Prevention of 90-day inpatient detoxification readmission for opioid use disorder by a community-based life-changing individualized medically assisted evidence-based treatment (C.L.I.M.B.) program: A quasi-experimental study.

BACKGROUND: Evidence for community-based strategies to reduce inpatient detoxification readmission for opioid use disorder (OUD) is scant. A pilot program was designed to provide individualized structured treatment plans, including addressing prolonged withdrawal symptoms, family/systems assessment, and contingency management, to reduce readmission after the index inpatient detoxification. METHODS: A non-randomized quasi-experimental design was used to compare the pilot facilities (treatment) and comparison facilities before and after the program started, i.e., a simple difference-in-differences (DID) strategy. Adults 18 years and older who met the Diagnostic and Statistical Manual of Mental Disorders version 5 criteria for OUD and had an inpatient detoxification admission at any OUD treatment facility in two study periods between 7/2016 and 3/2020 were included. Readmission for inpatient detoxification in 90-days after the index stay was the primary outcome, and partial hospitalization, intensive outpatient care, outpatient services, and medications for OUD were the secondary outcomes. Six statistical estimation methods were used to triangulate evidence and adjust for potential confounding factors between treatment and comparison groups. RESULTS: A total of 2,320 unique patients in the pilot and comparison facilities with 2,443 index inpatient detoxification admissions in the pre- and post-periods were included. Compared with patients in comparison facilities, patients in the C.L.I.M.B. facilities had higher readmission in the pre-period (unadjusted readmission 17.0% vs. 10.6%), but similar rates in the post-period (12.3% vs. 10.6%) after the implementation of the pilot program. For 90-day readmission, all DID estimates were not statistically significant (adjusted estimates ranged from 6 to 9 percentage points difference favoring the C.L.I.M.B. program). There was no significant improvement in the secondary outcomes of utilizations in lower level of care and medications for OUD in C.L.I.M.B. facilities. CONCLUSIONS: We found a reduction in readmission in the pilot facilities between the two periods, but the results were not statistically significant compared with the comparison facilities and the utilization of lower level of care services remained low. Even though providers in the pilot OUD treatment facilities actively worked with health plans to standardize care for patients with OUD, more strategies are needed to improve treatment engagement and retention after an inpatient detoxification.

Evidence of disparity in the application of quality improvement efforts for the treatment of acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice Initiative in Michigan.

BACKGROUND: Racial disparities exist in the management of patients with cardiovascular disease in the United States. The aim of the study was to evaluate if a structured initiative for improving care of patients with acute myocardial infarction (Guidelines Applied in Practice [GAP]) led to comparable care of white and nonwhite patients admitted to GAP hospitals in Michigan. METHODS: Medicare patients comprised 2 cohorts: (1) those admitted before GAP implementation (n = 1,368) and (2) those admitted after GAP implementation (n = 1,489). The main outcome measure was adherence to guideline-based medications/recommendations and use of the GAP discharge tool. chi(2) and Fisher exact tests were used to determine differences between white patients (n = 2,367) and nonwhite patients (n = 490). RESULTS: In-hospital GAP tool and aspirin use significantly improved for white and nonwhite patients. beta-Blocker use in hospital improved significantly for nonwhite patients only (66% vs 83.3%; P = .04). At discharge, nonwhite patients were 28% and 64% less likely than white patients to have had the GAP discharge tool used (P = .004) and receive smoking cessation counseling (P < .001), respectively. Among white patients, GAP improved discharge prescription rates for aspirin by 10.8% (P < .001) and beta-blockers by 7.0% (P = .047). Nonwhite patients' aspirin prescriptions increased by 1.0% and beta-blocker prescriptions decreased by 6.0% (both P values nonsignificant). CONCLUSIONS: The GAP program led to significant increases in rates of evidence-based care in both white and nonwhite Medicare patients. However, nonwhite patients received less quality improvement discharge tool and smoking cessation counseling. Policies designed to reduce racial disparities in health care must address disparity in the delivery of quality improvement programs.

The association between guideline-based treatment instructions at the point of discharge and lower 1-year mortality in Medicare patients after acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice (GAP) initiative in Michigan.

BACKGROUND: The American College of Cardiology's Guidelines Applied in Practice (GAP) initiative for acute myocardial infarction (AMI) has been shown to increase the use of guideline-based therapies and improve outcomes in patients with AMI. It is unknown whether hospitals that are more successful in using the standard discharge contract--a key component of GAP that emphasizes guideline-based medications, lifestyle modification, and follow-up planning--experience a proportionally greater improvement in patient outcomes. METHODS: Medicare patients treated for AMI in all 33 participating GAP hospitals in Michigan were enrolled. We aggregated the hospitals into 3 tertiles based on the rates of discharge contract use: 0% to 8.4% (tertile 1), >8.4% to 38.0% (tertile 2), and >38.0% to 61.1% (tertile 3). We analyzed 1-year follow-up mortality both pre- and post-GAP and compared the mortality decline post-GAP with discharge contract use according to tertile. RESULTS: There were 1368 patients in the baseline (pre-GAP) cohort and 1489 patients in the post-GAP cohort. After GAP implementation, mortality at 1 year decreased by 1.2% (P = .71), 1.2% (P = .68), and 6.0% (P = .03) for tertiles 1, 2, and 3, respectively. After multivariate adjustment, discharge contract use was significantly associated with decreased 1-year mortality in tertile 2 (odds ratio 0.43, 95% CI 0.22-0.84) and tertile 3 (odds ratio 0.45, 95% CI 0.27-0.75). CONCLUSIONS: Increased hospital utilization of the standard discharge contract as part of the GAP program is associated with decreased 1-year mortality in Medicare patient populations with AMI. Hospital efforts to promote adherence to guideline-based care tools such as the discharge contract used in GAP may result in mortality reductions for their patient populations at 1 year.

Sex differences in the application of evidence-based therapies for the treatment of acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice projects in Michigan.

BACKGROUND: Studies have shown that women with acute myocardial infarction (AMI) are less likely to receive evidence-based care compared with men. The American College of Cardiology's AMI Guidelines Applied in Practice (GAP) program has been shown to increase the rates of evidence-based medicine use and reduce mortality in patients with AMI. The objective of this study was to investigate the relative benefits of the GAP program in men and women. METHODS: By using a predesign-postdesign, standard orders, and a discharge tool to improve evidence-based indicator rates and long-term mortality in patients with AMI in Michigan, this study compared the success of GAP in men vs women. Logistic regression was used to develop predictive models for death at 30 days and 1 year in men and women. RESULTS: Use of evidence-based care, including use of beta-blockers and aspirin in men and women at hospital discharge and lipid-lowering agent use in men, was higher in the post-GAP sample (P<.01 for all). Use of the discharge tool promoted by the GAP program was independently protective against death at 1 year in women (adjusted odds ratio, 0.46; 95% confidence interval, 0.27-0.79), and a trend existed for similar results in men (adjusted odds ratio, 0.62; 95% confidence interval, 0.36-1.06). However, the tool was used slightly less often with women (27.9% vs 33.96%; P=.003). CONCLUSIONS: The GAP program increased the use of evidence-based therapies in male and female patients. In addition, the GAP discharge tool may decrease mortality rates at 1 year in patients with AMI; however, the tool was used less often with women. Greater use of the GAP discharge tool in women might narrow the post-MI sex mortality gap.

Guideline-based standardized care is associated with substantially lower mortality in medicare patients with acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan.

OBJECTIVES: We sought to assess the impact of the American College of Cardiology's Guidelines Applied in Practice (GAP) project for acute myocardial infarction (AMI) care, encompassing 33 acute-care hospitals in southeastern Michigan, on rates of mortality in Medicare patients treated in Michigan. BACKGROUND: The GAP project increases the use of evidence-based therapies in patients with AMI. It is unknown whether GAP also can reduce the rate of mortality in patients with AMI. METHODS: Using a before (n = 1,368) and after GAP implementation (n = 1,489) cohort study, 2,857 Medicare patients with AMI were studied to assess the influence of the GAP program on mortality. Multivariate models tested the independent impact of GAP after controlling for other conditions on in-hospital, 30-day, and one-year mortality. RESULTS: Average patient age was 76 years, 48% were women, and 16% represented non-white minorities. The rate of mortality decreased after GAP for each interval studied: hospital, 10.4% versus 13.6%; 30-day, 16.7% versus 21.6%; and one-year, 33.2% versus 38.3%; all p < 0.02. After multivariate adjustment, GAP correlated with a 21% to 26% reduction in mortality, particularly at 30 days (odds ratio of GAP to baseline 0.74; 95% confidence interval [CI] 0.59 to 0.94; p = 0.012) and one year (odds ratio 0.78; 95% CI 0.64 to 0.95; p = 0.013), particularly in the patients for whom a standard discharge tool was used (1-year mortality, odds ratio 0.53; 95% CI 0.36 to 0.76; p = 0.0006). CONCLUSIONS: Embedding AMI guidelines into practice was associated with improved 30-day and one-year mortality. This benefit is most marked when patients are cared for using standardized, evidence-based clinical care tools.

Improved quality of stroke care for hospitalized Medicare beneficiaries in Michigan.

BACKGROUND AND PURPOSE: We reported previously that acute ischemic stroke patients encountered delays in obtaining neuroimaging and receiving thrombolysis, and that deep venous thrombosis prophylaxis was used only in a minority of eligible patients. We investigated whether these and other measures improved after a quality improvement initiative. METHODS: Medicare fee-for-service ischemic stroke and transient ischemic attack discharges in 136 acute care hospitals in Michigan were identified by International Classification of Diseases, 9th Revision, Clinical Modification codes. Only patients with stroke symptoms persisting for >1 hour and present on arrival were included in the analysis. Seven quality indicators were abstracted from chart review at baseline (discharges between July 1, 1998, and June 30, 1999) and at remeasurement (discharges between January 1, 2001, and June 30, 2001) after an intensive quality improvement initiative throughout Michigan hospitals. Quality indicators were compared at baseline and remeasurement. RESULTS: Indicators of care were determined in 5146 patients at baseline and 4980 patients on remeasurement. Four quality-of-care indicators showed significant improvement on remeasurement: antithrombotic prescribed at discharge (81.9 baseline versus 83.7% remeasurement; P=0.026), avoidance of sublingual nifedipine in patients with acute ischemic stroke (97.1 versus 99.7%; P<0.0001), documentation of a computed tomography (CT)/MRI during hospitalization (98.0 versus 99.1%; P=0.024), and appropriate deep venous thrombosis prophylaxis (13.8 versus 26.9%; P<0.0001). Time to CT/MRI did not significantly change, but time to thrombolysis improved (113 versus 88.5 minutes; P=0.045). CONCLUSIONS: Improvement occurred in several indicators of quality of care in Michigan Medicare beneficiaries presenting with acute stroke symptoms.

Recurrent stroke risk is higher than cardiac event risk after initial stroke/transient ischemic attack.

BACKGROUND AND PURPOSE: Patients with ischemic stroke and transient ischemic attack (TIA) are at risk for recurrent cerebrovascular and cardiac events. Understanding which of these adverse events is more likely to occur next is instructive for preventive therapy planning. METHODS: Subjects (n=1923) were identified from a sample of hospital discharges from administrative claims for the Michigan Medicare population from January 2001 to June 2001 using International Classification of Diseases, 9th Revision codes for ischemic stroke/TIA. Outcomes (cardiac events, myocardial infarction [MI], percutaneous transluminal coronary angioplasty [PTCA], coronary artery bypass grafting [CABG] and ischemic strokes) were identified for 2001 to 2003. Comparison between cardiac and stroke as secondary events were made using cumulative incidence estimates. RESULTS: Over the follow-up period, 172 patients had a cardiac event (62.8% MI, 7.6% CABG, 14.5% PTCA, 9.3% MI and PTCA, and 5.8% MI and CABG) and 239 had a stroke as their first event. Cardiac event at 2 years had occurred in 7.7%, and stroke occurred in 11.8%. CONCLUSIONS: The risk of stroke after initial stroke/TIA is higher than the risk of cardiac events. The propensity after stroke/TIA to have the first recurrent ischemic event in the brain, rather than in the heart, has implications for prophylactic therapy selection.

Differences in quality of care among patients hospitalized with atrial fibrillation as primary or secondary cause for admission.

OBJECTIVE: Several factors have been linked to the variation in the quality of care for patients with atrial fibrillation (AF). Whether hospitalization primarily for AF (primary diagnosis of AF) as opposed to another primary diagnosis but having concomitant AF (secondary diagnosis of AF) impacts quality of care for AF is not known. Accordingly, we sought to evaluate the differences in quality of care of Medicare patients admitted with primary diagnosis versus secondary diagnosis of AF. DESIGN AND SETTING: We studied a random sample of Medicare fee-for-service discharges from Michigan's acute care hospitals over a 1-year period with a primary or secondary diagnosis of AF (ICD-9-CM 427.31). Main outcome measure. Warfarin use at the time of discharge. RESULTS: Of 5993 patients in the study, 772 had a primary diagnosis of AF and 5221 had a secondary diagnosis of AF. Patients with a secondary diagnosis of AF were older, more likely to be male, and less likely to be hypertensive. Patients with a secondary diagnosis of AF 'ideal' for anticoagulation (n = 1648) were less likely to receive warfarin compared with 'ideal' patients with primary diagnosis of AF (n = 363) (52.6% versus. 59.8%, P < 0.001). Adherence to test indicators was lower in patients with secondary diagnosis of AF. CONCLUSION: Secondary diagnosis of AF rather than AF as a primary diagnosis appears to account for most Medicare patients with AF admitted to hospitals. Whereas quality of care is lower in patients with secondary diagnosis of AF, opportunity for quality improvement exists for both groups of patients with AF.

Do gender and race impact the use of antithrombotic therapy in patients with stroke/TIA?

The authors examined the relationships between sex and race and antithrombotics prescribed at discharge in the Michigan Medicare population using retrospective medical record abstraction (n = 2,715) for the period January 1, 2001, to June 30, 2001. There were no differences in the use of antithrombotics at discharge by race or sex and no differences in the prescribing of aspirin, warfarin, aspirin/extended release dipyridamole, or clopidogrel by race or sex after adjustment for confounders.

Recognition and management of depression in skilled-nursing and long-term care settings: evolving targets for quality improvement.

OBJECTIVE: Depression is a common disorder associated with suffering, morbidity, and mortality in nursing home residents. It is treatable, and improving the quality of treatment can have a major impact. METHODS: MPRO, Michigan's Quality Improvement Organization, initiated a quality-improvement project in 14 nursing facilities to improve the accuracy of assessments, targeting, and monitoring of care. Electronic Minimum Data Set (MDS) data and medical-record abstraction results were combined to form the analytic dataset. RESULTS: Findings from the baseline phase demonstrated that, according to medical and administrative records, 26% of newly admitted nursing home residents had symptoms of depression that were apparent at admission, and an additional 12% were recognized early in their stay. Eighty-one percent of residents with depression were receiving treatment on admission to the facility, and 79% of those with depression recognized by Day 14 were treated by then. CONCLUSIONS: These data demonstrate progress toward improving the initiation of treatment for depression in nursing homes; however, there are still opportunities for improving the quality of care and, especially, the quality of assessments. The authors recommend the addition of the Geriatric Depression Scale to the federally mandated MDS for cognitively intact patients. There could also be mechanisms to ensure that providers and facilities follow recommended practice guidelines. Initiating treatment with antidepressant medications should be followed with monitoring of residents to identify those who still have depressive symptoms and to modify or intensify their treatment.

Analysis of OBQI outcomes in participating Michigan home health agencies.

As part of the Centers for Medicare & Medicaid Services' plan to implement Outcome-Based Quality Improvement (OBQI) in home health settings nationwide, a pilot project was initiated in 5 states. This article analyzes the results of the Michigan Peer Review Organization's (MPRO's) pilot project in terms of changes in patient outcomes that occurred in participating home health agencies between 2000 and 2001. Participating agencies had statistically significant improvements when comparing their performance in 2001 versus their performance in 2000. They did not achieve significant improvement though in comparison to the national reference group. Agencies should implement the OBQI process in its entirety annually until the desired outcome is achieved.

Acute ischemic stroke in hospitalized medicare patients: evaluation and treatment.

BACKGROUND AND PURPOSE: This study describes several quality indicators of care in hospitalized stroke patients in Michigan from 1998 to 1999. SUMMARY OF REPORT: Median times from admission to head CT/MRI (89.5 minutes) and thrombolysis (113 minutes) exceeded recommended guidelines. Deep venous thrombosis prophylaxis was used in only 13.8% of eligible patients. CONCLUSIONS: Timing for brain imaging and acute ischemic stroke symptom onset need to be better documented, along with more provider education for routine deep venous thrombosis prophylaxis.

Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative.

CONTEXT: Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals. OBJECTIVE: To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI. DESIGN AND SETTING: The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and remeasurement, in 10 acute-care hospitals in southeast Michigan. PATIENTS: A random sample of Medicare and non-Medicare patients at baseline (July 1998--June 1999; n = 735) and following intervention (September 1--December 15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January--December 1998; n = 513) and at remeasurement (March--August 2001; n = 388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group. INTERVENTION: The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators. MAIN OUTCOME MEASURES: Differences in adherence to quality indicators (use of aspirin, beta-blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment) in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group. RESULTS: Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; P =.02) and beta-blockers (65% vs 74%; P =.04) on admission and use of aspirin (84% vs 92%; P =.002) and smoking cessation counseling (53% vs 65%; P =.02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P<.001). Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant. Evidence of tool use noted during chart review was associated with a very high level of adherence to most quality indicators. CONCLUSIONS: Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement.