Scaling care coordination through digital engagement: stepped-wedge trial assessing readmissions.

OBJECTIVES: Transitions of care are pivotal, vulnerable times as patients are discharged from the hospital. Telephonic care coordination is standard care, but labor intensive. We implemented a patient postdischarge digital engagement (PDDE) program to scale coordination. We hypothesized that PDDE could reduce readmissions for low-risk patients and supplement care coordination for medium- and high-risk patients. STUDY DESIGN: Pragmatic, stepped-wedge cluster randomization trial with 5 implementation waves based upon primary care clinic region. METHODS: All inpatient hospital discharges between March 2020 and November 2020 were stratified by readmission risk. Low-risk patients were offered access to PDDE, and moderate-risk and high-risk patients were offered access to PDDE and care coordination. Readmission was defined as an unplanned inpatient admission within 30 days from discharge. An intention-to-treat primary analysis was conducted using mixed-effects logistic regression clustering for wave; a treatment-on-the-treated analysis was also conducted to assess the impact among program users. RESULTS: A total of 5490 patient discharges were examined (2735 control; 2755 intervention); 1949 patients were high risk, 2032 were medium risk, and 1509 were low risk. PDDE intervention did not significantly affect readmission among low-risk (95% CI, -0.23 to 0.90; P = .23), medium-risk (95% CI, -0.14 to 0.60; P = .21), and high-risk (95% CI, -0.32 to 0.64; P = .48) groups after adjustment for time and patient factors. In a treatment-on-the-treated analysis, among patients who activated the PDDE program, readmission was also similar among the low-, medium-, and high-risk cohorts. CONCLUSIONS: Our study expanded resource-limited care coordination by offering low-risk patients a service they were unable to receive previously while having no impact on readmission. PDDE efficiently provided additional touch points between patients and providers.

Underrepresentation of African Americans in Plastic Surgery: Examining Demographics, Specialty Factors, and Medical School Experiences.

BACKGROUND: Racial representation among medical trainees translates into physicians that are able to communicate with diverse patient populations and are perceptive to health disparities. This is important within plastic surgery where an optimal physicianpatient relationship is essential to health outcomes. OBJECTIVE: The purpose of this study is to address underrepresentation of African Americans (AA) in plastic surgery through improving understanding of factors that may contribute to AA medical student interest in plastic surgery. DESIGN: This was a voluntary, cross-sectional survey. An online survey was designed to collect information on demographics, specialty factor importance, medical school experiences, and plastic surgery interest among medical students. The survey was distributed to medical students within three national medical organizations between August 2018 and February 2019. The following groups of respondents were statistically COMPARED: AAs interested vs. AAs not interested in plastic surgery and AA vs. Caucasian medical students both interested in plastic surgery. SETTING: Online survey for medical students in the United States. PARTICIPANTS: All 428 participants were medical students that belonged to at least 1 of the 3 national medical organizations between August 2018 and February 2019. RESULTS: The survey was completed by 428 participants of which 142 were excluded for incomplete surveys, leaving 286 (66.8%) participants to be included in the study. Among AA medical students, 128 (75.3%) were not interested in Plastic Surgery and 42 (24.7%) were interested. The 2 groups were similar demographically but differed significantly across multiple specialty factors and medical school experiences (p < 0.05). When compared to interested Caucasian medical students (n = 30), interested AA medical students differed significantly in demographics, specialty factors, and medical school experiences (p < 0.05). CONCLUSIONS: This study supports the implementation of medical school interventions emphasizing specialty factors and medical school experiences unique to AA medical students interested in plastic surgery to promote their application into the specialty.

Development and Evaluation of an Enhanced Recovery Protocol to Reduce Length of Stay following Elective Endovascular Aneurysm Repair.

BACKGROUND: Elective endovascular abdominal aortic aneurysm repair (EVAR) can be performed safely with a short postoperative length of stay (LOS). We aimed to develop and assess the impact of an enhanced recovery protocol (ERP) on LOS after elective EVAR. METHODS: Pre-ERP development single center retrospective review of elective EVAR procedures from January 2012 to December 2019. ERP was developed by targeting factors associated with prolonged LOS (>2 days) elucidated from semistructured interviews and Bayesian additive regression tree analysis. Post-ERP development, a subsequent retrospective review of elective EVAR performed from January 2018 to June 2021 was performed to evaluate LOS before and after ERP. Primary outcome was LOS. RESULTS: Two hundred sixteen patients underwent elective infrarenal EVAR from 2012 to 2019. Periprocedural factors identified as associated with LOS >2 days included noncommercial insurance (43.6% vs. 26.5%; P = 0.01), preoperative anemia (hemoglobin 12.56 g/dL vs. 13.57 g/dL; P = 0.001), worse renal function (creatinine 1.31 mg/dL vs. 1.01/dL; P = 0.004), open femoral access (74.4% vs. 26.5%; P < 0.001), intensive care unit (ICU) stay (2.7 days vs. 0.9 days; P < 0.001), postoperative anemia (9.8 g/dL vs. 11.9 g/dL; P < 0.001), postoperative creatinine (1.55 mg/dL vs. 0.97 mg/dL; P < 0.001), and beta blocker need on discharge (45.5% vs. 25%; P = 0.003) as significant between patients with short and prolonged LOS groups. Semistructured interviews revealed postoperative day 1 complete blood count/chemistry, postoperative physical therapy evaluation, ICU admission, urinary retention, patient expectations, and unavailability of transportation home as modifiable factors that delayed early discharge. A 14-component ERP was created to target the factors identified from combined qualitative and quantitative results. Post-ERP development, 74 elective EVAR patients were reviewed from 2018 to 2021 (37 pre-ERP and 37 post-ERP). Following ERP development, the mean LOS was reduced from 2.6 (standard deviation: 1.9) to 1.3 days (standard deviation: 1.3); P < 0.01. There were no significant differences in 30-day readmission, postoperative complications, emergency room visits, or 90-day mortality before and after the ERP was used. CONCLUSIONS: Practice and procedural factors can be modified through an informed and safe process to reduce LOS after elective EVAR. LOS following elective EVAR was safely reduced following the use of a systematically developed ERP.

Analysis of Clinician and Patient Factors and Completion of Telemedicine Appointments Using Video.

Importance: Telemedicine provides patients access to episodic and longitudinal care. Policy discussions surrounding future support for telemedicine require an understanding of factors associated with successful video visits. Objective: To assess patient and clinician factors associated with successful and with failed video visits. Design, Setting, and Participants: This was a quality improvement study of 137 846 scheduled video visits at a single academic health system in southeastern Wisconsin between March 1 and December 31, 2020, supplemented with patient experience survey data. Patient information was gathered using demographic information abstracted from the electronic health record and linked with block-level socioeconomic data from the US Census Bureau. Data on perceived clinician experience with technology was obtained using the survey. Main Outcomes and Measures: The primary outcome of interest was the successful completion of a scheduled video visit or the conversion of the video visit to a telephone-based service. Visit types and administrative data were used to categorize visits. Mixed-effects modeling with pseudo R2 values was performed to compare the relative associations of patient and clinician factors with video visit failures. Results: In total, 75 947 patients and 1155 clinicians participated in 137 846 scheduled video encounters, 17 190 patients (23%) were 65 years or older, and 61 223 (81%) patients were of White race and ethnicity. Of the scheduled video encounters, 123 473 (90%) were successful, and 14 373 (10%) were converted to telephone services. A total of 16 776 patients (22%) completed a patient experience survey. Lower clinician comfort with technology (odds ratio [OR], 0.15; 95% CI, 0.08-0.28), advanced patient age (66-80 years: OR, 0.28; 95% CI, 0.26-0.30), lower patient socioeconomic status (including low high-speed internet availability) (OR, 0.85; 95% CI, 0.77-0.92), and patient racial and ethnic minority group status (Black or African American: OR, 0.75; 95% CI, 0.69-0.81) were associated with conversion to telephone visits. Patient characteristics accounted for systematic components for success; marginal pseudo R2 values decreased from 23% (95% CI, 21.1%-26.1%) to 7.8% (95% CI, 6.3%-9.4%) with exclusion of patient factors. Conclusions and Relevance: As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services.