Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study.

BACKGROUND: Project Re-Engineered Discharge (RED) is an evidence-based strategy to reduce readmissions disseminated and adapted by various health systems across the country. To date, little is known about how adapting Project RED from its original protocol impacts RED implementation and/or sustainability. The goal of this study was to identify and characterize contextual factors influencing how five California hospitals adapted and implemented RED and the subsequent impact on RED program sustainability. METHODS: Participant observation and key informant and focus group interviews with 64 individuals at five California hospitals implementing RED in 2012 and 2013 were conducted. These involved hospital leadership, personnel responsible for Project RED implementation, hospital staff, and clinicians. Interview transcripts were coded and analyzed using a modified grounded theory approach and constant comparative analysis. RESULTS: Both internal and external contextual factors were identified that influenced hospitals' decisions on RED adaptation and implementation. These also impacted RED sustainability. External factors included: impending federal penalties for hospitals with high readmission rates targeting specific diagnoses, and access to external funding and technical support to help hospitals implement RED. Internal or organizational level contextual factors included: committed leadership prioritizing Project RED; RED adaptations; depth, accountability and influence of the implementation team; sustainability planning; and hospital culture. Only three of the five hospitals continued Project RED beyond the implementation period. CONCLUSIONS: The sustainability of RED in participating hospitals was only possible when hospitals approached RED implementation as a transformational process rather than a patient safety project, maintained a high level of fidelity to the RED protocol, and had leadership and an implementation team who embraced change and failure in the pursuit of better patient care and outcomes. Hospitals who were unsuccessful in implementing a sustainable RED process lacked all or most of these components in their approach.

The association between adequacy of prenatal care utilization and subsequent pediatric care utilization in the United States.

OBJECTIVE: To explore the association between adequacy of prenatal care utilization and subsequent pediatric care utilization. DESIGN: A longitudinal follow-up of a nationally representative sample of infants born in 1988. PARTICIPANTS: Nine thousand four hundred forty women who had a live birth in 1988, and whose child was alive at the time of interview, and 8285 women from the original sample who were reinterviewed in 1991. MAIN OUTCOME MEASURE: There were four outcome measures: number of well-child visits; adequate immunization for diphtheria, tetanus, and pertussis; adequate immunization for polio; and continuity of a regular source of care, as measured by the number of sites for pediatric care. RESULTS: Children whose mothers had less than adequate prenatal care utilization had significantly fewer well-child visits, and were significantly less likely to have adequate immunizations, even after income, health insurance coverage, content of prenatal care, wantedness of child, sites of prenatal and pediatric care, and maternal and pregnancy risk characteristics were taken into account. Less than adequate prenatal care utilization was not associated with having more than one pediatric care site. CONCLUSIONS: Prenatal care utilization can be used to identify and target interventions to women who are at risk for not obtaining well-child care or complete immunizations for their children.

Addressing preconception risks identified at the time of a negative pregnancy test. A randomized trial.

BACKGROUND: A preconception care program has the potential to assist women who want to become pregnant by advising these women about risk factors, healthy lifestyles, and assessing readiness for pregnancy. We conducted a randomized controlled trial to determine whether comprehensive preconception risk assessment at the time of a negative pregnancy test followed by referral to primary care services is effective in initiating treatment for women with preconception risk factors. METHODS: One hundred seventy women were offered preconception risk assessment following a negative pregnancy test. Women were assigned randomly either to a usual care group or an intervention group. Women in the latter group were informed about the risks identified and received an appointment with a primary care clinician who was also informed. Women in the usual care group and their clinicians received no feedback. All charts were reviewed and the women were contacted by telephone to determine if interventions to reduce risk were offered by clinicians during the year following the assessment. RESULTS: An average of 8.96 risks were identified per woman. The proportion of women having risks in each of 12 risk categories studied ranged from 19% to 71%. One hundred women (59%) made at least one visit during the subsequent year, thus allowing the opportunity for preconception care. The proportion of these women who had a risk addressed ranged from 18% for psychosocial risks to 48% for those with fetal exposures (smoking, alcohol, and drug use). There was no difference between groups in the percentage of risks addressed. CONCLUSIONS: The notification of women and their clinicians of identified preconception risks did not improve intervention rates. A more organized intervention system including office-based protocols is needed.

The influence of site of care on the content of prenatal care for low-income women.

OBJECTIVE: To assess whether site of prenatal care influences the content of prenatal care for low-income women. DESIGN: Bivariate and logistic analyses of prenatal care content for low-income women provided at five different types of care sites (private offices, HMOs, publicly funded clinics, hospital clinics, and other sites of care), controlling for sociodemographic, behavioral, and maternal health characteristics. PARTICIPANTS: A sample of 3405 low-income women selected from a nationally representative sample of 9953 women surveyed by the National Maternal and Infant Health Survey, who had singleton live births in 1988, had some prenatal care (PNC), Medicaid participation, or a family income less than $12,000/year. OUTCOME MEASURES: Maternal report of seven initial PNC procedures (individually and combined), six areas of PNC advice (individually and combined), and participation in the Women Infant Children (WIC) nutrition program. RESULTS: The content of PNC provided for low-income women does not meet the recommendations of the U.S. Public Health Service, and varies by site of delivery. Low-income women in publicly funded clinics (health departments and community health centers) report receiving more total initial PNC procedures and total PNC advice and have greater participation in the WIC program than similar women receiving PNC in private offices. CONCLUSIONS: Publicly funded sites of care appear to provide more comprehensive prenatal care services than private office settings. Health care systems reforms which assume equality of care across all sites, or which limit services to restricted sites, may foster unequal access to comprehensive PNC.

The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States.

OBJECTIVE: To estimate the prevalence and length of gaps in health insurance coverage and their effect on having a regular source of care in a national sample of preschool-aged children. DESIGN: Follow-up survey of a nationally representative sample of 3-year-old children in the US population by phone or personal interview. PARTICIPANTS: A total of 8129 children whose mothers were interviewed for the 1991 longitudinal Follow-up to the National Maternal and infant Health Survey. MAIN OUTCOME MEASURES: Report of any gap in health insurance for the children, the length of the gap, and the number of different sites where the children were taken for medical care as a measure of continuity of a regular source of care. RESULTS: About one quarter of Us children were without health insurance for at least 1 month during their first 3 years of life. Over half of these children had a health insurance gap of more than 6 months. Less than half of US children had only one site of care during their first 3 years. Children with health insurance gaps of longer than 6 months were at increased risk of having more than one care site (odds ratio = 1.52; 95% confidence interval, 1.19 to 1.96). This risk further increased when an emergency treatment was discounted as a multiple site of care. CONCLUSIONS: Having a gap in health insurance coverage is an important determinant for not having a regular source of care for preschool-aged children. This finding is of concern, given the sizable percentage of children in the United States who lacked continuous health care coverage during a critical period of development.

The negative pregnancy test. An opportunity for preconception care.

OBJECTIVE: To identify women who would likely benefit from preconception care. METHODS: A comprehensive preconception risk survey was administered during a structured interview to 136 women who had a negative pregnancy test visit in a family practice residency ambulatory practice. The survey solicited the presence of self-reported risk variables associated with maternal conditions related to poor obstetric outcome, risk factors for poor obstetric outcome, and risks for developing these conditions. RESULTS: Seventy women (51.5%) reported a medical or reproductive risk that could adversely affect pregnancy. In addition, 68 women (50%) reported a genetic risk; 39 (28.7%) reported a risk for human immunodeficiency virus infection, 35 (25.7%) reported an indication for hepatitis B vaccine, and an equal number reported recent use of illegal substances; 23 (16.9%) reported at least one affirmative answer to the CAGE questionnaire; 79 (58.5%) smoked cigarettes; 74 (54.4%) reported a nutrition risk; 126 (92.6%) reported a psychosocial risk; and 39 (28.7%) reported a perceived barrier to ongoing medical care. Even with the psychosocial risk category excluded, 94% of the women still reported at least one factor requiring further evaluation, counseling, or intervention before pregnancy. CONCLUSIONS: We discovered a significant number of women with obstetric risk factors. A negative pregnancy test visit provides an opportunity for preconception risk assessment and counseling. These results will guide us to further develop practical preconception care protocols.

Comparing mothers' reports on the content of prenatal care received with recommended national guidelines for care.

The Public Health Service's Expert Panel on the Content of Prenatal Care Report in 1989 provided detailed guidelines for the components of each prenatal visit. However, the extent to which women were receiving the recommended care when the guidelines were being formulated has yet to be determined. The 1988 National Maternal and Infant Health Survey results permit an examination of the proportion of women who reported receiving some of the recommended procedures. Women were asked if they received six of the recommended procedures (blood pressure measurement, urine test, blood test, weight and height taken, pelvic examination, and pregnancy history) in the first two visits, and whether they received seven types of advice or counseling (nutrition; vitamin use; smoking, alcohol, and drug use cessation; breastfeeding; and maternal weight gain) any time during their pregnancy. Only 56 percent of the respondents said they received all of the recommended procedures in the first two visits, and only 32 percent of the respondents said they received advice in all of the areas. Logistic regression analysis indicated that women receiving their care from private offices were significantly less likely to receive all the procedures and advice than women at publicly funded sites of care. This study suggests that recommendations of the Public Health Service's expert panel were not being met.

A successful physician training program in cholesterol screening and management.

METHOD: Thirty-six resident physicians received a blood cholesterol training program which included training in blood cholesterol screening using a fingerstick method and a desktop analyzer, diet assessment and counseling, and a management protocol for follow-up diet and drug treatment. The program also included feedback to residents about their blood cholesterol screening activity, incentives, and biweekly articles in the department newsletter. RESULTS: Between 1986-1987 (baseline) and 1987-1988 (intervention), the percentage of the target patient population (ages 20-65 years, nonpregnant, not screened in the previous year) that was screened for hypercholesterolemia in this primary care practice increased from 16.2 to 23.2% [rate difference (RD) = 7.0; 95% confidence interval (CI) = 4.75-9.25]. The mean value of the screening tests decreased from 5.36 mmol/liter (207.2 mg/dl) to 5.08 mmol/liter (196.6 mg/dl; t = 2.98, P = 0.003) and the percentage of the population screened needing further evaluation decreased from 36.8 to 27.6% (RD 9.2; CI = 2.00-14.00). In the intervention year, compared with the baseline year, patients with a borderline blood cholesterol and cardiovascular risk factors were more likely to have a follow-up test (28.8% vs 11.9%, RD = 16.9; 95% CI = 0.80-33.00) and the low-density lipoprotein cholesterol test was used less for screening (8.2% vs 19.4%, P less than 0.0001). Conclusion. We conclude that this program was effectively integrated into a busy primary care practice, leading to improvement in blood cholesterol screening and management practices.

Severe hyponatremia: an association with lisinopril?

A 63-year-old white woman with a history of hypertension and chronic obstructive pulmonary disease presented to the emergency room with worsening shortness of breath, anorexia, coughing, increased thirst, and leg edema of two weeks' duration. Medications included lisinopril 10 mg/d, which had been started six weeks earlier, sustained-release theophylline 300 mg q12h, and an albuterol inhaler. The lisinopril was discontinued on admission. Serum sodium concentration was 109 mmol/L; the osmolality of the blood and of the urine were 253 mOsmol and 438 mOsmol, respectively, with a specific gravity of 1.025 and a urine sodium of 17 mmol/L. The hyponatremia initially was considered to be the syndrome of inappropriate antidiuretic hormone secretion in response to the patient's suspected pneumonia. Due to worsening blood pressure, lisinopril was restarted and the serum sodium concentration dropped from 134 to 126 mmol/L. Evaluation of the patient's hyponatremia included assessment of thyroid, adrenal, hepatic, and cardiac function that were within normal limits. The patient was discharged on the following medications: sustained-release theophylline 300 mg tid, prednisone 10 mg/d, albuterol inhaler 2 puffs q6h, and sustained-release verapamil 240 mg/d for blood pressure control. Her serum sodium concentration has remained between 135 and 140 mmol/L during hospitalizations for exacerbations of chronic obstructive pulmonary disease and for pneumonias 10 and 12 months after discharge.

A follow-up survey of family physicians' interest in and knowledge of nutrition.

Forty-two practicing family physicians completed a questionnaire about 33 nutrition topic areas. They were among 71 physicians who, over an eight-year period (1980-1988), completed an identical questionnaire upon entry to their first postgraduate year in the family practice residency program at Brown University/Memorial Hospital of Rhode Island. Specific topic areas were grouped into five scales. Perceived knowledge of these topics significantly increased (p less than .0001) in all areas except nutritional biochemistry. There was significantly less (p less than .0001) interest in learning more about nutrition. One major exception was that the physicians wanted to learn more about nutrition counseling. Another exception was that nutrition in the life cycle remained an area about which they wanted to learn more. The physicians rated nutritional skills as less relevant on the second questionnaire than on the first. The authors conclude that more emphasis on nutrition counseling skills and nutrition in the life cycle may be appropriate in medical education.

Routine obstetric ultrasound.

Routine ultrasound may have a positive effect on obstetric outcome when determination of gestational age and placental localization are combined with evaluation for multiple gestation, congenital anomalies and growth retardation. The potential risk and benefit of obstetric ultrasound must be better understood before this procedure is used as a screening tool in large populations.