Improving communication between hospital and primary care increases follow-up rates for asthmatic patients following casualty attendance

Predicting Continuity of Asthma Care Using a Machine Learning Model: Retrospective Cohort Study

Continuity of care (COC) has been shown to possess numerous health benefits for chronic diseases. Specifically, the establishment of its level can facilitate clinical decision-making and enhanced allocation of healthcare resources. However, the use of a generalizable predictive methodology to determine the COC in patients has been underinvestigated. To fill this research gap, this study aimed to develop a machine learning model to predict the future COC of asthma patients and explore the associated factors. We included 31,724 adult outpatients with asthma who received care from the University of Washington Medicine between 2011 and 2018, and examined 138 features to build the machine learning model. Following the 10-fold cross-validations, the proposed model yielded an accuracy of 88.20%, an average area under the receiver operating characteristic curve of 0.96, and an average F1 score of 0.86. Further analysis revealed that the severity of asthma, comorbidities, insurance, and age were highly correlated with the COC of patients with asthma. This study used predictive methods to obtain the COC of patients, and our excellent modeling strategy achieved high performance. After further optimization, the model could facilitate future clinical decisions, hospital management, and improve outcomes.

The Transition of Care Between Emergency Department and Primary Care: A Scoping Study

OBJECTIVES

Patients with chronic diseases are often forced to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge.

METHODS

We performed a MEDLINE search of English-language articles published between 1990 and March 2015. We created a data-charting form a priori of the search. Papers were organized into themes, with new themes created when none of the existing themes matched the paper. Papers with multiple themes were assigned preferentially to the theme that was consistent with their primary objectives. We created a descriptive numerical summary of the included studies.

RESULTS

Of 1,138 titles, there were 252 potentially relevant abstracts, and among those 122 met criteria for full paper review. An additional 11 papers were acquired from reference review. From the 133 papers, 85 were included in the study. The papers were categorized into seven themes. These included Follow-up compliance and its predictors (38 studies), Telephone calls to discharged ED patients (15 studies), ED navigators (14 studies), The current system (nine studies), Ways to alert primary care providers (PCPs) of the ED visit (seven studies), and Patient views and PCP information requirements (one each). In the Follow-up compliance and predictors theme, the two most frequently identified significant predictors for increasing the frequency of follow-up care were the provision of a follow-up appointment time prior to ED departure and the presence of health insurance. Follow-up telephone calls to patients resulted in better follow-up rates, but increased ED return visits in some studies. In the current system patients themselves are the conduit, and the barriers to follow-up care can be high. E-mail and/or electronic medical record alerts to the PCP are relatively new, and no studies limited the alerts to patients who had a defined need for follow-up care.

CONCLUSIONS

A plethora of work has been published on the transition of care from ED to primary care. To decrease hospitalizations among the upcoming wave of patients with chronic diseases, it appears that the two most efficient areas to target are a primary care follow-up appointment system and health insurance. Further research is needed in particular to identify the patients who actually need follow-up care and to develop information technology solutions that can be effectively implemented within the current emergency healthcare system.

Maintaining continuity of care: a look at the quality of communication between Ontario emergency departments and community physicians

Background:

To maintain continuity of care when a patient's care is transferred between physicians, continuity of patient information is required. This survey determined how, and how well, Ontario emergency departments (EDs) communicate patient information to physicians in the community.

Methods:

We surveyed Ontario ED chiefs to determine the most common media and methods used for disseminating information. We measured the perceived quality of their system, which was regressed against the hospital teaching status and community size using generalized logits modelling. Finally, we elicited the components of an ideal communication system for the ED.

Results:

One hundred and forty-three (85.6%) Ontario ED chiefs participated. The ED record of treatment was the most commonly used medium (95%). Postal service was the most common (55%) method of disseminating information. Thirty-three chiefs (23%) perceived the quality of communicating patient information from their ED as unsatisfactory or inadequate. This perception was significantly more prevalent in larger communities (excellent v. unsatisfactory [odds ratio (OR) 44.9, 95% confidence interval (CI) 13.9-140] and satisfactory v. unsatisfactory [OR 2.9, 95% CI 1.6-5.1]) and in teaching hospitals (satisfactory v. unsatisfactory [OR 9.7, 95% CI 4.7-20.3]). Seventy-eight percent of responding chiefs felt that patient information should be disseminated using electronic means, either through email or server access.

Conclusions:

To communicate patient information to community physicians, Ontario ED chiefs report that a copy of the ED record of treatment is sent by postal service. More than one-fifth of ED chiefs perceived communication from their department as unsatisfactory or inadequate. Studies that assess the completeness and accuracy of the record of treatment are required as a first step for measuring the quality of patient information communication in the Ontario ED system.

Improving adherence to asthma clinical guidelines and discharge documentation from emergency departments: implementation of a dynamic and integrated electronic decision support system

OBJECTIVE

The authors previously developed a dynamic and integrated electronic decision support system called ACAFE (Asthma Clinical Assessment Form and Electronic decision support). The objective of this present study was to evaluate the effectiveness of this system on asthma management and documentation in an ED.

METHOD

Observational study using a pre- and post-intervention design, comparing patients managed using ACAFE after its implementation with historical controls. A systematic data abstraction process was used to compare patient records.

RESULTS

A total of 50 patients were enrolled in the study group. These were compared with 50 historical controls. Use of ACAFE was associated with significantly higher rates of documentation of asthma severity (98% vs 18%, P < 0.01), as well as other clinically important variables, such as asthma precipitants, intensive care admission history and smoking history. ACAFE was also associated with significantly higher rate of asthma discharge plan documentation (76% vs 16%, P < 0.01), and this remained significant after adjustment for triage category and seniority of treating doctor in a regression model.

CONCLUSION

The use of this decision support system in patients presenting to emergency with asthma was associated with improvements in clinical documentation and discharge management plans. Electronic decision support systems developed collaboratively with clinicians should play an important part of system-wide efforts to improve guideline adherence and compliance in ED.

From emergency department to general practitioner: Evaluating emergency department communication and service to general practitioners

OBJECTIVE

To survey general practitioners' (GPs) opinions of communication and service received from the ED of a tertiary metropolitan hospital.

METHODS

Analysis of a postal survey form sent to 380 GPs in the hospital catchment area.

RESULTS

One hundred and forty-seven completed questionnaires (39%, 95% confidence interval [CI] 34-44%) were returned. Seventy-eight GPs (53%, 95% CI 45-61%) endorsed the current method of discharge letter delivery by patient; however, 43 (29%, 95% CI 22-37%) stated that letters were often not received. The most commonly proposed alternative to patient delivery was facsimile transmission. One hundred and thirty respondents (88%, 95% CI 83-94%) rated the overall standard of communication from ED as average or better; however, 64 (44%, 95% CI 36-52%) felt that important information was omitted from the discharge letter. One hundred and seventeen (79%, 95% CI 73-86%) GPs found the ED admitting officer role useful when referring patients. Fifty-nine (40%, 95% CI 32-48%) respondents cited difficulties accessing investigation results. The predominant source of patient dissatisfaction reported by GPs was excess waiting times.

CONCLUSIONS

Half of GPs surveyed supported the current system of patient delivered discharge letters and of those who did not the majority preferred faxed discharges. There was little support for email communication. GPs reported problems with the current communication system including discharge letters not reaching GPs and deficiencies in the discharge information. GP reported substantial difficulties in accessing outstanding investigation results. Most GPs felt that assessment and treatment of their patients in the ED was of above average quality, as was the overall service they received from the ED. There was GP support for the ED admitting officer role.

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.

Childhood asthma in the emergency department: trends, challenges, and opportunities

Acute exacerbations of childhood asthma are frequently managed in the emergency department (ED). ED-based surveillance and intervention projects highlight the limitations and challenges of acute and chronic childhood asthma management. Because a significant number of asthmatic children currently receive and will likely continue to seek acute asthma care in the ED, provision of asthma education and initiation of controller medication therapy during the ED visit, although controversial, may contribute to improving asthma outcomes and eventually to reducing the burden of asthma on our overcrowded EDs.

Clinical practice guidelines: medical follow-up of patients with asthma--adults and adolescents

The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks).

Self-reported antibiotic compliance: Emergency department to general practitioner follow up

BACKGROUND

General practitioner (GP) follow up is important in the management of patients who are discharged from an ED.

OBJECTIVES

To determine the antibiotic compliance and GP follow-up compliance rates in a population of patients seen and discharged from the ED with an antibiotic prescription. To test the hypothesis that the ability to nominate a GP is associated with improved antibiotic and GP follow-up compliance.

DESIGN

A prospective cohort study enrolling consecutive adults who were discharged from the ED with antibiotic prescriptions over a 3 month period. Patients were divided into those who nominated a GP at the time of ED presentation and those who did not. Two weeks after enrollment, patients were contacted and asked standardized questions regarding compliance.

RESULTS

In total, 123 patients were enrolled into the study. Of patients 76% were able to nominate a GP upon ED presentation. Analysis revealed that those patients who were able to nominate a GP had better compliance to follow up instructions (85 vs 44%, P < 0.01) and improved antibiotic compliance (99 vs 88%, P = 0.01).

CONCLUSION

The majority of patients who were seen and discharged from the ED with an antibiotic prescription were able to nominate a GP and this was associated with improved follow-up compliance and antibiotic compliance. Improving follow-up compliance and thus the quality of patient care would involve identifying those patients who present to the ED who are unable to nominate a GP.

Asthma economics: focusing on therapies that improve costly outcomes

PURPOSE OF REVIEW

In 1998, the economic burden of asthma was estimated to be 12.7 billion dollars. Subsequent research has focused on identifying important outcomes that reflect high resource utilization and finding therapies that improve these outcomes and decrease cost. Recent developments include an update to the National Heart, Lung, and Blood Institute (NHLBI) guidelines, new treatment strategies using combination therapy, and the development of a monoclonal antibody therapy for asthma.

RECENT FINDINGS

Two important costly outcomes are asthma-related hospitalizations and emergency department visits. Asthma-related hospitalizations started to decline in the 1990s, primarily in white Americans, but not in young African Americans. Many hospitalizations and emergency department visits are preventable, and costs were lowered by shifting management to the ambulatory care setting. Increased asthma severity and suboptimal compliance with NHLBI asthma care guidelines can contribute to the persistence of symptoms, which triggers behaviors that increase resource utilization.A recent economic analysis was one of the first well-controlled clinical trials to show that inhaled corticosteroids provide clinical benefit at modest costs. Combination therapy, particularly that containing an inhaled corticosteroid and long-acting bronchodilator in a single inhaler, potentially can reduce overall costs by improving compliance with inhaled corticosteroids. Nonpharmacologic therapies also have been shown to be cost-effective. However, a significant number of patients with asthma continue to have symptoms even while on recommended controller therapy. Omalizumab, a monoclonal antibody treatment that binds IgE, was released in the summer of 2003.

SUMMARY

Many costly asthma-related hospitalizations and emergency department visits are preventable, and chronic disease care can be shifted to the ambulatory setting. Increased asthma severity and noncompliance with NHLBI guidelines are associated with increased resource utilization. Combination therapies can assist in improving patient compliance, and omalizumab potentially offers a novel but expensive way to decrease symptoms and resource utilization.

Factors associated with emergency department use in asthma: acute care interventions improving chronic disease outcomes

OBJECTIVE

To provide a literature review of the factors associated with childhood asthma-related emergency department (ED) visits and to identify elements of effective ED interventions that reduce the frequency of childhood ED visits while increasing primary health care utilization.

DATA SOURCE

English Medline articles from 1990 that cross-referenced with the terms asthma, emergency, intervention, pediatric, and/or acute care. Experts in the field of allergy and asthma were also consulted.

STUDY SELECTION

Childhood asthma interventions in the ED.

RESULTS

Factors associated with childhood asthma-related ED visits include being impoverished, being exposed to allergens, receiving Medicaid or lacking insurance, being noncompliant with self-management skills, and having an African-American heritage. Other minorities may also be at risk, but further investigation is required to determine the extent. Attempts to link the patient to primary health care by the ED staff resulted in increased adherence to followup care.

CONCLUSIONS

The ED provides an opportunity to help patients and families deal with asthma to improve their quality of life. Further, current studies demonstrate that the ED is an appropriate setting for an intervention that links the patient back to the primary health care provider. More research is needed on the appropriate educational messages to be delivered in ED. Also, barriers to followup care and regular use of a primary health care provider need to be identified so that future intervention designs can address these issues.

Changing approaches to asthma management in Australia: effects on asthma morbidity

Asthma is an important public health issue in Australia and is responsible for significant morbidity and mortality in the community. Recognition of the impact of asthma on the health of Australians, and the apparent failure of new medications to reduce mortality and hospital admission rates resulted in a major review by the stakeholders in asthma care. This led to new approaches to asthma management based on strategic use of asthma medications and the development of the Asthma Management Plan (AMP). The AMP drew together current understanding of asthma to develop a simple stepwise approach to management that could be readily applied in patient management. The National Asthma Campaign (NAC), a coalition of the major stakeholders in asthma care, was launched in 1990 to lead the dissemination of the AMP. In association with other organisations interested in asthma care in Australia, the NAC has developed the AMP, and co-ordinated a decade of education and advocacy about asthma that targeted doctors, health professionals and the general public. These activities have been successful in raising awareness about asthma in the community. However, recent research, while demonstrating the continued uptake of written asthma action plans for asthma and decrease in use of inhaled bronchodilator medications, reported a decrease in use of preventive therapy by people with asthma. These activities have had a sustained impact on asthma-related health outcomes with mortality at the lowest level since 1960 and a decline in hospital readmission rates. This is useful information because there is sound evidence that the prevalence and possibly severity of asthma in children has increased. However, review of management in primary care and among people who present to emergency services with acute asthma suggest that many people continue to manage their asthma poorly. Continued education is needed to build on the progress that has been made. There are opportunities to do this through efforts to integrate general practitioners into the wider health system through the formation of Divisions of General Practice. Recognition of asthma as a health priority area at a national level will help to enhance and maintain awareness of the public health importance of asthma and facilitate the further development of the initiatives begun during the last decade or more.

[Gain, loss and agreement between respiratory specialists and generalists in the diagnosis of asthma]

OBJECTIVE

To determine and analyze the degree of agreement and disagreement in the diagnosis of bronchial asthma (BA) by respiratory disease specialists and generalists in regional hospital and primary care settings.

MATERIAL AND METHODS

Ninety-six outpatients (16 to 70 years of age) were studied; all had been assigned a diagnosis of BA by the referring physician or by the respiratory disease specialist. We recorded 1) clinical symptoms, determining the initial probability of a diagnosis (IPD)of BA to be high, medium or low; 2) results of spirometry and bronchodilator testing (BDT), peak flow variability and methacholine challenge testing; 3) prick test results, eosinophil levels and total serum IgE levels. Three diagnoses were recorded: the initial diagnosis (ID) by the referring physician to whom follow-up data were unavailable; diagnosis by the respiratory disease specialist based only on clinical symptoms (RSS); and the final diagnosis(FD). To arrive at a FD of BA, it was necessary to have a high or medium IPD and a positive BDT. A Kappa test was used to analyze the degree of agreement among the three diagnoses. Group features associated with greater or lesser agreement were analyzed by chi-square tests and analysis of variance.

RESULTS

Agreement was acceptable between RSS and FD (K = 0.63) but very low between ID and RSS and between ID and FD. In the latter two cases, agreement was greatest for patients diagnosed in hospital and for those with high IgE levels (p < 0.05), with high IPD, longer course of disease and a history of asthma (p < 0.01) (odds ratio =59.8). Diagnostic disagreement occurred mainly for patients for whom a BA diagnosis was gained later, the of under-diagnosis being 39%. The patients involved visited the physician only because they had observed an isolated symptom related to asthma (odds ratio = 119) and to arrive at a diagnosis bronchomotor tests other than BDT were required (p < 0.01).

CONCLUSIONS

a) The degree of agreement for a diagnosis of BA is low. b)The functional profile of patients for whom diagnostic agreement exists differs from that of patients for whom diagnosis is gained through testing. c) In the context of this study, a high rate of under-diagnosis is evident.

A childhood asthma severity scale: symptoms, medications, and health care visits

BACKGROUND

Although there are current measures to evaluate childhood asthma severity for clinical diagnosis and treatment, there is no standard valid measure to evaluate childhood asthma severity for large-scale epidemiologic studies.

OBJECTIVES

To develop and test a childhood asthma severity scale (CHAS) for clinimetric validity and to determine differences in symptoms, medication use, and health care visits by participant characteristics.

METHODS

Eight hundred ninety-seven actively asthmatic children under the age of 12 years were selected from a general population of children. Children were selected from a screening questionnaire administered at six Connecticut hospitals that serve large minority populations in Bridgeport, New Haven, Hartford, and Danbury and one hospital serving south central Massachusetts. Twelve-month baseline data for a prospective cohort study of childhood asthma severity were collected on a monthly basis through home interviews. Home interviews addressed questions on daily symptoms, medication use, and health care visits. A severity scale was constructed using three dimensions: symptoms, medication use, and health care visits.

RESULTS

CHAS has sufficient preliminary content, construct, and predictive validity. Despite similarities in symptoms, there were health care utilization and medication differentials according to race and ethnicity, insurance status, family income, and maternal education.

CONCLUSIONS

CHAS is a potentially useful measure of asthma severity for large-scale epidemiologic studies. It seems that CHAS has sufficient clinimetric properties.