On-line doctors: A disruptive innovation?

Banking, transportation, and retail have each been transformed by technology enabling on-demand access 24/7 at lower prices. This trend has not yet revolutionized the medical field, but on-line physician services are increasingly common in Canada and have the potential to change the way care is delivered. In this article, we will describe the state of on-line physician services in Canada and outline associated ethical considerations, including autonomy, beneficence, maleficence, and justice. We will suggest steps to mitigate risk so that these services add value for patients and the health system as a whole.

Acceptability of a Mobile Clinical Decision Tool Among Emergency Department Clinicians: Development and Evaluation of The Ottawa Rules App

Background

The Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule—together known as The Ottawa Rules—are a set of internationally validated clinical decision rules developed to decrease unnecessary diagnostic imaging in the emergency department. In this study, we sought to develop and evaluate the use of a mobile app version of The Ottawa Rules.

Objective

The primary objective of this study was to determine acceptability of The Ottawa Rules app among emergency department clinicians. The secondary objective was to evaluate the effect of publicity efforts on uptake of The Ottawa Rules app.

Methods

The Ottawa Rules app was developed and publicly released for free on iOS and Android operating systems in April 2016. Local and national news and academic media coverage coincided with app release. This study was conducted at a large tertiary trauma care center in Ottawa, Canada. The study was advertised through posters and electronically by email. Emergency department clinicians were approached in person to enroll via in-app consent for a 1-month study during which time they were encouraged to use the app when evaluating patients with suspected knee, foot, or neck injuries. A 23-question survey was administered at the end of the study period via email to determine self-reported frequency, perceived ease of use of the app, and participant Technology Readiness Index scores.

Results

A total of 108 emergency department clinicians completed the study including 42 nurses, 33 residents, 20 attending physicians, and 13 medical students completing emergency department rotations. The median Technology Readiness Index for this group was 3.56, indicating a moderate degree of openness for technological adoption. The majority of survey respondents indicated favorable receptivity to the app including finding it helpful to applying the rules (73/108, 67.6%), that they would recommend the app to colleagues (81/108, 75.0%), and that they would continue using the app (73/108, 67.6%). Feedback from study participants highlighted a desire for access to more clinical decision rules and a higher degree of interactivity of the app. Between April 21, 2016, and June 1, 2017, The Ottawa Rules app was downloaded approximately 4000 times across 89 countries.

Conclusions

We have found The Ottawa Rules app to be an effective means to disseminate the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule among all levels of emergency department clinicians. We have been successful in monitoring uptake and access of the rules in the app as a result of our publicity efforts. Mobile technology can be leveraged to improve the accessibility of clinical decision tools to health professionals.

The TEND (Tomorrow's Expected Number of Discharges) Model Accurately Predicted the Number of Patients Who Were Discharged from the Hospital the Next Day

BACKGROUND

Knowing the number of discharges that will occur is important for administrators when hospital occupancy is close to or exceeds 100%. This information will facilitate decision making such as whether to bring in extra staff, cancel planned surgery, or implement measures to increase the number of discharges. We derived and internally validated the TEND (Tomorrow's Expected Number of Discharges) model to predict the number of discharges from hospital in the next day.

METHODS

We identified all patients greater than 1 year of age admitted to a multisite academic hospital between 2013 and 2015. In derivation patients we applied survival-tree methods to patient-day covariates (patient age, sex, comorbidities, location, admission urgency, service, campus, and weekday) and identified risk strata having unique discharge patterns. Discharge probability in each risk strata for the previous 6 months was summed to calculate each day's expected number of discharges.

RESULTS

Our study included 192,859 admissions. The daily number of discharges varied extensively (median 139; interquartile range [IQR] 95-160; range 39-214). We identified 142 discharge risk strata. In the validation patients, the expected number of daily discharges strongly predicted the observed number of discharges (adjusted R2 = 89.2%; P < 0.0001). The relative difference between observed and expected number of discharges was small (median 1.4%; IQR -5.5% to 7.1%).

CONCLUSION

The TEND model accurately predicted the daily number of discharges using information typically available within hospital data warehouses. Further study is necessary to determine if this information improves hospital bed management.

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes

BACKGROUND

Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.

METHODS

This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.

RESULTS

A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority.

CONCLUSIONS

Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.

The feasibility of an interactive voice response system (IVRS) for monitoring patient safety after discharge from the ED

BACKGROUND

Return ED visits are frequent and may be due to adverse events: adverse outcomes related to healthcare received. An interactive voice response system (IVRS) is a technology that translates human telephone input into digital data. Use of IVRS has been explored in many healthcare settings but to a limited extent in the ED. We determined the feasibility of using an IVRS to assess for adverse events after ED discharge.

METHODS

This before and after study assessed detection of adverse events among consecutive high-acuity patients discharged from a tertiary care ED pre-IVRS and post-IVRS over two 2-week periods. The IVRS asked if the patient was having a health problem and if they wanted to speak to a nurse. Patients responding yes received a telephone interview. We searched health records for deaths, admissions to hospital and return ED visits. Three trained emergency physicians independently determined adverse event occurrence. We analysed the data using descriptive statistics.

RESULTS

Of 968 patients studied, patients' age, sex, acuity and presenting complaint were comparable pre-IVRS and post-IVRS. Postimplementation, 393 (81.7%) of 481 patients had successful IVRS contact. Of these, 89 (22.6%) wanted to speak to a nurse. A total of 37 adverse events were detected over the two periods: 10 patients with 10 (6.5%) adverse events pre-IVRS and 16 patients with 27 (16.9%) adverse events post-IVRS. In the postimplementation period, the adverse events of seven patients were detected by the IVRS and five patients spontaneously requested assistance navigating post-ED care.

CONCLUSIONS

This was a successful proof-of-concept study for applying IVRS technology to assess patient safety issues for discharged high-acuity ED patients.

Clinical factors contributing to high cost hospitalizations in a Canadian tertiary care centre

Background

Like much of the developed world, healthcare costs in Canada are rising. A small proportion of patients account for a large proportion of healthcare spending and much of this spending occurs in acute care settings. The purpose of our study was to determine potentially modifiable factors related to care processes that contribute to high-cost admissions.

Methods

Using a mixed-methods study design, factors contributing to high-cost admissions were identified from literature and case review. We defined pre- and post-admission factors contributing to high-cost admissions. Pre-admission factors included reason for admission (e.g. complex medical, elective surgery, trauma, etc.). Post-admission factors included medical complications, disposition delays, clinical services delays, and inefficient clinical decision-making. We selected a random sample of admissions in the top decile of inpatient cost from the Ottawa Hospital between January 1 and December 31, 2010. A single reviewer classified cases based on the pre- and post-admission factors. We combined this information with data derived from the Ottawa Hospital Data Warehouse to describe patient-level clinical and demographic characteristics and costs incurred.

Results

We reviewed 200 charts which represents ~5% of all high cost admissions within the Ottawa Hospital in 2010. Post-admission factors contributing to high-cost admissions were: complications (60%), disposition delays (53%), clinical service delays (39%), and inefficient clinical decision-making (13%). Further, these factors varied substantially across service delivery lines. The mean (standard deviation (SD)) cost per admission was $49,923 CDN ($45,773). The most common reason for admission was “complex medical” (49%) and the overall median (IQR) length of stay was 27 (18–48) days. Approximately 1 in 3 high cost admissions (29%) included time in the intensive care unit (ICU).

Conclusions

While high cost admissions often include time in ICU and have long lengths of stay, a substantial proportion of costs were attributable to complications and potentially preventable delays in care processes. These findings suggest opportunities exist to improve outcomes and reduce costs for this diverse patient population.

Physician performance feedback in a Canadian academic center

Purpose

This paper aims at the implementation and early evaluation of a comprehensive, formative annual physician performance feedback process in a large academic health-care organization.

Design/methodology/approach

A mixed methods approach was used to introduce a formative feedback process to provide physicians with comprehensive feedback on performance and to support professional development. This initiative responded to organization-wide engagement surveys through which physicians identified effective performance feedback as a priority. In 2013, physicians primarily affiliated with the organization participated in a performance feedback process, and physician satisfaction and participant perceptions were explored through participant survey responses and physician leader focus groups. Training was required for physician leaders prior to conducting performance feedback discussions.

Findings

This process was completed by 98 per cent of eligible physicians, and 30 per cent completed an evaluation survey. While physicians endorsed the concept of a formative feedback process, process improvement opportunities were identified. Qualitative analysis revealed the following process improvement themes: simplify the tool, ensure leaders follow process, eliminate redundancies in data collection (through academic or licensing requirements) and provide objective quality metrics. Following physician leader training on performance feedback, 98 per cent of leaders who completed an evaluation questionnaire agreed or strongly agreed that the performance feedback process was useful and that training objectives were met.

Originality/value

This paper introduces a physician performance feedback model, leadership training approach and first-year implementation outcomes. The results of this study will be useful to health administrators and physician leaders interested in implementing physician performance feedback or improving physician engagement.

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission

OBJECTIVE

To assess the efficacy of an electronic discharge communication tool (e-DCT) for preventing death or hospital readmission, as well as reducing patient-reported adverse events after hospital discharge. The e-DCT assessed has already been shown to yield high-quality discharge summaries with high levels of patient and physician satisfaction.

METHODS

This two-arm randomised controlled trial was conducted in a Canadian tertiary care centre's internal medicine medical teaching units. Out of the 1953 patients approached and screened for inclusion, 1399 were randomised and available for data linkage for determination of the primary outcome. Participants were randomly assigned to e-DCT versus usual care (traditional discharge communication generated by dictation). The primary outcome was a composite of death or readmission within 90 days. The secondary outcome included any patient-reported adverse events within 30 days of discharge.

RESULTS

Among 1399 randomised participants, 230 of 701 participants (32.8%) in the e-DCT group experienced the primary composite outcome of death or readmission within 90 days vs 205 of 698 participants (29.4%) in the usual care group (p=0.166). The incidence at 30 days of patient-reported adverse outcomes (35% for e-DCT vs 34% for usual care) and adverse events (2.1% for e-DCT vs 1.8% for usual care) also did not differ significantly between groups.

CONCLUSIONS

The e-DCT tested did not reduce the composite endpoint of death or readmission at 90 days, nor the incidence of patient-reported adverse events at 30 days. This neutral finding for hard clinical endpoints needs to be considered in the context of high patient and physician satisfaction, and high quality of discharge summaries.

The HOMR-Now! Model Accurately Predicts 1-Year Death Risk for Hospitalized Patients on Admission

BACKGROUND

The Hospital-patient One-year Mortality Risk (HOMR) score is an externally validated index using health administrative data to accurately predict the risk of death within 1 year of admission to the hospital. This study derived and internally validated a HOMR modification using data that are available when the patient is admitted to the hospital.

METHODS

From all adult hospitalizations at our tertiary-care teaching hospital between 2004 and 2015, we randomly selected one per patient. We added to all HOMR variables that could be determined from our hospital's data systems on admission other factors that might prognosticate. Vital statistics registries determined vital status at 1 year from admission.

RESULTS

Of 2,06,396 patients, 32,112 (15.6%) died within 1 year of admission to the hospital. The HOMR-now! model included patient (sex, comorbidities, living and cancer clinic status, and 1-year death risk from population-based life tables) and hospitalization factors (admission year, urgency, service and laboratory-based acuity score). The model explained that more than half of the total variability (Regenkirke's R² value of 0.53) was very discriminative (C-statistic 0.92), and accurately predicted death risk (calibration slope 0.98).

CONCLUSION

One-year risk of death can be accurately predicted using routinely collected data available when patients are admitted to the hospital.

Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score-matched observational cohort study

BACKGROUND

Delay of surgery for hip fracture is associated with increased risk of morbidity and mortality, but the effects of surgical delays on mortality and resource use in the context of other emergency surgeries is poorly described. Our objective was to measure the independent association between delay of emergency surgery and in-hospital mortality, length of stay and costs.

METHODS

We identified all adult patients who underwent emergency noncardiac surgery between January 2012 and October 2014 at a single tertiary care centre. Delay of surgery was defined as the time from surgical booking to operating room entry exceeding institutionally defined acceptable wait times, based on a standardized 5-level priority system that accounted for surgery type and indication. Patients with delayed surgery were matched to those without delay using propensity scores derived from variables that accounted for details of admission and the hospital stay, patient characteristics, physiologic instability, and surgical urgency and risk.

RESULTS

Of 15 160 patients, 2820 (18.6%) experienced a delay. The mortality rates were 4.9% (138/2820) for those with delay and 3.2% (391/12 340) for those without delay (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.30-1.93). Within the propensity-matched cohort, delay was significantly associated with mortality (OR 1.56, 95% CI 1.18-2.06), increased length of stay (incident rate ratio 1.07, 95% CI 1.01-1.11) and higher total costs (incident rate ratio 1.06, 95% CI 1.01-1.11).

INTERPRETATION

Delayed operating room access for emergency surgery was associated with increased risk of inhospital mortality, longer length of stay and higher costs. System issues appeared to underlie most delays and must be addressed to improve the outcomes of emergency surgery.

Risks and trends of red blood cell transfusion in obstetric patients: a retrospective study of 45,213 deliveries using administrative data

BACKGROUND

Transfusion data for obstetric patients are scarce. Identifying characteristics associated with red blood cell transfusion (RBCT) is of importance to better identify patients who would benefit from blood conservation strategies as the risk of alloimmunization from RBCT has the potential to affect the fetus and newborn.

STUDY DESIGN AND METHODS

We conducted a retrospective cohort study using hospital administrative data to identify trends and risk factors of RBCT in obstetric patients. Data were analyzed according to the mode of delivery.

RESULTS

A total of 45,213 deliveries were captured between January 1, 2007, and December 31, 2013. A higher proportion of patients undergoing cesarean sections (C/Ss) received an RBCT (2.3%) compared to other modes of delivery (0.7% for spontaneous vaginal delivery, 1.5% for instrumental delivery; p < 0.001). In addition, the risk of RBCT increased over the 7-year period for those patients undergoing C/S (relative risk [RR], 1.56; 95% confidence interval [CI], 1.14-2.15). An unavailable hemoglobin (Hb) level (RR, 12.94; 95% CI, 7.39-22.66) and Hb level of 70 to 80 g/L (RR, 7.78; 95% CI = 5.21-11.60) were strongly associated with RBCT among women undergoing C/S. Earlier gestational age at induction increased the risk of RBCT across all modes of delivery.

CONCLUSIONS

The higher frequency of RBCT for unknown and low Hb supports the need for predelivery patient blood management at the time of delivery. The additional risk factors associated with RBCT identified may be used to develop risk stratification tools by mode of delivery to assist in the identification of patients at the highest risk of requiring RBCT.

An environmental scan of quality indicators in critical care

BACKGROUND

We performed a directed environmental scan to identify and categorize quality indicators unique to critical care that are reported by key stakeholder organizations.

METHODS

We convened a panel of experts (n = 9) to identify key organizations that are focused on quality improvement or critical care, and reviewed their online publications and website content for quality indicators. We identified quality indicators specific to the care of critically ill adult patients and then categorized them according to the Donabedian and the Institute of Medicine frameworks. We also noted the organizations' rationale for selecting these indicators and their reported evidence base.

RESULTS

From 28 targeted organizations, we identified 222 quality indicators, 127 of which were unique. Of the 127 indicators, 63 (32.5%) were safety indicators and 61 (31.4%) were effectiveness indicators. The rationale for selecting quality indicators was supported by consensus for 58 (26.1%) of the 222 indicators and by published research evidence for 45 (20.3%); for 119 indicators (53.6%), the rationale was not reported or the reader was referred to other organizations' reports. Of the 127 unique quality indicators, 27 (21.2%) were accompanied by a formal grading of evidence, whereas for 52 (40.9%), no reference to evidence was provided.

INTERPRETATION

There are many quality indicators related to critical care that are available in the public domain. However, owing to a paucity of rationale for selection, supporting evidence and results of implementation, it is not clear which indicators should be adopted for use.

Time is of the essence: an observational time-motion study of internal medicine residents while they are on duty

BACKGROUND

The effects of changes to resident physician duty hours need to be measureable. This time-motion study was done to record internal medicine residents' workflow while on duty and to determine the feasibility of capturing detailed data using a mobile electronic tool.

METHODS

Junior and senior residents were shadowed by a single observer during six-hour blocks of time, covering all seven days. Activities were recorded in real-time. Eighty-nine activities grouped into nine categories were determined a priori.

RESULTS

A total of 17,714 events were recorded, encompassing 516 hours of observation. Time was apportioned in the following categories: Direct Patient Care (22%), Communication (19%), Personal tasks (15%), Documentation (14%), Education (13%), Indirect care (11%), Transit (6%), Administration (0.6%), and Non-physician tasks (0.4%). Nineteen percent of the education time was spent in self-directed learning activities. Only 9% of the total on duty time was spent in the presence of patients. Sixty-five percent of communication time was devoted to information transfer. A total of 968 interruptions were recorded which took on average 93.5 seconds each to service.

CONCLUSION

Detailed recording of residents' workflow is feasible and can now lead to the measurement of the effects of future changes to residency training. Education activities accounted for 13% of on-duty time.

Using structured incentives to increase value for money in an academic health sciences centre

As healthcare continues to consume more and more of provincial government spending, there is a continuing pressure to improve efficiency and cut overall costs. In this increasingly constrained healthcare system, value for money is a growing focus of discussions around accountability and system sustainability; healthcare leaders are required to find ways of measuring, enforcing, and reporting on that value. In 2014, our organization began implementing an innovative system of structured incentives, linking distribution of Ministry of Health and Long-Term Care academic physician funding to quality and performance goals. Through a carefully planned process of benchmarking, stakeholder consultation, model improvement, and change management, we were able to move to a new value for money allocation model. The new model drives accountability by linking distribution of government payments to quality and performance outcomes. Initial results include increased stakeholder satisfaction as well as broader physician engagement in corporate and academic quality improvement initiatives.

Factors contributing to high-cost hospital care for patients with COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of hospital admission, the fifth leading cause of death in North America, and is estimated to cost $49 billion annually in North America by 2020. The majority of COPD care costs are attributed to hospitalizations; yet, there are limited data to understand the drivers of high costs among hospitalized patients with COPD. In this study, we aimed to determine the patient and hospital-level factors associated with high-cost hospital care, in order to identify potential targets for the reorganization and planning of health services. We conducted a retrospective cohort study at a Canadian academic hospital between September 2010 and 2014, including adult patients with a first-time admission for COPD exacerbation. We calculated total costs, ranked patients by cost quintiles, and collected data on patient characteristics and health service utilization. We used multivariable regression to determine factors associated with highest hospital costs. Among 1,894 patients included in the study, the mean age was 73±12.6 years, median length of stay was 5 (interquartile range 3-9) days, mortality rate was 7.8% (n=147), and 9% (n=170) required intensive care. Hospital spending totaled $19.8 million, with 63% ($12.5 million) spent on 20% of patients. Factors associated with highest costs for COPD care included intensive care unit admission (odds ratio [OR] 32.4; 95% confidence interval [CI] 20.3, 51.7), death in hospital (OR 2.6; 95% CI 1.3, 5.2), discharge to long-term care facility (OR 5.7; 95% CI 3.5, 9.2), and use of the alternate level of care designation during hospitalization (OR 23.5; 95% CI 14.1, 39.2). High hospital costs are driven by two distinct groups: patients who require acute medical treatment for severe illness and patients with functional limitation who require assisted living facilities upon discharge. Improving quality of care and reducing cost in this high-needs population require a strong focus on early recognition and management of functional impairment for patients living with chronic disease.

Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative NT-proBNP

OBJECTIVES

We previously developed the Ottawa Heart Failure Risk Scale (OHFRS) to assist with disposition decisions for acute heart failure patients in the emergency department (ED). We sought to prospectively evaluate the accuracy, acceptability, and potential impact of OHFRS.

METHODS

This prospective observational cohort study was conducted at six tertiary hospital EDs. Patients with acute heart failure were evaluated by ED physicians for the 10 OHFRS criteria and then followed for 30 days. Quantitative NT-proBNP was measured where feasible. Serious adverse event (SAE) was defined as death within 30 days, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction, or relapse resulting in hospital admission within 14 days.

RESULTS

We enrolled 1,100 patients with mean (±SD) age 77.7 (±10.7) years. SAEs occurred in 170 (15.5%) cases (19.4% if admitted and 10.2% if discharged). Compared to actual practice, using an admission threshold of OHFRS score > 1 would have increased sensitivity (71.8% vs. 91.8%) but increased admissions (57.2% vs. 77.6%). For 684 cases with NT-proBNP values, using a threshold score > 1 would have significantly increased sensitivity (69.8% vs. 95.8%) while increasing admissions (60.8% vs. 88.0%). In only 11.9% of cases did physicians indicate discomfort with use of OHFRS.

CONCLUSION

Prospective clinical validation found the OHFRS tool to be highly sensitive for SAEs in acute heart failure patients, albeit with an increase in admission rates. When available, NT-proBNP values further improve sensitivity. With adequate physician training, OHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients.

The prevalence of potentially preventable deaths in an acute care hospital: A retrospective cohort

Studies estimate that 6% to 27% of deaths in hospitals might be prevented with higher quality care. These estimates may be inaccurate because they fail to account for the uncertainty associated with classifying preventability. The purpose of this study was to measure the prevalence of preventable deaths, accounting for the uncertainty in preventability ratings.We created standardized structured case abstracts for all deaths at a multisite academic teaching hospital over a 3-month period. Each case abstract was evaluated independently by 4 reviewers who rated death preventability on a 100-point scale ranging from 0 ("Definitely not preventable") to 100 ("Definitely preventable"). Ratings were categorized into a 4-level ordinal scale and latent class analysis was used to measure the prevalence of each preventability class and estimate the probability that deaths in each class were preventable.There were 480 deaths (3.4% of all admissions) during the study period. The latent class model (LCM) found that 91.6% (95% CI: 88.4-94.8%) of deaths were "nonpreventable" and 8.4% (5.2-11.6%) were "possibly preventable." "Possibly preventable" deaths could be identified with 90% certainty, but due to error in reviewer ratings, a "possibly preventable" death had a 50% probability of being receiving a rating of less than 25/100 by any single reviewer. Only 5 of 31 deaths classified as a "possibly preventable" (1.0% of all deaths) were judged to likely be alive in 3 months with perfect care.After accounting for uncertainty associated with rating the preventability of hospital deaths, we found that 8.4% of deaths were deemed possibly preventable. There was only moderate probability that these deaths were truly preventable.

Risk assessment tools to predict location of discharge and need for supportive services for medical patients after discharge from hospital: a systematic review protocol

BACKGROUND

Patients who are discharged from hospital after an acute medical illness often have impaired function that prevents them from returning to their previous place of residence. Assessing each patient's post-discharge needs takes time and resources but is important in order to reduce unplanned readmissions and adverse events post-discharge.

METHODS/DESIGN

We will conduct a systematic review to synthesize the evidence on prognostic models and their reported accuracy in predicting the location of discharge after a medical admission to an acute care hospital. We will perform searches in MEDLINE, EMBASE, CINAHL, and COCHRANE databases. Pre-defined study, population, and model characteristics will be reported. We will write a narrative summary of included studies. Methodological quality of the studies will be assessed using the QUIPS tool, and the quality of evidence will be evaluated using the GRADE tool.

DISCUSSION

Early and accurate assessment of patient needs for supportive services after discharge has the potential to improve patient outcomes and health system efficiency. This systematic review will identify factors that can accurately predict location of discharge using existing tools and identify priority knowledge gaps to inform future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016037144.

Comparative assessment of two frailty instruments for risk-stratification in elderly surgical patients: study protocol for a prospective cohort study

BACKGROUND

Frailty is an aggregate expression of susceptibility to poor outcomes, owing to age-, and disease-related deficits that accumulate within multiple domains. Older patients who are frail before surgery are at an increased risk of morbidity and mortality, and use a disproportionately high amount of healthcare resources. While frailty is now a well-established risk factor for adverse postoperative outcomes, the perioperative literature lacks studies that: 1) compare the predictive accuracy of different frailty instruments; 2) consider the impact of frailty on patient-reported outcome measures; and 3) consider the acceptability and feasibility of using frailty instruments in clinical practice.

METHODS

We will conduct a multicenter prospective cohort study comparing the predictive accuracy of the modified Fried Index (mFI) with the Clinical Frailty Scale (CFS) among consenting patients aged 65 years and older having elective major non-cardiac surgery. The primary outcome will be disability free survival at 90 days after surgery, a patient-reported outcome measure. Secondary outcomes will include complications, length of stay, discharge disposition, readmission and total health system costs. We will compare the accuracy of frailty instruments using the relative true positive rate and relative false positive rate. These measures can be interpreted as the relative difference in the probability of one instrument identifying a true case of death or new disability compared to another instrument, or the relative difference in the probability of one instrument identifying a false case of death or new disability, respectively. We will also assess the acceptability and feasibility of each instrument.

DISCUSSION

Frailty is an important prognostic factor in the growing population of older patients having surgery. This study will provide novel findings regarding the choice of an accurate, clinically useable frailty instrument in predicting patient reported outcomes, as well as morbidity, mortality and resource use. These findings will inform current practice and future research.

Comparing physical assessment with administrative data for detecting pressure ulcers in a large Canadian academic health sciences centre

OBJECTIVE

This study aimed to compare classification of pressure ulcers from administrative data with a gold standard assessment, specifically; pressure ulcers confirmed by an independent physical assessment performed by trained nurse surveyors.

SETTING

A retrospective analysis of pooled cross-sectional samples of inpatients assessed across 3 consecutive prevalence surveys in a large academic health sciences centre between 2012 and 2013.

PARTICIPANTS

There were 2001 patients for whom physical and chart assessments were completed, and for whom a discharge abstract was also available at the time of analysis. The cohort's mean age was 65 years and 55% were women.

RESULTS

Based on the physical assessment findings, 14.6% of patients (n=292) had at least 1 pressure ulcer, with a total of 345 pressure ulcers documented among these patients: (stage I=162; stage II=120; stage III=22; stage IV=22 and unstageable=19). Based on coded information, 78 (3.9%) of patients had a pressure ulcer. Of patients with a pressure ulcer determined by the physical assessment, only 21% also had a pressure ulcer captured in the administrative data. Furthermore, only 6% of the patients with a hospital-acquired pressure ulcer, stage II or greater determined by the physical assessment were coded in the Discharge Abstract Database (DAD).

CONCLUSIONS

The results of this study demonstrate that coding in the DAD may under-report and fail to accurately reflect the true burden of pressure ulcers in hospitalised patients. This may occur because the presence of pressure ulcers is currently documented in the health record by nurses and not by physicians, yet the administrative data recorded in the DAD only includes physician documented pressure ulcers. We recommend enhancements to the coding methods to monitor and report on pressure ulcers.

Association of Blood Donor Age and Sex With Recipient Survival After Red Blood Cell Transfusion

IMPORTANCE

While red blood cells (RBCs) are administered to improve oxygen delivery and patient outcomes, they also have been associated with potential harm. Unlike solid organ transplantation, the clinical consequences of donor characteristics on recipients have not been evaluated in transfusion medicine.

OBJECTIVE

To analyze the association of RBC donor age and sex with the survival of transfusion recipients.

DESIGN, SETTING, AND PARTICIPANTS

We established a longitudinal cohort by linking data from a blood collection agency with clinical and administrative data at 4 academic hospitals.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards regression models were fitted to evaluate the risk of donor age and sex on transfusion recipient survival.

RESULTS

Between October 25, 2006, and December 31, 2013, a total of 30 503 RBC transfusion recipients received 187 960 RBC transfusions from 80 755 unique blood donors. For recipients receiving an RBC unit from younger donors, the risk of death was increased compared with recipients receiving an RBC unit from a donor 40 to 49.9 years old (adjusted hazard ratio, 1.08; 95% CI, 1.06-1.10; P < .001 for donor age range 17-19.9 years and 1.06; 95% CI, 1.04-1.09; P < .001 for donor age range 20-29.9 years). Receiving an RBC transfusion from a female donor was associated with an 8% statistically significant increased risk of death compared with receiving an RBC transfusion from a male donor (adjusted hazard ratio, 1.08; 95% CI, 1.06-1.09; P < .001).

CONCLUSIONS AND RELEVANCE

Red blood cell transfusions from younger donors and from female donors were statistically significantly associated with increased mortality. These findings suggest that donor characteristics may affect RBC transfusion outcomes.

A framework to assess patient-reported adverse outcomes arising during hospitalization

BACKGROUND

The assessment of adverse events from a patient-centered view includes patient-reported adverse outcomes. An adverse outcome refers to any suboptimal outcome experienced by the patient; when adverse outcomes are identified through a patient interview these are called patient-reported adverse outcomes. An adverse event is an adverse outcome that is more likely due to the processes of medical care rather than to the mere progression of disease. In the context of a large-scale study assessing post-hospitalization adverse events, we developed a conceptual framework to assess patient-reported adverse outcomes (PRAOs). This methodological manuscript describes this conceptual framework.

METHODS

The PRAO framework builds on a validated adverse event ascertainment method including three phases: Phase 1 involves an inquiry to ascertain the occurrence of any patient-reported adverse outcome. It is completed by a structured telephone interview to obtain details - from a patient perspective - on symptoms that developed and/or worsened after hospitalization. Phase 2 involves the classification of PRAOs by physicians not involved in the patient care. Physician-reviewers then rate the PRAOs using well-adopted scales to determine whether the occurrence was the natural progression of the underlying illness or due to medical care. When the PRAO is rated as "due to medical care", it is then classified as an "adverse event". Phase 3 involves the classification of adverse events as preventable or ameliorable.

RESULTS

Out of the 1347 patients contacted at 1-month post-discharge, 469 reported AOs and after reviewing 369 cases, 29 were classified as AEs. Observed agreement levels between raters were 87.3, 85.5, and 85.2 % respectively displaying a good agreement (k > 0.60).

CONCLUSION

The framework incorporates PRAOs as a way to identify cases that need to be evaluated for adverse events. Further validation of this framework is warrant with the final aim of implementation at larger scale. The implementation of this framework will enable clinicians, researchers and healthcare institutions to compare outcome rates across providers and over time.

Variations in Resource Intensity and Cost Among High Users of the Emergency Department

OBJECTIVES

High users of emergency department (ED) services are often identified by number of visits per year, with little exploration of the distribution/pattern of visits over time. The purpose of this study was to examine patient- and encounter-level factors and costs related to periods of short-term resource intensity among high users of the ED within a tertiary care teaching facility.

METHODS

We identified all adults with at least three visits to the Ottawa Hospital ED within a 1-year period from April 1, 2012, to March 31, 2013. Within this high-user cohort, we then measured intensity of use by calculating average daily visit rates to identify individuals with a cluster of ED visits. Those with at least three ED visits/7 days at any point during follow-up were considered patients with clustered ED use (i.e., a period of short-term resource intensity). Detailed clinical and administrative data were used to compare patient- and encounter-level characteristics and cost profiles between the clustered and nonclustered groups. Analyses were repeated using varying cut points to define high users (at least five and at least eight visits per year).

RESULTS

Of the 16,153 patients identified as high ED users during the study period, 13.5% had their visits clustered within a short period of time. These clustered users were more likely to be homeless, to require psychiatric services, and to leave without being seen by a physician and less likely to be admitted to the hospital. Approximately one in three (31.2%) high ED users with clustered visits returned for the same medical problem (namely pain-related disorders, shortness of breath, and cellulitis) within a 1-week period. Similar trends were observed when the high-user cohort was restricted to those with at least five and at least eight ED visits/year. Finally, patients with short-term intensity periods had lower direct and indirect costs per encounter than those without.

CONCLUSIONS

Using a novel methodology that accounts for both number and intensity of ED encounters over time, we were able to identify specific subpopulations of high ED users. Further work is required to determine if this methodology has utility for targeting care pathways within this heterogeneous and high-risk patient group.

Clinical characteristics and preventable acute care spending among a high cost inpatient population

BACKGROUND

A small proportion of patients account for the majority of health care spending. The objectives of this study were to explore the clinical characteristics, patterns of health care use, and the proportion of acute care spending deemed potentially preventable among high cost inpatients within a Canadian acute-care hospital.

METHODS

We identified all individuals within the Ottawa Hospital with one or more inpatient hospitalization between April 1, 2010 and March 31, 2011. Clinical characteristics and frequency of hospital encounters were captured in the information systems of the Ottawa Hospital Data Warehouse. Direct inpatient costs for each encounter were summed using case costing information and those in the upper first and fifth percentiles of the cumulative direct cost distribution were defined as extremely high cost and high cost respectively. We quantified preventable acute care spending as hospitalizations for ambulatory care sensitive conditions (ACSC) and spending attributable to difficulty discharging patients as measured by alternate level of care (ALC) status.

RESULTS

During the study period, 36,892 patients had 44,066 hospitalizations. High cost patients (n = 1,844) accounted for 38 % of total inpatient spending ($122 million) and were older, more likely to be male, and had higher levels of co-morbidity compared to non-high cost patients. In over half of the high cost cohort (54 %), costs were accumulated from a single hospitalization. The majority of costs were related to nursing care and intensive care unit spending. High cost patients were more likely to have an encounter deemed to be ambulatory care sensitive compared to non-high cost inpatients (6.0 versus 2.8 %, p < 0.001). A greater proportion of inpatient spending was attributable to ALC days for high cost versus non-high cost patients (9.1 versus 4.9 %, p < 0.001).

CONCLUSIONS

Within a population of high cost inpatients, the majority of costs are attributed to a single, non-preventable, acute care episode. However, there are likely opportunities to improve hospital efficiency by focusing on different approaches to community based care directed towards specific populations.