The "continuity visit" and the hospitalist model of care

Burden and Outcomes of Fragmentation of Care in Hospitalized Patients With Inflammatory Bowel Diseases: A Nationally Representative Cohort

BACKGROUND

Fragmentation of care (FoC) may adversely impact health care quality in patients with chronic diseases. We conducted a US nationally representative cohort study to evaluate the burden and outcomes of FoC in hospitalized patients with inflammatory bowel disease (IBD).

METHODS

Using Nationwide Readmissions Database 2013, we created 2 cohorts of superutilizer patients with IBD with 2 hospitalizations (cohort 1: FoC, defined as readmission to nonindex hospital vs no FoC) or 3 hospitalizations (cohort 2: multiple episodes of fragmentation vs single episode of fragmentation vs no FoC) between January and June 2013, which were followed through December 2013. We evaluated burden, pattern, and outcomes of fragmentation (6-month risk of readmission, risk of surgery, and inpatient mortality).

RESULTS

In cohort 1, of 6073 patients with IBD with 2 admissions within 6 months, 1394 (23%) experienced FoC. Fragmentation of care was associated with modestly higher risk of readmission within 6 months (31% vs 28%, P < 0.01; adjusted relative risk, 1.11 [1.01-1.21]), without differences in risk of surgery (2.8% vs 4.3%, P = 0.19) or in-hospital mortality (0.2% vs 0.5%, P = 0.22). In cohort 2, of 1717 patients with 3 hospitalizations within 6 months, the number of patients with multiple episodes of fragmentation was associated with higher risk of readmission compared with patients with single episode of fragmentation or no FoC (52% vs 49% vs 43%, P = 0.03).

CONCLUSIONS

In a US cohort study, FoC is associated with a modestly higher risk of readmission, without higher risk of surgery or mortality in superutilizer patients with IBD. Future studies focusing on impact of outpatient care and postdischarge coordination are warranted in superutilizer patients.

Prevention of hospital-acquired thrombosis from a primary care perspective: a qualitative study

Background

Although there is considerable risk for patients from hospital-acquired thrombosis (HAT), current systems for reducing this risk appear inefficient and have focused predominantly on secondary care, leaving the role of primary care underexplored, despite the onset of HAT often occurring post-discharge.

Aim

To gain an understanding of the perspectives of primary care clinicians on their contribution to the prevention of HAT. Their current role, perceptions of patient awareness, the barriers to better care, and suggestions for how these may be overcome were discussed.

Design and setting

Qualitative study using semi-structured interviews in Oxfordshire and South Birmingham, England.

Method

Semi-structured telephone interviews with clinicians working at practices of a variety of size, socioeconomic status, and geographical location.

Results

A number of factors that influenced the management of HAT emerged, including patient characteristics, a lack of clarity of responsibility, limited communication and poor coordination, and the constraints of limited practice resources. Suggestions for improving the current system include a broader role for primary care supported by appropriate training and the requisite funding.

Conclusion

The role of primary care remains limited, despite being ideally positioned to either raise patient awareness before admission or support patient adherence to the thromboprophylaxis regimen prescribed in hospital. This situation may begin to be addressed by more robust lines of communication between secondary and primary care and by providing more consistent training for primary care staff. In turn, this relies on the allocation of appropriate funds to allow practices to meet the increased demand on their time and resources.

A Neurohospitalist Discharge Clinic Shortens the Transition From Inpatient to Outpatient Care

BACKGROUND AND PURPOSE

Medicine hospitalist programs have effectively incorporated hospitalist-run discharge clinics into clinical practice to help bridge the vulnerable transition periods after hospital discharge. A neurohospitalist discharge clinic would similarly allow continuity with the inpatient provider while addressing challenges in the coordination of neurologic care. We anticipated that this would afford a greater total number of patients to be seen and at a shorter interval.

METHODS

The number of posthospital discharge patients who were seen in general continuity per month in the 6 months prior to establishment of neurohospitalist discharge clinic and those seen over 1 full calendar year 6 months after clinic began was compared by reviewing medical records. Average length of time between discharge from hospital and first clinic visit was compared between patients seen in general neurology continuity clinic and those seen in discharge clinic.

RESULTS

There was a significant increase in the average number of postdischarge visits per month after initiation of neurohospitalist discharge clinic compared to prior (16.1 visits vs 10.5 visits, P = .001). Patients were seen significantly sooner after hospitalization in discharge clinic (35.9 ± 4.3 days) compared to those seen in general continuity clinic during the same time epoch (57.6 ± 4.1 days; p < 0.001).

CONCLUSIONS

Creation of a neurohospitalist discharge clinic was effective in increasing posthospital discharge follow-up frequency and shortening duration of time to follow-up.

Improving transitions of care from hospital to home: what works?

As the cost of care rises and fragmentation of health care increases, care transitions have become critical parts of the health care system. Physicians and other inpatient providers have the responsibility to communicate to subsequent providers, but such communication occurs far less than is optimal. Timely discharge summaries for the next-level provider, postdischarge phone calls to patients, and postdischarge follow-up appointments with primary-care physicians or inpatient providers may improve postdischarge health care utilization. Pharmacists may also reduce medication errors, adverse medication events, and even readmissions. The most promising data, however, come from studies of multidisciplinary approaches, some of which have shown large reductions in postdischarge utilization and costs. More study is needed to pinpoint the most cost-effective and efficient strategies to improve transitions from the inpatient setting to other settings.

The prescribing of specialist medicines: what factors influence GPs' decision making?

BACKGROUND

As Governments worldwide strive to integrate efficient health care delivery across the primary-secondary care divide, particular significance has been placed on the need to understand GPs' prescribing of specialist drugs.

OBJECTIVE

To explore the factors which influence GPs' decision-making process when requested to prescribe specialist drugs.

METHODS

A qualitative approach was used to explore the perspectives of a wide range of practice-, primary care trust-, strategic health authority-level staff and other relevant stakeholders in the North-West of England. All semi-structured interviews (n = 47) were analysed comprehensively using the five-stage 'framework' approach.

RESULTS

Six diverse factors were identified as having a crucial bearing on how GPs evaluate initial requests and subsequently decide whether or not to prescribe. These include GPs' lack of knowledge and expertise in using specialist drugs, the shared care arrangement, the influence of a locally agreed advisory list, financial and resource considerations, patient convenience and understanding and GPs' specific areas of interest.

CONCLUSION

This exploration of GPs' decision-making process is needed to support future integrated health care delivery.

Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record

BACKGROUND

The nationwide expansion of the hospitalist movement brings rapid change in communication and work processes in many hospitals. While our fast-growing hospitalist program has greatly improved length of stay and quality measures, it has also faced complex operational challenges affecting the whole organization rather than just our division: assigning and tracking hospitalist coverage of admitted patients was one of these challenges.

METHODS

We integrated a system of algorithms and interface solutions into our hospital's preexisting electronic health records (EHR) program to act as a decision support tool and computerized safety net during admission and patient distribution. Its main structural elements include: (1) algorithms that identify patients for hospitalist coverage and monitor coverage during transitions of care; (2) EHR data fields that enable hospitalists to assign and update each patient's coverage information in real time; and (3) a combination of display solutions to inform users of coverage arrangements and alert for potentially misassigned patients. Our system assists with correct attending selection on admission. It also assures continuity of coverage during transitions within the hospitalist program and across care settings.

RESULTS

Our enhancements to the EHR received unanimously positive assessment by users and added an important layer of patient safety and organizational efficiency for our hospitalist program.

DISCUSSION

Adaptations of our tools may provide similar opportunities for improvements in a variety of hospitalist settings; an integrated computerized physician order entry (CPOE) system is not a prerequisite. We demonstrate how the presented innovations can be used to enhance other EHR functions as well.

Assessing the value of pediatric hospitalist programs: the perspective of hospital leaders

OBJECTIVE

There has been a rapid increase in the number of pediatric hospitalist programs in the United States. As most pediatric hospitalist services are believed to be subsidized by hospitals, gaining a better understanding of the rationale for these subsidies is critical to the future success and existence of these programs. Our objective was to determine the rationale for pediatric hospitalist program subsidies from the perspective of hospital leaders.

METHODS

A survey was mailed to hospital executives from a national sample of 112 hospitals between October 2007 and February 2008.

RESULTS

The overall response rate was 69% (N = 77). Twelve hospitals no longer used hospitalists to provide care for children, leaving 65 hospitals for the analysis. The majority of hospital leaders indicated they subsidize their pediatric hospitalist program (78%, n = 51) and the average proportion subsidized was 49% of program costs. The majority of hospitals (82%, n = 40) do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate their program will be able to cover its costs. Hospital leaders provided a broad rational for this subsidization but most commonly cited the nonmonetary benefits of patient (83%, n = 39) and referring physician satisfaction (81%, n = 38) as reason for their investment.

CONCLUSIONS

Despite the fact that most pediatric hospitalist programs are unable to cover their costs, the majority of hospitals plan to continue subsidizing these programs. Discussions of the value added by hospitalists should not presume that hospital investment in hospitalist programs is based on monetary benefits alone.

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care

CONTEXT

Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events.

OBJECTIVES

To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process.

DATA SOURCES

MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies.

STUDY SELECTION

Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18).

DATA EXTRACTION

Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer.

DATA SYNTHESIS

Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents.

CONCLUSIONS

Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.

End-of-life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms

PURPOSE

To assess the effects of hospitalist care on communication, care patterns, and outcomes of dying patients.

METHODS

We examined the charts of 148 patients who had died at a community-based, urban teaching hospital, comparing the end-of-life care provided by community physicians and hospitalists.

RESULTS

Patients of hospitalists and community-based physicians were similar in age, race, severity of acute illness, and difficulties with activities of daily living. After admission, hospitalists had discussions with patients or their families regarding care more often than did community physicians (91% [67/74] vs. 73% [54/74], P = 0.006) and were more likely to document these discussions themselves. Among patients who were "full code" at admission, there was a trend towards patients of hospitalists receiving comfort care more frequently at the time of death (50% [25/48] vs. 37% [15/40], P = 0.14). Although there were no differences in the use of medications such as long-acting opioids, no symptoms in the 48 hours prior to death were more likely to be noted for patients of hospitalists (47% [n = 35] vs. 31% [n = 23]), P = 0.03). After adjustment for confounding factors in multivariable models, only findings regarding documentation of discussions and symptoms remained statistically significant.

CONCLUSION

Hospitalists at a community-based teaching hospital documented substantial efforts to communicate with dying patients and their families, which may have resulted in improved end-of-life care.