Hospital Readmissions from Patients' Perspectives.

OBJECTIVES: Healthcare expenditures in the United States have increased exponentially and hospital care accounts for one-third of these costs. Approximately 18% of hospitalized Medicare beneficiaries are being readmitted to the hospital within 30 days. Engaging patients in the discharge process can help better identify patients' postdischarge needs and implement more effective readmission prevention strategies. The objective of our study was to identify the factors that contribute to hospital readmission as seen from patients' perspectives in a large urban community hospital. METHODS: We evaluated all consecutive, unplanned readmissions to the hospitalist service within 30 days of discharge, using the STate Action on Avoidable Rehospitalizations diagnostic worksheet with face-to-face patient interviews and retrospective chart reviews. RESULTS: During the study period, 80 patients were readmitted within 30 days of their discharge, with 28 of them having more than one readmission. The mean age was 50.8 ± 18.3 years. Of the 80 patients, 51% were men and 51% were black. Sickle cell disease was the leading diagnosis (11.3%) in both index admissions and readmissions. Patient interviews identified some modifiable risk factors for readmissions such as the inability to obtain medications or schedule follow-up appointments as well as problems related to transportation, housing, and social support. Despite clear discharge planning and patient understanding of the plan being recorded at discharge, almost one-third of patients appeared to lack the ability to self-manage symptoms and understand the disease process. CONCLUSIONS: Our study demonstrated that engaging patients in discharge planning can help identify barriers within the process. Improvements in socioeconomic/environmental layers of population health have the potential to prevent hospitalizations and readmissions in the long term.

Reinvigorating pediatric care in an academic family medicine practice.

BACKGROUND AND OBJECTIVES: Primary care access is critical for all populations, and family physicians remain a vital link to pediatric care, especially for rural/underserved areas and adolescents. Pediatric visits to family physicians have declined nationally, a trend also noted at the University of North Carolina (UNC) Family Medicine Center (FMC). Academic FMCs are challenged with maintaining their pediatric population in a competitive environment and providing excellent pediatric training to prepare residents to care for children. We investigated potential factors impacting pediatric visits with a goal of reversing this trend. We developed a 360-degree approach to examine and reinvigorate pediatric care and training in our practice. METHODS: To determine which aspects of our practice made pediatric care challenging, we conducted focus groups with parents of former and current FMC pediatric practices. We used billing data to assess pediatric patient volume and performed chart audits to examine preventive health visits, immunizations, and developmental screening. We anonymously contacted local family medicine and pediatric practices to compare services offered in their practice versus ours. Resident in-training exam scores and graduate surveys were reviewed to assess our pediatric training. RESULTS: Based on our evaluation, we identified and implemented improvements in the areas of clinical quality interventions, provider/education competency, and community marketing/relationships. CONCLUSIONS: A longitudinal evaluation and quality improvement initiative positively impacted our pediatric practice and training. The 360-degree approach of quality improvement may be useful for other academic family practices that are challenged with pediatric volume.

Evaluation of prenatal and pediatric group visits in a residency training program.

BACKGROUND: It is well established that group visits offer an appropriate alternative to individual care with respect to efficiency, clinical effectiveness, and patient and provider satisfaction and are feasible in the training setting. The purpose of this paper is to describe resident educational outcomes from participation in prenatal and well-child group visits over the last 6 years. METHODS: We surveyed the 48 physicians who graduated from the University of North Carolina Family Medicine Residency from 2006 through 2011 regarding their current scope of practice, the number of group visits they experienced, and the educational value of group visits. RESULTS: Thirty-four (71%) of graduates responded. Twelve respondents (35%) include prenatal care in their current practice, 29 (85%) include pediatric care, and five (15%) include group visits. As residents, all respondents participated in group visits. Respondents most valued what they learned in group visits from patient questions, from the exposure to a bolus of patients at the same stage of development, and from faculty role modeling. CONCLUSIONS: Group visits are a potentially valuable adjunct to the standard training experience, with benefits for learning efficiency, scope of practice, and the promotion of patient-centered care that can be carried forward into practice.

Influence of a tobacco-free hospital campus policy on smoking status of hospital employees.

PURPOSE: To examine the influence of a tobacco-free hospital campus (TFHC) policy on employee smoking behavior. DESIGN: Questionnaires immediately prior to, 6 months after, and 1 year after implementation of a TFHC policy. SETTING: University-affiliated hospital system. SUBJECTS: A cohort of smokers and recent quitters. MEASURES: Smoking status, quit attempts, influence of TFHC policy. ANALYSIS: Descriptive. RESULTS: From 2024 employees who responded to an initial online survey prior to implementation of a TFHC policy, 307 respondents reported either current smoking or quitting smoking within the past 6 months. Of these, 210 (68%) agreed to follow-up surveys at 6 and 12 months post-policy implementation. At each of the three times, between 15% and 18.5% of the cohort reported not smoking, with at least 48% of those not smoking reporting 6 to 12 months continuous abstinence. Sixty percent or more of those who reported quit attempts or not smoking indicated that the TFHC policy was influential in their efforts. CONCLUSIONS: A TFHC policy may lead to increased employee smoking quit attempts and successful cessation. Health care facilities should broaden smoking restrictions to include the entire workplace campus, not only to reduce exposure to environmental tobacco smoke, but also to increase tobacco cessation.

Statewide diffusion of 100% tobacco-free college and university policies.

OBJECTIVES: As smoking among college students reached new highs in the 1990s, most interventions for college student smoking prevention focused on individual student knowledge, attitudes and beliefs. No published studies report on statewide movements to accelerate the adoption of tobacco-free policies on college campuses. The results of the first 4 years of the North Carolina Tobacco-Free Colleges Initiative are presented. METHODS: The North Carolina Health and Wellness Trust Fund developed a multilevel intervention to accelerate the diffusion of tobacco-free policies on college campuses, including funding campus coordinators and coalitions to tailor activities to the campus environment at 64 colleges. Evaluators tracked process and policy outcomes as well as the diffusion of policy adoption from January 2006-December 2009. RESULTS: Prior to the initiative, only one small, private college campus in North Carolina was tobacco-free. By 4 years into the initiative, 33 colleges and community colleges, representing more than 159 300 students, have adopted comprehensive tobacco-free policies to protect students, faculty, staff and visitors. Participating campuses also adopted 68 policies restricting smoking in certain areas and limiting industry activity. CONCLUSIONS: Tobacco-free policy adoption on college campuses can be accelerated with a multilevel statewide intervention.

Secondhand smoke policies at state and county fairs.

OBJECTIVES: We sought to assess the smoking policies at state and county fairs in North Carolina. METHODS: We contacted North Carolina fair managers by telephone to solicit participation in a survey that assessed the extent to which fairs have written policies about smoking and secondhand smoke (SHS) exposure, managers' beliefs concerning the health risks associated with SHS exposure, and specific reasons that might prompt managers to adopt smoke-free policies. RESULTS: Attempts were made to contact 47 fair managers, and 37 (66.0%) participated in the study. We found that although almost two-thirds of fairs prohibited smoking indoors, the vast majority (83.9%) had no limits on outdoor smoking. Most fair managers (84.6%) acknowledged that SHS may cause lung cancer, and a majority (51.6%) reported a belief that their patrons would largely be supportive of a more restrictive policy. LIMITATIONS: Fair managers' responses were primarily based on their own opinions, estimates, and attitudes. CONCLUSIONS: Because of the high number and density of fair patrons, unrestricted outdoor smoking likely exposes most patrons to SHS. Action to eliminate all exposure to SHS at state and county fairs is needed.

Using indoor air quality monitoring in 6 counties to change policy in North Carolina.

INTRODUCTION: Indoor air quality monitoring has become a valuable tool for states wanting to assess levels of particulate matter before and after smoke-free policies are implemented. However, many states face barriers in passing comprehensive smoke-free legislation, making such study comparisons unlikely. We used indoor air monitoring data to educate decision makers about the value of comprehensive smoke-free laws in a state with strong historical ties to tobacco. METHODS: We trained teams in 6 counties in North Carolina to monitor air quality in hospitality venues with 1 of 3 possible smoking policy designations: 1) smoke-free, 2) separate smoking and nonsmoking sections (mixed), or 3) smoking allowed in all areas. Teams monitored 152 venues for respirable suspended particles that were less than 2.5 microm in diameter and collected information on venue characteristics. The data were combined and analyzed by venue policy and by county. Our findings were presented to key decision makers, and we then collected information on media publicity about these analyses. RESULTS: Overall, smoke-free venues had the lowest particulate matter levels (15 microg/m3), well below established Environmental Protection Agency standards. Venues with mixed policies and venues that permitted smoking in all areas had particulate matter levels that are considered unhealthy by Environmental Protection Agency standards. The media coverage of our findings included newspaper, radio, and television reports. Findings were also discussed with local health directors, state legislators, and public health advocates. CONCLUSION: Study data have been used to quantify particulate matter levels, raise awareness about the dangers of secondhand smoke, build support for evidence-based policies, and promote smoke-free policies among policy makers. The next task is to turn this effort into meaningful policy change that will protect everyone from the harms of secondhand smoke.

State adoption of 100% smoke-free acute non federal hospital campus policies.

To assess the number and percentage of acute care hospitals in the U.S. that have adopted smoke-free hospital campus (SFHC) policies, researchers conducted an assessment from January 2008 to May 2008 of available data on SFHC policy adoption in each state. Slightly more than one third (34.4%) of acute care, non-Federal hospitals had adopted such policies, with wide variation of policy adoption between states.

Business policies affecting secondhand smoke exposure.

BACKGROUND: Despite recent legislative and voluntary policy changes, a significant number of workplaces, recreational venues, and public facilities do not offer the public full protection from secondhand smoke exposure. The current study assessed smoking policies, attitudes toward smoke-free policies, and support for policy change among business owners and managers of businesses open to the public in North Carolina. METHODS: Business owners and managers were interviewed over the phone. Businesses included all airports, arcades, malls, bowling alleys, and arenas (seating more than 500) in the state as well as a random sample of grocery and convenience stores. RESULTS: A 100% smoke-free policy was reported in 53% of businesses, ranging from 12% in bowling alleys to 97% in arenas. A large majority of business owners and managers understand the health risks of secondhand smoke exposure (82%-89%) and support restrictions on smoking in their businesses (84%-91%). Barriers to voluntary policy change included the lack of legal requirement (39%) and fear of the loss of business (53%). LIMITATIONS: This study used self-report data from business owners and managers; the accuracy of the business smoking policy, customer and employee exposure time, and number of complaints may vary across respondents. It is also possible some participants were influenced by factors of social desirability of responses. CONCLUSIONS: Continued progress in establishing 100% smoke-free indoor environments may depend on successful advocacy in instituting legislation mandating the elimination of secondhand smoke in all public places. Advocacy efforts should include education around addressing economic concerns of businesses.