Impact of care coordination based on insurance and zip code.

OBJECTIVES: To examine whether a care transitions program, Bridges, differentially reduced rehospitalizations among patients who underwent percutaneous coronary intervention (PCI) based on insurance status and zip code poverty level. STUDY DESIGN: Retrospective observational cohort. METHODS: We examined data from a single health system in Delaware, collected as part of a care transitions program for patients who underwent PCI from 2012 to 2015 compared with an unmatched historical control cohort from 2010 to 2011. Socioeconomic status was assessed by insurance status and zip code-level poverty data. Patients were divided into tertiles based on the proportion of their zip code of residence living under 100% of the federal poverty level. Rehospitalization rates were analyzed by negative binomial regression and included interaction terms to examine differential effects of Bridges by insurance and poverty level. RESULTS: There were 4638 patients representing 5710 hospitalizations: 3212 in the historical control and 2498 in the Bridges cohort. Among patients with Medicaid who received the Bridges intervention, those living in the wealthiest zip codes were 15.5% less likely to be rehospitalized than patients with Medicare and 9.4% less likely than patients with commercial insurance (P = .04). However, patients with Medicaid who lived in the poorest zip codes and those with dual Medicare/Medicaid status had higher rates of rehospitalization post intervention. CONCLUSIONS: The Bridges intervention was associated with improved rehospitalization rates for Medicaid patients compared with those with Medicare or commercial insurance within Delaware's wealthier communities. Care transitions programs may differentially affect Medicaid patients based on the wealth of the communities in which they reside.

Patient Satisfaction with Care After Coronary Revascularization.

OBJECTIVE: Bridging the Divides (Bridges), a Centers for Medicare and Medicaid Services-funded program, developed a post-hospitalization care management infrastructure integrating information technology-enabled informatics with patient care for ischemic heart disease patients. The objective of this study was to assess patient satisfaction with the Bridges program and determine the patient characteristics associated with higher satisfaction. METHODS: All adult English-speaking patients who underwent a percutaneous coronary intervention, coronary artery bypass grafting, or catheterization plus acute myocardial infarction and agreed to participate in the Bridges program were eligible. A survey instrument was administered to address patient satisfaction of care received, aspects of care that patients appreciated, and challenges faced. Descriptive statistics were calculated, and primary analyses included comparisons of overall patient satisfaction after discharge between procedure type, and according to age, sex, race, Elixhauser comorbidity count, and length of stay. RESULTS: Four hundred and sixty-seven (46%) had complete or partial response rates. There was a statistically significant difference in the overall satisfaction among patients undergoing percutaneous coronary intervention, coronary artery bypass grafting, or catheterization plus acute myocardial infarction (p = 0.023). There were significant procedure by sex (p = 0.052) and procedure by age (p = 0.039) interactions. There were no statistically significant differences in overall satisfaction according to age, sex, race, comorbidity count, or length of stay. CONCLUSIONS: This study identified several important components related to patient satisfaction for patients with ischemic heart disease. Results found that patients who underwent coronary artery bypass grafting were reportedly "very satisfied" when compared with patients who underwent percutaneous coronary intervention and catheterization plus acute myocardial infarction, as well as significant age and sex interactions between procedures.

Primary Care Provider Perspectives on Electronic Medication Refill History.

Improvements in health information technology have made aggregate multipayer pharmacy claims data increasingly available through the electronic health record (EHR). The objective of this study was to assess the current awareness, utilization, and impact of pharmacy history data available in the EHR on primary care provider (PCP) decision making. A 14-question survey was distributed to all PCPs in a large medical practice. Of the 55/72 responding PCPs, 47 (85.5%) were aware of the EHR medication history function, and 36 (65.5%) had used it previously. Respondents indicated the medication history could be most useful when considering prescribing a narcotic (33/36, 92%) and when addressing nonadherence concerns (28/35, 80%). Barriers included delays in data loading and the time pressures of clinical practice. Access to aggregate multipayer pharmacy history data has the potential to affect medication reconciliation, yet future implementation should focus on making these data complete and easily available in routine practice.

Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: A systematic review and suggested taxonomy.

BACKGROUND: Interdisciplinary rounds (IDR) have been described to improve outcomes. However, there is limited understanding of optimal IDR design. PURPOSE: To systematically review published reports of IDR to catalog types of IDR and outcomes, and assess the influence of IDR design on outcomes. DATA SOURCES: Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Journals Ovid, Cumulative Index to Nursing and Allied Health Literature (EBSCOhost), and PubMed from 1990 through December 2014, and hand searching of article bibliographies. STUDY SELECTION: Experimental, quasiexperimental, and observation studies in English-language literature where physicians rounded with another healthcare professional in inpatient medicine units. DATA EXTRACTION: Studies were abstracted for study setting and characteristics, and design and outcomes of IDR. DATA SYNTHESIS: Twenty-two studies were included in the qualitative analysis. Many were of low to medium quality with few high-quality studies. There is no clear definition of IDR in the literature. There was wide variation in IDR design and team composition across studies. We found three different models of IDR: pharmacist focused, bedside rounding, and interdisciplinary team rounding. There are reasonable data to support an association with length of stay and staff satisfaction but little data on patient safety or satisfaction. Positive outcomes may be related to particular components of IDR design, but the relationship between design and outcomes remains unclear. CONCLUSIONS: Future studies should be more deliberately designed and fully reported with careful attention to team composition and features of IDR and their impact on selected outcomes. We present a proposed IDR definition and taxonomy for future studies. Journal of Hospital Medicine 2016;11:513-523. © 2016 Society of Hospital Medicine.

Is the Care Transitions Measure Associated with Readmission Risk? Analysis from a Single Academic Center.

BACKGROUND: It is widely hypothesized that improvement in transitions of care will reduce unplanned hospital readmissions. However, the association between the Care Transitions Measure, the national quality metric for transitions of care and readmission risk, has not been established. OBJECTIVE: We aimed to determine the association between the Care Transition Measure and readmission. DESIGN: This was a single-center, prospective cohort study. PARTICIPANTS: Convenience sample of 2,963 patients enrolled in the "Bridging the Divides" program, a longitudinal care management program for patients with coronary revascularization, from 2013 to 2014. Of these, 1594 (54 %) patients completed a post-discharge Care Transition Measure questionnaire. INTERVENTION: Care Transition Measure scores were collected by trained research staff blinded to study hypothesis, by telephone, within 30 days of discharge. Higher Care Transition Measure scores reflect a higher quality transition of care. MAIN MEASURES: 30-day readmission was measured. KEY RESULTS: Of the1594 patients that completed the Care Transition Measure survey, 1216 (76 %) received percutaneous coronary intervention and 378 (24 %) received coronary artery bypass grafting. Mean Care Transition Measure scores were significantly lower among patients who had a prior admission (77.2 vs. 82.1, p < 0.001) and those with ≥ 5 comorbidities (77 vs. 82.6 vs. 81.6, p < 0.001). Mean scores were significantly lower among patients who were readmitted within the percutaneous coronary intervention subgroup (73 vs. 80.9, p < 0.001) and the total study population (74.6 vs. 81.1, p < 0.001) compared to those who were not readmitted. This was not the case in the coronary artery bypass grafting subgroup (78.5 vs. 81.7, p = 0.29). After multivariable adjustment, every ten-point increase in the Care Transition Measure score was associated with a 14 % reduction in readmission risk (adjusted odds ratio 0.86, 95 % CI 0.78-0.95). CONCLUSIONS: The Care Transition Measure is strongly associated with readmissions, which strengthens its validity. However, its association with patient variables linked with readmission and its inconsistent association with readmission across clinical groups raises concerns that scores may be influenced by patient characteristics.

An Interdepartmental Care Model to Expedite Admission from the Emergency Department to the Medical ICU.

BACKGROUND: Early evidence suggests that multidisciplinary programs designed to expedite transfer from the emergency department (ED) may decrease boarding times. However, few models exist that provide effective ways to improve the ED- to-ICU transition process. In 2012 Christiana Care Health System (Newark, Delaware) created and implemented an interdepartmental program designed to expedite the transition of care from the ED to the medical ICU (MICU). METHODS: This quasi-experimental study compared ED length of stay (LOS), MICU LOS, and overall hospital LOS before and after the MICU Alert Team (MAT) intervention program. The MAT consisted of a MICU nurse and physician assistant, with oversight by a MICU attending physician. The ED triggered the MAT after patients were stabilized and determined to require MICU admission. Following bedside face-to-face hand off, the MAT providers then assumed responsibly of a patient's care. If no MICU bed was available, the MAT cared for patients in the ED until they were transferred to the MICU. RESULTS: ED LOS was reduced by 30% (2.6 hours) from baseline (p < .001). There were no significant differences in MICU LOS (p = .26), overall hospital LOS (p = .43), or mortality (p = .59). ED LOS was shortened (p < .001) at each increasing level of MICU bed availability (31% when 0 MICU beds available; 26% when 1 or more MICU beds available). Time series analysis identified a 1.5-hour drop in ED LOS (p = .02) for patients transferred from the MICU immediately following intervention implementation and was sustained over time. CONCLUSION: Early outcomes demonstrate that the MAT intervention can reduce ED LOS for critically ill patients. Additional studies should determine optimal approaches to improve clinical outcomes.

Usefulness of pharmacy claims for medication reconciliation in primary care.

OBJECTIVES: Methods for efficient medication reconciliation are increasingly important in primary care. Aggregated pharmacy data within the native electronic health record (EHR) may create a new opportunity for efficient and systematic medication reconciliation in practice. Our objective was to identify the prevalence and predictors of medication discrepancies between pharmacy claims data and the medication list in a primary care EHR. STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective cohort study of patients prescribed a new antihypertensive in a large primary care practice network between January 2011 and September 2012. We compared patients' active medications recorded in the practice EHR with those listed in pharmacy claims data available through the EHR. The primary outcome was the presence of a medication discrepancy. RESULTS: Of 609 patients, 468 (76.9%) had at least 1 medication discrepancy. Significant predictors of discrepancies included the total medication count (odds ratio [OR], 2.18; 95% CI, 1.85-2.57) and having a recent emergency department visit (OR, 2.58; 95% CI, 1.03-6.45). The identified discrepancies included 171 patients (28.1%) with 229 controlled substance discrepancies. CONCLUSIONS: Our study revealed a high rate of discrepancies between pharmacy claims data and the provider medication list. Aggregated pharmacy claims data available through the EHR may be an important tool to facilitate medication reconciliation in primary care.

Effect of hospitalist workload on the quality and efficiency of care.

IMPORTANCE: Hospitalist physicians face increasing pressure to maximize productivity, which may undermine the efficiency and quality of care. OBJECTIVE: To determine the association between hospitalist workload and the efficiency and quality of inpatient care. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective cohort study of 20,241 admissions of inpatients cared for by a private hospitalist group at a large academic community hospital system between February 1, 2008, and January 31, 2011. EXPOSURES: Daily hospitalist workload as measured by relative value units and patient encounters from the hospitalist billing records. MAIN OUTCOMES AND MEASURES: The main outcomes were length of stay (LOS), cost, rapid response team activation, in-hospital mortality, patient satisfaction, and 30-day readmission rates. Key covariates included hospital occupancy and patient-level characteristics. RESULTS: The LOS increased as workload increased, particularly at lower hospital occupancy. For hospital occupancies less than 75%, LOS increased from 5.5 to 7.5 days as workload increased. For occupancies of 75% to 85%, LOS increased exponentially above a daily relative value unit of approximately 25 and a census value of approximately 15. At high occupancy (>85%), LOS was J-shaped, with significant increases at higher ranges of workload. After controlling for LOS, cost increased by $111 for each 1-unit increase in relative value unit and $205 for each 1-unit increase in census across the range of values. Changes in workload were not associated with the remaining outcomes. CONCLUSIONS AND RELEVANCE: Increasing hospitalist workload is associated with clinically meaningful increases in LOS and cost. Although our findings should be validated in different clinical settings, our results suggest the need for methods to mitigate the potential negative effects of increased hospitalist workload on the efficiency and cost of care.

Managing hypertension in urban underserved subjects using telemedicine--a clinical trial.

BACKGROUND: We evaluated an Internet- and telephone-based telemedicine system for reducing blood pressure (BP) in underserved subjects with hypertension. METHODS: A total of 241 patients with systolic BP ≥140 mm Hg were randomized to usual care (C; n = 121) or telemedicine (T; n = 120). The T group reported BP, heart rate, weight, steps/day, and tobacco use twice weekly. The primary outcome was BP control at 6 months. RESULTS: Average age was 59.6 years, average body mass index was 33.7 kg/m(2), 79% were female, 81% were African American, 15% were white, 53% were at or below the federal poverty level, 18% were smokers, and 32% had diabetes. Six-month follow-up was achieved in 206 subjects (C: 107, T: 99). Goal BP was achieved in 52.3% in C and 54.5% in T (P = .43). Systolic BP change (C: -13.9 mm Hg, T: -18.2; P = .118) was similar in both groups. Subjects in the T group reported BP 7.7 ± 6.9 d/mo. Results were not affected by age, sex, ethnicity, education, or income. In nondiabetic T subjects, goal BP was achieved in 58.2% compared with 45.2% of diabetic T subjects (P = .024). Nondiabetic T subjects demonstrated a greater reduction in systolic BP (T: -19 ± 20 mm Hg, C: -12 ± 19 mm Hg; P = .037). No difference in BP response between C and T was noted in patients with diabetes. CONCLUSION: In hypertensive subjects, engagement in a system of care with or without telemedicine resulted in significant BP reduction. Telemedicine for nondiabetic patients resulted in a greater reduction in systolic BP compared with usual care. Telemedicine may be a useful tool for managing hypertension particularly among nondiabetic subjects.

Patient-centered outcomes of a value-based insurance design program for patients with diabetes.

Value-based insurance design (VBID) initiatives have been associated with modest improvements in adherence based on evaluations of administrative claims data. The objective of this prospective cohort study was to report the patient-centered outcomes of a VBID program that eliminated co-payments for diabetes-related medications and supplies for employees and dependents with diabetes at a large health system. The authors compared self-reported values of medication adherence, cost-related nonadherence, health status, and out-of-pocket health care costs for patients before and 1 year after program implementation. Clinical metrics and satisfaction with the program also are reported. In all, 188 patients completed the follow-up evaluation. Overall, patients reported a significant reduction in monthly out-of-pocket costs (P<0.001), which corresponded to a significant reduction in cost-related nonadherence from 41% to 17.5% (P<0.001). Self-reported medication adherence increased for hyperglycemic medications (P=0.011), but there were no apparent changes in glycemic control. Overall, 89% of participants agreed that the program helped them take better care of their diabetes. The authors found that a VBID program for employees and dependents with diabetes was associated with self-reported reductions in cost-related nonadherence and improvements in medication adherence. Importantly, the program was associated with high levels of satisfaction among participants and strongly perceived by participants to facilitate medication utilization and self-management for diabetes. These findings suggest that VBID programs can accomplish the anticipated goals for medication utilization and are highly regarded by participants. Patient-centered outcomes should be included in VBID evaluations to allow decision makers to determine the true impact of VBID programs on participants.

Economic outcome of cardiac CT-based evaluation and standard of care for suspected acute coronary syndrome in the emergency department: a decision analytic model.

RATIONALE AND OBJECTIVES: Cardiac computed tomography (CCT) in the emergency department may be cost saving for suspected acute coronary syndrome (ACS), but economic outcome data are limited. The objective of this study was to compare the cost of CCT-based evaluation versus standard of care (SOC) using the results of a clinical trial. MATERIALS AND METHODS: We developed a decision analytic cost-minimization model to compare CCT-based and SOC evaluation costs to obtain a correct diagnosis. Model inputs, including Medicare-adjusted patient costs, were primarily obtained from a cohort study of 102 patients at low to intermediate risk for ACS who underwent an emergency department SOC clinical evaluation and a 64-channel CCT. SOC costs included stress testing in 77% of patients. Data from published literature completed the model inputs and expanded data ranges for sensitivity analyses. RESULTS: Modeled mean patient costs for CCT-based evaluation were $750 (24%) lower than the SOC ($2384 and $3134, respectively). Sensitivity analyses indicated that CCT was less expensive over a wide range of estimates and was only more expensive with a CCT specificity below 67% or if more than 44% of very low risk patients had CCT. Probabilistic sensitivity analysis suggested that CCT-based evaluation had a 98.9% probability of being less expensive compared to SOC. CONCLUSION: Using a decision analytic model, CCT-based evaluation resulted in overall lower cost than the SOC for possible ACS patients over a wide range of cost and outcome assumptions, including computed tomography-related complications and downstream costs.

Systemic barriers to diabetes management in primary care: a qualitative analysis of Delaware physicians.

Primary care providers deliver the majority of care for patients with diabetes. This article presents a qualitative analysis of systemic barriers to primary care diabetes management in the small office setting in Delaware. Grounded theory was used to identify key themes of focus group discussions with 25 Delaware physicians. A total of 6 systemic barriers were identified: (1) a persistent orientation toward acute care; (2) an inability to provide proactive, population-based patient management; (3) an inability to provide adequate self-management education; (4) poor integration of payer-driven disease management activities; (5) lack of universally available clinical information; and (6) lack of public health support. The results suggest that significant systemic barriers limit the ability of primary care providers, particularly those in small practices, to effectively manage diabetes in current practice. Future primary care reform should consider how to support providers, particularly those in small practices, to overcome these barriers.

Resident perceptions of a tele-intensive care unit implementation.

OBJECTIVE: Remote intensive care unit (ICU) monitoring (tele-ICU) may provide a means to address the shortage of intensive care physicians. However, the consequences of implementing a tele-ICU system for house staff education and clinical experience are unknown. The purpose of this study was to determine resident perceptions of the impact of a tele-ICU implementation on patient care, education, and the overall work environment. MATERIALS AND METHODS: Cross-sectional survey of residents who rotated through the medical ICU within the first year after the implementation of a tele-ICU in a large, academically affiliated, community hospital. Each question was graded on a 5-point Likert scale. RESULTS: Thirty-five of 60 residents completed the survey (58% response rate). Sixty-three percent of residents reported that tele-ICU was associated with an improved ability to focus on urgent patient issues, and 46% thought that the tele-ICU helped them to feel less overwhelmed. Although most residents were neutral (51%), 37% agreed that the tele-ICU was a valuable educational experience. Seventy-seven percent reported that the tele-ICU integration was associated with improved patient safety, but many were concerned about the impact on continuity and communication. There was no perceived association with patient or family satisfaction. CONCLUSIONS: Our study suggests that a tele-ICU implementation in a medical ICU does not seem to have a negative impact on the educational experience of residents and is associated with perceived improvements in patient safety and quality. Future studies should objectively measure the educational impact of implementing a tele-ICU system.

Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus.

OBJECTIVE: The goal was to compare the clinical effectiveness of monotherapy with beta-lactams, clindamycin, or trimethoprim-sulfamethoxazole in the outpatient management of nondrained noncultured skin and soft-tissue infections (SSTIs), in a methicillin-resistant Staphylococcus aureus (MRSA)-endemic region. METHODS: A retrospective, nested, case-control trial was conducted with a cohort of patients from 5 urban pediatric practices in a community-acquired MRSA-endemic region. All subjects were treated as outpatients with oral monotherapy for nondrained noncultured SSTIs between January 2004 and March 2007. The primary outcome was treatment failure, defined as a drainage procedure, hospitalization, change in antibiotic, or second antibiotic prescription within 28 days. RESULTS: Of 2096 children with nondrained noncultured SSTIs, 104 (5.0%) were identified as experiencing treatment failure and were matched to 480 control subjects. Compared with beta-lactam therapy, clindamycin was equally effective but trimethoprim-sulfamethoxazole was associated with an increased risk of failure. Other factors independently associated with failure included initial treatment in the emergency department, presence or history of fever, and presence of either induration or a small abscess. CONCLUSIONS: Compared with beta-lactams, clindamycin monotherapy conferred no benefit, whereas trimethoprim-sulfamethoxazole was associated with an increased risk of treatment failure in a cohort of children with nondrained noncultured SSTIs who were treated as outpatients. Even in regions with endemic community-acquired MRSA, beta-lactams may still be appropriate, first-line, empiric therapy for children presenting with these infections.

Health status outcomes after cardioversion for atrial fibrillation: results from the Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) II Trial.

BACKGROUND: Atrial fibrillation is the most common significant cardiac arrhythmia and substantially impacts the health status of patients. Enoxaparin has been shown to be a safe and effective alternative to unfractionated heparin for use with transesophageal echocardiography (TEE)-guided cardioversion, but the implications on health status remain unknown. The aim of the study was to compare the health status outcomes of patients who undergo TEE-guided cardioversion with enoxaparin or unfractionated heparin as anticoagulation bridging therapy. METHODS: The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) II multicenter trial randomized 155 patients to bridging therapy with either enoxaparin or unfractionated heparin. Of these, 118 were included in the health status substudy. Health status was assessed at baseline and 5 weeks using the RAND 36-item health survey (RAND-36), the Duke Activity Status Index (DASI), and the Health Utilities Index Mark 3 (HUI-3). RESULTS: There were no significant differences in the health status measures between the treatment groups. However, patients who remained in normal sinus rhythm at follow-up had absolute improvement in all measures of health status, whereas patients in atrial fibrillation at follow-up had an absolute decrease in the DASI, HUI-3, and 5 of 8 subscales of the RAND-36. These findings reached statistical significance in the HUI-3 and 3 of 8 subscales of the RAND-36. CONCLUSIONS: Health status outcomes in TEE-guided cardioversion do not significantly differ between anticoagulant bridging therapy with enoxaparin or unfractionated heparin. However, maintenance of sinus rhythm at 5 weeks was associated with an improvement in health status.