1
|
Palakshappa JA, Hale ER, Brown JD, Kittel CA, Dressler E, Rosenthal GE, Cutrona SL, Foley KL, Haines ER, Houston Ii TK. Longitudinal Monitoring of Clinician-Patient Video Visits During the Peak of the COVID-19 Pandemic: Adoption and Sustained Challenges in an Integrated Health Care Delivery System. J Med Internet Res 2024; 26:e54008. [PMID: 38587889 PMCID: PMC11036186 DOI: 10.2196/54008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/24/2024] [Accepted: 03/09/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Numerous prior opinion papers, administrative electronic health record data studies, and cross-sectional surveys of telehealth during the pandemic have been published, but none have combined assessments of video visit success monitoring with longitudinal assessments of perceived challenges to the rapid adoption of video visits during the pandemic. OBJECTIVE This study aims to quantify (1) the use of video visits (compared with in-person and telephone visits) over time during the pandemic, (2) video visit successful connection rates, and (3) changes in perceived video visit challenges. METHODS A web-based survey was developed for the dual purpose of monitoring and improving video visit implementation in our health care system during the COVID-19 pandemic. The survey included questions regarding rates of in-person, telephone, and video visits for clinician-patient encounters; the rate of successful connection for video visits; and perceived challenges to video visits (eg, software, hardware, bandwidth, and technology literacy). The survey was distributed via email to physicians, advanced practice professionals, and clinicians in May 2020. The survey was repeated in March 2021. Differences between the 2020 and 2021 responses were adjusted for within-respondent correlation across surveys and tested using generalized estimating equations. RESULTS A total of 1126 surveys were completed (511 surveys in 2020 and 615 surveys in 2021). In 2020, only 21.7% (73/336) of clinicians reported no difficulty connecting with patients during video visits and 28.6% (93/325) of clinicians reported no difficulty in 2021. The distribution of the percentage of successfully connected video visits ("Over the past two weeks of scheduled visits, what percentage did you successfully connect with patients by video?") was not significantly different between 2020 and 2021 (P=.74). Challenges in conducting video visits persisted over time. Poor connectivity was the most common challenge reported by clinicians. This response increased over time, with 30.5% (156/511) selecting it as a challenge in 2020 and 37.1% (228/615) in 2021 (P=.01). Patients not having access to their electronic health record portals was also a commonly reported challenge (109/511, 21.3% in 2020 and 137/615, 22.3% in 2021, P=.73). CONCLUSIONS During the pandemic, our health care delivery system rapidly adopted synchronous patient-clinician communication using video visits. As experience with video visits increased, the reported failure rate did not significantly decline, and clinicians continued to report challenges related to general network connectivity and patient access to technology.
Collapse
Affiliation(s)
- Jessica A Palakshappa
- Atrium Health Wake Forest Baptist, Winston Salem, NC, United States
- Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Erica R Hale
- Atrium Health Wake Forest Baptist, Winston Salem, NC, United States
- Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Joshua D Brown
- Atrium Health Wake Forest Baptist, Winston Salem, NC, United States
| | - Carol A Kittel
- Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Emily Dressler
- Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Gary E Rosenthal
- Atrium Health Wake Forest Baptist, Winston Salem, NC, United States
- Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Sarah L Cutrona
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States
| | - Kristie L Foley
- Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Emily R Haines
- Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Thomas K Houston Ii
- Atrium Health Wake Forest Baptist, Winston Salem, NC, United States
- Wake Forest University School of Medicine, Winston Salem, NC, United States
| |
Collapse
|
2
|
Rosenthal GE, McClain DA, High KP, Easterling D, Sharkey A, Wagenknecht LE, O’Byrne C, Woodside R, Houston TK. The Academic Learning Health System: A Framework for Integrating the Multiple Missions of Academic Medical Centers. Acad Med 2023; 98:1002-1007. [PMID: 37099650 PMCID: PMC10453356 DOI: 10.1097/acm.0000000000005259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
The learning health system (LHS) has emerged over the past 15 years as a concept for improving health care delivery. Core aspects of the LHS concept include: promoting improved patient care through organizational learning, innovation, and continuous quality improvement; identifying, critically assessing, and translating knowledge and evidence into improved practices; building new knowledge and evidence around how to improve health care and health outcomes; analyzing clinical data to support learning, knowledge generation, and improved patient care; and engaging clinicians, patients, and other stakeholders in processes of learning, knowledge generation, and translation. However, the literature has paid less attention to how these LHS aspects may integrate with the multiple missions of academic medical centers (AMCs). The authors define an academic learning health system (aLHS) as an LHS built around a robust academic community and central academic mission, and they propose 6 features that emphasize how an aLHS differs from an LHS. An aLHS capitalizes on embedded academic expertise in health system sciences; engages the full spectrum of translational investigation from mechanistic basic sciences to population health; builds pipelines of experts in LHS sciences and clinicians with fluency in practicing in an LHS; applies core LHS principles to the development of curricula and clinical rotations for medical students, housestaff, and other learners; disseminates knowledge more broadly to advance the evidence for clinical practice and health systems science methods; and addresses social determinants of health, creating community partnerships to mitigate disparities and improve health equity. As AMCs evolve, the authors expect that additional differentiating features and ways to operationalize the aLHS will be identified and hope this article stimulates further discussion around the intersection of the LHS concept and AMCs.
Collapse
Affiliation(s)
- Gary E. Rosenthal
- G.E. Rosenthal is professor and chair, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Donald A. McClain
- D.A. McClain is professor, Department of Internal Medicine, Section on Endocrinology and Metabolism, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kevin P. High
- K.P. High is professor, Department of Internal Medicine, and president, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Douglas Easterling
- D. Easterling is professor, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Angela Sharkey
- A. Sharkey is professor, Department of Pediatrics, and senior associate dean for undergraduate medical education, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lynne E. Wagenknecht
- L.E. Wagenknecht is professor and chair, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Christopher O’Byrne
- C. O’Byrne is vice president and associate dean, Research Administration and Operations, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Rachel Woodside
- R. Woodside is director, Research Strategy and Operations, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Thomas K. Houston
- T.K. Houston is professor and vice chair for learning health systems, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
3
|
Casacchia NJ, Rosenthal GE, O'Connell NS, Bundy R, Witek L, Wells BJ, Palakshappa D. Characteristics of Adult Primary Care Patients Who Use the Patient Portal: A Cross-Sectional Analysis. Appl Clin Inform 2022; 13:1053-1062. [PMID: 36167336 PMCID: PMC9629981 DOI: 10.1055/a-1951-3153] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/23/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The patient portal allows patients to engage with their health care team beyond the clinical encounter. While portals can improve patient outcomes, there may be disparities in which patients access the portal by sociodemographic factors. Understanding the characteristics of patients who use the portal could help design future interventions to expand portal adoption. OBJECTIVES This study aimed to (1) examine the socioeconomic factors, comorbid conditions, and health care utilization among patients of a large academic primary care network who are users and non-users of the patient portal; and (2) describe the portal functions most frequently utilized. METHODS We included all adult patients at Atrium Health Wake Forest Baptist who had at least two primary care visits between 2018 and 2019. Patients' demographics, comorbidities, health care utilization, and portal function usage were extracted from the electronic health record and merged with census data (income, education, and unemployment) from the American Community Survey. A myWakeHealth portal user was defined as a patient who used a bidirectional portal function at least once during the study period. We used multivariable logistic regression to determine which patient characteristics were independently associated with being a portal user. RESULTS Of the 178,720 patients who met inclusion criteria, 32% (N = 57,122) were users of myWakeHealth. Compared to non-users, users were more likely to be 18 to 64 years of age, female, non-Hispanic White, married, commercially insured, have higher disease burden, and have lower health care utilization. Patients residing in areas with the highest educational attainment had 51% higher odds of being a portal user than the lowest (p <0.001). Among portal users, the most commonly used function was messaging clinic providers. CONCLUSION We found that patient demographics and area socioeconomic factors were associated with patient portal adoption. These findings suggest that efforts to improve portal adoption should be targeted at vulnerable patients.
Collapse
Affiliation(s)
- Nicholas J. Casacchia
- Wake Forest Clinical and Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Gary E. Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Richa Bundy
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Lauren Witek
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Brian J. Wells
- Wake Forest Clinical and Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Deepak Palakshappa
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| |
Collapse
|
4
|
Palakshappa D, Ip EH, Berkowitz SA, Bertoni AG, Foley KL, Miller DP, Vitolins MZ, Rosenthal GE. Pathways by Which Food Insecurity Is Associated With Atherosclerotic Cardiovascular Disease Risk. J Am Heart Assoc 2021; 10:e021901. [PMID: 34743567 PMCID: PMC8751929 DOI: 10.1161/jaha.121.021901] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022]
Abstract
Background Food insecurity (FI) has been associated with an increased atherosclerotic cardiovascular disease (ASCVD) risk; however, the pathways by which FI leads to worse cardiovascular health are unknown. We tested the hypothesis that FI is associated with ASCVD risk through nutritional/anthropometric (eg, worse diet quality and increased weight), psychological/mental health (eg, increased depressive symptoms and risk of substance abuse), and access to care pathways. Methods and Results We conducted a cross-sectional study of adults (aged 40-79 years) using the 2007 to 2016 National Health and Nutrition Examination Survey. Our primary exposure was household FI, and our outcome was 10-year ASCVD risk categorized as low (<5%), borderline (≥5% -<7.5%), intermediate (≥7.5%-<20%), and high risk (≥20%). We used structural equation modeling to evaluate the pathways and multiple mediation analysis to determine direct and indirect effects. Of the 12 429 participants, 2231 (18.0%) reported living in a food-insecure household; 5326 (42.9%) had a low ASCVD risk score, 1402 (11.3%) borderline, 3606 (29.0%) intermediate, and 2095 (16.9%) had a high-risk score. In structural models, we found significant path coefficients between FI and the nutrition/anthropometric (β, 0.130; SE, 0.027; P<0.001), psychological/mental health (β, 0.612; SE, 0.043; P<0.001), and access to care (β, 0.110; SE, 0.036; P=0.002) pathways. We did not find a significant direct effect of FI on ASCVD risk, and the nutrition, psychological, and access to care pathways accounted for 31.6%, 43.9%, and 15.8% of the association, respectively. Conclusions We found that the association between FI and ASCVD risk category was mediated through the nutrition/anthropometric, psychological/mental health, and access to care pathways. Interventions that address all 3 pathways may be needed to mitigate the negative impact of FI on cardiovascular disease.
Collapse
Affiliation(s)
- Deepak Palakshappa
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNC
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
- Department of PediatricsWake Forest School of MedicineWinston‐SalemNC
| | - Edward H. Ip
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - Seth A. Berkowitz
- Division of General Medicine and Clinical EpidemiologyDepartment of MedicineUniversity of North Carolina at Chapel Hill School of MedicineChapel HillNC
- Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillNC
| | - Alain G. Bertoni
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNC
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - Kristie L. Foley
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - David P. Miller
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNC
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - Mara Z. Vitolins
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - Gary E. Rosenthal
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNC
| |
Collapse
|
5
|
Sunkara PR, Lippert WC, Rosenthal GE, Hiestand BC, Blalock J, Huang CC. Implementing a Second-Level Observation Unit at a Large Academic Medical Center. South Med J 2021; 114:322-325. [PMID: 33942120 DOI: 10.14423/smj.0000000000001241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Supplemental digital content is available in the text.
Collapse
Affiliation(s)
- Padageshwar R Sunkara
- From the Departments of Internal Medicine and Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - William C Lippert
- From the Departments of Internal Medicine and Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Gary E Rosenthal
- From the Departments of Internal Medicine and Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brian C Hiestand
- From the Departments of Internal Medicine and Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John Blalock
- From the Departments of Internal Medicine and Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Chi C Huang
- From the Departments of Internal Medicine and Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
6
|
Estiri H, Klann JG, Weiler SR, Alema-Mensah E, Joseph Applegate R, Lozinski G, Patibandla N, Wei K, Adams WG, Natter MD, Ofili EO, Ostasiewski B, Quarshie A, Rosenthal GE, Bernstam EV, Mandl KD, Murphy SN. A federated EHR network data completeness tracking system. J Am Med Inform Assoc 2020; 26:637-645. [PMID: 30925587 PMCID: PMC6586954 DOI: 10.1093/jamia/ocz014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/04/2019] [Accepted: 01/17/2019] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE The study sought to design, pilot, and evaluate a federated data completeness tracking system (CTX) for assessing completeness in research data extracted from electronic health record data across the Accessible Research Commons for Health (ARCH) Clinical Data Research Network. MATERIALS AND METHODS The CTX applies a systems-based approach to design workflow and technology for assessing completeness across distributed electronic health record data repositories participating in a queryable, federated network. The CTX invokes 2 positive feedback loops that utilize open source tools (DQe-c and Vue) to integrate technology and human actors in a system geared for increasing capacity and taking action. A pilot implementation of the system involved 6 ARCH partner sites between January 2017 and May 2018. RESULTS The ARCH CTX has enabled the network to monitor and, if needed, adjust its data management processes to maintain complete datasets for secondary use. The system allows the network and its partner sites to profile data completeness both at the network and partner site levels. Interactive visualizations presenting the current state of completeness in the context of the entire network as well as changes in completeness across time were valued among the CTX user base. DISCUSSION Distributed clinical data networks are complex systems. Top-down approaches that solely rely on technology to report data completeness may be necessary but not sufficient for improving completeness (and quality) of data in large-scale clinical data networks. Improving and maintaining complete (high-quality) data in such complex environments entails sociotechnical systems that exploit technology and empower human actors to engage in the process of high-quality data curating. CONCLUSIONS The CTX has increased the network's capacity to rapidly identify data completeness issues and empowered ARCH partner sites to get involved in improving the completeness of respective data in their repositories.
Collapse
Affiliation(s)
- Hossein Estiri
- Laboratory of Computer Science, Massachusetts General Hospital, Boston, Massachusetts, USA.,Research Information Science and Computing, Partners HealthCare, Charlestown, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey G Klann
- Laboratory of Computer Science, Massachusetts General Hospital, Boston, Massachusetts, USA.,Research Information Science and Computing, Partners HealthCare, Charlestown, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - R Joseph Applegate
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Galina Lozinski
- Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - Nandan Patibandla
- Information Services Department, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kun Wei
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - William G Adams
- Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - Marc D Natter
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Program in Pediatric Rheumatology, Department of Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA
| | | | | | | | - Gary E Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Elmer V Bernstam
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA.,Division of General Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kenneth D Mandl
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Shawn N Murphy
- Laboratory of Computer Science, Massachusetts General Hospital, Boston, Massachusetts, USA.,Research Information Science and Computing, Partners HealthCare, Charlestown, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Dharod A, Bundy R, Russell GB, Rice WY, Golightly CE, Rosenthal GE, Freedman BI. Primary care referrals to nephrology in patients with advanced kidney disease. Am J Manag Care 2020; 26:468-474. [PMID: 33196280 DOI: 10.37765/ajmc.2020.88526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Optimizing care for patients with advanced kidney disease requires close collaboration between primary care physicians (PCPs) and nephrologists. Factors associated with PCP referral to nephrology were assessed in patients with estimated glomerular filtration rates (eGFRs) less than 30 mL/min/1.73 m2. STUDY DESIGN Electronic health record review at an integrated health care network. METHODS Factors associated with referral status were identified using Fisher's exact tests, t tests, and multivariable logistic regression. RESULTS Of 133,913 patients regularly seeing PCPs between October 2017 and September 2019, 1119 had a final eGFR less than 30 mL/min/1.73 m2 and were not on renal replacement therapy. Care was provided by 185 PCPs (61 practices). Analyses were restricted to the 97.1% (n = 1087) of patients who were African American or European American. Of these, 54.6% had not been referred to nephrology. Nonreferred patients had higher numbers of PCP visits (P = .004). In contrast, referred patients were younger, were more often African American, and had PCPs at the academic medical center (all P < .0001). Referred patients had more complex medical histories with higher Charlson Comorbidity Index scores, more hospitalizations, and greater numbers of inpatient days (all P < .0001). Analyses restricted to patients with serum creatinine concentration of at least 2 mg/dL yielded similar results. Age, number of hospitalizations, ancestry, academic physician, diabetic end-organ damage, peripheral vascular disease, and tumor status were independent predictors of nephrology referral. CONCLUSIONS Impediments to appropriately timed nephrology referrals persist in patients with high likelihoods of progression to end-stage kidney disease. Improved access to nephrology care should be rapidly addressed to meet targets in the 2019 Executive Order on Advancing American Kidney Health.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Barry I Freedman
- Section on Nephrology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1053.
| |
Collapse
|
8
|
Palakshappa D, Benefield AJ, Furgurson KF, Harley MG, Bundy R, Moses A, Taxter AJ, Bensinger AS, Cao X, Denizard-Thompson N, Rosenthal GE, Miller DP. Feasibility of Mobile Technology to Identify and Address Patients' Unmet Social Needs in a Primary Care Clinic. Popul Health Manag 2020; 24:385-392. [PMID: 32924796 DOI: 10.1089/pop.2020.0059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Mobile health tools may overcome barriers to social needs screening; however, there are limited data on the feasibility of using these tools in clinical settings. The objective was to determine the feasibility of using a mobile health system to screen for patients' social needs. In one large primary care clinic, the authors tested a tablet-based system that screens patients for social needs, transmits results to the electronic health record, and alerts providers. All adult patients presenting for a nonurgent visit were eligible. The authors evaluated the feasibility of the system and conducted follow-up surveys to determine acceptability and if patients accessed resources through the process. All providers were surveyed. Of the 252 patients approached, 219 (86.9%) completed the screen. Forty-three (19.6%) required assistance with the tablet, and 150 (68.5%) screened positive for at least 1 unmet need (food, housing, or transportation). Of the 150, 103 (68.7%) completed a follow-up survey. The majority agreed that people would learn to use the tablet quickly. Forty-eight patients (46.6%) reported contacting at least 1 community organization through the process. Of the 27 providers, 23 (85.2%) completed a survey and >70% agreed the system would result in patients having better access to resources. It was feasible to use a tablet-based system to screen for social needs. Clinics considering using mobile tools will need to determine how to screen patients who may need assistance with the tool and how to connect patients to resources through the system based on the burden of unmet needs.
Collapse
Affiliation(s)
- Deepak Palakshappa
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Andrew J Benefield
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Katherine F Furgurson
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael G Harley
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Richa Bundy
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Adam Moses
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alysha J Taxter
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Andrew S Bensinger
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Xiangkun Cao
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nancy Denizard-Thompson
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gary E Rosenthal
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David P Miller
- Department of Internal Medicine and Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
9
|
Barak-Corren Y, Castro VM, Nock MK, Mandl KD, Madsen EM, Seiger A, Adams WG, Applegate RJ, Bernstam EV, Klann JG, McCarthy EP, Murphy SN, Natter M, Ostasiewski B, Patibandla N, Rosenthal GE, Silva GS, Wei K, Weber GM, Weiler SR, Reis BY, Smoller JW. Validation of an Electronic Health Record-Based Suicide Risk Prediction Modeling Approach Across Multiple Health Care Systems. JAMA Netw Open 2020; 3:e201262. [PMID: 32211868 DOI: 10.1001/jamanetworkopen.2020.1262] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Importance Suicide is a leading cause of mortality, with suicide-related deaths increasing in recent years. Automated methods for individualized risk prediction have great potential to address this growing public health threat. To facilitate their adoption, they must first be validated across diverse health care settings. Objective To evaluate the generalizability and cross-site performance of a risk prediction method using readily available structured data from electronic health records in predicting incident suicide attempts across multiple, independent, US health care systems. Design, Setting, and Participants For this prognostic study, data were extracted from longitudinal electronic health record data comprising International Classification of Diseases, Ninth Revision diagnoses, laboratory test results, procedures codes, and medications for more than 3.7 million patients from 5 independent health care systems participating in the Accessible Research Commons for Health network. Across sites, 6 to 17 years' worth of data were available, up to 2018. Outcomes were defined by International Classification of Diseases, Ninth Revision codes reflecting incident suicide attempts (with positive predictive value >0.70 according to expert clinician medical record review). Models were trained using naive Bayes classifiers in each of the 5 systems. Models were cross-validated in independent data sets at each site, and performance metrics were calculated. Data analysis was performed from November 2017 to August 2019. Main Outcomes and Measures The primary outcome was suicide attempt as defined by a previously validated case definition using International Classification of Diseases, Ninth Revision codes. The accuracy and timeliness of the prediction were measured at each site. Results Across the 5 health care systems, of the 3 714 105 patients (2 130 454 female [57.2%]) included in the analysis, 39 162 cases (1.1%) were identified. Predictive features varied by site but, as expected, the most common predictors reflected mental health conditions (eg, borderline personality disorder, with odds ratios of 8.1-12.9, and bipolar disorder, with odds ratios of 0.9-9.1) and substance use disorders (eg, drug withdrawal syndrome, with odds ratios of 7.0-12.9). Despite variation in geographical location, demographic characteristics, and population health characteristics, model performance was similar across sites, with areas under the curve ranging from 0.71 (95% CI, 0.70-0.72) to 0.76 (95% CI, 0.75-0.77). Across sites, at a specificity of 90%, the models detected a mean of 38% of cases a mean of 2.1 years in advance. Conclusions and Relevance Across 5 diverse health care systems, a computationally efficient approach leveraging the full spectrum of structured electronic health record data was able to detect the risk of suicidal behavior in unselected patients. This approach could facilitate the development of clinical decision support tools that inform risk reduction interventions.
Collapse
Affiliation(s)
- Yuval Barak-Corren
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - Victor M Castro
- Partners Research Information Science and Computing, Boston, Massachusetts
| | - Matthew K Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | - Kenneth D Mandl
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Emily M Madsen
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashley Seiger
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - William G Adams
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - R Joseph Applegate
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston
| | - Elmer V Bernstam
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston
- McGovern Medical School, Division of General Internal Medicine, The University of Texas Health Science Center at Houston, Houston
| | - Jeffrey G Klann
- Partners Research Information Science and Computing, Boston, Massachusetts
| | - Ellen P McCarthy
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shawn N Murphy
- Partners Research Information Science and Computing, Boston, Massachusetts
| | - Marc Natter
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - Brian Ostasiewski
- Clinical and TranslationalScience Institute, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nandan Patibandla
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - Gary E Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - George S Silva
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kun Wei
- Clinical and TranslationalScience Institute, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Griffin M Weber
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sarah R Weiler
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Ben Y Reis
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - Jordan W Smoller
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
10
|
Lin KJ, Rosenthal GE, Murphy SN, Mandl KD, Jin Y, Glynn RJ, Schneeweiss S. External Validation of an Algorithm to Identify Patients with High Data-Completeness in Electronic Health Records for Comparative Effectiveness Research. Clin Epidemiol 2020; 12:133-141. [PMID: 32099479 PMCID: PMC7007793 DOI: 10.2147/clep.s232540] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/06/2019] [Indexed: 11/25/2022] Open
Abstract
Objective Electronic health records (EHR) data-discontinuity, i.e. receiving care outside of a particular EHR system, may cause misclassification of study variables. We aimed to validate an algorithm to identify patients with high EHR data-continuity to reduce such bias. Materials and Methods We analyzed data from two EHR systems linked with Medicare claims data from 2007 through 2014, one in Massachusetts (MA, n=80,588) and the other in North Carolina (NC, n=33,207). We quantified EHR data-continuity by Mean Proportion of Encounters Captured (MPEC) by the EHR system when compared to complete recording in claims data. The prediction model for MPEC was developed in MA and validated in NC. Stratified by predicted EHR data-continuity, we quantified misclassification of 40 key variables by Mean Standardized Differences (MSD) between the proportions of these variables based on EHR alone vs the linked claims-EHR data. Results The mean MPEC was 27% in the MA and 26% in the NC system. The predicted and observed EHR data-continuity was highly correlated (Spearman correlation=0.78 and 0.73, respectively). The misclassification (MSD) of 40 variables in patients of the predicted EHR data-continuity cohort was significantly smaller (44%, 95% CI: 40–48%) than that in the remaining population. Discussion The comorbidity profiles were similar in patients with high vs low EHR data-continuity. Therefore, restricting an analysis to patients with high EHR data-continuity may reduce information bias while preserving the representativeness of the study cohort. Conclusion We have successfully validated an algorithm that can identify a high EHR data-continuity cohort representative of the source population.
Collapse
Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gary E Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Shawn N Murphy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Research Information Science and Computing, Partners Healthcare, Somerville, MA, USA
| | - Kenneth D Mandl
- Computational Health Informatics Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
11
|
Abstract
The learning health system (LHS) has gained traction as a powerful framework for improving the cost and quality of healthcare. The goal of an LHS is to systematically integrate internal data and experience with external evidence so patients receive higher-quality, safer, and more efficient care. However, if the goal of an LHS is to improve health, as well as healthcare, it must account for and mitigate the negative impact of social and economic factors on health, known as the social determinants of health. In this paper, we discuss the critical role the LHS can play in addressing patients' social risk factors. We also discuss how integrating data on the social determinants and activities to reduce patients' social risk factors could advance the mission of the LHS to enhance patient engagement, improve the delivery of personalized care, and more accurately evaluate the effectiveness of care. Without the collection and integration of data on the social determinants of health, the LHS may fail to reach its full potential to improve health and healthcare.
Collapse
Affiliation(s)
- Deepak Palakshappa
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157.
| | | | | |
Collapse
|
12
|
Sunkara PR, Islam T, Bose A, Rosenthal GE, Chevli P, Jogu H, TK LA, Huang CC, Chaudhary D, Beekman D, Dutta A, Menon S, Speiser JL. Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre. BMJ Qual Saf 2019; 29:569-575. [DOI: 10.1136/bmjqs-2019-009936] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 11/03/2019] [Accepted: 11/18/2019] [Indexed: 11/04/2022]
Abstract
BackgroundEffective communication between healthcare providers and patients and their family members is an integral part of daily care and discharge planning for hospitalised patients. Several studies suggest that team-based care is associated with improved length of stay (LOS), but the data on readmissions are conflicting. Our study evaluated the impact of structured interdisciplinary bedside rounding (SIBR) on outcomes related to readmissions and LOS.MethodsThe SIBR team consisted of a physician and/or advanced practice provider, bedside nurse, pharmacist, social worker and bridge nurse navigator. Outcomes were compared in patients admitted to a hospital medicine unit using SIBR (n=1451) and a similar control unit (n=770) during the period of October 2016 to September 2017. Multivariable negative binomial regression analysis was used to compare LOS and logistic regression analysis was used to calculate 30-day and 7-day readmission in patients admitted to SIBR and control units, adjusting for covariates.ResultsPatients admitted to SIBR and control units were generally similar (p≥0.05) with respect to demographic and clinical characteristics. Unadjusted readmission rates in SIBR patients were lower than in control patients at both 30 days (16.6% vs 20.3%, p=0.03) and 7 days (6.3% vs 9.0%, p=0.02) after discharge, while LOS was similar. After adjusting for covariates, SIBR was not significantly related to the odds of 30-day readmission (OR 0.81, p=0.07) but was lower for 7-day readmission (OR 0.70, p=0.03); LOS was similar in both groups (p=0.58).ConclusionSIBR did not reduce LOS and 30-day readmissions but had a significant impact on 7-day readmissions.
Collapse
|
13
|
Palakshappa D, Speiser JL, Rosenthal GE, Vitolins MZ. Food Insecurity Is Associated with an Increased Prevalence of Comorbid Medical Conditions in Obese Adults: NHANES 2007-2014. J Gen Intern Med 2019; 34:1486-1493. [PMID: 31161567 PMCID: PMC6667608 DOI: 10.1007/s11606-019-05081-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/26/2018] [Accepted: 04/23/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Numerous studies have examined if food insecurity (FI) leads to increased weight gain, but little is known about how FI affects obese participants. OBJECTIVE Our objective was to determine if obese, food-insecure adults are more likely to have medical comorbidities than obese, food-secure adults. DESIGN We conducted a cross-sectional study using the 2007-2014 National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS All obese participants (≥ 20 years) in NHANES were eligible. Participants who were pregnant or missing FI data were excluded. MAIN MEASURES The primary exposure was household FI, and the primary outcome was the total number of obesity-related comorbidities. Secondary outcomes evaluated the association between FI and individual comorbidities. Propensity score weighting was used to improve covariate balance. We used negative binomial regression to test the association between FI and the total number of comorbidities. We used logistic regression to test the association between FI and individual comorbidities. KEY RESULTS Of the 9203 obese participants, 15.6% were food insecure. FI (β = 0.09, 95% CI: 0.02, 0.15; p = 0.01) and very low food security (β = 0.17, 95% CI: 0.07, 0.28; p = 0.003) were associated with an increased number of comorbidities. In secondary analyses, FI was associated with increased odds of coronary artery disease (OR: 1.5, 95% CI: 1.1, 2.0) and asthma (OR: 1.3, 95% CI: 1.1, 1.6). Very low food security was associated with increased odds of coronary artery disease, diabetes, and asthma. CONCLUSION Obese adults living in food-insecure households were more likely to have an increased number of comorbid conditions than obese adults living in food-secure households. Clinicians should be aware of the association between FI and comorbid medical conditions when treating patients with obesity.
Collapse
Affiliation(s)
- Deepak Palakshappa
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Jaime L Speiser
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gary E Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mara Z Vitolins
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| |
Collapse
|
14
|
Vaughan Sarrazin M, Rosenthal GE, Turvey CL. Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans. Health Serv Res 2018; 53 Suppl 3:5181-5200. [PMID: 29896771 DOI: 10.1111/1475-6773.12995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. METHODS The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. RESULTS Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. CONCLUSIONS VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.
Collapse
Affiliation(s)
- Mary Vaughan Sarrazin
- Iowa City VA Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Gary E Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Carolyn L Turvey
- Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA.,Department of Psychiatry, University of Iowa, Iowa City, IA
| |
Collapse
|
15
|
Gruca TS, Hottel WJ, Comstock J, Olson A, Rosenthal GE. Sex and cardiovascular disease status differences in attitudes and willingness to participate in clinical research studies/clinical trials. Trials 2018; 19:300. [PMID: 29843818 PMCID: PMC5975677 DOI: 10.1186/s13063-018-2667-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 05/03/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND While women are under-represented in research on cardiovascular disease (CVD), little is known about the attitudes of men and women with CVD regarding participation in clinical research studies/clinical trials. METHODS Patients with CVD (and/or risk factors) and patients with other chronic conditions from Iowa were recruited from a commercial panel. An on-line survey assessed willingness to participate (WTP) and other attitudes towards aspects of clinical research studies. RESULTS Based on 504 respondents, there were no differences in WTP in patients with CVD compared to patients with other chronic diseases. Across all respondents, men had 14% lower WTP (relative risk (RR) for men, 0.86, 95% CI, 0.72-1.02). Among patients with CVD, there was no significant difference in WTP between women (RR for women = 1) and men (RR for men, 0.96, 95% CI, 0.82-1.14). There were no significant differences based on sex or CVD status for attitudes on randomization, blinding, side effects, conflict of interest, experimental treatments or willingness to talk to one's physician. Women had more favorable attitudes about participants being treated like "guinea pigs" (RR for men, 0.84, 95% CI, 0.73-0.98) and clinical trials being associated with terminally ill patients (RR for men, 0.93, 95% CI, 0.86-1.00). CONCLUSIONS The findings reported here suggest that the observed lower levels of participation by women are due to factors other than a lower WTP or to women having more negative attitudes towards aspects of study participation. Patients with CVD have similar attitudes and WTP as patients with other chronic conditions.
Collapse
Affiliation(s)
| | | | | | | | - Gary E. Rosenthal
- Department of Internal Medicine, Wake Forest University, Winston-Salem, NC USA
| |
Collapse
|
16
|
Simon CM, Schartz HA, Rosenthal GE, Eisenstein EL, Klein DW. Perspectives on Electronic Informed Consent From Patients Underrepresented in Research in the United States: A Focus Group Study. J Empir Res Hum Res Ethics 2018; 13:338-348. [PMID: 29790410 DOI: 10.1177/1556264618773883] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Digital informed consent may better inform individuals about health research and increase participation. In the United States and elsewhere, minorities and rural populations are underrepresented in health research and may benefit from well-designed electronic informed consent (eIC). Seven focus groups were conducted with 50 Caucasian, African American, and rural patients in the United States. Participants were asked their preferences for a paper versus electronic informed consent document. Participants found the e-version easier to use, more interesting, and better for understanding. Minority participants emphasized limited access, computer literacy, and trust barriers to eIC. Rural participants were concerned about accessibility, connectivity, privacy, and confidentiality. People see value in electronic consenting. Researchers should consider barriers to eIC among underrepresented populations before recruitment.
Collapse
|
17
|
Weinfurt KP, Hernandez AF, Coronado GD, DeBar LL, Dember LM, Green BB, Heagerty PJ, Huang SS, James KT, Jarvik JG, Larson EB, Mor V, Platt R, Rosenthal GE, Septimus EJ, Simon GE, Staman KL, Sugarman J, Vazquez M, Zatzick D, Curtis LH. Pragmatic clinical trials embedded in healthcare systems: generalizable lessons from the NIH Collaboratory. BMC Med Res Methodol 2017; 17:144. [PMID: 28923013 PMCID: PMC5604499 DOI: 10.1186/s12874-017-0420-7] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/31/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. METHODS To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. RESULTS In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. CONCLUSION A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.
Collapse
Affiliation(s)
- Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, 220 W Main St., Suite 720A, Durham, NC 27705 USA
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Department of Psychology and Neuroscience, Duke Clinical Research Institute, Durham, NC 27710 USA
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Duke University School of Medicine, 3115 N. Duke Street, Durham, NC 27704 USA
| | - Gloria D. Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - Lynn L. DeBar
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - Laura M. Dember
- Perelman School of MedicineBlockley Hall, Office 920, 423 Guardian Drive, Philadelphia, PA 19104 USA
| | - Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | - Patrick J. Heagerty
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Susan S. Huang
- University of California Irvine School of Medicine, 101 The City Drive South, City Tower, Suite 400, Mail Code: 4081, Orange, CA 92868 USA
| | - Kathryn T. James
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Jeffrey G. Jarvik
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Eric B. Larson
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | - Vincent Mor
- Department of Community Health, Brown University, Box G-S121-2, Providence, RI 02912 USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215 USA
| | - Gary E. Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Edward J. Septimus
- Hospital Corporation of America Nashville TN, AND Texas A&M College of Medicine, One Park Plaza, Nashville, TN 37203 USA
| | - Gregory E. Simon
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | | | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Ave., Room 203, Baltimore, MD 21205 USA
| | - Miguel Vazquez
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8856 USA
| | - Douglas Zatzick
- University of Washington School of Medicine, 325 9th Ave, Seattle, WA 98104 USA
| | - Lesley H. Curtis
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Duke University School of Medicine, 3115 N. Duke Street, Durham, NC 27704 USA
| |
Collapse
|
18
|
Feria MI, Sarrazin MV, Rosenthal GE. Perceptions of Care of Patients Undergoing Coronary Artery Bypass Surgery in Veterans Health Administration and Private Sector Hospitals. Am J Med Qual 2016; 18:242-50. [PMID: 14717382 DOI: 10.1177/106286060301800604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Few studies have examined differences in patient perceptions of care between health care systems. This study compared the perceptions of male patients undergoing coronary artery bypass graft surgery in 43 Veterans Health Administration (VA) hospitals (N = 808) and 102 US private sector hospitals (N = 2271) from 1995 to 1998. Patient perceptions were measured by a validated survey that was mailed to patients after discharge. For 8 of the 9 dimensions assessed by the survey, VA patients were more likely (P < .001) than private sector patients to note a problem with care (eg, Coordination, 48% versus 40%; Patient Education and Communication, 50% versus 40%; Respect for Patient Preferences, 49% versus 41%). In comparisons limited to major teaching hospitals, VA patients were more likely to note a problem for 5 dimensions. The findings indicate that patient perceptions of care may be lower in VA than in private sector hospitals. Future studies should examine whether the VA's recent focus on improving patient satisfaction has narrowed these differences.
Collapse
Affiliation(s)
- Mary I Feria
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa 52242, USA
| | | | | |
Collapse
|
19
|
Ibrahim SA, Cook CF, Kwoh CK, Rosenthal GE, Snow RJ, Harper DL, Baker DW. Racial Differences in Mortality among Elderly Patients Admitted for Heart Failure. Res Aging 2016. [DOI: 10.1177/0164027501234004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Several studies have examined predictors of mortality among elderly patients hospitalized with heart failure. In some, elderly African American patients hospitalized for heart failure were reported to have lower risk-adjusted in-hospital mortality compared with Whites. Whether this difference is sustained in the long term and what factors account for this difference remain poorly understood. The objective of this study was to compare risk-adjusted short-term and long-term mortality of a cohort of elderly African American and White patients hospitalized for heart failure to all 30 hospitals in northeast Ohio. The database used for this analysis includes information on demographics and detailed clinical information abstracted from patients’ hospital records. Crude and adjusted 30-day and 18-month survival were compared using Kaplan-Meier method and logistic regression models for multivariate analysis. African American patients had significantly lower 30-day mortality compared with Whites. However, this difference diminished over time and when adjusted for important explanatory covariates, including “do not resuscitate” orders.
Collapse
Affiliation(s)
- Said A. Ibrahim
- Louis Stokes VA Medical Center, University Hospitals of Cleveland, and Case Western Reserve University School of Medicine,
| | | | - C. Kent Kwoh
- University of Pittsburgh, School of Medicine, and Pittsburgh VA Health System
| | | | | | | | - David W. Baker
- MetroHealth Medical Center and Case Western Reserve University School of Medicine
| |
Collapse
|
20
|
Abstract
Research evaluating the effectiveness, function, and implementation of patient-centered medical homes (PCMHs) has found major socioprofessional transformations and contributions of primary care physicians and, to a lesser degree, nurses. Our longitudinal ethnographic research with teams implementing PCMH in Veterans Health Administration (VHA) primary care identifies the important but largely underutilized contributions of clerks to PCMH outcomes. Although the relationship of high-performing clerical staff to patient satisfaction is widely acknowledged, PCMH can be further enhanced by enabling clerks to use administrative tasks as conduits for investing in long-term personalized relationships with patients that foster trust in the PCMH and the broader health care organization. Such relationships are engendered through the care-coordination activities clerks perform, which may be bolstered by organizational investment in clerks as skilled health care team members.
Collapse
Affiliation(s)
- Samantha L Solimeo
- VISN 23 Patient Aligned Care Team Demonstration Lab, and Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Greg L Stewart
- VISN 23 Patient Aligned Care Team Demonstration Lab, and Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa Tippie College of Business, University of Iowa, Iowa City, Iowa
| | - Gary E Rosenthal
- VISN 23 Patient Aligned Care Team Demonstration Lab, and Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| |
Collapse
|
21
|
Solimeo SL, Ono SS, Stewart KR, Lampman MA, Rosenthal GE, Stewart GL. Gatekeepers as Care Providers: The Care Work of Patient-centered Medical Home Clerical Staff. Med Anthropol Q 2016; 31:97-114. [DOI: 10.1111/maq.12281] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Samantha L. Solimeo
- VISN 23 Patient Aligned Care Team Demonstration Lab and; CADRE, the Center for Comprehensive Access & Delivery Research and Evaluation Department of Veterans Affairs Iowa City VA Health Care System and Division of General Internal Medicine University of Iowa Carver College of Medicine
| | - Sarah S. Ono
- VISN 23 Patient Aligned Care Team Demonstration Lab, Department of Veterans Affairs; Iowa City VA Health Care System and Division of Family Medicine Oregon Health and Science University and CIVIC (Center to Improve Veteran Involvement in Care), Department of Veterans Affairs VA Portland Health Care System
| | - Kenda R. Stewart
- VISN 23 Patient Aligned Care Team Demonstration Lab and; CADRE, the Center for Comprehensive Access & Delivery Research and Evaluation Department of Veterans Affairs Iowa City VA Health Care System
| | - Michelle A. Lampman
- VISN 23 Patient Aligned Care Team Demonstration Lab; Department of Veterans Affairs Iowa City VA Health Care System
| | - Gary E. Rosenthal
- VISN 23 Patient Aligned Care Team Demonstration Lab and; CADRE, the Center for Comprehensive Access & Delivery Research and Evaluation Department of Veterans Affairs Iowa City VA Health Care System and Division of General Internal Medicine University of Iowa Carver College of Medicine
| | - Greg L. Stewart
- VISN 23 Patient Aligned Care Team Demonstration Lab and; CADRE, the Center for Comprehensive Access & Delivery Research and Evaluation Department of Veterans Affairs Iowa City VA Health Care System and Tippie College of Business, University of Iowa
| |
Collapse
|
22
|
Selker HP, Buse JB, Califf RM, Carter R, Cooper DM, Davis J, Ford DE, Galassetti P, Guay-Woodford L, Huggins GS, Kasper A, Kieburtz K, Kirby A, Klein AK, Kline J, O' Neill RT, Rape M, Reichgott DJ, Rojevsky S, Rosenthal GE, Rubinstein EP, Shepherd A, Stacy M, Terrin N, Wallace M, Welch L. CTSA Consortium Consensus Scientific Review Committee (SRC) Working Group Report on the SRC Processes. Clin Transl Sci 2015; 8:623-31. [PMID: 26184433 PMCID: PMC4703465 DOI: 10.1111/cts.12306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Human research projects must have a scientifically valid study design, analytic plan, and be operationally feasible in order to be successfully completed and thus to have translational impact. To ensure this, institutions that conduct clinical research should have a scientific review process prior to submission to the Institutional Review Committee (IRB). This paper reports the Clinical and Translational Science Award (CTSA) Consortium Scientific Review Committee (SRC) Consensus Working Group's proposed framework for a SRC process. Recommendations are provided for institutional support and roles of CTSAs, multisite research, criteria for selection of protocols that should be reviewed, roles of committee members, application process, and committee process. Additionally, to support the SCR process effectively, and to ensure efficiency, the Working Group recommends information technology infrastructures and evaluation metrics to determine outcomes are provided.
Collapse
Affiliation(s)
- Harry P Selker
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - John B Buse
- University of North Carolina at Chapel Hill, Translational & Clinical Sciences Institute, Chapel Hill, North Carolina, USA
| | - Robert M Califf
- Duke Translational Medicine Institute, Duke University, Durham, North Carolina, USA
| | - Robert Carter
- National Institutes of Health, Bethesda, Maryland, USA
| | - Dan M Cooper
- Institute for Clinical and Translational Science, University of California, Irvine, California, USA
| | - Jonathan Davis
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Daniel E Ford
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Pietro Galassetti
- Institute for Clinical and Translational Science, University of California, Irvine, California, USA
| | - Lisa Guay-Woodford
- Clinical and Translational Science Institute at Children's National, Washington, DC, USA
| | | | - Amanda Kasper
- Clinical and Translational Science Institute at Children's National, Washington, DC, USA
| | - Karl Kieburtz
- Clinical and Translational Science Institute, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Aaron Kirby
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Joel Kline
- Institute for Clinical and Translational Science at the University of Iowa, University of Iowa, Iowa City, Iowa, USA
| | | | - Marie Rape
- University of North Carolina at Chapel Hill, Translational & Clinical Sciences Institute, Chapel Hill, North Carolina, USA
| | | | - Svetlana Rojevsky
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Gary E Rosenthal
- Institute for Clinical and Translational Science at the University of Iowa, University of Iowa, Iowa City, Iowa, USA
| | - Eric P Rubinstein
- Clinical and Translational Science Institute, University of Rochester Medical Center, University of Rochester, Rochester, New York, USA
| | - Amy Shepherd
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mark Stacy
- Duke Translational Medicine Institute, Duke University, Durham, North Carolina, USA
| | - Norma Terrin
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mark Wallace
- Clinical and Translational Research Institute, University of California, San Diego, USA
| | - Lisa Welch
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
23
|
Khera R, Cram P, Lu X, Vyas A, Gerke A, Rosenthal GE, Horwitz PA, Girotra S. Trends in the use of percutaneous ventricular assist devices: analysis of national inpatient sample data, 2007 through 2012. JAMA Intern Med 2015; 175:941-50. [PMID: 25822170 PMCID: PMC4780323 DOI: 10.1001/jamainternmed.2014.7856] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Percutaneous ventricular assist devices (PVADs) provide robust hemodynamic support compared with intra-aortic balloon pumps (IABPs), but clinical use patterns are unknown. OBJECTIVE To examine contemporary patterns in PVAD use in the United States and compare them with use of IABPs. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of adults older than 18 years who received a PVAD or IABP while hospitalized in the United States (2007-2012). MAIN OUTCOMES AND MEASURES Temporal trends in utilization, patient and hospital characteristics, in-hospital mortality, and cost of PVAD use compared with IABP. RESULTS During 2007 through 2012, utilization of PVADs increased 30-fold (4.6 per million discharges in 2007 to 138 per million discharges in 2012; P for trend < .001) while utilization of IABPs decreased from 1738 per million discharges in 2008 to 1608 per million discharges in 2012 (P for trend = .02). In 2007, an estimated 72 hospitals used PVADs, increasing to 477 in 2011 (P for trend < .001). The number of hospitals with an annual volume of 10 or more PVAD procedures per year increased from 0 in 2007 to 102 in 2011 (21.4% of PVAD-using hospitals; P for trend < .001). Among PVAD recipients, 67.3% had a diagnosis of cardiogenic shock or acute myocardial infarction (AMI). There was a temporal increase in the use of PVADs in older patients and patients with AMI, hypertension, diabetes mellitus, and chronic kidney disease (P for trend < .001 for all). Overall, mortality in PVAD recipients was 28.8%, and mean (SE) hospitalization cost was $85,580 ($4165); both were significantly higher in PVAD recipients with cardiogenic shock (mortality, 47.5%; mean [SE] cost, $113,695 [$6260]; P < .001 for both). The PVAD recipients were less likely than IABP recipients to have cardiogenic shock (34.3% vs 41.2%; P = .001), AMI (48.0% vs 68.6%; P < .001), and undergo coronary artery bypass graft surgery (6.2% vs 43.2%; P < .001), but more likely to undergo percutaneous coronary intervention (70.9% vs 40.4%; P < .001). In propensity-matched analysis, PVADs were associated with higher mortality compared with IABP (odds ratio, 1.23 [95% CI, 1.06-1.43]; P = .007). CONCLUSIONS AND RELEVANCE There has been a substantial increase in the use of PVADs in recent years with an accompanying decrease in the use of IABPs. Given the high mortality, associated cost, and uncertain evidence for a clear benefit, randomized clinical trials are needed to determine whether use of PVADs leads to improved patient outcomes.
Collapse
Affiliation(s)
- Rohan Khera
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada3Division of General Internal Medicine, University Health Network/Mt Sinai Hospitals, Toronto, Ontario, Canada
| | - Xin Lu
- Institute of Clinical and Translational Science, University of Iowa Carver College of Medicine, Iowa City
| | - Ankur Vyas
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Alicia Gerke
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Gary E Rosenthal
- Institute of Clinical and Translational Science, University of Iowa Carver College of Medicine, Iowa City7Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Phillip A Horwitz
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Saket Girotra
- Institute of Clinical and Translational Science, University of Iowa Carver College of Medicine, Iowa City5Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| |
Collapse
|
24
|
Carter BL, Vander Weg MW, Parker CP, Goedken CC, Richardson KK, Rosenthal GE. Sustained Blood Pressure Control Following Discontinuation of a Pharmacist Intervention for Veterans. J Clin Hypertens (Greenwich) 2015; 17:701-8. [DOI: 10.1111/jch.12577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 03/24/2015] [Accepted: 03/29/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Barry L. Carter
- Department of Pharmacy Practice and Science; College of Pharmacy; Iowa City IA
- Center for Comprehensive Access & Delivery Research and Evaluation; Iowa City VA Health Care System; Iowa City IA
- Department of Family Medicine; Roy J. and Lucille A. Carver College of Medicine; University of Iowa; Iowa City IA
| | - Mark W. Vander Weg
- Center for Comprehensive Access & Delivery Research and Evaluation; Iowa City VA Health Care System; Iowa City IA
- Department of Internal Medicine; Division of General Internal Medicine; Carver College of Medicine; Iowa City IA
- Department of Psychology; University of Iowa; Iowa City IA
| | | | - Cassie C. Goedken
- Center for Comprehensive Access & Delivery Research and Evaluation; Iowa City VA Health Care System; Iowa City IA
| | - Kelly K. Richardson
- Center for Comprehensive Access & Delivery Research and Evaluation; Iowa City VA Health Care System; Iowa City IA
| | - Gary E. Rosenthal
- Center for Comprehensive Access & Delivery Research and Evaluation; Iowa City VA Health Care System; Iowa City IA
- Department of Internal Medicine; Division of General Internal Medicine; Carver College of Medicine; Iowa City IA
- University of Iowa Institute for Clinical and Translational Science; Iowa City IA
| |
Collapse
|
25
|
Malhotra A, Vaughan-Sarrazin M, Rosenthal GE. Elderly veterans with dual eligibility for VA and Medicare services: where do they obtain a colonoscopy? Am J Manag Care 2015; 21:e264-e270. [PMID: 26244789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To examine the receipt of colonoscopy through the Veterans Health Administration (VA) or through Medicare by older veterans who are dually enrolled. STUDY DESIGN Retrospective cohort study. METHODS The VA Outpatient Care Files and Medicare Enrollment Files were used to identify 1,060,523 patients 65 years and older in 15 of the 22 Veterans Integrated Service Networks nationally, who had 2 or more VA primary care visits in 2009 and who were simultaneously enrolled in Medicare. VA and Medicare files were used to identify the receipt of an outpatient colonoscopy. Patients were categorized as receiving care in community-based outpatient clinics (CBOCs) (n=601,337; 57%) or VA medical centers (n=459,186; 43%) based on where most patient-centered encounters occurred. Analyses used multinomial logistic regression to identify patient characteristics related to the odds of receiving a colonoscopy at the VA or through Medicare. RESULTS Patients had a mean age of 76.9 (SD=7.0) years; 98% were male, 89% were white, and 21% resided in a rural location. Overall, 100,060 (9.4%) patients underwent outpatient colonoscopy either through the VA (n=33,600; 35.5%) or Medicare providers (n=65,716; 65.5%). The adjusted odds of receiving a colonoscopy from Medicare providers were higher (P<.001) for patients who were male, white, receiving primary care at CBOCs, and for residents of an urban location. The receipt of colonoscopy through the VA decreased dramatically by age; for example, the odds of colonoscopy by the VA in patients aged >85 years and 80 to 84 years, relative to patients aged 65 to 69 years, were 0.26 and 0.13, respectively. In contrast, the receipt of colonoscopy through Medicare did not decline as markedly with age. CONCLUSIONS In a national analysis of the receipt of an outpatient colonoscopy by older veterans, more veterans received their colonoscopies through CMS than through the VA. The use of colonoscopy within the VA was found to be more concordant with age-related practice guidelines.
Collapse
Affiliation(s)
- Ashish Malhotra
- CADRE, Bldg 42, Iowa City VA Medical Center, 601 US Highway 6, Iowa City, IA 52246. E-mail:
| | | | | |
Collapse
|
26
|
Patterson BJ, Solimeo SL, Stewart KR, Rosenthal GE, Kaboli PJ, Lund BC. Perceptions of pharmacists' integration into patient-centered medical home teams. Res Social Adm Pharm 2015; 11:85-95. [DOI: 10.1016/j.sapharm.2014.05.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/14/2014] [Accepted: 05/15/2014] [Indexed: 11/17/2022]
|
27
|
Parker CP, Cunningham CL, Carter BL, Vander Weg MW, Richardson KK, Rosenthal GE. A mixed-method approach to evaluate a pharmacist intervention for veterans with hypertension. J Clin Hypertens (Greenwich) 2014; 16:133-40. [PMID: 24588813 DOI: 10.1111/jch.12250] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 11/29/2013] [Indexed: 01/13/2023]
Abstract
This paper examines blood pressure (BP) control after 6 months of an intensive pharmacist-managed intervention in a mixed-methods randomized controlled trial conducted at the Iowa City Veteran Affairs Health Care System and two community-based outreach clinics. Patients received the pharmacist intervention for the first 6 months. The study coordinator conducted a summative evaluation with 37 patients 18 to 24 months following the initial 6-month intervention period. BP was significantly reduced in diabetic patients following an intensive pharmacist intervention (-8.0/-4.0 ± 14.4/9.1 mm Hg systolic/diastolic, P<.001 and P=.001, respectively). BP was reduced even more in nondiabetic patients (-14.0/-5.0 ± 1.9/10.0 mm Hg, P<.001). Medication adherence significantly improved from baseline to 6 months (P=.017). BPs were significantly lower at 6 months following an intensive pharmacist intervention. Patients also expressed a high level of satisfaction with and preference for co-management of their hypertension, as well as other chronic diseases.
Collapse
|
28
|
Edwards ST, Abrams MK, Baron RJ, Berenson RA, Rich EC, Rosenthal GE, Rosenthal MB, Landon BE. Structuring payment to medical homes after the affordable care act. J Gen Intern Med 2014; 29:1410-3. [PMID: 24687292 PMCID: PMC4175661 DOI: 10.1007/s11606-014-2848-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 02/20/2014] [Accepted: 03/12/2014] [Indexed: 12/23/2022]
Abstract
The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.
Collapse
Affiliation(s)
- Samuel T Edwards
- Section of General Internal Medicine, Veterans Affairs (VA) Boston Healthcare System, Boston, MA, USA
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- Michael E Ohl
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City2Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), at the Iowa City VA Medical Center, Iowa City, Iowa
| | - Gary E Rosenthal
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), at the Iowa City VA Medical Center, Iowa City, Iowa3Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa C
| |
Collapse
|
30
|
Abstract
BACKGROUND There is little objective evidence to support concerns that patients are transferred between hospitals based on insurance status. OBJECTIVE To examine the relationship between patients' insurance coverage and interhospital transfer. DESIGN Data analyzed from the 2010 Nationwide Inpatient Sample. PATIENTS All patients aged 18 to 64 years discharged alive from U.S. acute care hospitals with 1 of 5 common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, and skin or subcutaneous infection). MEASUREMENTS For each diagnosis, the proportion of hospitalized patients who were transferred to another acute care hospital based on insurance coverage (private, Medicare, Medicaid, or uninsured) was compared. Logistic regression was used to estimate the odds of transfer for uninsured patients (reference category, privately insured) while patient- and hospital-level factors were adjusted for. All analyses incorporated sampling and poststratification weights. RESULTS Among 315 748 patients discharged from 1051 hospitals with any of the 5 diagnoses, the percentage of patients transferred to another acute care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses, uninsured patients were significantly less likely to be transferred for 3 diagnoses (P 0.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for 4 diagnoses: biliary tract disease (odds ratio, 0.73 [95% CI, 0.55 to 0.96]), chest pain (odds ratio, 0.63 [CI, 0.44 to 0.89]), septicemia (odds ratio, 0.76 [CI, 0.64 to 0.91]), and skin infections (odds ratio, 0.64 [CI, 0.46 to 0.89]). Women were significantly less likely to be transferred than men for all diagnoses. LIMITATION This analysis relied on administrative data and lacked clinical detail. CONCLUSION Uninsured patients (and women) were significantly less likely to undergo interhospital transfer. Differences in transfer rates may contribute to health care disparities. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
|
31
|
Rosenthal GE. The role of pragmatic clinical trials in the evolution of learning health systems. Trans Am Clin Climatol Assoc 2014; 125:204-218. [PMID: 25125735 PMCID: PMC4112713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Pragmatic clinical trials (PCTs) test clinical interventions (eg, treatments, diagnostic tests, delivery strategies) that are widely used in practice and for which there is often clinical equipoise. Similar to traditional explanatory trials of novel therapeutics, PCTs use randomization to decrease selection bias. In contrast, PCTs rely on extant data sources (eg, electronic medical records [EMRs]) and test interventions that can be implemented with minimal research infrastructures. Thus, PCTs have drawn interest as vehicles for decreasing the cost of clinical research and for creating learning health systems, which, as articulated by the Institute of Medicine, seek to generate new knowledge as an integral by-product of the delivery experience. However, realizing this vision for PCTs will require innovative approaches for engaging clinicians, improving the efficiency of subject recruitment, improving the reliability of EMR data, and new paradigms for the regulatory review of low-risk trials to decrease unncessary hurdles to practice-based knowledge generation.
Collapse
Affiliation(s)
- Gary E. Rosenthal
- Correspondence and reprint requests: Gary E. Rosenthal, MD,
Institute for Clinical and Translational Science, University of Iowa Hospitals and Clinics, SW44-N GH, 200 Hawkins Drive, Iowa City, IA 52242319-384-5282319-356-8101
| |
Collapse
|
32
|
Vander Weg MW, Rosenthal GE, Vaughan Sarrazin M. Smoking bans linked to lower hospitalizations for heart attacks and lung disease among medicare beneficiaries. Health Aff (Millwood) 2013; 31:2699-707. [PMID: 23213154 DOI: 10.1377/hlthaff.2011.0385] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Policies limiting exposure to cigarette smoke have been associated with reduced hospitalizations for heart attacks, but little is known about the impact of smoking bans on other health conditions and whether findings from individual communities generalize to other areas. We investigated the association between smoking bans targeting workplaces, restaurants, and bars passed throughout the United States during 1991-2008 and hospital admissions for smoking-related illnesses-acute myocardial infarction and chronic obstructive pulmonary disease-among Medicare beneficiaries age sixty-five or older. Risk-adjusted hospital admission rates for acute myocardial infarction fell 20-21 percent thirty-six months following implementation of new restaurant, bar, and workplace smoking bans. Admission rates for chronic obstructive pulmonary disease fell 11 percent where workplace smoking bans were in place and 15 percent where bar smoking bans were present. By contrast, very little effect was found for hospitalization for gastrointestinal hemorrhage and hip fracture-two conditions largely unrelated to smoking and examined as points of comparison. These findings provide further support for the public health benefits of laws that limit exposure to tobacco smoke.
Collapse
Affiliation(s)
- Mark W Vander Weg
- University of Iowa Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | | | | |
Collapse
|
33
|
Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis 2013; 73:2107-15. [PMID: 24047869 DOI: 10.1136/annrheumdis-2013-203494] [Citation(s) in RCA: 267] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine whether racial disparities in usage and outcomes of total knee and total hip arthroplasty (TKA and THA) have declined over time. METHODS We used data from the US Medicare Program (MedPAR data) for years 1991-2008 to identify four separate cohorts of patients (primary TKA, revision TKA, primary THA, revision THA). For each cohort, we calculated standardised arthroplasty usage rates for Caucasian and African-American Medicare beneficiaries for each calendar year, and examined changes in disparities over time. We examined unadjusted and adjusted outcomes (30-day readmission rate, discharge disposition etc.) for Caucasians and African-Americans, and whether disparities decreased over time. RESULTS In 1991, the use of primary TKA was 36% lower for African-Americans compared with Caucasians (20.6 per 10,000 for African-Americans; 32.1 per 10,000 for Caucasians; p<0.0001); in 2008, usage of primary TKA was 40% lower for African-Americans (41.5 per 10,000 for African-Americans; 68.8 per 10,000 for Caucasians; p<0.0001) with similar findings for the other cohorts. Black-White disparities in 30-day hospital readmission increased significantly from 1991-2008 among three patient cohorts. For example in 1991 30-day readmission rates for African-Americans receiving primary TKA were 6% higher than for Caucasians; by 2008 readmission rates for African-Americans were 24% higher (p<0.05 for change in disparity). Similarly, black-white disparities in the proportion of patients discharged to home after surgery increased across the study period for all cohorts (p<0.05). CONCLUSIONS In an 18-year analysis of US Medicare data, we found little evidence of declines in racial disparities for joint arthroplasty usage or outcomes.
Collapse
Affiliation(s)
- Jasvinder A Singh
- Birmingham Veterans Affairs Medical Center, AL and the Departments of Medicine and Epidemiology, Medicine Service, University of Alabama at Birmingham, Birmingham, Alabama, USA Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Xin Lu
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA CADRE, Iowa City Veterans Administration Medical Center, Iowa City, Iowa, USA
| | - Gary E Rosenthal
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA CADRE, Iowa City Veterans Administration Medical Center, Iowa City, Iowa, USA
| | - Said Ibrahim
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, and the Perelman University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA CADRE, Iowa City Veterans Administration Medical Center, Iowa City, Iowa, USA
| |
Collapse
|
34
|
Malhotra A, Vaughan-Sarrazin M, Charlton ME, Rosenthal GE. Comparison of colorectal cancer screening in veterans based on the location of primary care clinic. J Prim Care Community Health 2013; 5:24-9. [PMID: 24327586 DOI: 10.1177/2150131913494842] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To compare colorectal cancer screening rates in veterans receiving primary care (PC) in Veterans Administration (VA) community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs). METHODS The VA Outpatient Care Files were used to identify 2 837 770 patients ≥ 50 years with ≥ 2 PC visits in 2010. Veterans undergoing screening/surveillance colonoscopy, sigmoidoscopy, fecal-occult-blood testing (FOBT), and double-contrast barium enema (DCBE) were identified from ICD-9-CM/CPT codes. Patients were categorized as VAMC (n = 1 403 273; 49.5%) or CBOC (1 434 497; 50.5%) based on where majority of PC encounters occurred and as high risk (n = 284 090) or average risk (n = 2 553 680) based on colorectal cancer risk factors and validated ICD-9-CM-based algorithms. RESULTS CBOC patients were older than VAMC (mean ages 69.3 vs 67.4 years; P < .001), more likely (P < .001) to be male (96.5% vs 95.1%), and white (67.8% vs 64.2%), but less likely to be high-risk (9.4% vs 10.5%; P < .001). Rates of colonoscopy, sigmoidoscopy, and DCBE were all lower in CBOC (P < .001). Among high-risk veterans, rates in CBOC and VAMC, respectively, were 27.4% versus 36.8% for colonoscopy, 1.3% versus 0.8% for sigmoidoscopy, and 0.8% versus 0.5% for DCBE. Among average-risk veterans, these rates were 1.3% versus 1.9%, 0.2% versus 0.1%, and 0.2% versus 0.1%, respectively. The differences remained after adjusting for age/comorbidity. The adjusted odds of colonoscopy for CBOC were 0.73 (95% confidence interval = 0.64-0.82) for average risk and 0.76 (95% confidence interval = 0.67-0.87) for high risk. In contrast, the use of FOBT was relatively similar in CBOCs and VAMCs among both high risk (11.1% vs 11.2%) and average risk (14.3% vs 14.1%). Screening rates were similar between those younger than 65 years and older than 65 years. CONCLUSIONS Veterans receiving PC in CBOCs are less likely to receive screening colonoscopy, sigmoidoscopy, and DCBE than VAMC according to VA records. The lower use in CBOC was not offset by higher use of FOBT, including the degree to which CBOC patients may be more reliant to use non-VA services. The clinical appropriateness of these differences merits further examination.
Collapse
Affiliation(s)
- Ashish Malhotra
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA, USA
| | | | | | | |
Collapse
|
35
|
Abrams TE, Vaughan-Sarrazin M, Richardson K, Cram P, Rosenthal GE. Patterns of illness explaining the associations between posttraumatic stress disorder and the use of CT. Radiology 2013; 267:470-8. [PMID: 23360739 DOI: 10.1148/radiol.13121593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine the relationship between posttraumatic stress disorder (PTSD) and computed tomography (CT) utilization and to determine whether there were patterns of comorbid illness that could explain the relationship. MATERIALS AND METHODS The study was approved by the University of Iowa Institutional Review Board and the Iowa City Veterans Affairs Medical Center Research and Development Committee. By using a retrospective cohort design, a national sample of new veteran enrollees aged 18-35 years was studied. Associations were examined between the presence of PTSD, receipt of at least one and multiple CT scans, comorbid medical conditions (eg, abdominal pain, headaches), and measures of health care utilization (eg, primary care, emergency room, and mental health visits) and the daily probability of the receipt of at least one CT scan before and after a diagnosis of PTSD. Analyses included sequential multivariable generalized linear mixed models to examine the independent relationship between PTSD and CT scan utilization. RESULTS Among the full cohort, 13.0% (10 018 of 76 812) received at least one CT scan. PTSD was identified in 21.1% (16 182 of 76 812) of the cohort, and 22.9% (3711 of 16 182) of veterans with PTSD received at least one CT scan as compared with 10.4% (6307 of 60 630) of veterans without PTSD (P < .0001). In sequential modeling, comorbid factors explaining the relationship between CT scans and PTSD were traumatic brain injury (odds ratio, 3.54; P < .0001), abdominal pain (odds ratio, 4.01; P < .0001), and headaches (odds ratio, 3.07; P < .0001). Associations were also strong for high levels of emergency room (odds ratio, 2.73; P < .0001) and primary care (odds ratio, 2.38; P < .0001) utilization. The daily chance of receiving a CT scan was seven times higher prior to the recognition of PTSD (daily chance, 0.007 before vs 0.001 after; P < .0001). CONCLUSION Young veterans with PTSD are receiving more CT scans compared with those without PTSD; the daily probability of receiving CT scans is higher prior to recognition of PTSD. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13121593/-/DC1.
Collapse
Affiliation(s)
- Thad E Abrams
- VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City VA Medical Center, 601 Highway 6 West, Mailstop 152, Iowa City, IA 52246-2208, USA
| | | | | | | | | |
Collapse
|
36
|
Kaboli PJ, Go JT, Hockenberry J, Glasgow JM, Johnson SR, Rosenthal GE, Jones MP, Vaughan-Sarrazin M. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med 2012; 157:837-45. [PMID: 23247937 DOI: 10.7326/0003-4819-157-12-201212180-00003] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions. OBJECTIVE To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration. DESIGN Observational study from 1997 to 2010. SETTING All 129 acute care Veterans Affairs hospitals in the United States. PATIENTS 4,124,907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). MEASUREMENTS Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals. RESULTS For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected). LIMITATIONS This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used. CONCLUSION Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission. PRIMARY FUNDING SOURCE Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.
Collapse
Affiliation(s)
- Peter J Kaboli
- Veterans Rural Health Resource Center–Central Region, Iowa City Veterans Affairs Medical Center, Center for Comprehensive Access & Delivery Research and Evaluation at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa 52246, USA.
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Wakefield BJ, Holman JE, Ray A, Scherubel M, Adams MR, Hills SL, Rosenthal GE. Outcomes of a home telehealth intervention for patients with diabetes and hypertension. Telemed J E Health 2012; 18:575-9. [PMID: 22873700 DOI: 10.1089/tmj.2011.0237] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Home telehealth programs often focus on a single disease, yet many patients who need monitoring have multiple conditions. This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension. SUBJECTS AND METHODS A single-center randomized controlled clinical trial compared two remote monitoring intensity levels (low and high) and usual care in patients with type 2 diabetes and hypertension being treated in primary care. Secondary outcomes assessed were knowledge (diabetes, hypertension, medications), self-efficacy, adherence (diabetes, medications), and patient perceptions of the intervention mode. RESULTS Knowledge scores improved in the high-intensity intervention group participants, but upon further analysis, we found the intervention effect was not mediated by gain in knowledge. No significant differences were found across the groups in self-efficacy, adherence, or patient perceptions of the intervention mode. CONCLUSIONS Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits. While our intervention improved glycemic and blood pressure control, the mechanism of the effect for this improvement was not clear.
Collapse
Affiliation(s)
- Bonnie J Wakefield
- Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA
| | | | | | | | | | | | | |
Collapse
|
38
|
|
39
|
Kaskie B, Obrizan M, Jones MP, Bentler S, Weigel P, Hockenberry J, Wallace RB, Ohsfeldt RL, Rosenthal GE, Wolinsky FD. Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns. BMC Geriatr 2011; 11:65. [PMID: 22018160 PMCID: PMC3215637 DOI: 10.1186/1471-2318-11-65] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 10/21/2011] [Indexed: 11/17/2022] Open
Abstract
Background It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates. Methods Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects. Results We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58). Conclusions We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.
Collapse
Affiliation(s)
- Brian Kaskie
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Wakefield BJ, Holman JE, Ray A, Scherubel M, Adams MR, Hillis SL, Rosenthal GE. Effectiveness of home telehealth in comorbid diabetes and hypertension: a randomized, controlled trial. Telemed J E Health 2011; 17:254-61. [PMID: 21476945 DOI: 10.1089/tmj.2010.0176] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Increased emphasis is being placed on the critical need to control hypertension (HTN) in patients with diabetes. OBJECTIVE The objective of this study was to evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN. DESIGN A single-center, randomized, controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used. MEASUREMENTS Primary outcomes were hemoglobin A1c and systolic blood pressure (SBP); secondary outcome was adherence. RESULTS Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group, but 6 months after the intervention was withdrawn, the intervention groups were comparable with the control group. For SBP, the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months. Adherence improved over time for all groups, but there were no differences among the three groups. LIMITATIONS Subjects had relatively good baseline control for A1c and SBP; minorities and women were underrepresented. CONCLUSIONS Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention. Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness.
Collapse
Affiliation(s)
- Bonnie J Wakefield
- Department of Veterans Affairs Health Services Research and Development Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City, Iowa 52246, USA.
| | | | | | | | | | | | | |
Collapse
|
41
|
Weigel P, Hockenberry JM, Bentler SE, Obrizan M, Kaskie B, Jones MP, Ohsfeldt RL, Rosenthal GE, Wallace RB, Wolinsky FD. A longitudinal study of chiropractic use among older adults in the United States. Chiropr Osteopat 2010; 18:34. [PMID: 21176137 PMCID: PMC3019203 DOI: 10.1186/1746-1340-18-34] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 12/21/2010] [Indexed: 11/10/2022]
Abstract
Background Longitudinal patterns of chiropractic use in the United States, particularly among Medicare beneficiaries, are not well documented. Using a nationally representative sample of older Medicare beneficiaries we describe the use of chiropractic over fifteen years, and classify chiropractic users by annual visit volume. We assess the characteristics that are associated with chiropractic use versus nonuse, as well as between different levels of use. Methods We analyzed data from two linked sources: the baseline (1993-1994) interview responses of 5,510 self-respondents in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD), and their Medicare claims from 1993 to 2007. Binomial logistic regression was used to identify factors associated with chiropractic use versus nonuse, and conditional upon use, to identify factors associated with high volume relative to lower volume use. Results There were 806 users of chiropractic in the AHEAD sample yielding a full period prevalence for 1993-2007 of 14.6%. Average annual prevalence between 1993 and 2007 was 4.8% with a range from 4.1% to 5.4%. Approximately 42% of the users consumed chiropractic services only in a single calendar year while 38% used chiropractic in three or more calendar years. Chiropractic users were more likely to be women, white, overweight, have pain, have multiple comorbid conditions, better self-rated health, access to transportation, higher physician utilization levels, live in the Midwest, and live in an area with fewer physicians per capita. Among chiropractic users, 16% had at least one year in which they exceeded Medicare's "soft cap" of 12 visits per calendar year. These over-the-cap users were more likely to have arthritis and mobility limitations, but were less likely to have a high school education. Additionally, these over-the-cap individuals accounted for 58% of total chiropractic claim volume. High volume users saw chiropractors the most among all types of providers, even more than family practice and internal medicine combined. Conclusion There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".
Collapse
Affiliation(s)
- Paula Weigel
- Department of Health Management and Policy, College of Public Health, the University of Iowa, Iowa City, Iowa, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Abstract
OBJECTIVE To examine the potential effect of 5 existing psychiatric comorbidities on postsurgical mortality. DESIGN Retrospective cohort. SETTING Intensive care units of all Veterans Health Administration hospitals designated as providing acute care. PATIENTS We studied 35 539 surgical patients admitted to intensive care units from October 1, 2003, through September 30, 2006. MAIN OUTCOME MEASURES Psychiatric comorbidity (depression, anxiety, posttraumatic stress disorder, bipolar disease, and schizophrenia) was identified using outpatient encounters in the 12 months preceding the index admission. End points included in-hospital and 30-day mortality. Generalized estimating equations accounted for hospital clustering and adjusted mortality for demographics, type of surgery, medical comorbidity, and disease severity. RESULTS We identified 8922 patients (25.1%) with an existing psychiatric comorbidity on admission. Unadjusted 30-day mortality rates were similar among patients with and without psychiatric comorbidity (3.8% vs 4.0%, P = .56). After adjustment, 30-day mortality was higher for patients with psychiatric comorbidity (odds ratio, 1.21; 95% confidence interval, 1.07-1.37; P = .003). In individual analyses, patients with depression and anxiety had higher odds of 30-day mortality (P = .01 and P = .02, respectively) but the odds were similar for the other conditions. CONCLUSION Existing psychiatric comorbidity was associated with a modest increased risk of death among postsurgical patients. Estimates of the increased risk across the individual conditions were highest for anxiety and depression. The higher mortality may reflect higher unmeasured severity or unique management issues in patients with psychiatric comorbidity.
Collapse
Affiliation(s)
- Thad E Abrams
- Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center, IA 52246-2208, USA.
| | | | | |
Collapse
|
43
|
Kaskie B, Obrizan M, Cook EA, Jones MP, Liu L, Bentler S, Wallace RB, Geweke JF, Wright KB, Chrischilles EA, Pavlik CE, Ohsfeldt RL, Rosenthal GE, Wolinsky FD. Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiaries. BMC Health Serv Res 2010; 10:173. [PMID: 20565949 PMCID: PMC2903585 DOI: 10.1186/1472-6963-10-173] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2009] [Accepted: 06/21/2010] [Indexed: 11/12/2022] Open
Abstract
Background Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization. Methods We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents ≥70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity. Results Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001). Conclusions We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.
Collapse
Affiliation(s)
- Brian Kaskie
- Department of Health Management and Policy, College of Public Health, the University of Iowa, Iowa City, Iowa, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Abrams TE, Vaughan-Sarrazin M, Rosenthal GE. Preexisting comorbid psychiatric conditions and mortality in nonsurgical intensive care patients. Am J Crit Care 2010; 19:241-9. [PMID: 20436063 DOI: 10.4037/ajcc2010967] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PURPOSE To examine the effects of preexisting comorbid psychiatric conditions on mortality in a large cohort of patients admitted to a nonsurgical intensive care unit. METHODS This retrospective cohort study involved 66,672 consecutive eligible nonsurgical patients admitted to intensive care units in 129 Veterans Health Administration hospitals during 2005 and 2006. Preexisting comorbid psychiatric conditions were identified by using diagnoses from outpatient encounters in the prior year for depression, anxiety, psychosis, bipolar disorders, and posttraumatic stress disorder. Generalized estimating equations were used to adjust the risks of in hospital and 30-day mortality for demographics, comorbid medical conditions, markers of severity, and abnormal findings on laboratory tests at admission. RESULTS Comorbid psychiatric conditions were identified in 28% (n = 18 698) of patients. Patients with preexisting comorbid psychiatric conditions had lower (P < .001) unadjusted in hospital mortality (7.3% vs 8.7%) and 30-day mortality (10.0% vs 12.8%) than did patients without such conditions. After demographics, comorbid medical conditions, and severity were adjusted for, risk of in-hospital mortality among patients with comorbid psychiatric conditions was somewhat higher (odds ratio, 1.07, 95% confidence interval, 1.01-1.14; P = .02), although differences in 30-day mortality (odds ratio, 1.01, 95% confidence interval, 0.94-1.08; P = .70) were no longer significant. CONCLUSION Preexisting comorbid psychiatric conditions are common among intensive care patients, but after comorbid medical conditions and severity were adjusted for, preexisting comorbid psychiatric conditions were not associated with a higher risk of 30-day mortality in a large national cohort of veterans.
Collapse
Affiliation(s)
- Thad E. Abrams
- Thad E. Abrams is an associate physician in internal medicine and psychiatry, Mary Vaughan-Sarrazin is an associate professor in the Department of Internal Medicine, and Gary E. Rosenthal is a professor of internal medicine and director of The Center for Research in the Implementation of Innovative Strategies in Practice at the Iowa City VA Healthcare System, Iowa City, Iowa. Dr Abrams is also an associate physician in the Department of Internal Medicine at the University of Iowa in Iowa City
| | - Mary Vaughan-Sarrazin
- Thad E. Abrams is an associate physician in internal medicine and psychiatry, Mary Vaughan-Sarrazin is an associate professor in the Department of Internal Medicine, and Gary E. Rosenthal is a professor of internal medicine and director of The Center for Research in the Implementation of Innovative Strategies in Practice at the Iowa City VA Healthcare System, Iowa City, Iowa. Dr Abrams is also an associate physician in the Department of Internal Medicine at the University of Iowa in Iowa City
| | - Gary E. Rosenthal
- Thad E. Abrams is an associate physician in internal medicine and psychiatry, Mary Vaughan-Sarrazin is an associate professor in the Department of Internal Medicine, and Gary E. Rosenthal is a professor of internal medicine and director of The Center for Research in the Implementation of Innovative Strategies in Practice at the Iowa City VA Healthcare System, Iowa City, Iowa. Dr Abrams is also an associate physician in the Department of Internal Medicine at the University of Iowa in Iowa City
| |
Collapse
|
45
|
Kaboli PJ, Glasgow JM, Jaipaul CK, Barry WA, Strayer JR, Mutnick B, Rosenthal GE. Identifying Medication Misadventures: Poor Agreement Among Medical Record, Physician, Nurse, and Patient Reports. Pharmacotherapy 2010; 30:529-38. [DOI: 10.1592/phco.30.5.529] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
46
|
Cram P, Bayman L, Popescu I, Vaughan-Sarrazin MS, Cai X, Rosenthal GE. Uncompensated care provided by for-profit, not-for-profit, and government owned hospitals. BMC Health Serv Res 2010; 10:90. [PMID: 20374637 PMCID: PMC2907758 DOI: 10.1186/1472-6963-10-90] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 04/07/2010] [Indexed: 01/28/2023] Open
Abstract
Background There is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals. Methods We used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served. Results Our cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth. Conclusions For the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.
Collapse
Affiliation(s)
- Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | | | | | | | | | | |
Collapse
|
47
|
Wolinsky FD, Bentler SE, Liu L, Jones MP, Kaskie B, Hockenberry J, Chrischilles EA, Wright KB, Geweke JF, Obrizan M, Ohsfeldt RL, Rosenthal GE, Wallace RB. Prior hospitalization and the risk of heart attack in older adults: a 12-year prospective study of Medicare beneficiaries. J Gerontol A Biol Sci Med Sci 2010; 65:769-77. [PMID: 20106961 DOI: 10.1093/gerona/glq003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old. METHODS Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect. RESULTS The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.
Collapse
Affiliation(s)
- Fredric D Wolinsky
- Department of Health Management, University of Iowa, 200 Hawkins Drive, E-205 General Hospital, Iowa City, IA 52242, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Wolinsky FD, Bentler SE, Liu L, Geweke JF, Cook EA, Obrizan M, Chrischilles EA, Wright KB, Jones MP, Rosenthal GE, Ohsfeldt RL, Wallace RB. Continuity of care with a primary care physician and mortality in older adults. J Gerontol A Biol Sci Med Sci 2009; 65:421-8. [PMID: 19995831 DOI: 10.1093/gerona/glp188] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We examined whether older adults who had continuity of care with a primary care physician (PCP) had lower mortality. METHODS Secondary analyses were conducted using baseline interview data (1993-1994) from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The analytic sample included 5,457 self-respondents 70 years old or more who were not enrolled in managed care plans. AHEAD data were linked to Medicare claims for 1991-2005, providing up to 12 years of follow-up. Two time-dependent measures of continuity addressed whether there was more than an 8-month interval between any two visits to the same PCP during the prior 2-year period. The "present exposure" measure calculated this criterion on a daily basis and could switch "on" or "off" daily, whereas the "cumulative exposure" measure reflected the percentage of follow-up days, also on a daily basis allowing it to switch on or off daily, for which the criterion was met. RESULTS Two thousand nine hundred and fifty-four (54%) participants died during the follow-up period. Using the cumulative exposure measure, 27% never had continuity of care, whereas 31%, 20%, 14%, and 8%, respectively, had continuity for 1%-33%, 34%-67%, 68%-99%, and 100% of their follow-up days. Adjusted for demographics, socioeconomic status, social support, health lifestyle, and morbidity, both measures of continuity were associated (p < .001) with lower mortality (adjusted hazard ratios of 0.84 for the present exposure measure and 0.31, 0.39, 0.46, and 0.62, respectively, for the 1%-33%, 34%-67%, 68%-99%, and 100% categories of the cumulative exposure measure). CONCLUSION Continuity of care with a PCP, as assessed by two distinct measures, was associated with substantial reductions in long-term mortality.
Collapse
Affiliation(s)
- Fredric D Wolinsky
- Departments of Health Management and Policy and General Internal Medicine, The University of Iowa, 200 Hawkins Drive, E-205 General Hospital, Iowa City, IA 52242, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Splaine ME, Ogrinc G, Gilman SC, Aron DC, Estrada CA, Rosenthal GE, Lee S, Dittus RS, Batalden PB. The Department of Veterans Affairs National Quality Scholars Fellowship Program: experience from 10 years of training quality scholars. Acad Med 2009; 84:1741-8. [PMID: 19940583 PMCID: PMC3800745 DOI: 10.1097/acm.0b013e3181bfdcef] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The Department of Veterans Affairs (VA) National Quality Scholars Fellowship Program (VAQS) was established in 1998 as a postgraduate medical education fellowship to train physicians in new methods of improving the quality and safety of health care for veterans and the nation. The VAQS curriculum is based on adult learning theory, with a national core curriculum of face-to-face components, technologically mediated distance learning components, and a unique local curriculum that draws from the strengths of regional resources. VAQS has established strong ties with other VA programs. Fellows' research and quality improvement projects are integrated with local and regional VA leaders' priorities, enhancing the relevance and visibility of the fellows' efforts and promoting recruitment of fellows to VA positions. VAQS has enrolled 98 fellows since 1999; 75 have completed the program and 24 are currently enrolled. Fellowship graduates have pursued a variety of career paths: 17% are continuing training (most in VA), 31% hold a VA faculty/staff position, 66% are academic faculty, and 80% conduct clinical or research work related to health care improvement. Graduates have held leadership positions in VA, Department of Defense, academic medicine, and public health agencies. Combining knowledge about the improvement of health care with adult learning strategies, distance learning technologies, face-to-face meetings, local mentorship, and experiential projects has been successful in improving care in VA and preparing physicians to participate in, study, and lead the improvement of health care quality and safety.
Collapse
Affiliation(s)
- Mark E Splaine
- Center for Leadership and Improvement, Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, New Hampshire 03756, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Bentler SE, Liu L, Obrizan M, Cook EA, Wright KB, Geweke JF, Chrischilles EA, Pavlik CE, Wallace RB, Ohsfeldt RL, Jones MP, Rosenthal GE, Wolinsky FD. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol 2009; 170:1290-9. [PMID: 19808632 PMCID: PMC2781759 DOI: 10.1093/aje/kwp266] [Citation(s) in RCA: 318] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 08/03/2009] [Indexed: 01/18/2023] Open
Abstract
The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Fredric D. Wolinsky
- Correspondence to Dr. Fredric D. Wolinsky, Department of Health Management and Policy, College of Public Health, University of Iowa, 200 Hawkins Drive, E-205 General Hospital, Iowa City, IA 52242 (e-mail: )
| |
Collapse
|