of life on supplemental oxygen. Results: The VAR intervention was used in 46.2 percent of post-implementation cases and is associated with (1) a 12 percentage points reduction in the transfer rate, p = 0.02, (2) a reduction in spoke hospital (SH) LOS of 8.33 h (p < 0.01) for all transfers; (3) a reduction in SH LOS of 2.21 h (p < 0.01) for newborns transferred within 24 h; (4) a reduction in SH LOS of 17.85 h (p = 0.06) among non-transferred newborns; (5) a reduction in days of life on supplemental oxygen of 1.4 days (p = 0.08) among all transferred newborns, and (6) a reduction in days of life on supplemental oxygen of 0.41 days (p = 0.04) among non-transferred newborns. Conclusion: This study provides evidence that neonatal VAR improves care quality and increases local hospitals' capabilities to keep patients close to home. There is an ongoing demand for support to rural and community hospitals for urgent newborn resuscitations, and complex, mandatory NICU transfers. Efforts may be necessary to encourage neonatal VAR since the intervention was only used in 46.2 percent of this study's potential cases. Additional work is needed to understand the short- and long-term impacts of Neonatal VAR on health outcomes.

Virtual vs traditional care settings for low-acuity urgent conditions: An economic analysis of cost and utilization using claims data.

BACKGROUND: On-demand, direct-to-consumer video (or virtual) visits represent one of the fastest growing telemedicine services. Due to the absence of an in-person physical examination, some question the effectiveness, efficiency and value of virtual care visits. To address these questions, we conducted a retrospective, cross-sectional review of Intermountain Healthcare's virtual care programme. METHOD: This study used SelectHealth claims for virtual, urgent, primary and emergency care delivered between 1 April 2016-31 March 2017. We included all claims with primary diagnosis from the nine most common categories for virtual care. A secondary data source included survey data indicating how virtual visits redirect care. RESULTS: We matched 1531 virtual visit claims with claims from urgent (4377), primary (4388) and emergency care (2285). There were no differences in follow-up rates between virtual and urgent care and no differences in antibiotic use between virtual and urgent or primary care. Virtual care was significantly lower than all other care settings in utilization of laboratory and imaging services, index visit cost and total costs over 21 days. CONCLUSIONS: This study affirmed lower cost for virtual care without an associated increase in overall follow-up rates or antibiotic use when compared with urgent or primary care. This suggests that virtual visits are can be used to lower the total cost of care for applicable conditions. The implications are that virtual visits help lower operational costs of providing care, particularly in integrated systems with capitated reimbursement. Under the right circumstances, the increased adoption of virtual care should lead to greater savings.

The role of psychological safety and learning behavior in the development of effective quality improvement teams in Ghana: an observational study.

BACKGROUND: As lower-income countries look to develop a mature healthcare workforce and to improve quality and reduce costs, they are increasingly turning to quality improvement (QI), a widely-used strategy in higher-income countries. Although QI is an effective strategy for promoting evidence-based practices, QI interventions often fail to deliver desired results. This failure may reflect a problem with implementation. As the key implementing unit of QI, teams are critical for the success or failure of QI efforts. Thus, we used the model of work-team learning to identify factors related to the effectiveness of newly-formed hospital-based QI teams in Ghana. METHODS: This was a cross-sectional, observational study. We used structural equation modeling to estimate relationships between coaching-oriented team leadership, perceived support for teamwork, team psychological safety, team learning behavior, and QI implementation. We used an observer-rated measure of QI implementation, our outcome of interest. Team-level factors were measured using aggregated survey data from 490 QI team members, resulting in a sample size of 122 teams. We assessed model fit and tested significance of standardized parameters, including direct and indirect effects. RESULTS: Learning behavior mediated a positive relationship between psychological safety and QI implementation (ß = 0.171, p = 0.001). Psychological safety mediated a positive relationship between team leadership and learning behavior (ß = 0.384, p = 0.068). Perceived support for teamwork did not have a significant effect on psychological safety or learning behavior. CONCLUSIONS: Psychological safety and learning behavior are key for the success of newly formed QI teams working in lower-income countries. Organizational leaders and implementation facilitators should consider these leverage points as they work to establish an environment where QI and other team-based activities are supported and encouraged.

The Effect Of The Hospital Readmissions Reduction Program On Readmission And Observation Stay Rates For Heart Failure.

The Hospital Readmissions Reduction Program reduces Medicare prospective payments for hospitals with excess readmissions for selected diagnoses. By comparing data for patients who were readmitted or placed on observation status immediately before and immediately after the thirty-day cutoff for penalties, we sought to determine whether hospitals have responded to the program by shifting readmissions for heart failure to observation status. We used regression discontinuity, taking advantage of the cutoff to generate unbiased estimates of treatment effects. Overall, we found no evidence that the program has affected the use of observation stays. However, for nonpenalized hospitals, the use of observation status was 5.4 percent higher for patients returning to the hospital immediately before the thirty-day cutoff than for patients returning immediately after the cutoff, which suggests that some hospitals may have used observation status to help avoid penalties. Because differences in the cost-sharing rules may lead to higher out-of-pocket expenses for Medicare patients placed on observation status, the program could have an inequitable financial impact.

Contextual factors that influence quality improvement implementation in primary care: The role of organizations, teams, and individuals.

BACKGROUND: Recent emphasis on value-based health care has highlighted the importance of quality improvement (QI) in primary care settings. QI efforts, which require providers and staff to work in cross-functional teams, may be implemented with varying levels of success, with implementation being affected by factors at the organizational, teamwork, and individual levels. PURPOSE: The purpose of our study was to (a) identify contextual factors (organizational, teamwork, and individual) that affect implementation effectiveness of QI interventions in primary care settings and (b) compare perspectives about these factors across roles (health care administrators, physician and nonphysician clinicians, and administrative staff). METHODS/APPROACH: We conducted semistructured interviews with 24 health care administrators, physician and nonphysician primary care providers, and administrative staff representing 10 primary care practices affiliated with one integrated delivery system. RESULTS: Participants across all roles identified similar organizational- and team-level factors that influence QI implementation including organizational capacity to take on new initiatives (e.g., time availability of physicians), technical capability for QI (e.g., data analysis skills), and team climate (e.g., how well staff work together). There was greater variation in terms of individual-level factors, particularly perceived meaning and purpose of QI. Perceptions about value of QI ranged from positive impacts on patient care and practice competitiveness to decreased efficiency and distractions from patient care, but differences did not appear attributable to role. CONCLUSIONS: Successful QI implementation requires effective collaboration within cross-functional teams. Additional research is needed to assess how best to employ implementation strategies that promote cross-understanding of QI among team members and, ultimately, effective implementation of QI programs. PRACTICE IMPLICATIONS: Health care managers in primary care settings should strive to create a strong teamwork climate, reinforced by opportunities for staff in various roles to discuss QI as a collective.

The Effect Of A Newborn Telehealth Program On Transfers Avoided: A Multiple-Baseline Study.

Clinicians who rarely perform neonatal resuscitation exhibit skill deterioration. Telehealth addresses this challenge by facilitating video connections between neonatologists at tertiary care centers and providers at smaller hospitals. However, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation. Thus, we conducted a multiple-baseline study to evaluate the effect of video-assisted resuscitation on the transfer of newborns from eight community hospitals that implemented neonatal telehealth in the period November 2014-December 2015 to level 3 newborn intensive care units. The intervention was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn's odds of being transferred. Annually, this corresponds to 67.2 fewer transfers and an estimated savings of $1,220,352 per year. Avoiding transfers keeps families closer to home, increases community hospital revenue, and eliminates transfer-associated risk. Yet lack of reimbursement for telehealth limits its adoption. Policy changes are necessary to align payment incentives and promote the use of telehealth services.

The Effect of the Hospital Readmission Reduction Program on the Duration of Observation Stays: Using Regression Discontinuity to Estimate Causal Effects.

RESEARCH OBJECTIVE: Determine whether hospitals are increasing the duration of observation stays following index admission for heart failure to avoid potential payment penalties from the Hospital Readmission Reduction Program. STUDY DESIGN: The Hospital Readmission Reduction Program applies a 30-day cutoff after which readmissions are no longer penalized. Given this seemingly arbitrary cutoff, we use regression discontinuity design, a quasi-experimental research design that can be used to make causal inferences. POPULATION STUDIED: The High Value Healthcare Collaborative includes member healthcare systems covering 57% of the nation's hospital referral regions. We used Medicare claims data including all patients residing within these regions. The study included patients with index admissions for heart failure from January 1, 2012 to June 30, 2015 and a subsequent observation stay within 60 days. We excluded hospitals with fewer than 25 heart failure readmissions in a year or fewer than 5 observation stays in a year and patients with subsequent observation stays at a different hospital. PRINCIPAL FINDINGS: Overall, there was no discontinuity at the 30-day cutoff in the duration of observation stays, the percent of observation stays over 12 hours, or the percent of observation stays over 24 hours. In the sub-analysis, the discontinuity was significant for non-penalized. CONCLUSION: The findings reveal evidence that the HRRP has resulted in an increase in the duration of observation stays for some non-penalized hospitals.

Quality improvement teams, super-users, and nurse champions: a recipe for meaningful use?

OBJECTIVE: This study assessed whether having an electronic health record (EHR) super-user, nurse champion for meaningful use (MU), and quality improvement (QI) team leading MU implementation is positively associated with MU Stage 1 demonstration. METHODS: Data on MU demonstration of 596 providers in 37 ambulatory care clinics came from the clinical data warehouse and administrative systems of UNC Health Care. We surveyed the 37 clinics about champions, super-users, and QI teams. We used generalized estimating equation methods with an independence working correlation matrix to account for clustering within clinics and to weight contributions from each clinic according to clinic size. RESULTS: Having a QI team lead MU implementation was significantly associated with MU demonstration (odds ratio, OR = 3.57, 95% CI, 1.83-6.96, P < .001, Table 2). Having neither a nurse champion nor an EHR super-user was significant. CONCLUSION: Our findings support the alignment of MU with QI efforts by having the QI team lead MU implementation.

Measuring Fidelity and Adaptation: Reliability of a Instrument for School-Based Prevention Programs.

There is a need to standardize methods for assessing fidelity and adaptation. Such standardization would allow program implementation to be examined in a manner that will be useful for understanding the moderating role of fidelity in dissemination research. This article describes a method for collecting data about fidelity of implementation for school-based prevention programs, including measures of adherence, quality of delivery, dosage, participant engagement, and adaptation. We report about the reliability of these methods when applied by four observers who coded video recordings of teachers delivering All Stars, a middle school drug prevention program. Interrater agreement for scaled items was assessed for an instrument designed to evaluate program fidelity. Results indicated sound interrater reliability for items assessing adherence, dosage, quality of teaching, teacher understanding of concepts, and program adaptations. The interrater reliability for items assessing potential program effectiveness, classroom management, achievement of activity objectives, and adaptation valences was improved by dichotomizing the response options for these items. The item that assessed student engagement demonstrated only modest interrater reliability and was not improved through dichotomization. Several coder pairs were discordant on items that overall demonstrated good interrater reliability. Proposed modifications to the coding manual and protocol are discussed.

Styles of Adaptation: The Impact of Frequency and Valence of Adaptation on Preventing Substance Use.

Purpose: To be effective, evidence-based programs should be delivered as prescribed. This suggests that adaptations that deviate from intervention goals may limit a program's effectiveness. This study examines the impact that number and quality of adaptations have on substance use outcomes. Design: We examined 306 video recordings of teachers delivering 'All Stars', a middle school drug prevention program. Multiple observers coded each recording, noting the number and type of adaptation each teacher made. Each adaptation was given a valence rating. Adaptations that were deleterious to program goals received negative valence ratings; positive ratings were given for adaptations that were likely to facilitate achievement of program goals; neutral ratings were given to adaptations that were expected to have neither a positive nor negative impact on program goals. Findings: All teachers made adaptations. Teachers were consistent across time in the types of adaptations they made, suggesting each teacher has a personalized style of adapting. Those who made few adaptations, and whose average adaptation was rated as being positive had a higher percentage of students who remained non-drug users. In contrast, teachers who made many adaptations, whether their average valence rating was positive, neutral or negative, failed to have as many students remain non-drug users. Measures of fidelity, including quality of delivery and teacher understanding were related to valence of adaptations, with better performance related to making positive adaptations. Practical Implications: Through training and supervision, teachers should be guided and encouraged to follow programs directions, making few adaptations and ensuring that adaptations that are made advance the goals of intervention. Programs should define acceptable and unacceptable ways they may be adapted. Value: This study provides significant evidence about the challenges that face disseminated evidence-based programs.