Obstacles to Accepting Care: Understanding Why Obstetric Patients Leave against Medical Advice.

INTRODUCTION: Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated with worse perinatal outcomes. Reasons for discharges AMA are not well understood. The objective of this study is to identify the obstacles that prevent obstetric patients from accepting recommended care and highlight the structural reasons behind AMA discharges. METHODS: Electronic health records of patients admitted to antepartum, peripartum, or postpartum services between 2008 and 2018 who left "AMA" were reviewed. Progress notes from clinicians and social workers were extracted and analyzed. Reasons behind discharge were categorized using qualitative thematic analysis. RESULTS: Fifty-seven (0.12%) obstetric patients were discharged AMA. Reasons for discharge were organized into two overarching themes: extrinsic (50.9%) and intrinsic (40.4%) obstacles to accepting care. Eleven participants (19.3%) had no reason documented for their discharge. Extrinsic obstacles included childcare, familial responsibilities, and other obligations. Intrinsic obstacles included disagreement with provider regarding medical condition or plan, emotional distress, mistrust or discontent with care team, and substance use. DISCUSSION: The term "AMA" casts blame on individual patients and fails to represent the systemic barriers to staying in care. Obstetric patients were found to encounter both extrinsic and intrinsic obstacles that led them to leave AMA. Healthcare providers and institutions can implement strategies that ameliorate structural barriers. Partnering with patients to prevent discharges AMA would improve maternal and infant health and progress towards reproductive justice.

Estimating the Impact of Hospital-Level Variation on the Use of Inpatient Rehabilitation Facilities Versus Skilled Nursing Facilities on Individual Patients With Stroke.

BACKGROUND: There is substantial hospital-level variation in the use of Inpatient Rehabilitation Facilities (IRFs) versus Skilled Nursing Facilities (SNFs) among patients with stroke, which is poorly understood. Our objective was to quantify the net effect of the admitting hospital on the probability of receiving IRF or SNF care for individual patients with stroke. METHODS: Using Medicare claims data (2011-2013), a cohort of patients with acute stroke discharged to an IRF or SNF was identified. We generated 2 multivariable logistic regression models. Model 1 predicted IRF admission (versus SNF) using only patient-level factors, whereas model 2 added a hospital random effect term to quantify the hospital effect. The statistical significance and direction of the random effect terms were used to categorize hospitals as being either IRF-favoring, SNF-favoring, or neutral with respect to their discharge patterns. The hospital's impact on individual patient's probability of IRF discharge was estimated by taking the change in individual predicted probabilities (change in individual predicted probability) between the 2 models. Hospital-level effects were categorized as small (<10%), moderate (10%-19%), or large (≥20%) depending on change in individual predicted probability. RESULTS: The cohort included 135 415 patients (average age, 81.5 [SD=8.0] years, 61% female, 91% ischemic stroke) who were discharged from 1816 acute care hospitals to IRFs (n=66 548) or SNFs (n=68 867). Half of hospitals were classified as being either IRF-favoring (n=461, 25.4%) or SNF-favoring (n=485, 26.7%) with the remainder (n=870, 47.9%) considered neutral. Overall, just over half (n=73 428) of patients were treated at hospitals that had moderate or large independent effects on discharge settings. Hospital effects for neutral hospitals were small (ie, change in individual predicted probability <10%) for most patients (72.5%). However, hospital effects were moderate or large for 78.8% and 84.6% of patients treated at IRF- or SNF-favoring hospitals, respectively. CONCLUSIONS: For most patients with stroke, the admitting hospital meaningfully changed the type of rehabilitation care that they received.

Fulfilling last wishes: improving the compassionate discharge process.

BACKGROUND: Compassionate discharges (ComD), commonly known as rapid discharges, are urgent one-way discharges for critically ill hospitalised patients with death expected within hours or less than 7 days, to die at their place of choice-usually in their own home. Challenges abound in this time-sensitive setting when multiple parties must work together to prepare medically unstable patients for discharge, yet healthcare staff are largely unaware of the process, resulting in delays. METHODS: Process mapping, an Ishikawa diagram and a Pareto chart were used to identify barriers, which included timely acquisition of home equipment and medication and poor communication among stakeholders. In May 2020, the Quality Improvement (QI) team embarked on a pilot project to reduce family caregiver anxiety and delays in the ComD process while maintaining a success rate above 90% over a 12-month period. INTERVENTIONS: Three Plan-Do-Study-Act (PDSA) cycles were used to refine a ComD resource package that was developed; this consisted of a checklist, a kit and caregiver resources. This was to support nurses, doctors and families during this difficult and emotional transition. Items in the ComD resource package were revised iteratively based on user feedback, with further data collected to measure its usefulness. RESULTS: The 12-month ComD success rate over 3 PDSA cycles were 88.9%, 94.2% and 96.7%, respectively, after each cycle. There was a consistent reduction in the level of family anxiety before and after caregiver training and resources. Reasons for failed ComD included acute clinical deterioration or delays in obtaining home oxygen support. CONCLUSION: The ComD resource package allowed collaborative work across different disciplines, strengthening the safety and utility of ComD and allowing patients to die in their place of choice. These are ubiquitous across settings; this QI problem is thus relevant beyond our local institution.

Discharge against medical advice in rural and remote emergency departments: views of healthcare providers.

INTRODUCTION: The aim of the study was to explore, in one remote hospital, emergency department healthcare providers' experience and perceptions of the factors surrounding a patient's decision to discharge against medical advice (DAMA). The secondary objective was to gain insight into staff experiences of the current protocols for managing DAMA cases and explore their recommendations for reducing DAMA incidence. METHODS: This was a cross-sectional study involving a survey and semi-structured interviews exploring healthcare providers' (n=19) perceptions of factors perceived to be influencing DAMA, current practice for managing DAMA and recommendations for practice improvements. Health professionals (doctors, nurses, Aboriginal Health Workers) all worked in the emergency department of a remote community hospital, Queensland, Australia. Responses relating to influencing factors for DAMA were provided on a three-point rating scale from 'no influence/little influence' to 'very strong influence'. DAMA management protocol responses were a three-point rating scale from 'rarely/never' to 'always'. Semi-structured interviews were conducted after the survey and explored participants' perceptions in greater detail and current DAMA management protocol. RESULTS: Feedback from the total of 19 participants across the professions presented four prominent yet interconnected themes: patient, culture, health service and health provider, and health literacy and education-related factors. Factors that were perceived to have a strong influence on DAMA events included alcohol and drug abuse (100%), a lack of culturally sensitive healthcare services (94.7%), and family commitments or obligations (89.5%). Healthcare provider recommendations for preventing DAMA presented themes of right communication, culturally safe care (right place, right time) and the right staff to support DAMA prevention. The healthcare providers described the pivotal role the Indigenous Liaison Officer (ILO) plays and the importance of this position being filled. CONCLUSION: DAMA is a multifaceted issue, influenced by both personal and hospital system-related factors. Participants agreed that the presence of ILO and/or Aboriginal Health Workers in the emergency department may reduce DAMA occurrences for Indigenous Australians who are disproportionately represented in DAMA rates, particularly in rural and remote regions of Australia.

Experiences and preferences of people with stroke and caregivers, around supports provided at the transition from hospital to home: a qualitative descriptive study.

BACKGROUND: Transitioning home from the structured hospital setting poses challenges for people with stroke (PWS) and their caregivers (CGs), as they navigate through complex uncertainties. There are gaps in our understanding of appropriate support interventions for managing the transition home. In this qualitative study, we explored the perspectives of PWS and their CGs regarding their support experiences and preferences during this period. METHODS: Between November 2022 and March 2023, and within six months of hospital discharge, audio-recorded, semi-structured interviews were conducted with PWS and CGs. All interviews were transcribed, imported into NVivo software, and analysed using reflexive thematic analysis. RESULTS: Sixteen interviews were conducted, nine with PWS and seven with CGs. Four themes relevant to their collective experiences and preferences were identified: (i) Need for tailored information-sharing, at the right time, and in the right setting; (ii) The importance of emotional support; (iii) Left in limbo, (iv) Inequity of access. Experiences depict issues such as insufficient information-sharing, communication gaps, and fragmented and inequitable care; while a multi-faceted approach is desired to ease anxiety and uncertainty, minimise delays, and optimise recovery and participation during transition. CONCLUSIONS: Our findings highlight that regardless of the discharge route, and even with formal support systems in place, PWS and families encounter challenges during the transition period. The experiences of support at this transition and the preferences of PWS and CGs during this important period highlights the need for better care co-ordination, early and ongoing emotional support, and equitable access to tailored services and support. Experiences are likely to be improved by implementing a partnership approach with improved collaboration, including joint goal-setting, between PWS, CGs, healthcare professionals and support organisations.

Medication Reconciliation Errors on Discharge for Epilepsy Monitoring Unit Patients.

Background and Purpose: Medication errors are common in the inpatient setting. Epilepsy patients who miss doses of their antiseizure medications are at risk for breakthrough seizures and subsequent complications. The purpose of this study was to quantify and characterize anti-seizure medications reconciliation errors on discharge from the epilepsy monitoring unit (EMU). Methods: Consecutive admissions to an academic medical center EMU were retrospectively reviewed. Medication reconciliation errors on discharge, including drug errors, dosing errors, and dose timing errors, were recorded. Associations between medication errors and clinical and demographic variables were analyzed using binary logistic regression for continuous variables and Fisher exact tests for categorical variables. Results: One hundred and eleven admissions between January 1, 2021 and December 31, 2021 were identified. Fourteen anti-seizure medication reconciliation errors were recorded during 11 unique admissions (9.9% of admissions). The most common error type was dosing error (10/14 errors; 71.4%). Number of antiseizure medications on admission (p=0.004), total number of medications on admission (p=0.013), number of medication changes during admission (p=0.0007), and length of stay (p=0.0001) were associated with increased likelihood of errors. Conclusions: Medication reconciliation errors upon discharge from the EMU occur during approximately 10% of admissions. A higher number of preadmission antiseizure medications, higher total number of preadmission medications, higher number of medication changes during admission, and longer length of stay are associated with increased risk of discharge medication reconciliation errors. Careful attention should be paid to patients with these risk factors.

What comes next? A cross-sectional study on post-discharge referrals of adolescents treated in emergency services following a suicide attempt.

AIM: To assess the proportions and associated factors of different post-discharge referrals among adolescents treated in the emergency department after a suicide attempt. DESIGN: Observational, cross-sectional retrospective study. METHODS: We conducted a study using the medical records of 140 adolescents treated for a suicide attempt between January 2015 and May 2023 in a Brazilian emergency department, focusing on post-discharge referrals, defined as discharge without referral, unaddressed referral and referral addressed to the network. Associations between the outcomes and other variables were analysed using a Poisson regression model. RESULTS: Discharges without referrals prevailed, followed by addressed and unaddressed referrals. Regression models showed associations between post-discharge and age, prior continuous use of psychotropic medications, location of care, continued suicidal ideation at discharge and evaluation by a multi-professional team. CONCLUSION: A high number of adolescents were discharged from emergency departments without co-ordination with the mental health network, and the involvement of the multi-professional team was positively associated with addressed referrals. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: This study informs healthcare professionals by raising awareness of their practices in discharging adolescents after suicide attempts in emergency departments, with the possibility of improving care quality and reducing the likelihood of readmission. REPORTING METHOD: STrengthening the Reporting of OBservational studies in Epidemiology (STROBE). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Early Discharge versus 6-hour Observation in Mild Traumatic Brain Injury with Normal Brain CT Scan; a Comparative Pilot study of Outcomes.

Introduction: Early discharge from the emergency department (ED) or a 6-hour observation in the ED are two methods for management of patients with mild traumatic brain injury (mTBI) with normal brain computed tomography (CT) scan. This study aimed to compare the outcomes of the two management options. Methods: This study is a single-center, open-label, pilot randomized case control study conducted in the ED of Ramathibodi Hospital from June 2022 to September 2023. Eligible participants included all individuals with mTBI who had negative findings on Brain CT scans. They were randomly assigned to either the early ED discharge or 6-hour ED observation group and compared regarding the outcomes (rate of 48-hour ED revisits; occurrence of post-concussion syndrome (PCS) 1 day, 1 month, and 3 months after the initial injury; and 3-month mortality). Results: 122 patients with the mean age of 74.62 ± 14.96 (range: 25-99) years were consecutively enrolled (57.37% female). No significant differences were observed between the early discharge and observation groups regarding the severity of TBI (p=0.853), age (p=0.334), gender (p=0.588), triage level (p=0.456), Glasgow Coma Scale (GCS) score (p=0.806), comorbidities (p=0.768), medication usage (p=0.548), mechanism of injury (p=0.920), indication for brain CT scan (p=0.593), time from TBI onset to ED arrival (p=0.886), and time from ED triage to brain CT scan (p=0.333). Within 48 hours after randomization, the incidence of revisits was similar between the two groups (1.57% vs. 3.23%; p = 1.000). There were no statistically significant differences in the incidence of PCS between the early discharge and observation groups at 1 day (33.90% vs. 35.48%, p = 0.503), at 1 month (12.07% vs. 13.11%, p = 0.542), and at 3 months (1.92% vs. 5.56%, p = 0.323) after randomization. After a three-month follow-up period, four patients in the early discharge group, had expired (none of the deaths were associated with TBI). Conclusion: It seems that, in mTBI patients with normal initial brain CT scan and the absence of other injuries or neurological abnormalities, early discharge from the ED without requiring observation could be considered safe.

Healthcare professionals' experiences of eHealth in palliative care for older people: challenges, compromises and the price of dignity.

PURPOSE: To explore whether and how eHealth solutions support the dignity of healthcare professionals and patients in palliative care contexts. METHOD: This qualitative study used phenomenographic analysis involving four focus group interviews, with healthcare professionals who provide palliative care to older people. RESULTS: Analysis revealed four categories of views on working with eHealth in hierarchical order: Safeguarding the patient by documenting-eHealth is a grain of support, Treated as less worthy by authorities-double standards, Distrust in the eHealth solution-when the "solution" presents a danger; and Patient first-personal contact with patients endows more dignity than eHealth. The ability to have up-to-date patient information was considered crucial when caring for vulnerable, dying patients. eHealth solutions were perceived as essential technological support, but also as unreliable, even dangerous, lacking patient information, with critical information potentially missing or overlooked. This caused distrust in eHealth, introduced unease at work, and challenged healthcare professionals' identities, leading to embodied discomfort and feeling of a lack of dignity. CONCLUSION: The healthcare professionals perceived work with eHealth solutions as challenging their sense of dignity, and therefore affecting their ability to provide dignified care for the patients. However, healthcare professionals managed to provide dignified palliative care by focusing on patient first.

Post-discharge sedentary behavior and light-intensity physical activity-associated stroke recurrence in patients with minor ischemic stroke: A preliminary retrospective observational study.

BACKGROUND AND PURPOSE: Evidence regarding whether reducing sedentary behavior and increasing physical activity levels to prevent stroke recurrence is insufficient. Therefore, this study preliminarily investigated whether post-discharge sedentary behavior and physical activity levels in patients with minor ischemic stroke were associated with stroke recurrence. METHODS: This retrospective observational study included 73 patients (aged 72.0 years) with minor ischemic stroke from a previous study. The outcome was recurrent stroke 2 years after stroke onset, assessed using medical records. Exposure factors including sedentary behavior and physical activity levels 6 months post-discharge were measured using accelerometers; patients were classified into the recurrence or non-recurrence groups. Logistic regression analyses were then conducted to determine whether sedentary behavior and physical activity 6 months after discharge were associated with stroke recurrence. RESULTS: Six patients experienced stroke recurrence (recurrence rate, 8.2%). The recurrence group showed greater sedentary behavior (recurrence group 68.0%, non-recurrence group 52.0%, p = 0.007) and less light-intensity physical activity (LPA) (recurrence group 21.0%, non-recurrence group 37.0%, p = 0.002) than in the non-recurrence group. Logistic regression analysis showed that sedentary behavior (odds ratio = 1.083, 95% confidence interval = 1.007-1.165, p = 0.032) and LPA (odds ratio = 0.874, 95% confidence interval = 0.785-0.975, p = 0.015) were independent factors for recurrence of stroke. DISCUSSION: Post-discharge sedentary behavior and LPA in patients with minor ischemic stroke were associated with stroke recurrence. Results suggest that reducing post-discharge sedentary behavior and increasing LPA may be crucial for reducing the risk of stroke recurrence in patients with minor ischemic stroke.

The effects of a hospital-to-home care transition program on perceived stress and readiness for hospital discharge in mothers of children with congenital heart disease undergoing corrective surgery.

BACKGROUND: The aim of this study was to investigate the effects of a hospital-to-home care transition (H2H-CT) program on perceived stress and readiness for hospital discharge (RHD) in mothers of children with congenital heart disease (CHD) undergoing corrective surgery. METHODS: This study used a quasi-experimental design and involved 78 mother-child dyads, 40 dyads in the intervention group and 38 dyads in the control group, who were affected by CHD undergoing corrective surgery. The participants received the H2H-CT program, which consisted of six face-to-face training sessions during hospitalization and six telephone counselling sessions. For perceived stress, data were collected at four intervals, including baseline, immediately, one month and three months after completion of the intervention. For RHD, data were collected at two times: baseline and immediately after the intervention. RESULTS: The results demonstrated a statistically significant reduction in the mean perceived stress score in mothers of children with CHD in intervention group before, immediately, four weeks and eight weeks after H2H-CT (P < 0.001). The results also indicated a significant increase in the mean RHD score in the intervention group following H2H-CT (P < 0.001). CONCLUSION: The H2H-CT program was found to be an effective intervention in reducing perceived stress and increasing RHD in mothers of children with CHD who undergoing corrective surgery. IMPLICATIONS TO PRACTICE: The results can be used by the nursing planners, nursing instructors, and pediatric nurses to use the results to enhance the mental health of mothers and enable them to provide quality care at home.

High-risk subgroups were not identified to benefit from thromboprophylaxis after hospitalization for COVID-19.

Background: The Accelerating COVID-19 Therapeutic Interventions and Vaccines-4c (ACTIV-4c) trial investigated prophylactic apixaban for 30 days following hospitalization for COVID-19. The overall incidence of early postdischarge death or thromboembolism was low, and the trial was closed early. Objectives: To identify a high-risk patient population who might benefit from postdischarge thromboprophylaxis through subgroup analyses stratified by age, race/ethnicity, obesity, D-dimer elevation, World Health Organization score, and modified International Medical Prevention Registry on Venous Thromboembolism score on 30-day composite outcome of all-cause death, arterial thromboembolism (ATE), and venous thromboembolism (VTE). Methods: Cumulative incidences of all-cause death, ATE, and VTE within 30 days were described for each subgroup. Time to death, ATE, or VTE by 30 days was analyzed using Cox proportional hazard models with interaction testing for each subgroup. Results: Among 1217 patients randomized to apixaban or placebo group, 32% were >60 years old. Modified International Medical Prevention Registry on Venous Thromboembolism score was ≥4 in 2% and 2 or 3 with an elevated D-dimer in an additional 9% of participants. The overall incidence of the primary endpoint was 2.13% in the apixaban group and 2.31% in the placebo group. At day 30, similar rates of the primary endpoint occurred within subgroups, except for participants aged >60 years. No benefit of thromboprophylaxis was seen in any subgroup. Conclusion: The combined incidence of 30-day death, ATE, and VTE was low in patients who survived COVID-19 hospitalization, except in patients over age 60 years. Due to the limited number of events, the findings remain inconclusive; nonetheless, the study did not identify a high-risk subgroup that would derive benefits from extended thromboprophylaxis.

Improving patients', carers' and primary care healthcare professionals' experiences of discharge communication from specialist palliative care to community settings: a protocol for a qualitative interview study.

BACKGROUND: Patients who have benefited from specialist intervention during periods of acute/complex palliative care needs often transition from specialist-to-primary care once such needs have been controlled. Effective communication between services is central to co-ordination of care to avoid the potential consequences of unmet needs, fragmented care, and poor patient and family experience. Discharge communications are a key component of care transitions. However, little is known about the experiences of those primarily receiving these communications, to include patients', carers' and primary care healthcare professionals. This study aims to have a better understanding of how the discharge communications from specialist palliative care services to primary care are experienced by patients, carers, and healthcare professionals, and how these communications might be improved to support effective patient-centred care. METHODS: This is a 15-month qualitative study. We will interview 30 adult patients and carers and 15 healthcare professionals (n = 45). We will seek a range of experiences of discharge communication by using a maximum variation approach to sampling, including purposively recruiting people from a range of demographic backgrounds from 4-6 specialist palliative care services (hospitals and hospices) as well as 5-7 general practices. Interview data will be analysed using a reflexive thematic approach and will involve input from the research and advisory team. Working with clinicians, commissioners, and PPI representatives we will co-produce a list of recommendations for discharge communication from specialist palliative care. DISCUSSION: Data collection may be limited by the need to be sensitive to participants' wellbeing needs. Study findings will be shared through academic publications and presentations. We will draft principles for how specialist palliative care clinicians can best communicate discharge with patients, carers, and primary care clinicians. These will be shared with clinicians, policy makers, commissioners, and PPI representatives and key stakeholders and organisations (e.g. Hospice UK) and on social media. Key outputs will be recommendations for a specialist palliative care discharge proforma. TRIAL REGISTRATION: Registered in ISRCTN Registry on 29.12.2023 ref: ISRCTN18098027.

[Quality of medication documentation in patients discharge summaries after implementing new legal requirements]. / Dokumentationsqualität der Medikation in Entlassbriefen ­ eine Bestandsaufnahme nach Einführung des Rahmenvertrags Entlassmanagement.

INTRODUCTION: Discharge from hospital is a risk to drug continuity and medication safety. In Germany, new legal requirements concerning the management of patient discharge from the hospital came into force in 2017. They set minimum requirements for the documentation of medications in patient discharge summaries, which are the primary means of communication at transitions of care. Six years later, data on their practical implementation in routine care are lacking. METHODS: Within the scope of an explorative retrospective observational study, the minimum requirements were operationalized and a second set of assessment criteria was derived from the recommendation "Good Prescribing Practice in Drug Therapy" published by the Aktionsbündnis Patientensicherheit e.V. as a comparative quality standard. A sample of discharge summaries was drawn from routine care at the University Hospital Heidelberg and assessed according to their fulfilment of the criteria sets. In addition, the potential influence of certain context factors (e. g., involvement of clinical pharmacists or software usage) was evaluated. RESULTS: In total, 11 quality criteria were derived from the minimum requirements. According to the eligibility criteria (i. e., three or more discharge medications) 352 discharge summaries (42 wards; issued in May-July 2021), containing in total 3,051 medications, were included. The practical implementation of the minimum requirements for documenting medications in patient discharge summaries differed considerably depending on the criterion and defined context factors. Core elements (i. e., drug name, strength, and dosage at discharge) were fulfilled in 82.8 %, while further minimum requirements were rarely met or completely lacking (e. g., explanations for special pharmaceutical forms). Involvement of clinical pharmacists and usage of software were shown to be a facilitator of documentation quality, while on-demand medication (compared to long-term medication) as well as newly prescribed medication (compared to home medication or medication changed during hospitalisation) showed poorer documentation quality. In addition, the documentation quality seemed to depend on the department and the day of discharge. CONCLUSION: To date, the wording of the German legal requirements allows for different interpretations without considering the respective clinical setting and the medication actually prescribed. For future clarification of the requirements, implications of the wording for the clinical setting should be considered.

Pharmacist-Led Medication Management in Acute Geriatric Medicine and Its Associations with Rehospitalizations: A Cohort Study.

INTRODUCTION: Hospitalization and discharge in older patients are critical and clinical pharmacists have shown to ameliorate risks. Our objective was to assess their benefit as part of the geriatric team regarding rehospitalizations and related outcomes after discharge focusing on general practitioners' decision to continue or change discharge medication (GPD). METHODS: Prospective implementation study with 6-month follow-up in an acute geriatric clinic. Patients ≥70 years with comorbidities, impairments, and a current drug therapy were consecutively assigned to three groups: control group (CG), implementation group (IG), and wash-out group (WG). CG only received medication reconciliation (MR) at admission; IG and their hospital physicians received a pharmaceutical counseling and medication management; during WG, pharmaceutical counseling except for MR was discontinued. We used a negative-binomial model to calculate rehospitalizations and days spent at home as well as a recurrent events survival model to investigate recurrent rehospitalizations. RESULTS: One hundred thirty-two patients (mean age 82 years, 76 women [57.6%]) finished the project. In most of the models for rehospitalizations, a positive GPD led to fewer events. We also found an effect of pharmaceutical counseling on rehospitalizations and recurrent rehospitalizations in the CG versus WG but not in the CG versus IG models. 95.3% of medication recommendations by the pharmacist in the clinic setting were accepted. While the number of positive GPDs in CG was low (38%), pharmaceutical counseling directly to the GP in IG led to a higher number of positive GPDs (60%). DISCUSSION: Although rehospitalizations were not directly reduced by our intervention in the CG versus IG, the pharmacist's acceptance rate in the hospital was very high and a positive GPD led to fewer rehospitalization in most models.

Hospital Readmission Rates for Patients Receiving In-Person vs. Telemedicine Discharge Follow-Up Care.

INTRODUCTION: Unplanned readmissions can be avoided by standardizing and improving the coordination of care after discharge. Telemedicine has been increasingly utilized; however, the quality of this care has not been well studied. Standardized measures can provide an objective comparison of care quality. The purpose of our study was to compare quality performance transitions of care management in the office vs telemedicine. METHODS: The Epic SlicerDicer tool was used to compare the percentage of encounters that were completed via telemedicine (video visits); or via in-person for comparison, Chi-squared tests were used. RESULTS: A total of 13,891 patients met the inclusion criteria during the study time frame. There were 12,846 patients in the office and 1,048 in the telemedicine cohort. The office readmission rate was 11.9% with 1,533 patients out of 12,846 compared with telemedicine with the rate of readmission at 12.1% with 126 patients out of 1,045 patients. The P-value for the Chi-squared test between the prepandemic and study time frame was 0.15 and 0.95, respectively. Demographic comparability was seen. DISCUSSION: Our study found a comparable readmission rate between patients seen via in-office and telemedicine for Transitions of Care Management (TCM) encounters. The findings of this study support the growing body of evidence that telemedicine augments quality performance while reducing cost and improving access without negatively impacting HEDIS performance in health care systems. CONCLUSION: Telemedicine poses little threat of negatively impacting HEDIS performance and might be as effective as posthospitalization traditional office care transitions of care management.

Prognostic Impact of Heart Rhythm Shockability Trajectory in Out-of-Hospital Cardiac Arrest: A Multicenter Retrospective Study.

BACKGROUND: This study aimed to investigate the association between the temporal transitions in heart rhythms during cardiopulmonary resuscitation (CPR) and outcomes after out-of-hospital cardiac arrest. METHODS: This was an analysis of the prospectively collected databases in 3 academic hospitals in northern and central Taiwan. Adult patients with out-of-hospital cardiac arrest transported by emergency medical service between 2015 and 2022 were included. Favorable neurological recovery and survival to hospital discharge were the primary and secondary outcomes, respectively. Time-specific heart rhythm shockability was defined as the probability of shockable rhythms at a particular time point during CPR. The temporal changes in the time-specific heart rhythm shockability were calculated by group-based trajectory modeling. Multivariable logistic regression analyses were performed to examine the association between the trajectory group and outcomes. Subgroup analyses examined the effects of extracorporeal CPR in different trajectories. RESULTS: The study comprised 2118 patients. The median patient age was 69.1 years, and 1376 (65.0%) patients were male. Three distinct trajectories were identified: high-shockability (52 patients; 2.5%), intermediate-shockability (262 patients; 12.4%), and low-shockability (1804 patients; 85.2%) trajectories. The median proportion of shockable rhythms over the course of CPR for the 3 trajectories was 81.7% (interquartile range, 73.2%-100.0%), 26.7% (interquartile range, 16.7%-37.5%), and 0% (interquartile range, 0%-0%), respectively. The multivariable analysis indicated both intermediate- and high-shockability trajectories were associated with favorable neurological recovery (intermediate-shockability: adjusted odds ratio [aOR], 4.98 [95% CI, 2.34-10.59]; high-shockability: aOR, 5.40 [95% CI, 2.03-14.32]) and survival (intermediate-shockability: aOR, 2.46 [95% CI, 1.44-4.18]; high-shockability: aOR, 2.76 [95% CI, 1.20-6.38]). The subgroup analysis further indicated extracorporeal CPR was significantly associated with favorable neurological outcomes (aOR, 4.06 [95% CI, 1.11-14.81]) only in the intermediate-shockability trajectory. CONCLUSIONS: Heart rhythm shockability trajectories were associated with out-of-hospital cardiac arrest outcomes, which may be a supplementary factor in guiding the allocation of medical resources, such as extracorporeal CPR.