RESUMO
Background: During the height of the coronavirus (COVID-19) pandemic, there was an unprecedented demand for "virtual visits," or ambulatory visits conducted via video interface, in order to decrease the risk of transmission. Objective: To describe the implementation and evaluation of a video visit program at a large, academic primary care practice in New York, NY, the epicenter of the COVID-19 pandemic. Design and participants: We included consecutive adults (age > 18) scheduled for video visits from March 16, 2020 to April 17, 2020 for COVID-19 and non-COVID-19 related complaints. Intervention: New processes were established to prepare the practice and patients for video visits. Video visits were conducted by attendings, residents, and nurse practitioners. Main measures: Guided by the RE-AIM Framework, we evaluated the Reach, Effectiveness, Adoption, and Implementation of video visits. Key results: In the 4 weeks prior to the study period, 12 video visits were completed. During the 5-weeks study period, we completed a total of 1,030 video visits for 817 unique patients. Of the video visits completed, 42% were for COVID-19 related symptoms, and the remainder were for other acute or chronic conditions. Video visits were completed more often among younger adults, women, and those with commercial insurance, compared to those who completed in-person visits pre-COVID (all p < 0.0001). Patients who completed video visits reported high satisfaction (mean 4.6 on a 5-point scale [SD: 0.97]); 13.3% reported technical challenges during video visits. Conclusions: Video visits are feasible for the delivery of primary care for patients during the COVID-19 pandemic.
Assuntos
COVID-19 , Telemedicina , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Atenção Primária à Saúde , SARS-CoV-2RESUMO
OBJECTIVE: We aimed to address deficiencies in structured electronic health record (EHR) data for race and ethnicity by identifying black and Hispanic patients from unstructured clinical notes and assessing differences between patients with or without structured race/ethnicity data. MATERIALS AND METHODS: Using EHR notes for 16 665 patients with encounters at a primary care practice, we developed rule-based natural language processing (NLP) algorithms to classify patients as black/Hispanic. We evaluated performance of the method against an annotated gold standard, compared race and ethnicity between NLP-derived and structured EHR data, and compared characteristics of patients identified as black or Hispanic using only NLP vs patients identified as such only in structured EHR data. RESULTS: For the sample of 16 665 patients, NLP identified 948 additional patients as black, a 26%increase, and 665 additional patients as Hispanic, a 20% increase. Compared with the patients identified as black or Hispanic in structured EHR data, patients identified as black or Hispanic via NLP only were older, more likely to be male, less likely to have commercial insurance, and more likely to have higher comorbidity. DISCUSSION: Structured EHR data for race and ethnicity are subject to data quality issues. Supplementing structured EHR race data with NLP-derived race and ethnicity may allow researchers to better assess the demographic makeup of populations and draw more accurate conclusions about intergroup differences in health outcomes. CONCLUSIONS: Black or Hispanic patients who are not documented as such in structured EHR race/ethnicity fields differ significantly from those who are. Relatively simple NLP can help address this limitation.
Assuntos
Negro ou Afro-Americano , Registros Eletrônicos de Saúde , Hispânico ou Latino , Processamento de Linguagem Natural , Populações Vulneráveis , Algoritmos , Estudos Transversais , Registros Eletrônicos de Saúde/normas , Etnicidade , Feminino , Humanos , Masculino , Grupos RaciaisRESUMO
We sought to determine whether hospitalizations affect where patients seek ambulatory care. We conducted a retrospective cohort study of 569 adults who were attributed by a commercial payer to a large physician organization (PO) and hospitalized in 2015. Approximately half of the patients (55%) were admitted to the hospital affiliated with the PO; the rest were hospitalized elsewhere. Patients hospitalized elsewhere were significantly less likely to be seen by a PO provider in the 6 months posthospitalization than those hospitalized at the affiliated hospital (adjusted odds ratio = 0.29; 95% confidence interval = 0.17-0.48). These results have important implications for population management.
Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde , Preferência do Paciente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Revisão da Utilização de Recursos de SaúdeRESUMO
BACKGROUND: There are few engaging, patient centered, and reliable e-Health sources, particularly for patients with low health literacy. OBJECTIVES: We tested the Patient Activated Learning System (PALS) against WebMD. We hypothesized that participants using PALS would have higher knowledge scores, greater perceived learning, comfort, and trust than participants using WebMD. METHODS: Participants with hypertension from an urban Internal Medicine practice were randomized to view 5 web pages in PALS orWebMD containing information about chlorthalidone. We assessed knowledge, learning perceptions, comfort, and trust through surveys immediately and one week following the intervention. RESULTS: 104 participants completed both survey sets (PALS = 51,WebMD = 53). Immediate post intervention mean knowledge scores were higher for the PALS participants [(4.33 vs. 3.62 (P = .003)]. A greater proportion of PALS participants answered ≥4/5 questions correctly (82% vs. 57%; IRR 1.46 [95% CI 1.13-1.89]). A greater proportion of PALS participants agreed they would feel comfortable taking chlorthalidone if prescribed to them (73% vs. 55%; IRR 1.38 [95% CI 1.04-1.84]). One-week recall and trust were similar in the two groups. CONCLUSIONS: PALS may have advantages overWebMD for immediate knowledge acquisition, perceived learning, and comfort. IMPLICATIONS: PALS is a promising new approach to eHealth patient education. ClinicalTrials.gov registration identifier: NCT03156634.
Assuntos
Anti-Hipertensivos/uso terapêutico , Clortalidona/uso terapêutico , Tomada de Decisões , Hipertensão/tratamento farmacológico , Educação de Pacientes como Assunto , Retenção Psicológica , Feminino , Letramento em Saúde , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Inquéritos e QuestionáriosRESUMO
The objective of this study was to test the feasibility of video discharge education to improve self-efficacy in dealing with medication barriers around hospital discharge. We conducted a single-arm intervention feasibility trial to evaluate the use of video education in participants who were being discharged home from the hospital. The scores of pre- and post-intervention self-efficacy involving medication barriers were measured. We also assessed knowledge retention, patient and nursing feedback, follow-up barrier assessments, and hospital revisits. A total of 40 patients participated in this study. Self-efficacy scores ranged from 5 to 25. Median pre- and post-intervention scores were 21.5 and 23.5, respectively. We observed a median increase of 2.0 points from before to after the intervention (p = 0.046). In total, 95 percent of participants reported knowledge retention and 90 percent found the intervention to be helpful. Video discharge education improved patient self-efficacy surrounding discharge medication challenges among general medicine inpatients. Patients and nurses reported satisfaction with the video discharge education.
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Prescrições de Medicamentos/enfermagem , Educação de Pacientes como Assunto/normas , Pacientes/psicologia , Autoeficácia , Gravação de Videoteipe/normas , Adulto , Idoso , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Entrevistas como Assunto/métodos , Masculino , Pessoa de Meia-Idade , New York , Alta do Paciente/normas , Alta do Paciente/estatística & dados numéricos , Educação de Pacientes como Assunto/métodos , Educação de Pacientes como Assunto/estatística & dados numéricos , Pacientes/estatística & dados numéricos , Projetos Piloto , Pesquisa Qualitativa , Estatísticas não Paramétricas , Inquéritos e Questionários , Gravação de Videoteipe/métodos , Gravação de Videoteipe/estatística & dados numéricosRESUMO
INTRODUCTION: Hospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Some patients admitted from the ED may not require inpatient care if outpatient care could be optimized. However, access to primary care especially immediately after ED discharge is challenging. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center. METHODS: We conducted a retrospective review of patients referred from the ED to primary care (Weill Cornell Internal Medicine Associates - WCIMA) through a rapid-access-to-primary-care program developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals were classified as either an avoided admission or not, and classifications were performed by both emergency physician (EP) and internal medicine physician reviewers. We also collected outcome data on rapid visit completion, ED revisits, hospitalizations and primary care engagement. RESULTS: EPs classified 26 (16%) of referrals for rapid primary care follow-up as avoided admissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapid appointment. There were no differences in rates of ED revisits or subsequent hospitalizations between those who attended the rapid follow-up and those who did not attend. Patients who attended the rapid appointment were significantly more likely to attend at least one subsequent appointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8 (18%), P=0.001]. CONCLUSION: A rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care.
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Assistência ao Convalescente/estatística & dados numéricos , Assistência Ambulatorial/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Centros Médicos Acadêmicos/estatística & dados numéricos , Adulto , Agendamento de Consultas , Protocolos Clínicos , Feminino , Humanos , Cobertura do Seguro , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , População UrbanaRESUMO
OBJECTIVES: After hospitalization, timely discharge follow-up has been linked to reduced readmissions in the heart failure population, but data from general inpatients has been mixed. The objective of this study was to determine if there was an association between completed follow-up appointments within 14 days of hospital discharge and 30-day readmission amongst primary care patients at an urban academic medical center. Index discharges included both inpatient and emergency room settings. A secondary objective was to identify patient factors associated with completed follow-up appointments within 14 days. METHODS: We conducted a retrospective review of primary care patients at an urban academic medical center who were discharged from either the emergency department (ED) or inpatient services at the Weill Cornell Medical Center/New York Presbyterian Hospital from 1 January 2014-31 December 2014. Cox proportional hazard models were used to identify the relationship between follow-up in primary care within 14 days and readmission within 30 days. Logistic regression was used to evaluate the association of patient factors with 14-day follow-up. RESULTS: Among 9,662 inpatient and ED discharges, multivariable analysis (adjusting for age, gender, race/ethnicity, insurance, number of diagnoses on problem list, length of stay, and discharge service) showed that follow-up with primary care within 14 days was not associated with a lower hazard of readmission within 30 days (HR = 0.78; 95% CI 0.56-1.09). A higher number of diagnoses on the problem list was associated with greater odds of follow-up for both inpatient and emergency department discharges (inpatient: HR = 1.03, 95% CI 1.02-1.04; ED: HR = 1.02, 95% CI 1.00-1.04). For inpatient discharges, each additional day in length of stay was associated with 3% lower odds of follow-up (HR = 0.97, 95% CI 0.96-0.99). CONCLUSION: Early follow-up within 14 days after discharge from general inpatient services was associated with a trend toward lower hazard of 30-day readmission though this finding was not significant. Future studies should focus on identifying additional cohorts of patients in which readmission is reduced by early follow-up, so that access to primary care appointments is not compromised.
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Serviço Hospitalar de Emergência/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Centros Médicos Acadêmicos/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Comorbidade , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Grupos Raciais/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores Socioeconômicos , Fatores de TempoRESUMO
BACKGROUND: Beta-blockers reduce mortality among patients with systolic heart failure (HF), yet primary care provider prescription rates remain low. OBJECTIVE: To examine the association between primary care physician characteristics and both self-reported and actual prescription of beta-blockers among patients with systolic HF. DESIGN: Cross-sectional survey with supplementary retrospective chart review. PARTICIPANTS: Primary care providers at three New York City Veterans Affairs medical centers. MEASUREMENTS: MAIN OUTCOMES WERE: 1) self-reported prescribing of beta-blockers, and 2) actual prescribing of beta-blockers among HF patients. Physician HF practice patterns and confidence levels, as well as socio-demographic and clinical characteristics, were also assessed. RESULTS: Sixty-nine of 101 physicians (68%) completed the survey examining self-reported prescribing of beta-blockers. Physicians who served as inpatient ward attendings self-reported significantly higher rates of beta-blocker prescribing among their HF patients when compared with physicians who did not attend (78% vs. 58%; p = 0.002), as did physicians who were very confident in managing HF patients when compared with physicians who were not (82% vs. 68%; p = 0.009). Fifty-one of these 69 surveyed physicians (74%) were successfully matched to 287 HF patients for whom beta-blocker prescribing data was available. Physicians with greater self-reported rates of prescribing beta-blockers were significantly more likely to actually prescribe beta-blockers (p = 0.02); however, no other physician characteristics were significantly associated with actual prescribing of beta-blockers among HF patients. CONCLUSIONS: Physician teaching responsibilities and confidence levels were associated with self-reported beta-blocker prescribing among their HF patients. Educational efforts focused on improving confidence levels in HF care and increasing exposure to teaching may improve beta-blocker presciption in HF patients managed in primary care.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Médicos de Família/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise de RegressãoRESUMO
BACKGROUND: Beta-blockers reduce mortality in patients with systolic chronic heart failure (CHF), yet prescription rates have remained low among primary care providers. OBJECTIVE: To determine the beta-blocker prescription rate among patients with systolic CHF at primary care Veterans Affairs (VA) clinics, its change over time; and to determine factors associated with nonprescription. DESIGN: Retrospective chart review. SUBJECTS: Seven hundred and forty-five patients with diagnostic codes for CHF followed in primary care clinics at 3 urban VA Medical Centers. MEASUREMENTS: Rate of beta-blocker prescription and comparison of patient characteristics between those prescribed versus those not prescribed beta-blockers. RESULTS: Only 368 (49%) had documented systolic CHF. Eighty-two percent (303/368) of these patients were prescribed a beta-blocker. The prescription rate rose steadily over 3 consecutive 2-year time periods. Patients with more severely depressed ejection fractions were more likely to be on a beta-blocker than patients with less severe disease. Independent predictors of nonprescription included chronic obstructive pulmonary disease, asthma, depression, and age. Patients under 65 years old were 12 times more likely to receive beta-blockers than those over 85. CONCLUSION: Primary care providers at VA Medical Centers achieved high rates of beta-blocker prescription for CHF patients. Subgroups with relative contraindications had lower prescription rates and should be targeted for quality improvement initiatives.