Exploring physicians' decision-making in hospital readmission processes - a comparative case study

Occupational stress among Norwegian physicians: A literature review of long-term prospective studies 2007-2019

AIMS

There are signs of increased stress at work among Norwegian physicians over the last decades, not least among general practitioners (GPs). In this review, we identify trends in both occupational stress and adverse work-related predictors of such stress and burnout in Norwegian physicians.

METHODS

We performed an extensive literature search using MEDLINE, Embase and PsycINFO. We included prospective and repeated cross-sectional studies of work stress among Norwegian physicians published in 2007-2019.

RESULTS

Nine studies with observation periods of 1-20 years were included. Occupational stress (global measure) among all doctors decreased gradually from medical school to 20 years later. The prevalence of an effort-reward imbalance increased fourfold among GPs during the period 2010-2019. Five studies reported higher levels of occupational stress among female physicians than among their male colleagues. Work-home conflict levels increased after graduation until 10 years after leaving medical school and plateaued thereafter. Physicians who graduated in a later cohort reported lower levels of work-home conflict and less workplace violence. Work-home conflict, low colleague support, number of work hours and workload/low autonomy were all independent predictors of occupational stress.

CONCLUSIONS

The reduction in occupational stress during the years after leaving medical school may result from increased competency in clinical work and decreased on-call work. The Co-ordination Act implemented in 2012 may explain the increase in occupational stress among GPs. These findings suggest that both reducing work-home conflict and increasing colleague support are important for doctors' well-being.

Primary care gatekeeping during the COVID-19 pandemic: a survey of 1234 Norwegian regular GPs

BACKGROUND

In the Nordic healthcare systems, GPs regulate access to secondary health services as gatekeepers. Limited knowledge exists about the gatekeeper role of GPs during public health crises seen from the perspective of GPs.

AIM

To document GPs' gatekeeper role and organisational changes during the initial COVID-19 lockdown in Norway.

DESIGN & SETTING

A cross-sectional online survey was addressed to all regular Norwegian GPs (n = 4858) during pandemic lockdown in spring 2020.

METHOD

Each GP documented how patients with potential COVID-19 disease were triaged and handled during a full regular workday. The survey also covered workload, organisational changes, and views on advice given by the authorities.

RESULTS

A total of 1234 (25.4%) of Norway's GPs participated. Together, they documented nearly 18 000 consultations, of which 65% were performed digitally (video, text, and telephone). Suspected COVID-19 symptoms were reported in 11% of the consultations. Nearly all these patients were managed in primary care, either in regular GP offices (55.7%) or GP-run municipal respiratory clinics (40.7%), while 3.7% (n = 73) were admitted to hospitals. The GPs proactively contacted an average of 0.8 at-risk patients per day. While 84% were satisfied with the information provided by the medical authorities, only 20% were able to reorganise their practice in accordance with national recommendations.

CONCLUSION

During the early stage of the COVID-19 pandemic in Norway, the vast majority of patients with COVID-19-suspected symptoms were handled in primary care. This is likely to have protected secondary health services from potentially detrimental exposure to contagion and breakdown of capacity limits.

Association between prehospital physician clinical experience and discharge at scene - retrospective cohort study

BACKGROUND

Clinical experience has been shown to affect many patient-related outcomes but its impact in the prehospital setting has been little studied.

OBJECTIVES

To determine whether rates of discharge at scene, handover to paramedics and supervision are associated with clinical experience.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective study, performed on all prehospital interventions carried out by physicians working in a mobile medical unit ("service mobile d'urgence et de réanimationˮ [SMUR]) at Geneva University Hospitals between 1 January 2010 and 31 December 2019. The main exclusion criteria were phone consultations and major incidents with multiple casualties.

EXPOSURE

The exposure was the clinical experience of the prehospital physician at the time of the intervention, in number of years since graduation.

OUTCOME MEASURES AND ANALYSIS

The main outcome was the rate of discharge at scene. Secondary outcomes were the rate of handover to paramedics and the need for senior supervision. Outcomes were tabulated and multilevel logistic regression was performed to take into account the cluster effect of physicians.

RESULTS

In total, 48,368 adult patients were included in the analysis. The interventions were performed by 219 different physicians, most of whom were male (53.9%) and had graduated in Switzerland (82.7%). At the time of intervention, mean (standard deviation [SD]) level of experience was 5.2 (3.3) years and the median was 4.6 (interquartile range [IQR]: 3.4-6.0). The overall discharge at scene rate was 7.8% with no association between clinical experience and discharge at scene rate. Greater experience was associated with a higher rate of handover to paramedics (adjusted odds ratio [aOR]: 1.17, 95% confidence interval [CI]: 1.13-1.21) and less supervision (aOR: 0.85, 95% CI: 0.82-0.88).

CONCLUSION

In this retrospective study, there was no association between level of experience and overall rate of discharge at scene. However, greater clinical experience was associated with higher rates of handover to paramedics and less supervision.

Changes in weekly working hours, proportion of doctors with hours above the limitations of European Working Time Directive (EWTD) and time spent on direct patient care for doctors in Norway from 2016 to 2019: a study based on repeated surveys

OBJECTIVES

To compare the total weekly working hours, proportions with work hours above the limitations of European working time directive (EWTD) and time spent on direct patient care in 2016 and 2019 for doctors working in different job positions in Norway.

DESIGN

Repeated postal surveys in 2016 and 2019.

SETTING

Norway.

PARTICIPANTS

Representative samples of doctors; the response rates were 73.1% (1604/2195) in 2016 and 72.5% (1511/2084) in 2019.

MAIN OUTCOME MEASURES

Self-reported weekly working hours, proportions with hours above the limitations of EWTD defined as >48 hours/week and time spent on direct patient care.

ANALYSES

Linear mixed models with estimated marginal means and proportions.

RESULTS

From 2016 to 2019, the weekly working hours increased significantly for male general practitioners (GPs) (48.7 hours to 50.9 hours) and male hospital doctors in leading positions (48.2 hours to 50.5 hours), and significantly decreased for female specialists in private practice (48.6 hours to 44.9 hours). The proportion of time spent on direct patient care was noted to be similar between genders and over time. In 2019, it was higher for specialists in private practice (66.4%) and GPs (65.5%) than for doctors in other positions, such as senior hospital consultants (43.5%), specialty registrars (39.8%) and hospital doctors in leading positions (34.3%). Working >48 hours/week increased significantly for both male and female GPs (m: 45.2% to 57.7%; f: 27.8% to 47.0%) and hospital doctors in leading positions (m: 34.4% to 57.1%; f: 17.4% to 46.4%), while it significantly decreased for female specialty registrars (13.2% to 6.9%).

CONCLUSIONS

Working hours increased significantly for GPs and hospital doctors in leading positions from 2016 to 2019, resulting in increased proportions of doctors with work hours above the EWTD. As work hours above the EWTD can be harmful for health personnel and for safety at work, initiatives to reduce long working weeks are needed.

Nursing factors associated with length of stay and readmission rate of the elderly residents from nursing home based on LTCfocus database

OBJECTIVES

Nursing factors have been found to be associated with a reduction in readmission rates. Nevertheless, few attentions have been given to the effect of nursing factors on nursing home (NH) residents. This study was to assess the impact of nursing factors on the hospital readmissions and length of stay (LOS) of the elderly residents from the NH.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Data were extracted from the NH of the LTCFocus.org data set between 2011 and 2018. The study included residents aged ≥55 years who were admitted to NH in the United States, following a hospitalization event. The nursing factors included facility-level data elements and medical care personnel. An unsupervised machine learning algorithm (K-means) was used to cluster NH according to readmission rate and LOS. Multivariate logistic regression analysis was performed.

RESULTS

This study consisted of 107,000 NH-year observations. The median readmission rate was 17%, with a median LOS was 28.00 days. Three clusters were identified: cluster 1 was a high readmission rate with high LOS, cluster 2 was a low readmission rate with low LOS, and cluster 3 was a high readmission rate with low LOS. Multifacility and admission/bed were associated with a reduction in readmission rate and LOS in both cluster 1 vs cluster 2 and cluster 3 vs cluster 2. The special care unit and registered nurses' ratio were associated with decreased readmission rate and LOS in cluster 1 vs cluster 2. Total beds and Alzheimer unit decreased the readmission rate and LOS, whereas certified nursing assistant increased the readmission rate and LOS in cluster 3 vs cluster 2. NH for profit was associated with elevated readmission rate and LOS in cluster 1 vs cluster 2 and decreased readmission rate and LOS in cluster 3 vs cluster 2. Based on the subgroup analysis, the certified nursing assistant decreased readmission rate and LOS in cluster 1 vs cluster 2 and increased readmission rate and LOS in cluster 3 vs cluster 2 (all P < 0.005).

CONCLUSION

This study indicates the importance of the improvement of nurse number and level and the inputs of facility characteristics in NH.

Hospital physicians' experiences and reflections on their work and role in relation to older patients' pathways - a qualitative study in two Norwegian hospitals

Background

Older patients are the most frequent users of initial hospital admissions and readmissions. Both hospital admission and discharge require communication and coordination between healthcare professionals within the hospital, and between professionals in hospitals and primary healthcare. We have identified few studies exploring hospital physicians’ perspectives on older patients’ pathways in the interface between hospital and primary healthcare services. The aim of this study was to explore hospital physicians’ experiences and reflections on their work and role in relation to older patients’ pathways between hospital and primary healthcare. Specifically, we focused on the challenges they faced and how they dealt with these in relation to admission and discharge, and their suggestions for service improvements that could facilitate older patients’ pathway.

Methods

We used a qualitative approach, conducting individual in-depth interviews with 18 hospital physicians from two hospitals in eastern Norway. Data were analyzed using systematic text condensation, in line with a four-step prosedure developed by Malterud.

Results

The participants emphasized challenges in the communication about patients across the two service levels. Moreover, they described being in a squeeze between prioritizing patients and trying to ensure a proper flow of patients through the hospital wards, but with restricted possibilities to influence on the admissions. They also described a frustration regarding the lack of influence on the healthcare delivery after discharge. The participants had various suggestions for service improvements which might be beneficial to older patients.

Conclusions

The results demonstrate that the hospital physicians perceived being squeezed between professional autonomy and limited capacity at the hospital, and between their medical judgement as a specialist and their power to decide on hospital admissions for old patients and also on the delivery of health care services to patients after discharge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07846-1.

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

BACKGROUND

Transitions of care are often risky, particularly for older people, and shorter hospital stays mean that patients can go home with ongoing care needs. Most previous research has focused on fundamental system flaws, however, care generally goes right far more often than it goes wrong. We explored staff perceptions of how high performing general practice and hospital specialty teams deliver safe transitional care to older people as they transition from hospital to home.

METHODS

We conducted a qualitative study in six general practices and four hospital specialties that demonstrated exceptionally low or reducing readmission rates over time. Data were also collected across four community teams that worked into or with these high-performing teams. In total, 157 multidisciplinary staff participated in semi-structured focus groups or interviews and 9 meetings relating to discharge were observed. A pen portrait approach was used to explore how teams across a variety of different contexts support successful transitions and overcome challenges faced in their daily roles.

RESULTS

Across healthcare contexts, staff perceived three key themes to facilitate safe transitions of care: knowing the patient, knowing each other, and bridging gaps in the system. Transitions appeared to be safest when all three themes were in place. However, staff faced various challenges in doing these three things particularly when crossing boundaries between settings. Due to pressures and constraints, staff generally felt they were only able to attempt to overcome these challenges when delivering care to patients with particularly complex transitional care needs.

CONCLUSIONS

It is hypothesised that exceptionally safe transitions of care may be delivered to patients who have particularly complex health and/or social care needs. In these situations, staff attempt to know the patient, they exploit existing relationships across care settings, and act to bridge gaps in the system. Systematically reinforcing such enablers may improve the delivery of safe transitional care to a wider range of patients.

TRIAL REGISTRATION

The study was registered on the UK Clinical Research Network Study Portfolio (references 35272 and 36174 ).

Predicting Patients' Readmission: Do Clinicians Outperform a Statistical Model? An Exploratory Study on Clinical Risk Judgment in Mental Health

This study explores whether clinicians or a statistical model can better identify patients at risk of early readmission and investigates variables potentially associated with clinicians' risk judgment. We focus on a total of 142 patients discharged from acute psychiatric wards in the Verona Mental Health Department (Italy). Psychiatrists assessed patients' risk of readmission at 30 and 90 days postdischarge, predicted their postdischarge compliance, and assessed their Global Assessment of Functioning (GAF) score at admission and discharge. Clinicians' judgment outperformed the statistical model, with the difference reaching statistical significance for 30-day readmission. Clinicians' readmission risk judgment, both for 30 and 90 days, was found to be statistically associated with predicted compliance with community treatment and GAF score at discharge. Clinicians' superior performance might be explained by their risk judgment depending on nonmeasurable factors, such as experience and intuition. Patients with a poorer GAF score at discharge and poor assumed compliance were predicted to have a higher risk of readmission.

Patient and caregiver priorities in the transition from hospital to home: results from province-wide group concept mapping

BACKGROUND

Patients and caregivers often face significant challenges when they are discharged home from hospital. We sought to understand what influenced patient and caregiver experience in the transition from hospital to home and which of these aspects they prioritised for health system improvement.

METHODS

We conducted group concept mapping over 11 months with patients-and their caregivers-who were admitted to a hospital overnight in the last 3 years in Ontario, Canada and discharged home. Home included supportive housing, shelters and long-term care. Participants responded to a single focal prompt about what affected their experience during the transition. We summarised responses in unique statements. We then recruited participants to rate each statement on a five-point scale on whether addressing this gap should be a priority for the health system. The provincial quality agency recruited participants in partnership with patient, community and healthcare organisations. Participation was online, in-person or virtual.

RESULTS

736 participants provided 2704 responses to the focal prompt. Unique concepts were summarised in 52 statements that were then rated by 271 participants. Participants rated the following three statements most highly as a gap that should be a priority for the health system to address (in rank order): 'Not enough publicly funded home care services to meet the need', 'Home care support is not in place when arriving home from hospital' and 'Having to advocate to get enough home care'. The top priority was consistent across multiple subgroups.

CONCLUSIONS

In a country with universal health insurance, patients and caregivers from diverse backgrounds consistently prioritised insufficient public coverage for home care services as a gap the health system should address to improve the transition from hospital to home.

Avoidable 30-day readmissions in patients undergoing vascular surgery

BACKGROUND

Vascular surgery has one of the highest unplanned 30-day readmission rates of all surgical specialties. The degree to which these may be avoidable and the optimal strategies to reduce their occurrence are unknown. The aim of this study was to identify and classify avoidable 30-day readmissions in patients undergoing vascular surgery in order to plan targeted interventions to reduce their occurrence, improve outcomes and reduce cost.

METHODS

A retrospective analysis of discharges over a 12-month period from a single tertiary vascular unit was performed. A multidisciplinary panel conducted a manual case-note review to identify and classify those 30-day unplanned emergency readmissions deemed avoidable.

RESULTS

An unplanned 30-day readmission occurred in 72 of 885 admissions (8·1 per cent). These unplanned readmissions were deemed avoidable in 36 (50 per cent) of these 72 patients, and were most frequently due to unresolved medical issues (19 of 36, 53 per cent) and inappropriate admission with the potential for outpatient management (7 of 36, 19 per cent). A smaller number were due to inadequate social care provision (4 of 36, 11 per cent) and the occurrence of other avoidable adverse events (4 of 36, 11 per cent).

CONCLUSION

Half of all 30-day readmissions following vascular surgery are potentially avoidable. Multidisciplinary coordination of inpatient care and the transition from hospital to community care after discharge need to be improved.

Life satisfaction in Norwegian medical doctors: a 15-year longitudinal study of work-related predictors

BACKGROUND

Despite many recent studies on burn-out and dissatisfaction among American medical doctors, less is known about doctors in the Scandinavian public health service. The aims of this study were to analyse long-term work-related predictors of life satisfaction among established doctors in Norway and to identify predictors in a subgroup of doctors who reported a decline in life satisfaction.

METHODS

Two nationwide cohorts of doctors (n = 1052), who graduated medical school 6 years apart, were surveyed at graduation from medical school (T1, 1993/94 and 1999), and 4 (T2), 10 (T3), and 15 (T4) years later. Work-related predictors of life satisfaction (three items) obtained at T2 to T4 were analysed. Individual and lifestyle confounders were controlled for using mixed-models repeated-measures analyses, and logistic regression analyses were applied to identify predictors of the decrease in life satisfaction.

RESULTS

Ninety per cent (947/1052) responded at least once, and 42% (450/1052) responded at all four times. Work-related predictors of higher life satisfaction in the adjusted model were work-home stress (β = - 0.20, 95% confidence interval [CI] = - 0.25 to - 0.16, p < 0.001), perceived job demands (β = - 0.10, CI = - 0.15 to - 0.05, p < 0.001), and colleague support (β = 0.05, CI = 0.04 to 0.07, p < 0.001). The new adjusted individual predictors that we identified included female gender, reality weakness trait, and problematic drinking behaviour. Neuroticism trait and low colleague support predicted a decrease in life satisfaction.

CONCLUSIONS

Work-home stress, perceived job demands, and colleague support were the most important predictors of life satisfaction related to doctors' work. When personality traits were controlled for, female doctors were more satisfied with their life than male doctors. These findings suggest that improving work-related factors with targeted interventions, including a supportive work environment, may increase life satisfaction among doctors.

Hospital physicians' views on discharge and readmission processes: a qualitative study from Norway

OBJECTIVES

To explore hospital physicians' views on readmission and discharge processes in the interface between hospitals and municipalities.

DESIGN

Qualitative case study.

SETTING

The Norwegian healthcare system.

PARTICIPANTS

Fifteen hospital physicians (residents and consultants) from one hospital, involved in the treatment and discharge of patients.

RESULTS

The results of this study showed that patients were being discharged earlier, with more complex medical conditions, than they had been previously, and that discharges sometimes were perceived as premature. Insufficient capacity at the hospital resulted in pressure to discharge patients, but the primary healthcare service of the area was not always able to assume care of these patients. Communication between levels of the healthcare service was limited. The hospital stay summary was the most important, and sometimes only, form of communication between levels. The discharge process was described as complicated and was affected by healthcare personnel, by patients themselves and by aspects of the primary healthcare service. Early hospital discharges, poor communication between healthcare services and inadequacies in the discharge process were perceived to affect hospital readmissions.

CONCLUSION

The results of this study provide a better understanding of hospital physicians' views on the discharge and hospital readmission processes in the interface between the hospital and the primary healthcare service. The study also identifies discrepancies in governmental requirements, reform regulations and current practices in municipalities and hospitals.

Nursing home leaders' and nurses' experiences of resources, staffing and competence levels and the relation to hospital readmissions - a case study

Background

Thirty-day hospital readmissions represent an international challenge leading to increased prevalence of adverse events, reduced quality of care and pressure on healthcare service’s resources and finances. There is a need for a broader understanding of hospital readmissions, how they manifest, and how resources in the primary healthcare service may affect hospital readmissions. The aim of the study was to examine how nurses and nursing home leaders experienced the resource situation, staffing and competence level in municipal healthcare services, and if and how they experienced these factors to influence hospital readmissions.

Method

The study was conducted as a comparative case study of two municipalities affiliated with the same hospital, chosen for historical differences in readmission rates. Nurses and leaders from four nursing homes participated in focus groups and interviews. Data were analyzed within and across cases.

Results

The analysis resulted in four common themes, with some variation in each municipality, describing nurses’ and leaders’ experience of the nursing home resource situation, staffing level and competence and their perception of factors affecting hospital readmissions. The nursing home patients were described as becoming increasingly complex with a subsequent need for increased nurse competence. There was variation in competence and staffing between nursing homes, but capacity building was an overall focus. Economic limitations and attempts at saving through cost-cutting were present, but not perceived as affecting patient care and the availability of medical equipment. Several factors such as nurse competence and staffing, physician coverage, and adequate communication and documentation, were recognized as factors affecting hospital readmissions across the municipalities.

Conclusion

Several factors related to nurses’ and leaders’ experience of the resource situation, staffing and competence level were suggested to affect hospital readmissions and the municipalities were similar in their answers regarding these factors. Patients were perceived as more complex with higher patient mortality forcing long-term nursing homes to shift towards an acute care or palliative function, and short-term nursing homes to function as “small hospitals”, requiring higher nurse competence. Staffing, competence and physician coverage did not seem to have adjusted to the new patient group in some nursing homes.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3769-3) contains supplementary material, which is available to authorized users.