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.

Racial, Ethnic, and Geographic Disparities in Immunization Rates Among Patients With Inflammatory Bowel Disease.

Background and Aims: Racial and ethnic disparities exist in the treatment of IBD. These disparities exist in adult vaccine uptake among the general population and may extend to patients with IBD. The primary aim of this study was to determine whether racial, ethnic, or geographic disparities existed in influenza vaccine uptake among patients with IBD. Methods: We performed a multicenter, retrospective cohort study evaluating adult vaccine uptake among patients with IBD seen at two tertiary referral centers between September 2019 and February 2020. The primary outcome was to determine if racial/ethnic and geographic disparities existed in influenza vaccine uptake for the two prior seasons. Our secondary outcomes were to determine if disparities existed for pneumococcal, zoster, or hepatitis B vaccines. Results: Among the 2453 patients who met the inclusion criteria, most identified as non-Hispanic White (89.9%), were on immunosuppressive therapy (74.5%), and received the influenza vaccine in both seasons (56.0%). Older age (prevalence ratio (PR) 0.98; 95% confidence interval (95%CI) 0.98-0.99; P < .001) and non-Hispanic White patients (PR 0.76, 95%CI 0.59-0.98, P < 0.03) were significantly more likely to be immunized. Black patients (PR 1.37; 95%CI 1.18-1.59; P < .001) and those living in underserved geographic areas (PR 1.35; 95%CI 1.17-1.56; P < 0.001) were less likely to be immunized. Racial/ethnic and geographic disparities were identified for pneumococcal, zoster, and hepatitis B vaccine uptake. Conclusions: Racial and ethnic vaccination uptake disparities exist among patients with IBD; patients from medically underserved areas are also vulnerable to these disparities Studies identifying patient, provider, and system-level opportunities to address these disparities are needed.

Student Leadership Development Initiative for Medical Students: Lessons Learned From Transitioning to Virtual Modalities.

Leadership training is a necessary component of undergraduate medical education. Our group successfully implemented a student-led organization starting from 2016 (Student Leadership Development Initiative; SLDI) that aimed to provide medical students with exposure to physician-leader career paths in an informal, organic, interactive setting. The COVID-19 pandemic necessitated a shift to online programming, and given the high prevalence of ZOOMTM fatigue, we incorporated monthly, freely available, self-directed modules as an additional leadership training opportunity. The goals of this study are to assess the (1) feasibility of and participation in a virtual student organization focused on leadership training, (2) whether students' perceptions of the importance of leadership were associated with participation in SLDI, and (3) lessons learned from transitioning to virtual modalities. An anonymous, retrospective cross-sectional survey with 13-items was distributed through an email listserv and a 6-question survey was sent to attendees following each virtual group-discussion. A Fisher's exact test was conducted to assess whether the number of modules completed was associated with students' perception of leadership importance. Survey results showed that 85% strongly agreed or agreed that SLDI helped them develop professional goals and career paths, and 74% reported benefits in becoming more compassionate physician leaders and valuing wellness. All respondents completed ≥1 self-directed module, and the students' perception of leadership importance did not influence the number of self-directed modules completed (p > .05). Most participants (63%) attended ≥67% of virtual events, and postevent feedback was positive; however, only 46% of respondents reported meeting someone new at events and 32% reported that they intended on connecting with new contacts. Our results suggest that virtual leadership student-organization, involving small-group discussions and self-directed modules, is feasible and beneficial for medical students. However, the inability to promote meaningful networking opportunities is a major limitation of a virtual training model.

Hospitalization Outcomes Among Patients With COVID-19 Undergoing Remote Monitoring.

Importance: Health care systems have implemented remote patient monitoring (RPM) programs to manage patients with COVID-19 at home, but the associations between participation and outcomes or resource utilization are unclear. Objective: To assess whether an RPM program for COVID-19 is associated with lower or higher likelihood of hospitalization and whether patients who are admitted present earlier or later for hospital care. Design, Setting, and Participants: This retrospective, observational, cohort study of RPM was performed at Froedtert & Medical College of Wisconsin Health Network, an academic health system in southeastern Wisconsin. Participants included patients with internal primary care physicians and a positive SARS-CoV-2 test in the ambulatory setting between March 30, 2020, and December 15, 2020. Data analysis was performed from February 15, 2021, to February 2, 2022. Exposures: Activation of RPM program. Main Outcomes and Measures: Hospitalizations within 2 to 14 days of a positive test. Inverse propensity score weighting was used to account for differences between groups. Sensitivity analyses were performed looking at usage of the RPM among patients who activated the program. Results: A total of 10 660 COVID-19-positive ambulatory patients were eligible, and 9378 (88.0%) had email or mobile numbers on file and were invited into the RPM program; the mean (SD) age was 46.9 (16.3) years and 5448 patients (58.1%) were women. Patients who activated monitoring (5364 patients [57.2%]) had a mean (SD) of 35.3 (33.0) check-ins and a mean (SD) of 1.27 (2.79) (median [IQR], 0 [0-1]) free-text comments. A total of 878 patients (16.4%) experienced at least 1 alert; 128 of 5364 activated patients (2.4%) and 158 of 4014 inactivated patients (3.9%) were hospitalized (χ21 = 18.65; P < .001). In weighted regression analysis, activation of RPM was associated with a lower odds of hospitalization (odds ratio, 0.68; 95% CI, 0.54-0.86; P = .001) adjusted for demographics, comorbidities, and time period. Monitored patients had a longer mean (SD) time between test and hospitalization (6.67 [3.21] days vs 5.24 [3.03] days), a shorter length of stay (4.44 [4.43] days vs 7.14 [8.63] days), and less intensive care use (15 patients [0.3%] vs 44 patients [1.1%]). Conclusions and Relevance: These findings suggest that activation of an RPM program is associated with lower hospitalization, intensive care use, and length of stay among patients with COVID-19.