When do patient-reported outcome measures inform readmission risk?

OBJECTIVE: To characterize changes in patient-reported outcome measures from hospital discharge to assess when they best inform risk of utilization as defined by readmissions or emergency department use. PARTICIPANTS: Patients discharged from an urban safety-net hospital. DESIGN: Longitudinal cohort study. MAIN MEASURES: We serially administered the Memorial Symptom Assessment Scale (MSAS) and the PROMIS Global Health short form assessing General Self-Rated Health (GSRH), Global Physical (GPH), and Mental (GMH) Health at 0, 30, 90, and 180 days from hospital discharge. Time to first utilization from each survey was plotted by dichotomizing our sample on each patient-reported measure, and equivalence of the time-to-event curves was assessed using the log-rank test. Cox proportional hazard models were used to control for available covariates including prior utilization during the study, Charlson score, age, gender, and race/ethnicity. We assessed each measure's effect on the fit of the predictive models using the likelihood ratio test. KEY RESULTS: We recruited 196 patients, of whom 100%, 98%, 90%, and 88% completed each respective survey wave. Participants' mean age was 52 years, 51% were women, 60% were non-Hispanic black, and 21% completed the questionnaires in Spanish. In-hospital assessments revealed high symptom burden and poor health status. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas posthospitalization assessments of MSAS and GPH predicted subsequent utilizations. Each measure selectively improved predictive model fit. CONCLUSIONS: Routine measurement of patient-reported outcomes can help identify patients at higher risk for utilizations. At different time points, MSAS, GPH, GMH, and GSRH all informed utilization risk.

From Albania to Zambia: travel back to country of origin as a goal of care for terminally ill patients.

BACKGROUND: With unprecedented levels of international migration, physicians in the United States may care for terminally ill patients who have strong connections to their country of origin and such patients may desire to return in the final stages of life. OBJECTIVE: In this study, we analyzed how often terminally ill patients cited travel to country of origin as a goal of care, how often travel occurred, and factors associated with successful travel. DESIGN: A retrospective chart review from January 1, 2005 through May 1, 2007. SETTING/SUBJECTS: All foreign-born patients seen by a palliative care consultation service, including inpatient and outpatient consultations, in an urban safety-net health system in the United States. MEASUREMENTS: We determined whether patients expressed a desire to travel to their country of origin and the factors, including demographics and functional status associated with travel. RESULTS: Of 336 foreign-born patients, 129 (38%) expressed a desire to travel to their country of origin; 60 (47%) successfully returned to 24 unique countries. Countries to which the largest number of patients returned were Mexico (n=14), Poland (n=11), and the Philippines (n=7). Although patients with the best functional status were most likely to travel successfully, 16 (31%) who wanted to travel despite having the worst functional status (Eastern Cooperative Oncology Group [ECOG] score indicating confinement to bed or chair) traveled successfully. There were no deaths en route or flight diversions due to medical crisis; all trips were made on regularly scheduled commercial airline flights. CONCLUSIONS: A substantial proportion of patients in our cohort expressed a desire to return to their country of origin. We facilitated successful travel for nearly half of these patients. Our findings identify the need to include travel back to country of origin in the framework of planning care for terminally ill patients.

Health perceptions and symptom burden in primary care: measuring health using audio computer-assisted self-interviews.

PURPOSE: To assess the relationships among somatic symptoms and health perception measures in data collected from the implementation of audio computer-assisted self-interview (ACASI) technology in a primary care clinic of a safety-net healthcare system. METHODS: We approached 2,848 English- or Spanish-speaking patients to complete an ACASI-administered survey before their clinic appointment between April 2011 and July 2012. We administered the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health-10 assessing General Self-Rated Health (GSRH), Global Physical and Mental Health; Memorial Symptom Assessment Scale (MSAS) assessing symptom burden; and the Patient Health Questionnaire-2 (PHQ-2). We calculated population attributable fractions (PAF) of symptoms on poorly perceived health. RESULTS: Participation rate was 90 %, but 51 % of observations were analyzable. Mean age was 57 years; 53 % were non-Hispanic black; and 20 % completed the survey in Spanish. All but 2 % reported at least one symptom most commonly lack of energy (87 %) and pain (83 %). The MSAS was well correlated with PHQ-2 (r = 0.65) and Global Physical Health (r = -0.65), but less with GSRH (r = -0.49). All negative health perception measures were largely attributable to lack of energy and pain, while depression-range PHQ-2 was attributable also to less prevalent symptoms including decreased appetite and sexual disinterest. CONCLUSIONS: Symptom burden was less correlated with GSRH than with other measures of poor health perception. Fatigue and pain contributed the highest PAF to all measures of perceived poor health. Success with collecting PROMs in a resource-limited clinical setting demonstrates that the implementation of ACASI technology is feasible.