Self-Identified Social Determinants of Health during Transitions of Care in the Medically Underserved: a Narrative Review

The application of machine learning algorithms for predicting length of stay before and during the COVID-19 pandemic: evidence from Wuhan-area hospitals

Objective

The COVID-19 pandemic has placed unprecedented strain on healthcare systems, mainly due to the highly variable and challenging to predict patient length of stay (LOS). This study aims to identify the primary factors impacting LOS for patients before and during the COVID-19 pandemic.

Methods

This study collected electronic medical record data from Zhongnan Hospital of Wuhan University. We employed six machine learning algorithms to predict the probability of LOS.

Results

After implementing variable selection, we identified 35 variables affecting the LOS for COVID-19 patients to establish the model. The top three predictive factors were out-of-pocket amount, medical insurance, and admission deplanement. The experiments conducted showed that XGBoost (XGB) achieved the best performance. The MAE, RMSE, and MAPE errors before and during the COVID-19 pandemic are lower than 3% on average for household registration in Wuhan and non-household registration in Wuhan.

Conclusions

Research finds machine learning is reasonable in predicting LOS before and during the COVID-19 pandemic. This study offers valuable guidance to hospital administrators for planning resource allocation strategies that can effectively meet the demand. Consequently, these insights contribute to improved quality of care and wiser utilization of scarce resources.

Development of a Multifaceted Program for Pharmacogenetics Adoption at an Academic Medical Center: Practical Considerations and Lessons Learned

In 2019, Indiana University launched the Precision Health Initiative to enhance the institutional adoption of precision medicine, including pharmacogenetics (PGx) implementation, at university-affiliated practice sites across Indiana. The overarching goal of this PGx implementation program was to facilitate the sustainable adoption of genotype-guided prescribing into routine clinical care. To accomplish this goal, we pursued the following specific objectives: (i) to integrate PGx testing into existing healthcare system processes; (ii) to implement drug-gene pairs with high-level evidence and educate providers and pharmacists on established clinical management recommendations; (iii) to engage key stakeholders, including patients to optimize the return of results for PGx testing; (iv) to reduce health disparities through the targeted inclusion of underrepresented populations; (v) and to track third-party reimbursement. This tutorial details our multifaceted PGx implementation program, including descriptions of our interventions, the critical challenges faced, and the major program successes. By describing our experience, we aim to assist other clinical teams in achieving sustainable PGx implementation in their health systems.

Transitional care clinics for patients discharged from hospital without a primary care provider: A systematic review

BACKGROUND

The transition from hospital to home is a high-risk period. Timely follow-up care is essential to reducing avoidable harms such as adverse drug events, yet may be unattainable for patients who lack attachment to a primary care provider. Transitional care clinics (TCCs) have been proposed as a measure to improve health outcomes for patients discharged from hospital without an established provider. In this systematic review, we compared outcomes for unattached patients seen in TCCs after hospital discharge relative to care as usual.

METHODS

We searched the following bibliographic databases for articles published on or before August 12, 2022: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, PsycINFO, and Web of Science. Five studies were identified that examined the effects of a dedicated postdischarge clinic on emergency department (ED) visits, readmissions, and/or mortality within 90 days of discharge for patients with no attachment to a primary care provider.

RESULTS

Studies were heterogeneous in design and quality; all were from urban centers within the United States. Four of the five studies reported a reduction in either the number of ED visits or readmissions in patients seen in a TCC following hospitalization.

CONCLUSIONS

TCCs may be effective in reducing hospital contacts in the period following hospital discharge in patients with no established primary care provider. Further studies are required to evaluate the health benefits attributable to the implementation of TCCs across a broad range of practice contexts, as well as the cost implications of this model.

Transition of Intensive Care Unit Patients and Their Families to Home After Acute Hospital Care

Patients in the intensive care unit (ICU) increasingly are expected to eventually return home after acute hospital care. Yet transitional care for ICU patients and their families is often delayed until the patient is about to be transferred to another location or level of care. Transitions theory is a middle-range nursing theory that aims to provide guidance for safe and effective nursing care and research while an individual experiences a transition. Intensive care unit nurses are well positioned to provide ICU transitional care planning early. This article applies the transitions theory as a theoretical model to guide the study of the transition to home after acute hospital care for ICU patients and their families. This theory application can help ICU nurses provide holistic patient- and family-centered transitional care to achieve optimal outcomes by addressing the predischarge and postdischarge needs of patients and families.

Ready for Discharge, but Are They Ready to Go Home? Examining Neighborhood-Level Disadvantage as a Marker of the Social Exposome and the Swallowing Care Process in a Retrospective Cohort of Inpatients With Dementia

PURPOSE

Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge.

METHOD

A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated.

RESULTS

ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided.

CONCLUSIONS

These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care.

Can stepped collaborative care interventions improve post-traumatic stress disorder symptoms for racial and ethnic minority injury survivors?

Objectives

No large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors.

Methods

The investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds.

Results

The investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference -3.72 (95% CI -7.33 to -0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference -1.29 (95% CI -4.89 to 2.31) ES=0.10, p=ns).

Conclusion

In this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities.

Level of evidence

Level II, secondary analysis of randomized clinical trial data reporting a significant difference.

Trial registration number

NCT02655354.

Feasibility of preemptive pharmacogenetic testing and improvement of medication treatment satisfaction among medically underserved patients

Previous findings suggest that medically underserved patients are prescribed medications with pharmacogenetic (PGx) guidelines at a high frequency. Thus, underserved patients may especially benefit from PGx testing, but little evidence exists regarding the effect of testing in this population. This pilot study aimed to generate key feasibility data and explore clinical outcomes of PGx implementation in underserved populations. Black and Latino patients were recruited from an outpatient clinic and underwent PGx testing. Feasibility measures included enrollment metrics and actionable genotype frequencies. The primary clinical outcome was patient medication treatment satisfaction 6 months after testing. Implementation outcomes included the number of healthcare provider encounters and medication changes within the 6-month follow-up. Effectiveness outcomes included medication adherence, patient-perceived test value, and time spent discussing medications with providers. Ninety-nine patients completed the study. Proton-pump inhibitors were the most frequent PGx drug class prescribed at baseline (61%) followed by nonsteroidal anti-inflammatory drugs (36%). Patients with an actionable genotype constituted 96% of the population, whereas 28% had an actionable genotype related to their PGx drug. Patient treatment satisfaction significantly increased over the 6 months after PGx testing. In addition, medication adherence and the number of provider encounters significantly increased over the study period. In a pilot study, preemptive PGx testing was feasible in primary care clinics, improved patient treatment satisfaction and adherence, and increased the number of provider encounters in medically underserved patients. Future clinical trials are warranted to assess the long-term effects of PGx testing in a larger diverse patient population.

Relationship of health-related social needs and hospital readmissions in patients following a hospitalization for atrial fibrillation

Atrial fibrillation (AF) has a high economic burden on the healthcare system with rehospitalizations as the most significant contributing factor necessitating an understanding of aspects related to hospitalizations to minimize economic costs and improve patient outcomes. Our study aims to assess whether all-cause 30-day hospital readmission following AF-specific hospitalization is associated with health-related social needs (HRSN) using the Nationwide Readmissions Database (NRD). All hospitalization data were abstracted from the 2015-2019 NRD, including hospitalizations for patients at least 18 years of age with a primary discharge diagnosis of AF. For each hospitalization, we identified secondary diagnoses for five HRSN domains including employment, family, housing, psychosocial, and socioeconomic status. Primary outcomes included all-cause 30-day readmission rates. Secondary outcomes included all-cause 90-day readmissions and diagnosis on readmissions. An estimated 1,807,460 index hospitalizations in the United States included a primary discharge diagnosis of AF. Of these, 97.3 % included a diagnosis in only one HRSN domain with the most frequently diagnosed HRSN domain being housing (54.5 %) followed by socioeconomic (29.4 %), family (10.0 %), employment (6.1 %), and psychosocial (2.8 %). Index hospitalizations that included any HRSN diagnosis had 2.2-times greater unadjusted odds of all-cause 30-day readmission (95 % CI: 2.1 to 2.3-times greater, p < .001). Index hospitalizations that included an HRSN diagnosis were associated with higher rates of 90-day readmission due to conduction disorder and COPD. In conclusion, there is a significant association between HRSN and hospital readmissions in patients with AF. Further research is required to explain the true nature of this relationship with a specific emphasis on housing insecurity.

Underreporting contextual factors preclude the applicability appraisal in primary care randomized controlled trials

OBJECTIVES

To assess applicability reporting in randomized controlled trials (RCTs) conducted in primary care (PC).

STUDY DESIGN AND SETTING

We used a random sample of PC RCTs published between 2000 and 2020 to assess applicability. We extracted data related to setting, population, intervention (including implementation), comparator, outcomes, and context. Based on data availability, we assessed whether the five predefined applicability questions were adequately addressed by each PC RCT.

RESULTS

Adequately described elements that were reported frequently (>50%) included the responsible organization for intervention provision (97, 93.3%), study population characteristics (94, 90.4%), intervention implementation including monitoring and evaluation (92, 88.5%), intervention components (89, 85.6%), time frame (82, 78.8%), baseline prevalence (58, 55.8%), and the type of setting and location (53, 51%). Elements that were often underreported included contextual factors, that is, evidence of differential effects across sociodemographic or other groupings (2, 1.9%), intervention components tailored for specific settings (7, 6.7%), health system structure (32, 30.8%), factors affecting implementation (40, 38.5%) and organization structure (50, 48.1%). The proportion of trials that adequately addressed each applicability question ranged between 1% and 20.2%, while none RCT could address all of them.

CONCLUSION

Underreporting contextual factors jeopardize the appraisal of applicability in PC RCTs.

Pediatric Bowel Management Options and Organizational Aspects

A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.

Disparities in melanoma-specific mortality by race/ethnicity, socioeconomic status, and health care systems

BACKGROUND

Despite encouraging trends in survival, sociodemographic inequalities persist among patients with melanoma.

OBJECTIVE

We sought to quantify the effect of race/ethnicity, socioeconomic status, and health care systems on melanoma-specific mortality within an insured population of patients.

METHODS

Using a retrospective cohort study, we identified insured adults diagnosed with Stage I to IV melanoma from January 1, 2009, to December 31, 2014, followed through 2017, from the California Cancer Registry. We compared melanoma-specific mortality between insured patients diagnosed within the largest vertically integrated health care system in California, Kaiser Permanente Southern California, and insured patients with other private insurance (OPI).

RESULTS

Our cohort included 14,614 adults diagnosed with melanoma. Multivariable analyses demonstrated that race/ethnicity was not associated with survival disparities, while socioeconomic status was a strong predictor of melanoma-specific mortality, particularly for those with OPI. For example, hazard ratios demonstrate that the poorest patients with OPI have a 70% increased risk of dying from their melanoma compared to their wealthiest counterparts, while the poorest patients in Kaiser Permanente Southern California have no increased risk.

LIMITATIONS

Our main limitation includes inadequate data for certain racial/ethnic groups, such as Native Americans.

CONCLUSIONS

Our findings underscore the persistence of socioeconomic disparities within an insured population, specifically among those in non-integrated health care systems.

Transitions in care between hospital and community settings for individuals with a substance use disorder: A systematic review

BACKGROUND AND AIMS

Individuals with a substance use disorder (SUD) have high rates of hospital service utilization including emergency department (ED) presentations and hospital admissions. Acute care settings offer a critical opportunity to engage individuals in addiction care and improve health outcomes especially given that the period of transition from hospital to community is challenging. This review summarizes literature on interventions for optimizing transitions in care from hospital to community for individuals with a SUD.

METHODS

The literature search focused on key terms associated with transitions in care and SUD. The search was conducted on three databases: MEDLINE, CINAHL, and PsychInfo. Eligible studies evaluated interventions acting prior to or during transitions in care from hospital to community and reported post-discharge engagement in specialized addiction care and/or return to hospital and were published since 2010.

RESULTS

Title and abstract screening were conducted for 2337 records. Overall, 31 studies met inclusion criteria, including 7 randomized controlled trials and 24 quasi-experimental designs which focused on opioid use (n = 8), alcohol use (n = 5), or polysubstance use (n = 18). Interventions included pharmacotherapy initiation (n = 7), addiction consult services (n = 9), protocol implementation (n = 3), screening, brief intervention, and referral to treatment (n = 2), patient navigation (n = 4), case management (n = 1), and recovery coaching (n = 3).

CONCLUSIONS

Both pharmacologic and psychosocial interventions implemented around transitions from acute to community care settings can improve engagement in care and reduce hospital readmission and ED presentations. Future research should focus on long-term health and social outcomes to improve quality of care for individuals with a SUD.

Care Transition Interventions to Improve Stroke Outcomes: Evidence Gaps in Underserved and Minority Populations

In many countries hospital length of stay after an acute stroke admission is typically just a few days, therefore, most of a person's recovery from stroke occurs in the community. Care transitions, which occur when there is a change in, or handoff between 2 different care settings or providers, represent an especially vulnerable period for patients and caregivers. For some patients with stroke the return home is associated with substantial practical, psychosocial, and health-related challenges leading to substantial burden for the individual and caregiver. Underserved and minority populations, because of their exposure to poor environmental, social, and economic conditions, as well as structural racism and discrimination, are especially vulnerable to the problems of complicated care transitions which in turn, can negatively impact stroke recovery. Overall, there remain significant unanswered questions about how to promote optimal recovery in the post-acute care period, particularly for those from underserved communities. Evidence is limited on how best to support patients after they have returned home where they are required to navigate the chronic stages of stroke with little direct support from health professionals.

Examining Real-World Therapy Practice of Cognitive Screening and Assessment in Post-Acute Care

OBJECTIVES

Routine implementation of cognitive screening and assessment by therapy providers in post-acute settings may promote improved care coordination. This study examined the frequency of cognitive screening and assessment documentation across post-acute settings, as well as its relationship with contextual factors and outcomes.

DESIGN

Cross-sectional observational study using Medicare claims and electronic health record data from 1 large health system.

SETTING AND PARTICIPANTS

Older adults admitted to post-acute care after an acute hospitalization.

METHODS

Descriptive analysis examined documentation of cognitive screening and assessment. Logistic and hierarchical linear regression evaluated the relationship among patient factors, cognitive screening and assessment, and patient outcomes.

RESULTS

The most common admission diagnoses for the final sample (n=2535) were total hip or knee joint replacement (41.7%) and stroke (15.3%). Following acute hospitalization, patients were discharged to inpatient rehabilitation (22.6%), skilled nursing (9.3%), or home health (68.1%). During the post-acute care stay, 38% of patients had documentation of cognitive screening by any therapy discipline. Patterns of documentation varied across disciplines and post-acute settings. Documentation of standardized cognitive assessments was limited, occurring for less than 2% of patients. Admission for stroke was associated with significantly higher odds of cognitive screening or assessment [odds ratio (OR) 2.07, 95% CI 1.13, 3.82] compared to patients with other diagnoses. There was no significant relationship between documentation of cognitive screening or assessment and 30-day readmissions (OR 0.81, 95% CI 0.53, 1.28).

CONCLUSION AND IMPLICATIONS

The key finding was inconsistent documentation of cognitive screening and assessment across disciplines and post-acute settings, which could be in part due to variation in electronic health record platforms. Future work can expand on these results to understand the degree to which contextual factors facilitate or inhibit routine delivery and documentation of cognitive screening and assessment. Findings can support implementation of standardized data elements to lead to improved care coordination and outcomes.

"I Had Bills to Pay": a Mixed-Methods Study on the Role of Income on Care Transitions in a Public-Payer Healthcare System

BACKGROUND

Income disparities may affect patients' care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited.

OBJECTIVE

To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities.

DESIGN

Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial.

PARTICIPANTS

Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals.

MAIN MEASURES

The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted.

KEY RESULTS

Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0-3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health.

CONCLUSIONS

There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research.

Exploring perceptions, knowledge, and attitudes regarding pharmacogenetic testing in the medically underserved

Introduction: Pharmacogenetic testing may hold promise in addressing health disparities, as medically underserved patients appear to be prescribed medications with pharmacogenetic guidelines at higher rates. While routine clinical implementation of testing in medically underserved populations has not yet been achieved, using patient perspectives to inform implementation should increase the likelihood of success. The aim of this study was to assess the perceptions, knowledge, and attitudes regarding pharmacogenetic testing in medically underserved patients. Methods: We developed a survey instrument to assess respondent views on pharmacogenetic testing. The survey instrument was developed through a process of literature review, expert input, iterative pilot testing, and final refinement. The survey instrument was fielded to US adults with an estimated household income of $42,000 per year or less. Results: During the survey instrument development, 59 pilot testers provided 133 comments which lead to 38 revisions to the survey instrument. The nationwide survey resulted in 1,060 respondents, of which half (49.8%) reported having no health insurance or being on Medicaid. Most patients (78.9%) had not previously heard of pharmacogenetic testing. After being provided an explanation of pharmacogenetic testing, 60.5% were very or moderately interested in receiving testing if there were no cost and 75.8% of respondents agreed or strongly agreed that pharmacogenetic testing should be available to help with medication selection regardless of cost. Respondents shared that their greatest concern with pharmacogenetic testing was that the test would cost them money, which was expressed by over half (52.7%). This was followed by concerns that the results could reveal a risk for a disease, could affect health insurance, and would not improve care. Discussion: Our results indicate a strong interest in pharmacogenetic testing and identify key perceptions, attitudes, concerns, and potential barriers that can be addressed as pharmacogenetic testing is clinically implemented in medically underserved patient populations.

A comparison of the COVID-19 response for urban underserved patients experiencing healthcare transitions in three Canadian cities

OBJECTIVES

The COVID-19 pandemic and response has highlighted existing strengths within the system of care for urban underserved populations, but also many fault lines, in particular during care transitions. The objectives of this study were to describe COVID-19 response policies for urban underserved populations in three Canadian cities; examine how these policies impact continuity of care for urban underserved populations; determine whether and how urban underserved community members were engaged in policy processes; and develop policy and operational recommendations for optimizing continuity of care for urban underserved populations during public health crises.

METHODS

Using Walt & Gilson's Policy Triangle framework as a conceptual guide, 237 policy and media documents were retrieved. Five complementary virtual group interview sessions were held with 22 front-line and lived-experience key informants to capture less well-documented policy responses and experiences. Documents and interview transcripts were analyzed inductively for policy content, context, actors, and processes involved in the pandemic response.

RESULTS

Available documents suggest little focus on care continuity for urban underserved populations during the pandemic, despite public health measures having disproportionately negative impacts on their care. Policy responses were largely reactive and temporary, and community members were rarely involved. However, a number of community-based initiatives were developed in response to policy gaps. Promising practices emerged, including examples of new multi-level and multi-sector collaboration.

CONCLUSION

The pandemic response has exposed inequities for urban underserved populations experiencing care transitions; however, it has also exposed system strengths and opportunities for improvement to inform future policy direction.

Follow-up Post-discharge and Readmission Disparities Among Medicare Fee-for-Service Beneficiaries, 2018

BACKGROUND

Previous studies have identified disparities in readmissions among Medicare beneficiaries hospitalized for the Hospital Readmissions Reduction Program's (HRRP's) priority conditions. Evidence suggests timely follow-up is associated with reduced risk of readmission, but it is unknown whether timely follow-up reduces disparities in readmission.

OBJECTIVE

To assess whether follow-up within 7 days after discharge from a hospitalization reduces risk of readmission and mitigates identified readmission disparities.

DESIGN

A retrospective cohort study using Cox proportional hazards models to estimate the associations between sociodemographic characteristics (race and ethnicity, dual-eligibility status, rurality, and area social deprivation), follow-up, and readmission. Mediation analysis was used to examine if disparities in readmission were mitigated by follow-up.

PARTICIPANTS

We analyzed data from 749,402 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, or pneumonia, and discharged home between January 1 and December 1, 2018.

MAIN MEASURE

All-cause unplanned readmission within 30 days after discharge.

KEY RESULTS

Post-discharge follow-up within 7 days of discharge was associated with a substantially lower risk of readmission (HR: 0.52, 95% CI: 0.52-0.53). Across all four HRRP conditions, beneficiaries with dual eligibility and beneficiaries living in areas with high social deprivation had a higher risk of readmission. Non-Hispanic Black beneficiaries had higher risk of readmission after hospitalization for pneumonia relative to non-Hispanic Whites. Mediation analysis suggested that 7-day follow-up mediated 21.2% of the disparity in the risk of readmission between dually and non-dually eligible beneficiaries and 50.7% of the disparity in the risk of readmission between beneficiaries living in areas with the highest and lowest social deprivation. Analysis suggested that after hospitalization for pneumonia, 7-day follow-up mediated nearly all (97.5%) of the increased risk of readmission between non-Hispanic Black and non-Hispanic White beneficiaries.

CONCLUSIONS

Improving rates of follow-up could be a strategy to reduce readmissions for all beneficiaries and reduce disparities in readmission based on sociodemographic characteristics.

Clinical characteristics and social determinants of health associated with 30-day hospital readmissions of patients with COVID-19

COVID-19 readmissions are associated with increased patient mortality and healthcare system strain. This retrospective cohort study of PCR-confirmed COVID-19 positive adults (>18 years) hospitalized and readmitted within 30 days of discharge from index admission was performed at eight Atlanta hospitals from March to December 2020. The objective was to describe COVID-19 patient-level demographics and clinical characteristics, and community-level social determinants of health (SDoH) that contribute to 30-day readmissions. Demographics, comorbidities, COVID-19 treatment, and discharge disposition data were extracted from the index admission. ZIP codes were linked to a demographic/lifestyle database interpolating to community-level SDoH. Of 7155 patients with COVID-19, 463 (6.5%) had 30-day, unplanned, all-cause hospital readmissions. Statistically significant differences were not found in readmissions stratified by age, sex, race, or ethnicity. Patients with a high-risk Charlson Comorbidity Index had higher odds of readmission (OR 4.8 (95% CI: 2.1 to 11.0)). Remdesivir treatment and intensive care unit (ICU) care were associated with lower odds of readmission (OR 0.5 (95% CI: 0.4 to 0.8) and OR 0.5 (95% CI: 0.4 to 0.7), respectively). Patients residing in communities with larger average household size were less likely to be readmitted (OR 0.7 (95% CI: 0.5 to 0.9). In this cohort, patients who received remdesivir, were cared for in an ICU, and resided in ZIP codes with higher proportions of residents with increased social support had lower odds of readmission. These patient-level factors and community-level SDoH may be used to identify patients with COVID-19 who are at increased risk of readmission.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Implementing screening for social determinants of health using the Core 5 screening tool

Social determinants of health (SDOH) have been documented to underpin 80% of overall health and are being increasingly recognised as key factors in addressing tertiary health outcomes. Yet, despite the widespread acceptance of the association of SDOH with health outcomes, more than two-thirds of hospitals do not screen for social risk factors that indicate individual-level adverse SDOH. Such screening for social risk factors represents the first step in connecting patients with resources and documents the prevalence of social needs. The aim of this project was to implement the Core 5 social risk screening tool and evaluate its efficacy and usability in identifying social risk factors in a presurgical spine population. Prior to this implementation, screening for social risk had not been performed. The Model for Improvement provided a framework for implementing and evaluating the Core 5 social risk screening tool. Methods included implementation of a patient self-report social risk screening tool, referral workflow to connect patients with needed resources and evaluation of staff feasibility in using the Core 5 tool. The results indicated that the screening tool identified patients with social risk factors and staff reported perceptions of efficacy and usability in clinical workflow. Overall, 52 of 88 (59%) of subjects in the presurgical spine population were effectively screened. Of these, five patients (10%) had identified social needs that needed to be addressed prior to surgery. The staff usability survey for the Core 5 tool demonstrated high acceptance and usability, with an average score of 4.4 (out of 5). Future work should evaluate the efficacy of the screening tool in other ambulatory and tertiary settings.

Opening Pandora's Box: From Readmissions to Transitional Care Patient-Centered Outcome Measures

BACKGROUND

Measuring the effectiveness of transitional care interventions has historically relied on health care utilization as the primary outcome. Although the Care Transitions Measure was the first outcome measure specifically developed for transitional care, its applicability beyond the hospital-to-home transition is limited. There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings (ie, TC-PCOMs) to ensure that outcomes are both meaningful to patients and relevant to the particular care transition. The overall objective of this paper is to describe the opportunities and challenges of integrating TC-PCOMs into research and practice.

METHODS AND RESULTS

This narrative review was conducted by members of the Patient-Centered Outcomes Research Institute (PCORI) Transitional Care Evidence to Action Network. We define TC-PCOMs as outcomes that matter to patients because they account for their individual experiences, concerns, preferences, needs, and values during the transition period. The cardinal features of TC-PCOMs should be that they are developed following direct input from patients and stakeholders and reflect their lived experience during the transition in question. Although few TC-PCOMs are currently available, existing patient-reported outcome measures could be adapted to become TC-PCOMs if they incorporated input from patients and stakeholders and are validated for the relevant care transition.

CONCLUSION

Establishing validated TC-PCOMs is crucial for measuring the responsiveness of transitional care interventions and optimizing care that is meaningful to patients.

Patient-Centered Approaches to Transitional Care Research and Implementation: Overview and Insights From Patient-Centered Outcomes Research Institute's Transitional Care Portfolio

BACKGROUND

This Special Issue, Future Directions in Transitional Care Research, focuses on the approaches used and lessons learned by researchers conducting care transitions studies funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI's approach to transitional care research augments prior research by encouraging researchers to focus on head-to-head comparisons of interventions, the use of patient-centered outcomes, and the engagement of stakeholders throughout the research process.

OBJECTIVES

This paper introduces the themes and topics addressed by the articles that follow, which are focused on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care. It provides an overview of the state of the care transitions field, a description of PCORI's programmatic objectives, highlights of the patient and stakeholder engagement activities that have taken place during the course of these studies, and a brief overview of PCORI's Transitional Care Evidence to Action Network, a learning community designed to foster collaboration between investigators and their research teams and enhance the collective impact of this body of work.

CONCLUSIONS

The papers in this Special Issue articulate challenges, lessons learned, and new directions for measurement, stakeholder engagement, implementation, and methodological and design approaches that reflect the complexity of transitional care comparative effectiveness research and seek to move the field toward a more holistic understanding of transitional care that integrates social needs and lifespan development into our approaches to improving care transitions.

Patient Activation, Depressive Symptoms, and Self-Rated Health: Care Management Intervention Effects among High-Need, Medically Complex Adults

The purpose of this randomized controlled trial (n = 268) at a Federally Qualified Health Center was to evaluate the outcomes of a care management intervention versus an attention control telephone intervention on changes in patient activation, depressive symptoms and self-rated health among a population of high-need, medically complex adults. Both groups had similar, statistically significant improvements in patient activation and self-rated health. Both groups had significant reductions in depressive symptoms over time; however, the group who received the care management intervention had greater reductions in depressive symptoms. Participants in both study groups who had more depressive symptoms had lower activation at baseline and throughout the 12 month study. Findings suggest that patients in the high-need, medically complex population can realize improvements in patient activation, depressive symptoms, and health status perceptions even with a brief telephone intervention. The importance of treating depressive symptoms in patients with complex health conditions is highlighted.

Understanding Variation in Postacute Care: Developing Rehabilitation Service Areas Through Geographic Mapping

OBJECTIVE

The aims of the study were to demonstrate a method for developing rehabilitation service areas and to compare service areas based on postacute care rehabilitation admissions to service areas based on acute care hospital admissions.

DESIGN

We conducted a secondary analysis of 2013-2014 Medicare records for older patients in Texas (N = 469,172). Our analysis included admission records for inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies. We used Ward's algorithm to cluster patient ZIP Code Tabulation Areas based on which facilities patients were admitted to for rehabilitation. For comparison, we set the number of rehabilitation clusters to 22 to allow for comparison to the 22 hospital referral regions in Texas. Two methods were used to evaluate rehabilitation service areas: intraclass correlation coefficient and variance in the number of rehabilitation beds across areas.

RESULTS

Rehabilitation service areas had a higher intraclass correlation coefficient (0.081 vs. 0.076) and variance in beds (27.8 vs. 21.4). Our findings suggest that service areas based on rehabilitation admissions capture has more variation than those based on acute hospital admissions.

CONCLUSIONS

This study suggests that the use of rehabilitation service areas would lead to more accurate assessments of rehabilitation geographic variations and their use in understanding rehabilitation outcomes.

Patterns of overall mortality by race/ethnicity and socioeconomic status in insured cancer patients in Southern California

Purpose

We evaluated the influence of race/ethnicity and geocoded socioeconomic status (SES) on all-cause mortality in cancer patients with health insurance.

Methods

We identified adults diagnosed with eight common cancers from 2009 to 2014 from the California Cancer Registry and followed them through 2017 (8 years maximum). We calculated person-year mortality rates by race/ethnicity and SES. Adjusted hazard ratios for the association between overall mortality and race/ethnicity and SES were estimated using Cox proportional hazards models accounting for other demographics, stage at diagnosis, and cancer treatments.

Results

A total of 164,197 adults were diagnosed with cancer originating from breast, prostate, lung, colon, skin melanoma, uterus, kidney, and bladder. For all race/ethnic groups combined, the mortality rates from lowest to highest SES groups were 112.1/1000 PY (lowest); 100.2/1000 PY (lower-middle); 91.2/1000 PY (middle); 79.1/1000 PY (upper-middle); and 63.5/1000 PY (upper). These rates suggest that person with lowest SES have a markedly increased mortality risk after cancer diagnosis even if they have health insurance. In multivariable analyses, those in the lowest SES group had a 40–78% increased risk of all-cause mortality compared to those in the upper SES group across all race/ethnicities. For example, within African Americans, the adjusted mortality risk was up to 61% higher (HR 1.61, 95% CI 1.41–1.83) in the lowest SES group compared to the highest SES group.

Conclusion

This study suggests disparities in overall mortality risk after cancer diagnoses persist even in a cohort with health insurance, and that SES is an important driver of this disparity.

The temporal nature of social context: Insights from the daily lives of patients with HIV

Background

Patients’ life contexts are increasingly recognized as important, as evidenced by growing attention to the Social Determinants of Health (SDoH). This attention may be particularly valuable for patients with complex needs, like those with HIV, who are more likely to experience age-related comorbidities, mental health or substance use issues. Understanding patient perceptions of their life context can advance SDoH approaches.

Objectives

We sought to understand how aging patients with HIV think about their life context and explored if and how their reported context was documented in their electronic medical records (EMRs).

Design

We combined life story interviews and EMR data to understand the health-related daily life experiences of patients with HIV. Patients over 50 were recruited from two US Department of Veterans Affairs HIV clinics. Narrative analysis was used to organize data by life events and health-related metrics.

Key results

EMRs of 15 participants documented an average of 19 diagnoses and 10 medications but generally failed to include social contexts salient to patients. In interviews, HIV was discussed primarily in response to direct interviewer questions. Instead, participants raised past trauma, current social engagement, and concern about future health with varying salience. This led us to organize the narratives temporally according to past-, present-, or future-orientation. “Past-focused” narratives dwelled on unresolved experiences with social institutions like the school system, military or marriage. “Present-focused” narratives emphasized daily life challenges, like social isolation. “Future-focused” narratives were dominated by concerns that aging would limit activities.

Conclusions

A temporally informed understanding of patients’ life circumstances that are the foundation of their individualized SDoH could better focus care plans by addressing contextual concerns salient to patients. Trust-building may be a critical first step in caring for past-focused patients. Present-focused patients may benefit from support groups. Future-focused patients may desire discussing long term care options.

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial

BACKGROUND

Older adults (> 65 years) with multiple chronic conditions (MCC) and depressive symptoms experience frequent transitions between hospital and home. Care transitions for this population are often poorly coordinated and fragmented, resulting in increased readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden. There is a dearth of evidence on best practices in the provision of transitional care for older adults with MCC and depressive symptoms transitioning from hospital-to-home. This paper presents a protocol for a two-armed, multi-site pragmatic effectiveness-implementation trial of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led six-month intervention that supports older adults with MCC and depressive symptoms transitioning from hospital-to-home. The Collaborative Intervention Planning Framework is being used to engage patients and other key stakeholders in the implementation and evaluation of the intervention and planning for intervention scale-up to other communities.

METHODS

Participants will be considered eligible if they are > 65 years, planned for discharged from hospital to the community in three Ontario locations, self-report at least two chronic conditions, and screen positive for depressive symptoms. A total of 216 eligible and consenting participants will be randomly assigned to the control (usual care) or intervention (CAST) arm. The intervention consists of tailored care delivery comprising in-home visits, telephone follow-up and system navigation support. The primary measure of effectiveness is mental health functioning of the older adult participant. Secondary outcomes include changes in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health and social service use and cost, from baseline to 6- and 12-months. Caregivers will be assessed for caregiver strain, depressive symptoms, anxiety, health-related quality of life, and health and social service use and costs. Descriptive and qualitative data from older adult and caregiver participants, and the nurse interventionists will be used to examine implementation of the intervention, how the intervention is adapted within each study region, and its potential for sustainability and scalability to other jurisdictions.

DISCUSSION

A nurse-led transitional care strategy may provide a feasible and effective means for improving health outcomes and patient/caregiver experience and reduce service use and costs in this vulnerable population.

TRIAL REGISTRATION

# NCT03157999 . Registration Date: April 4, 2017.

Understanding Perceived Barriers to Care Among Suburban Super-Utilizers Who Have an Identified Primary Care Provider

Patients who are admitted to the hospital frequently (>3 admissions in a 6-month period) are a large driver of health care costs. Recently, research has focused on these groups of super-utilizing patients to try to find ways to meet their care needs in the outpatient setting. However, most research so far has focused on the urban underserved population who do not have a usual source of care. The goal of this study is to identify a group of patients from a suburban academic family medicine practice who have been admitted to the hospital frequently over a 6-month period and interview them to identify patient-perceived barriers to care in the outpatient setting. Nine of the 176 patients identified as frequently hospitalized were interviewed. Interpretive phenomenology analysis was used to identify perceived barriers and facilitators to care. Although some identified barriers were similar to those noted in groups of the urban underserved, including chronic disease and polypharmacy, other barriers were uniquely identified in the nonurban population, including transportation and support at home. Transportation issues, lack of support at home, and poor interdisciplinary communication were found to increase risk for readmission. Conversely, good interdisciplinary communication and ample support from family, including support services at home, were viewed as facilitators to outpatient care.