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Zagursky JM, Burke RE, Olson APJ, Readlynn JK. Gridlock: What hospitalists and health systems can do to help. J Hosp Med 2024. [PMID: 38606548 DOI: 10.1002/jhm.13353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Jennifer M Zagursky
- Department of Medicine, Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Cresencz VA Medical Center, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew P J Olson
- Department of Medicine, Division of Hospital Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Pediatrics, Division of Pediatric Hospital Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer K Readlynn
- Department of Medicine, Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Bressman E, Long JA, Burke RE, Ahn A, Honig K, Zee J, McGlaughlin N, Balachandran M, Asch DA, Morgan AU. Automated Text Message-Based Program and Use of Acute Health Care Resources After Hospital Discharge: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e243701. [PMID: 38564221 PMCID: PMC10988348 DOI: 10.1001/jamanetworkopen.2024.3701] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/21/2024] [Indexed: 04/04/2024] Open
Abstract
Importance Postdischarge outreach from the primary care practice is an important component of transitional care support. The most common method of contact is via telephone call, but calls are labor intensive and therefore limited in scope. Objective To test whether a 30-day automated texting program to support primary care patients after hospital discharge reduces acute care revisits. Design, Setting, and Participants A 2-arm randomized clinical trial was conducted from March 29, 2022, through January 5, 2023, at 30 primary care practices within a single academic health system in Philadelphia, Pennsylvania. Patients were followed up for 60 days after discharge. Investigators were blinded to assignment, but patients and practice staff were not. Participants included established patients of the study practices who were aged 18 years or older, discharged from an acute care hospitalization, and considered medium to high risk for adverse health events by a health system risk score. All analyses were conducted using an intention-to-treat approach. Intervention Patients in the intervention group received automated check-in text messages from their primary care practice on a tapering schedule for 30 days following discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox. Patients in the control group received a standard transitional care management telephone call from their practice within 2 business days of discharge. Main Outcomes and Measures The primary study outcome was any acute care revisit (readmission or emergency department visit) within 30 days of discharge. Results Of the 4736 participants, 2824 (59.6%) were female; the mean (SD) age was 65.4 (16.5) years. The mean (SD) length of index hospital stay was 5.5 (7.9) days. A total of 2352 patients were randomized to the intervention arm and 2384 were randomized to the control arm. There were 557 (23.4%) acute care revisits in the control group and 561 (23.9%) in the intervention group within 30 days of discharge (risk ratio, 1.02; 95% CI, 0.92-1.13). Among the patients in the intervention arm, 79.5% answered at least 1 message and 41.9% had at least 1 need identified. Conclusions and Relevance In this randomized clinical trial of a 30-day postdischarge automated texting program, there was no significant reduction in acute care revisits. Trial Registration ClinicalTrials.gov Identifier: NCT05245773.
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Affiliation(s)
- Eric Bressman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Judith A. Long
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Robert E. Burke
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Aiden Ahn
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Katherine Honig
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy McGlaughlin
- Penn Primary Care, University of Pennsylvania Health System, Philadelphia
| | - Mohan Balachandran
- Center for Health Care Innovation and Transformation, University of Pennsylvania Health System, Philadelphia
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Anna U. Morgan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Gilmartin H, Jones C, Nunnery M, Leonard C, Connelly B, Wills A, Kelley L, Rabin B, Burke RE. An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up. PLoS One 2024; 19:e0298552. [PMID: 38457367 PMCID: PMC10923440 DOI: 10.1371/journal.pone.0298552] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/25/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years. METHODS The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis. RESULTS The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time. CONCLUSIONS The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.
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Affiliation(s)
- Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Christine Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Division of Geriatric Medicine and Division of Hospital Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Mary Nunnery
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Brigid Connelly
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Ashlea Wills
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Borsika Rabin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California, United States of America
- Altman Clinical and Translational Research Institute, Dissemination and Implementation Science Center, University of California San Diego, San Diego, California, United States of America
| | - Robert E. Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States of America
- Hospital Medicine Section – Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Bressman E, Burke RE, Ryan Greysen S. Connected transitions: Opportunities and challenges for improving postdischarge care with technology. J Hosp Med 2024. [PMID: 38180274 DOI: 10.1002/jhm.13264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/05/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Eric Bressman
- Division of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert E Burke
- Division of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S Ryan Greysen
- Division of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Readlynn JK, Zagursky J, Burke RE, Lee JSG, Olson APJ. Gridlock in hospital medicine. J Hosp Med 2023. [PMID: 38085675 DOI: 10.1002/jhm.13259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Jennifer K Readlynn
- Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jennifer Zagursky
- Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Cresencz VA Medical Center, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jin Sol G Lee
- Divisions of Geriatrics, Hospital Medicine, Palliative Care and General Internal Medicine, Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - Andrew P J Olson
- Division of Hospital Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Burke RE, Pelcher L, Tjader A, Linsky AM, Thorpe CT, Turner JP, Rose L. Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations. J Gen Intern Med 2023; 38:3509-3516. [PMID: 37349639 PMCID: PMC10713889 DOI: 10.1007/s11606-023-08250-z] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans. OBJECTIVE We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D). DESIGN Retrospective cohort study from 2015 to 2019. PARTICIPANTS Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states). MAIN MEASURES Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups. KEY RESULTS The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions. CONCLUSIONS The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Lindsay Pelcher
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Andrew Tjader
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Amy M Linsky
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Justin P Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada
- Centre de Recherche, Institut Universiaire de Gériatrie de Montréal, Montréal, QC, Canada
| | - Liam Rose
- Health Economics Resource Center, Palo Alto VA Medical Center, Palo Alto, CA, USA
- Stanford Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, CA, USA
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Ryskina KL, Geng Z, Raghavan S, Waddell KJ, Burke RE. Association between Timing of Clinical Evaluation by a Physician or Advanced Practitioner and Risk of Rehospitalization in Older Adults Admitted to a Skilled Nursing Facility Following Hospitalization: A Cohort Study. J Am Med Dir Assoc 2023; 24:1881-1887. [PMID: 37837998 PMCID: PMC10840785 DOI: 10.1016/j.jamda.2023.09.004] [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: 06/01/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVES How transitional care services are provided to patients receiving post-acute care in skilled nursing facilities (SNFs) is not well understood. We aimed to determine the association of timing of physician or advanced practice provider (APP) visit after SNF admission with rehospitalization risk in a national cohort of older adults. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS 2,482,616 Medicare fee-for-service beneficiaries aged ≥66 years who entered an SNF for post-acute care following hospitalization. METHODS We measured the relative risk of being rehospitalized within 14 days of SNF admission as a function of time to the first PAP visit, using time to follow-up as a time-dependent covariate, adjusted for patient demographics and clinical characteristics. We also evaluated whether findings extended across groups with different SNF prognosis on admission. RESULTS Patients seen sooner after admission to an SNF (0-1 days) were less likely to be rehospitalized compared to patients seen later (≥2 days). The relative difference was similar across different risk groups. CONCLUSIONS AND IMPLICATIONS Timely evaluation by a physician or APP after SNF admission may protect against rehospitalization. Investment in the workforce such as training programs, practice innovations, and equitable reimbursement for SNF visits after hospital discharge may mitigate labor shortages that were exacerbated by the COVID pandemic.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Zhi Geng
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Sridharan Raghavan
- US Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, CO, USA
| | - Kimberly J Waddell
- Division of General Internal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Burke
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Prusaczyk B, Burke RE. It's time for the field of geriatrics to invest in implementation science. BMJ Qual Saf 2023; 32:700-703. [PMID: 37479476 DOI: 10.1136/bmjqs-2023-016263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Beth Prusaczyk
- Department of Medicine, Division of General Medical Sciences, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Institute for Informatics, Data Science, and Biostatistics, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Divisions of General Internal Medicine and Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Stevens-Lapsley JE, Derlein D, Churchill L, Falvey JR, Nordon-Craft A, Sullivan WJ, Forster JE, Stutzbach JA, Butera KA, Burke RE, Mangione KK. High-intensity home health physical therapy among older adult Veterans: A randomized controlled trial. J Am Geriatr Soc 2023; 71:2855-2864. [PMID: 37224397 PMCID: PMC10684313 DOI: 10.1111/jgs.18413] [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: 11/17/2022] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Older adult Veterans are at high risk for adverse health outcomes following hospitalization. Since physical function is one of the largest potentially modifiable risk factors for adverse health outcomes, our purpose was to determine if progressive, high-intensity resistance training in home health physical therapy (PT) improves physical function in Veterans more than standardized home health PT and to determine if the high-intensity program was comparably safe, defined as having a similar number of adverse events. METHODS We enrolled Veterans and their spouses during an acute hospitalization who were recommended to receive home health care on discharge because of physical deconditioning. We excluded individuals who had contraindications to high-intensity resistance training. A total of 150 participants were randomized 1:1 to either (1) a progressive, high-intensity (PHIT) PT intervention or (2) a standardized PT intervention (comparison group). All participants in both groups were assigned to receive 12 visits (3 visits/week over 30 days) in their home. The primary outcome was gait speed at 60 days. Secondary outcomes included adverse events (rehospitalizations, emergency department visits, falls and deaths after 30 and 60-days), gait speed, Modified Physical Performance Test, Timed Up-and-Go, Short Physical Performance Battery, muscle strength, Life-Space Mobility assessment, Veterans RAND 12-item Health Survey, Saint Louis University Mental Status exam, and step counts at 30, 60, 90, 180 days post-randomization. RESULTS There were no differences between groups in gait speed at 60 days, and no significant differences in adverse events between groups at either time point. Similarly, physical performance measures and patient reported outcomes were not different at any time point. Notably, participants in both groups experienced increases in gait speed that met or exceeded established clinically important thresholds. CONCLUSIONS Among older adult Veterans with hospital-associated deconditioning and multimorbidity, high-intensity home health PT was safe and effective in improving physical function, but not found to be more effective than a standardized PT program.
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Affiliation(s)
- Jennifer E Stevens-Lapsley
- Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado, USA
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Danielle Derlein
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Churchill
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Science, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Amy Nordon-Craft
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - William J Sullivan
- VA Tennessee Valley Healthcare System, Professor, Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeri E Forster
- VA Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Julie A Stutzbach
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- School of Physical Therapy, Regis University, Denver, Colorado, USA
| | - Katie A Butera
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen K Mangione
- College of Health Science, Department of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA
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Maliha G, Burke RE, Reddy YN. Peritoneal Dialysis: Are We Approaching a Modern Renaissance? Kidney360 2023; 4:e1314-e1317. [PMID: 37364586 PMCID: PMC10550002 DOI: 10.34067/kid.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023]
Affiliation(s)
- George Maliha
- Department of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert E. Burke
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yuvaram N.V. Reddy
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Gustavson AM, Miller MJ, Boening N, Wisdom JP, Burke RE, Hagedorn HJ. Applying i-PARIHS to Identify Emerging Innovations in Hospital Discharge Decision Making in Response to System Stress: A Qualitative Study. Res Sq 2023:rs.3.rs-3189638. [PMID: 37645780 PMCID: PMC10462240 DOI: 10.21203/rs.3.rs-3189638/v1] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background The purpose of this qualitative study was to use a Learning Health System approach to identify factors influencing the emergence of innovation in rehabilitation hospital discharge decision-making during the Coronavirus 2019 (COVID-19) pandemic. Methods Rehabilitation clinicians were recruited from the Veterans Affairs Health Care System and participated in individual semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Data were analyzed using a rapid qualitative, deductive team-based approach informed by directed content analysis. Results Twenty-three rehabilitation clinicians representing physical (N = 11) and occupational therapy (N = 12) participated in the study. Three primary themes were generated: (1) Recipients: innovations emerged as approaches to communicating discharge recommendations changed (in-person to virtual) and strong patient/family preferences to discharge to the home challenged collaborative goal setting; (2) Context: the ability of rehabilitation clinicians to innovate and the form of innovations were influenced by the broader hospital system, interdisciplinary team dynamics, and policy fluctuations; (3) Innovation: emerging innovations in discharge processes included perceived increases in team collaboration, shifts in caseload prioritization, and alternative options for post-acute care. Conclusions Our findings reinforce that rehabilitation clinicians developed innovative strategies to quickly adapt to multiple systems-level factors that were changing in the face of the COVID-19 pandemic. Future research is needed to assess the impact of innovations, remediate unintended consequences, and evaluate the implementation of promising innovations to respond to emerging healthcare delivery needs more rapidly.
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Kelley L, Broadfoot K, McCreight M, Wills A, Leonard C, Connelly B, Gilmartin H, Burke RE. Implementation and Evaluation of a Training Curriculum for Experienced Nurses in Care Coordination: The VA Rural Transitions Nurse Training Program. J Nurs Care Qual 2023; 38:286-292. [PMID: 36857291 PMCID: PMC10205654 DOI: 10.1097/ncq.0000000000000698] [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] [Indexed: 03/02/2023]
Abstract
BACKGROUND High-quality transitional care at discharge is essential for improved patient outcomes. Registered nurses (RNs) play integral roles in transitions; however, few receive structured training. PURPOSE We sought to create, implement, and evaluate an evidence-informed nursing transitional care coordination curriculum, the Transitions Nurse Training Program (TNTP). METHODS We conceptualized the curriculum using adult learning theory and evaluated with the New World Kirkpatrick Model. Self-reported engagement, satisfaction, acquired knowledge, and confidence were assessed using surveys. Clinical and communication skills were evaluated by standardized patient assessment and behavior sustainment via observation 6 to 9 months posttraining. RESULTS RNs reported high degrees of engagement, satisfaction, knowledge, and confidence and achieved a mean score of 92% on clinical and communication skills. Posttraining observation revealed skill sustainment (mean score 98%). CONCLUSIONS Results suggest TNTP is effective for creating engagement, satisfaction, acquired and sustained knowledge, and confidence for RNs trained in transitional care.
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Affiliation(s)
- Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Health Care System, Aurora CO, United States of America
| | - Kirsten Broadfoot
- University of Colorado School of Medicine, Center for Advancing Professional Excellence, University of Colorado Anschutz Medical Campus, Aurora CO, United States of America
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
| | - Ashlea Wills
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora CO, United States of America
| | - Brigid Connelly
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
| | - Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora CO, United States of America
- Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora CO, United States of America
| | - Robert E. Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, United States of America
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine Philadelphia PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Piazza KM, Ashcraft LE, Rose L, Hall DE, Brown RT, Bowen MEL, Mavandadi S, Brecher AC, Keddem S, Kiosian B, Long JA, Werner RM, Burke RE. Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults. Implement Sci Commun 2023; 4:57. [PMID: 37231459 PMCID: PMC10209584 DOI: 10.1186/s43058-023-00431-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/23/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults. METHODS We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions. DISCUSSION To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities. TRIAL REGISTRATION Registered 05 May 2021, at ISRCTN #60,657,985. REPORTING GUIDELINES Standards for Reporting Implementation Studies (see attached).
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Affiliation(s)
- Kirstin Manges Piazza
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA.
| | - Laura Ellen Ashcraft
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Liam Rose
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA, USA
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rebecca T Brown
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Mary Elizabeth Libbey Bowen
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Education, and Clinical Center, VISN4 Mental Illness Research, Corporal Michael JCrescenz VA Medical Center, Philadelphia, PA, USA
| | - Shahrzad Mavandadi
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- School of Nursing, University of Delaware, Newark, DE, USA
| | | | - Shimrit Keddem
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine & Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bruce Kiosian
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Judith A Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Waddell KJ, Patel MS, Wilkinson JR, Burke RE, Bravata DM, Koganti S, Wood S, Morley JF. Deploying Digital Health Technologies for Remote Physical Activity Monitoring of Rural Populations with Chronic Neurologic Disease. Arch Rehabil Res Clin Transl 2022; 5:100250. [PMID: 36968173 PMCID: PMC10036227 DOI: 10.1016/j.arrct.2022.100250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective The objective of this pilot study was to examine the feasibility of a remote physical activity monitoring program, quantify baseline activity levels, and examine predictors of activity among rurally residing adults with Parkinson disease (PD) or stroke. Design Thirty-day observational study. Participants completed standardized assessments, connected a wearable device, and synced daily step counts via a remote monitoring platform. Setting Community-based remote monitoring. Participants Rurally residing adults with PD or stroke enrolled in the Veterans Health Administration. Intervention N/A. Main Outcome Measures Feasibility was evaluated using recruitment data (response rates), study completion (completed assessments and connected the wearable device), and device adherence (days recording ≥100 steps). Daily step counts were examined descriptively. Predictors of daily steps were explored across the full sample, then by diagnosis, using linear mixed-effects regression analyses. Results Forty participants (n=20 PD; n=20 stroke) were included in the analysis with a mean (SD) age of 72.9 (7.6) years. Participants resided 252.6 (105.6) miles from the coordinating site. Recruitment response rates were 11% (PD) and 6% (stroke). Study completion rates were 71% (PD) and 80% (stroke). Device adherence rates were 97.0% (PD) and 95.2% (stroke). Participants with PD achieved a median [interquartile range] of 2618 [3896] steps per day and participants with stroke achieved 4832 [7383] steps. Age was the only significant predictor of daily steps for the full sample (-265 steps, 95% confidence interval [-407, -123]) and by diagnosis (PD, -175 steps, [-335, -15]; stroke, -357 steps [-603, -112]). Conclusions A remote physical activity monitoring program for rurally residing individuals with PD or stroke was feasible. This study establishes a model for a scalable physical activity program for rural, older populations with neurologic conditions from a central coordinating site.
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Bressman E, Long JA, Honig K, Zee J, McGlaughlin N, Jointer C, Asch DA, Burke RE, Morgan AU. Evaluation of an Automated Text Message-Based Program to Reduce Use of Acute Health Care Resources After Hospital Discharge. JAMA Netw Open 2022; 5:e2238293. [PMID: 36287564 PMCID: PMC9606844 DOI: 10.1001/jamanetworkopen.2022.38293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Posthospital contact with a primary care team is an established pillar of safe transitions. The prevailing model of telephone outreach is usually limited in scope and operationally burdensome. OBJECTIVE To determine whether a 30-day automated texting program to support primary care patients after hospital discharge is associated with reductions in the use of acute care resources. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a difference-in-differences approach at 2 academic primary care practices in Philadelphia from January 27 through August 27, 2021. Established patients of the study practices who were 18 years or older, were discharged from an acute care hospitalization, and received the usual transitional care management telephone call were eligible for the study. At the intervention practice, 604 discharges were eligible and 430 (374 patients, of whom 46 had >1 discharge) were enrolled in the intervention. At the control practice, 953 patients met eligibility criteria. The study period, including before and after the intervention, ran from August 27, 2020, through August 27, 2021. EXPOSURE Patients received automated check-in text messages from their primary care practice on a tapering schedule during the 30 days after discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox. MAIN OUTCOMES AND MEASURES The primary study outcome was any emergency department (ED) visit or readmission within 30 days of discharge. Secondary outcomes included any ED visit or any readmission within 30 days, analyzed separately, and 30- and 60-day mortality. Analyses were based on intention to treat. RESULTS A total of 1885 patients (mean [SD] age, 63.2 [17.3] years; 1101 women [58.4%]) representing 2617 discharges (447 before and 604 after the intervention at the intervention practice; 613 before and 953 after the intervention at the control practice) were included in the analysis. The adjusted odds ratio (aOR) for any use of acute care resources after implementation of the intervention was 0.59 (95% CI, 0.38-0.92). The aOR for an ED visit was 0.77 (95% CI, 0.45-1.30) and for a readmission was 0.45 (95% CI, 0.23-0.86). The aORs for death within 30 and 60 days of discharge at the intervention practice were 0.92 (95% CI, 0.23-3.61) and 0.63 (95% CI, 0.21-1.85), respectively. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that an automated texting program to support primary care patients after hospital discharge was associated with significant reductions in use of acute care resources. This patient-centered approach may serve as a model for improving postdischarge care.
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Affiliation(s)
- Eric Bressman
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Judith A. Long
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Katherine Honig
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy McGlaughlin
- Primary Care Service Line, University of Pennsylvania Health System, Philadelphia
| | - Carlondra Jointer
- Primary Care Service Line, University of Pennsylvania Health System, Philadelphia
| | - David A. Asch
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia
| | - Robert E. Burke
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Anna U. Morgan
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Landau HG, Myers JS, Burke RE, Patel N. Early Career Outcomes following a Quality Improvement Leadership Track in Graduate Medical Education. J Gen Intern Med 2022; 37:3199-3201. [PMID: 35015258 PMCID: PMC9485323 DOI: 10.1007/s11606-021-07378-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/17/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Hillary G Landau
- Internal Medicine Residency, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jennifer S Myers
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Burke
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Neha Patel
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Burke RE, Ashcraft LE, Manges K, Kinosian B, Lamberton CM, Bowen ME, Brown RT, Mavandadi S, Hall DE, Werner RM. What matters when it comes to measuring
Age‐Friendly
Health System transformation. J Am Geriatr Soc 2022; 70:2775-2785. [DOI: 10.1111/jgs.18002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/21/2022] [Accepted: 07/24/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Robert E. Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
| | - Laura Ellen Ashcraft
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Kirstin Manges
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Division of Geriatric Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Geriatrics and Extended Care Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Cait M. Lamberton
- Wharton School at the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Mary E. Bowen
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- School of Nursing University of Delaware Newark Delaware USA
| | - Rebecca T. Brown
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Division of Geriatric Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Geriatrics and Extended Care Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Shahrzad Mavandadi
- Mental Illness Research, Education, and Clinical Center Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion VA Pittsburgh Healthcare System Pittsburgh Pennsylvania USA
- Department of Surgery, School of Medicine University of Pittsburgh Medical Center (UPMC) Pittsburgh Pennsylvania USA
- Geriatrics Research Education and Clinical Center VA Pittsburgh Healthcare System Pittsburgh Pennsylvania USA
- Wolff Center at University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA
| | - Rachel M. Werner
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
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Prusaczyk B, Burke RE. Age-friendly learning health systems: Opportunities for model synergy and care improvement. J Am Geriatr Soc 2022; 70:2458-2461. [PMID: 35652488 PMCID: PMC9378562 DOI: 10.1111/jgs.17901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/10/2022] [Accepted: 05/01/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Beth Prusaczyk
- Department of Medicine, Division of General Medical Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO,Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Robert E. Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, PA,Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Manges KA, Medvedeva E, Ersek M, Burke RE. VA nursing home compare metrics as an indicator of skilled nursing facility quality for veterans. J Am Geriatr Soc 2022; 70:2269-2279. [PMID: 35678768 DOI: 10.1111/jgs.17906] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 03/18/2022] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Veterans Administration (VA) provides several post-acute care (PAC) options for Veterans, including VA-owned nursing homes (called Community Living Centers, CLCs). In 2016, the VA released CLC Compare star ratings to support decision-making. However, the relationship between CLC Compare star ratings and Veterans CLC post-acute outcomes is unknown. METHODS Retrospective observational study using national VA and Medicare data for Veterans discharged to a CLC for PAC. We used a multivariate regression model with hospital random effects to examine the association between CLC Compare overall star ratings and PAC outcomes while controlling for patient, facility, and hospital factors. Our sample included Veteran enrollees age 65+ who were community-dwelling, experienced a hospitalization, and were discharged to a CLC in 2016-2017. PAC outcomes included 30-day unplanned hospital readmission, 30-day mortality, 100-day successful community discharge, and a secondary composite outcome of unplanned readmission or death within 30-days of the hospital discharge. RESULTS Of the 25,107 CLC admissions, 4088 (16.3%) experienced an unplanned readmission, 4069 (16.2%) died within 30-days of hospital discharge, and 12,093 (48.2%) had a successful 100-day community discharge. Admission to a lower-quality (1-star) facility was associated with lower odds of successful community discharge (OR 0.78; 95% CI 0.66, 0.91) and higher odds of a combined endpoint of 30-day mortality and readmission (OR 1.27; 95% CI 1.09, 1.49), compared to 5-star facilities. However, outcomes were not consistently different between 5-star and 2, 3, or 4-star facilities. Star ratings were not associated with individual readmission or mortality outcomes when considered separately. CONCLUSION These findings suggest comparisons of 1-star and 5-star CLCs may provide meaningful information for Veterans making decisions about post-acute care. Identifying ways to alter the star ratings so they are differentially associated with outcomes meaningful to Veterans at each level is essential. We found that 1-star facilities had higher rates of 30-day unplanned hospital readmission/death, and lower rates of 100-day successful community discharges compared to 5-star facilities. Yet, like past work on CMS Nursing Home Compare ratings, these relationships were found to be inconsistent or not meaningful across all star levels. CLC Compare may provide useful information for discharge and organizational planning, with some limitations.
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Affiliation(s)
- Kirstin A Manges
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elina Medvedeva
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Mary Ersek
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Abstract
IMPORTANCE Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. OBJECTIVE To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. EXPOSURES Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. MAIN OUTCOMES AND MEASURES Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. RESULTS Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. CONCLUSIONS AND RELEVANCE In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.
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Affiliation(s)
- Pamela R. Bosch
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
| | - Amol M. Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond
- Sheltering Arms Institute, Richmond, Virginia
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff
| | - Corey R. Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Marcus Institute for Aging Research, Boston, Massachusetts
| | - Robert E. Burke
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amit Kumar
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
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Gilmartin HM, Warsavage T, Hines A, Leonard C, Kelley L, Wills A, Gaskin D, Ujano-De Motta L, Connelly B, Plomondon ME, Yang F, Kaboli P, Burke RE, Jones CD. Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study. J Hosp Med 2022; 17:149-157. [PMID: 35504490 DOI: 10.1002/jhm.12802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 09/15/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.
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Affiliation(s)
- Heather M Gilmartin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Theodore Warsavage
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Anne Hines
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Chelsea Leonard
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lynette Kelley
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Ashlea Wills
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - David Gaskin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lexus Ujano-De Motta
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Brigid Connelly
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Mary E Plomondon
- Clinical Assessment Reporting and Tracking Program, Office of Quality and Patient Safety, Veterans' Health Administration, Washington, District of Columbia, USA
| | - Fan Yang
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Peter Kaboli
- Research Department, Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Robert E Burke
- Research Department, Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Health Administration Medical Center, Philadelphia, Pennsylvania, USA
- Hospital Medicine Section - Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine D Jones
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Division of Hospital Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
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Abstract
IMPORTANCE The new Medicare Skilled Nursing Facility Value-Based Purchasing program (SNF VBP) seeks to improve patient outcomes by awarding financial incentives or penalties based on 30-day hospital readmission rates. Skilled nursing facilities (SNFs) can avoid a penalty through low baseline readmission rates or improvement over time. OBJECTIVE To assess the baseline performance and improvement over time of SNFs in the SNF VBP program. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study examined readmission rates, financial penalties and incentives, and facility and patient characteristics associated with these outcomes at 14 959 US SNFs that received Medicare payments between January 1, 2015, and December 31, 2019. MAIN OUTCOMES AND MEASURES Outcomes were readmission rates and financial penalties by facility. The SNFs were classified as improvers in the analysis if they had better improvement scores than baseline scores under the program and achievers if they had higher baseline scores than improvement scores. RESULTS Of 14 959 SNFs studied, 1849 (12.3%) were assigned their improvement score as their performance score in the first year of the program. Of these, 1167 (63.1%) received a financial penalty, whereas 374 (20.2%) received a bonus. Only 52 facilities that performed poorly at baseline (0.3% of all SNFs and 0.7% of below-median performers) were able to improve enough to avoid a financial penalty, despite large improvements in readmission rates. Improver SNFs treated larger racial minority populations (mean [SD], 74.57% [23.42%] White in the improver group vs 79.15% [22.18%] in the achiever group) and were located in counties with larger minority populations (mean [SD], 15.48% [14.05%] Black in the improver group vs 11.57% [12.72%] Black in the achiever group). The most important predictors of improvement were related to SNF finances, such as operating margin (mean [SD], -0.74 [13.87]) and occupancy rates (mean [SD], 79.93 [14.81]). CONCLUSIONS AND RELEVANCE This cross-sectional study suggests that the SNF VBP program did not offer a viable path for nearly all low-performing SNFs to avoid financial penalties through improved readmission rates.
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Affiliation(s)
- Robert E. Burke
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Yao Xu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Liam Rose
- Health Economics Resource Center, Department of Veterans Affairs, Palo Alto, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, California
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Burke RE, Hoffman ND, Guy L, Bailey J, Silver EJ. Screening, Monitoring, and Referral to Treatment for Young Adolescents at an Urban School-Based Health Center. J Sch Health 2021; 91:981-991. [PMID: 34647330 DOI: 10.1111/josh.13089] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/12/2021] [Accepted: 02/12/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND This study describes the experience of implementing a screening, monitoring, and referral to treatment (SMARTT) initiative at an urban middle school school-based health center. METHODS Retrospective data were collected for adolescents screened with the Pediatric Symptom Checklist-17-Y. At-risk adolescents having unmet health needs were offered a mental health referral, and those that declined a mental health referral were offered a primary care monitoring (PCM) visit with the medical provider. Chi-square analyses were used to evaluate differences in screening and outcomes by age, sex, and race/ethnicity. RESULTS One out of four adolescents had a positive PSC-17-Y or negative screen with other identified concerns. Approximately half of these at-risk adolescents accepted a mental health referral, and 86% of those who declined agreed to the PCM visit. More than two-thirds of the PCM group did not need continued monitoring and support at follow-up, and 85.4% of youth who had a mental health assessment accepted mental health services. CONCLUSIONS The SMARTT initiative successfully demonstrated that co-located and integrated mental health services can enhance access and connection to mental health services for at-risk youth. In addition, PCM visits were found to be an effective option for youth who declined mental health referrals.
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Affiliation(s)
- Robert E Burke
- Nurse Practitioner, , Montefiore Health System, Montefiore School Health Program, 3380 Reservoir Oval, Bronx, NY 10467
| | - Neal D Hoffman
- Associate Professor of Pediatrics, , Division of Adolescent Medicine, Albert Einstein College of Medicine, Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467
| | - Laura Guy
- Supervisor/ Program Director, , Montefiore Health System, Montefiore School Health Program, 3380 Reservoir Oval, Bronx, NY, 10467
| | - Jodi Bailey
- Director of Quality and Performance Improvement, , NYC Department of Health and Mental Hygiene, Office of School Health, Adolescent Health Unit, 30-30 47th Avenue, Long Island City, NY, 11101
| | - Ellen Johnson Silver
- Research Professor of Pediatrics, , Division of Academic General Pediatrics, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Van Etten 6B-24, Bronx, NY, 10461
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24
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Burke RE, Brown RT, Kinosian B. Selecting implementation strategies to drive Age-Friendly Health System Adoption. J Am Geriatr Soc 2021; 70:313-318. [PMID: 34651696 DOI: 10.1111/jgs.17489] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca T Brown
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Geriatric Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Geriatrics and Extended Care, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Geriatric Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Geriatrics and Extended Care, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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25
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Burke RE, Xu Y, Ritter AZ. Use of Post-Acute Care by Medicare Beneficiaries With a Diagnosis of Dementia. J Am Med Dir Assoc 2021; 23:877-879.e3. [PMID: 34644532 DOI: 10.1016/j.jamda.2021.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Hospitalized patients with dementia transitioning to post-acute care may be particularly vulnerable to changes in post-acute care utilization driven by payment reforms; however, use of post-acute care in this population is incompletely understood. We sought to describe post-acute care utilization in skilled nursing facilities (SNFs) and from home health (HH) agencies among Medicare beneficiaries with a diagnosis of dementia. DESIGN Retrospective, observational study using 100% sample of Medicare beneficiaries from 2013 to 2016. SETTING AND PARTICIPANTS We identified hospitalizations and diagnoses using Medicare Provider Analysis and Review (MedPAR), SNF stays using the Minimum Data Set, HH episodes using the Outcome and Assessment Information Set, and dementia diagnoses using the Medicare Beneficiary Summary File Chronic Conditions segment. METHODS We calculated overall utilization and trends in post-acute care use over time, stratified by dementia diagnosis, type of post-acute care (SNF vs HH), and payer (fee-for-service vs Medicare Advantage). RESULTS Of the 9,762,208 Medicare fee-for-service beneficiaries who received post-acute care from 2013 to 2016, 3,155,560 (32.3%) carried a diagnosis of dementia. Rates of post-acute care use were similar over time. More beneficiaries with a diagnosis of dementia received post-acute care (44.2% vs 27.7%) and proportionally more SNF care (71.7% vs 49.6%). Overall use and trends were similar in the Medicare Advantage population. CONCLUSIONS AND IMPLICATIONS One-third of all fee-for-service Medicare beneficiaries receiving post-acute care have a diagnosis of dementia, and more than 7 in 10 receive this care in an SNF. These findings serve as a foundation for needed evaluations of how best to meet the post-hospital needs of older adults with dementia.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA; Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Yao Xu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Z Ritter
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
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26
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Burke RE, Xu Y, Ritter AZ, Werner RM. Postacute care outcomes in home health or skilled nursing facilities in patients with a diagnosis of dementia. Health Serv Res 2021; 57:497-504. [PMID: 34389982 DOI: 10.1111/1475-6773.13855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare the outcomes of postacute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with a diagnosis of dementia. DATA SOURCES 100% MedPAR data, Minimum Data Set, and Outcome and Assessment Information Set assessment data from January 1, 2015 to December 31, 2016. STUDY DESIGN Retrospective cohort analysis using an instrumental variable design to compare outcomes (30-day readmission and mortality, 100-day mortality) of HH versus SNF following acute hospitalization. We used the differential distance between patients' home and the closest HH agency and SNF to instrument for nonrandom allocation of patients. DATA COLLECTION/EXTRACTION METHODS We identified hospital discharges followed by SNF and HH stays for Medicare fee-for-service beneficiaries with dementia. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or enrolled in hospice. We identified dementia using validated diagnostic codes with a 3-year look-back. PRINCIPAL FINDINGS Our sample included 977,946 beneficiaries with a diagnosis of dementia; 297,732 (30.4%) received HH, while 680,214 (69.6%) went to SNF. Overall, 16.8% were readmitted to the hospital and 6.1% died within 30 days, while 15.4% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two postacute care settings. CONCLUSIONS Medicare beneficiaries with a diagnosis of dementia receiving postacute care in HH or SNF experienced similar rates of readmission and mortality across settings. This finding raises important questions about current postacute care referral patterns, given 7 in 10 patients with a diagnosis of dementia in our sample were discharged to SNF.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Yao Xu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Z Ritter
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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27
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Valverde PA, Ayele R, Leonard C, Cumbler E, Allyn R, Burke RE. Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives. J Gen Intern Med 2021; 36:2251-2258. [PMID: 33532965 PMCID: PMC8342702 DOI: 10.1007/s11606-020-06511-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/01/2020] [Accepted: 12/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions. OBJECTIVE We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions. DESIGN Semi-structured interviews with interdisciplinary hospital and SNF providers. PARTICIPANTS Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6). APPROACH Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs. KEY RESULTS Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge. CONCLUSIONS As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.
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Affiliation(s)
- Patricia A Valverde
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA. .,Department of Community and Behavioral Health, Colorado School of Public Health, Aurora, CO, 80045, USA.
| | - Roman Ayele
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA.,Health Systems, Management and Policy Department, Colorado School of Public Health, Aurora, CO, USA
| | - Chelsea Leonard
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA
| | - Ethan Cumbler
- Division of Hospital Medicine, Departments of Medicine and Surgery, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Rebecca Allyn
- Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Robert E Burke
- VA Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Section of Hospital Medicine, Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Burke RE, Xu Y, Ritter AZ. Outcomes of post-acute care in skilled nursing facilities in Medicare beneficiaries with and without a diagnosis of dementia. J Am Geriatr Soc 2021; 69:2899-2907. [PMID: 34173231 DOI: 10.1111/jgs.17321] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND More than 600,000 Medicare beneficiaries with a diagnosis of dementia are discharged to skilled nursing facilities (SNFs) after hospitalization annually. However, it is unclear how their risks and benefits of a SNF stay compare to beneficiaries without a diagnosis of dementia. DESIGN Retrospective analysis comparing SNF outcomes for Medicare beneficiaries with and without a diagnosis of dementia. SETTING One hundred percent sample of Medicare beneficiaries from 2015 to 2016. PARTICIPANTS Dementia was identified using validated diagnosis codes. In beneficiaries who had an acute hospitalization followed by SNF stay, we used propensity score matching to balance demographics, comorbidities, characteristics of the index hospital stay, prior hospital and SNF utilization, and cognitive status on SNF admission. MEASUREMENTS Outcomes included unplanned hospital readmission, community discharge rate, and mortality during the SNF stay. Multivariate models were adjusted for hospital and SNF characteristics. RESULTS Our sample included 2,418,853 Medicare beneficiaries discharged from hospital to SNF; 830,524 (34.3%) carried a diagnosis of dementia. Overall, 14.7% of the sample had a hospital readmission, 5.0% died, and 61.5% were successfully discharged to the community. In the propensity-matched cohort, beneficiaries with a diagnosis of dementia had a lower odds ratio of mortality (OR 0.87; 95% confidence interval [CI] 0.86-0.89), similar odds of hospital readmission (OR 0.99; 95% CI 0.98-1.00), and reduced odds of discharge to the community (OR 0.92; 95% CI 0.91-0.93). However, these findings varied by the severity of cognitive impairment on SNF admission: in beneficiaries with no impairment, those with a diagnosis of dementia had higher odds of adverse outcomes. In beneficiaries with severe impairment, beneficiaries with a diagnosis of dementia had lower odds of adverse outcomes. CONCLUSIONS Cognitive dysfunction on SNF admission is a stronger predictor of outcomes than a diagnosis of dementia, suggesting the need to individualize decisions about the benefits and risks of SNF care in populations with cognitive impairment.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yao Xu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashley Z Ritter
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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29
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Manges KA, Wallace AS, Groves PS, Schapira MM, Burke RE. Ready to Go Home? Assessment of Shared Mental Models of the Patient and Discharging Team Regarding Readiness for Hospital Discharge. J Hosp Med 2021; 16:326-332. [PMID: 33357321 PMCID: PMC8025658 DOI: 10.12788/jhm.3464] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/08/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND A critical task of the inpatient interprofessional team is readying patients for discharge. Assessment of shared mental model (SMM) convergence can determine how much team members agree about patient discharge readiness and how their mental models align with the patient's self-assessment. OBJECTIVE Determine the convergence of interprofessional team SMMs of hospital discharge readiness and identify factors associated with these assessments. DESIGN We surveyed interprofessional discharging teams and each team's patient at time of hospital discharge using validated tools to capture their SMMs. PARTICIPANTS Discharge events (N = 64) from a single hospital consisting of the patient and their team (nurse, coordinator, physician). MEASURES Clinician and patient versions of the validated Readiness for Hospital Discharge Scales/Short Form (RHDS/SF). We measured team convergence by comparing the individual clinicians' scores on the RHDS/SF, and we measured team-patient convergence as the absolute difference between the Patient-RHDS/SF score and the team average score on the Clinician-RHDS/SF. RESULTS Discharging teams assessed patients as having high readiness for hospital discharge (mean score, 8.5 out of 10; SD, 0.91). The majority of teams had convergent SMMs with high to very high interrater agreement on discharge readiness (mean r*wg(J), 0.90; SD, 0.10). However, team-patient SMM convergence was low: Teams overestimated the patient's self-assessment of readiness for discharge in 48.4% of events. We found that teams reporting higher-quality teamwork (P = .004) and bachelor's level-trained nurses (P < .001) had more convergent SMMs with the patient. CONCLUSION Measuring discharge teams' SMM of patient discharge readiness may represent an innovative assessment tool and potential lever to improve the quality of care transitions.
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Affiliation(s)
- Kirstin A Manges
- National Clinician Scholars Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corresponding Author: Kirstin A Manges PhD, RN; ; Telephone: 231-838-3231; Twitter: @Kirstin_Manges
| | - Andrea S Wallace
- Division of Health Systems and Community Based Care, College of Nursing, University of Utah, Salt Lake City, Utah
| | | | - Marilyn M Schapira
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert E Burke
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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30
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Ayele R, Manges KA, Leonard C, Lee M, Galenbeck E, Molla M, Levy C, Burke RE. How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study. J Am Med Dir Assoc 2021; 22:1248-1254.e3. [PMID: 32943342 PMCID: PMC7956149 DOI: 10.1016/j.jamda.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/27/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Improving hospital discharge processes and reducing adverse outcomes after hospital discharge to skilled nursing facilities (SNFs) are gaining national recognition. However, little is known about how the social-contextual factors of hospitals and their affiliated SNFs may influence the discharge process and drive variations in patient outcomes. We sought to categorize contextual drivers that vary between high- and low-performing hospitals in older adult transition from hospitals to SNFs. DESIGN To identify contextual drivers, we used a rapid ethnographic approach with interviews and direct observations of hospital and SNF clinicians involved in discharging patients. We conducted thematic analysis to categorize contextual factors and compare differences in high- and low-performing sites. SETTING AND PARTICIPANTS We stratified hospitals on 30-day hospital readmission rates from SNFs and used convenience sampling to identify high- and low-performing sites and associated SNFs. The final sample included 4 hospitals (n = 2 high performing, n = 2 low performing) and affiliated SNFs (n = 5) with 148 hours of observations. MEASURES Central themes related to how contextual factors influence variations in high- and low-performing hospitals. RESULTS We identified 3 main contextual factors that differed across high- and low-performing hospitals and SNFs: team dynamics, patient characteristics, and organizational context. First, we observed high-quality communication, situational awareness, and shared mental models among team members in high-performing sites. Second, the types of patients cared for at high-performing hospitals had better insurance coverage that made it feasible for clinicians to place patients based on their needs instead of financial abilities. Third, at high-performing hospitals a more engaged staff in the transition process and building rapport with SNFs characterized smooth transitions from hospitals to SNFs. CONCLUSIONS AND IMPLICATIONS Contextual factors distinguish high- and low-performing hospitals in transitions to SNF and can be used to develop interventions to reduce adverse outcomes in transitions.
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Affiliation(s)
- Roman Ayele
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA; University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| | - Kirstin A Manges
- National Clinician Scholar, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Chelsea Leonard
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Marcie Lee
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Emily Galenbeck
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Mithu Molla
- Hospital Medicine Section, UC Davis Health System, Sacramento, CA, USA
| | - Cari Levy
- Denver-Seattle Center of Innovation, Eastern Colorado Healthcare System, Aurora, CO, USA; University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Robert E Burke
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA
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Affiliation(s)
- Robert E Burke
- Section of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA .,Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsyllvania, Philadelphia, PA, USA
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Albinusdreef, Leiden, The Netherlands
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Leonard C, Gilmartin H, McCreight M, Kelley L, Mayberry A, Burke RE. Training registered nurses to conduct pre-implementation assessment to inform program scale-up: an example from the rural Transitions Nurse Program. Implement Sci Commun 2021; 2:28. [PMID: 33685521 PMCID: PMC7938579 DOI: 10.1186/s43058-021-00127-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 07/24/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Adapting evidence-based practices to local settings is critical for successful implementation and dissemination. A pre-implementation assessment evaluates local context to inform implementation, but there is little published guidance for clinician-implementers. The rural Transitions Nurse Program (TNP) is a care coordination intervention that facilitates care transitions for rural veterans. In year 1 of TNP, pre-implementation assessments were conducted by a centralized project team through multi-day visits at five sites nationwide. In year 2, we tested if local site TNP nurses could conduct pre-implementation assessments using evidence-based tools and coaching from the TNP team. This required developing a multicomponent pre-implementation strategy bundle to guide data collection and synthesis. We hypothesized that (1) nurses would find the pre-implementation assessment useful for tailoring TNP to local contexts and (2) nurses would identify similar barriers and facilitators to those identified at first year sites. METHODS The bundle included guides for conducting key informant interviews, brainwriting, process mapping, and reflective journaling. We evaluated TNP nurse satisfaction and perceived utility of the structure and process of the training and bundle through pre-post surveys. To assess the outcome of data collection efforts, we interviewed nurses 4 months after completion of the pre-implementation assessment to determine if and how they used pre-implementation findings to tailor implementation of TNP to local contexts. To further assess outcomes, all data that the nurses collected were analyzed thematically. Themes related to barriers and facilitators were compared across years. FINDINGS Five nurses at different VA medical centers used the pre-implementation strategy bundle to collect site-level data and completed pre-post surveys. Findings indicated that the pre-implementation assessment was highly recommended, and the bundle provided adequate training. Nurses felt that pre-implementation work oriented them to the local context and illustrated how to integrate TNP into existing processes. Barriers and facilitators identified by nurses were similar to those collected in year 1 by the TNP research team, including communication challenges, need for buy-in, and logistical concerns. CONCLUSIONS This proof-of-concept study suggests that evidence-based tools can effectively guide clinician-implementers through the process of conducting a pre-implementation assessment. This approach positively informed TNP implementation and oriented nurses to their local context prior to implementation.
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Affiliation(s)
- Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA.
| | - Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA.,Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Ashlea Mayberry
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Hospital Medicine Section, Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Abstract
IMPORTANCE Decreasing use of low-value care is a major goal for Medicare given the potential to decrease costs and harms. Compared with traditional fee-for-service Medicare (TM), Medicare Advantage (MA) is more strongly financially incentivized to decrease use of low-value care. OBJECTIVES To compare use of low-value care among individuals enrolled in TM and those enrolled in MA overall and to examine trends in use of low-value care in both programs from 2006 to 2015. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed individuals enrolled in TM and MA using data from the 2006 to 2015 Medical Expenditure Panel Survey. To account for differences in characteristics between individuals enrolled in TM and those enrolled in MA, a propensity score-based approach was used. Data were analyzed from August 2020 through January 2021. EXPOSURES Being enrolled in MA or TM. MAIN OUTCOMES AND MEASURES Binary measures of use were collected for 13 low-value services in 4 categories (ie, [1] cancer screening: cervical, colorectal, and prostate cancer screening in older adults; [2] antibiotic use: antibiotic for acute upper respiratory infection and antibiotic for influenza; [3] medication: anxiolytic, sedative, or hypnotic in an adult older than 65 years; benzodiazepine for depression; opioid for headache; opioid for back pain; and nonsteroidal anti-inflammatory drug [NSAID] for hypertension, heart failure, or chronic kidney disease; and [4] imaging: magnetic resonance imaging [MRI] or computed tomography [CT] for back pain, radiograph for back pain, and MRI or CT for headache) and 4 low-value composites corresponding to the categories (ie, cancer screening composite, antibiotic use composite, medication composite, and imaging composite). RESULTS Among 11 677 individuals enrolled in TM and 5164 individuals enrolled in MA, 9429 (56.0%) were women and the mean (SD) age was 74.5 (6.3) years. Of 13 low-value services and 4 low-value composites, statistically significant differences were found in 2 measures. For the low-value medication composite, 2054 of 11 636 eligible individuals enrolled in TM (adjusted mean, 17.6%; 95% CI, 16.8%-18.3%) received the care, and 981 of 5141 eligible individuals enrolled in MA (adjusted mean, 19.7%; 95% CI, 18.3%-21.2%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.2 percentage points (95% CI, 0.5-3.8 percentage points; P = .02). For the NSAID use for hypertension, heart failure, or kidney disease metric, 807 of 7832 individuals enrolled in TM (adjusted mean, 10.0%; 95% CI, 9.2%-10.8%) received the care, and 447 of 3566 individuals enrolled in MA (adjusted mean, 12.9%; 95% CI, 19.7%-27.1%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.9 percentage points (95% CI, 1.3-4.6 percentage points; P = .001). Overall, there were no decreases in use of low-value care in TM or MA over time. CONCLUSIONS AND RELEVANCE This cross-sectional study found that use of low-value care was similarly prevalent in MA and TM, suggesting that MA enrollment was not associated with decreased provision of low-value care compared with TM.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Jeah Jung
- Department of Health Policy and Administration, College of Health and Human Development, Pennsylvania State University, University Park
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle
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Abstract
OBJECTIVE The objective of this study was to analyze new telehealth benefits offered by Medicare Advantage (MA) plans in 2020 and examine plan characteristics associated with the provision of the new telehealth benefits. RESEARCH DESIGN Using publicly available data from the Centers for Medicare and Medicaid Services, we identified unique MA plans with at least 1 enrollee in January 2020. We examined whether plans offered any new telehealth benefits in 2020, the 20 most common types of telehealth services covered, and cost-sharing. Next, we used multivariable logistic regression to identify associations between offering any telehealth benefits and plan characteristics. We conducted a similar analysis for each of the 3 most commonly covered telehealth services. RESULTS Of 2992 unique MA plans, 58.1% offered new telehealth benefits in 2020. The most frequently covered services were primary care, mental health, and urgent care. Coverage for other types of services was limited. Our multivariable logistic regression showed that offering any new telehealth benefits was not more common among plans in rural areas, but was more likely among national plans, those with a monthly premium, those with >3540 enrollees, and those with a star rating of 4.0-4.5. The new telehealth benefits were less likely to be provided by for-profit plans. Overall, findings remained similar when analyzed according to the type of services. CONCLUSIONS MA plans are embracing new telehealth benefits, but there is room for improvement. Policymakers should consider how to accelerate the adoption curve of telehealth in MA plans.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University
| | - Brent A Langellier
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
- Research at the Hospital Medical Section, University of Pennsylvania, Philadelphia, PA
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Burke RE, Canamucio A, Medvedeva E, Hume EL, Navathe AS. Association of Discharge to Home vs Institutional Postacute Care With Outcomes After Lower Extremity Joint Replacement. JAMA Netw Open 2020; 3:e2022382. [PMID: 33095251 PMCID: PMC7584947 DOI: 10.1001/jamanetworkopen.2020.22382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Changes in financial incentives have led to more patients being discharged home than to institutional forms of postacute care, such as skilled nursing facilities (SNFs), after elective lower extremity total joint replacement (LEJR). OBJECTIVE To evaluate the association of this change with hospital readmissions, surgical complications, and mortality. DESIGN, SETTING, AND PARTICIPANTS This cohort study used cross-temporal propensity-matching to identify 104 828 adult patients who were discharged home following LEJR between 2016 and 2018 (after changes in financial incentives) and 84 121 adult patients discharged to institutional forms of postacute care (eg, SNFs) between 2011 and 2013 (before changes in financial incentives). A difference-in-differences design was used to compare differences in outcomes between these groups to a propensity-matched group of patients discharged to institutional postacute care in both periods. Data were collected from Pennsylvania all-payer claims database, which includes all surgical procedures and hospitalizations across payers and hospitals in Pennsylvania. Data were analyzed between August 2019 and February 2020. EXPOSURES Type of postacute care (home, including home with home health vs institutional postacute care, including SNF, inpatient rehabilitation facilities, and long-term acute care hospitals). MAIN OUTCOMES AND MEASURES Main outcomes were 30- and 90-day hospital readmissions, LEJR complication rates, and mortality rates. RESULTS Of 189 949 patients, 113 981 (60.0%) were women, and 83 444 (43.9%) were aged 40 to 64 years. The rate of discharge home increased from 63.6% (54 097 of 85 121) in 2011 to 2013 to 78.4% (82 199 of 104 828) in 2016 to 2018. In the adjusted difference-in-differences comparison, matched patients discharged home in 2016 to 2018 had significantly lower 30-day (difference, -2.9%; 95% CI, -4.2% to -1.6%) and 90-day (difference, -3.9%; 95% CI, -5.8% to -2.0%) readmission rates compared with similar patients sent to institutional postacute care in 2011 to 2013. Surgical complication and mortality rates were unchanged. Results were similar across payers and across hospital bundled payment participation status. CONCLUSIONS AND RELEVANCE In this cohort study, increases in discharges home following LEJR surgery did not seem to be associated with increased harm during a period in which changes in financial incentives likely spurred observed changes in postacute care.
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Affiliation(s)
- Robert E. Burke
- Center for Health Equity Research and Promotion, Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Anne Canamucio
- Center for Health Equity Research and Promotion, Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Elina Medvedeva
- Center for Health Equity Research and Promotion, Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Eric L. Hume
- Department of Orthopaedic Surgery, University of Pennsylvania, Penn Musculoskeletal Center, Philadelphia
| | - Amol S. Navathe
- Center for Health Equity Research and Promotion, Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Manges KA, Ayele R, Leonard C, Lee M, Galenbeck E, Burke RE. Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach. BMJ Qual Saf 2020; 30:648-657. [PMID: 32958550 DOI: 10.1136/bmjqs-2020-011204] [Citation(s) in RCA: 3] [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] [Received: 03/20/2020] [Revised: 07/07/2020] [Accepted: 08/02/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite the increased focus on improving patient's postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between hospital-SNF pairs with high or low 30-day readmission rates. DESIGN We used a rapid ethnographic approach with intensive multiday observations and key informant interviews at high-performing and low-performing hospitals, and their most commonly used SNF. We used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals. SETTING AND PARTICIPANTS Hospitals were classified as high or low performers based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals (n=2 high performing, n=2 low performing) and corresponding SNFs (n=5). FINDINGS We identified variation in five major processes prior to SNF discharge that could affect care transitions: recognising need for postacute care, deciding level of care, selecting an SNF, negotiating patient fit and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: (1) earlier, ongoing, systematic identification of high-risk patients; (2) discussing the decision to go to an SNF as an iterative team-based process and (3) anticipating barriers with knowledge of transitional and SNF care processes. CONCLUSION Identifying variations in processes used to prepare patients for SNF provides critical insight into the best practices for transitioning patients to SNFs and areas to target for improving care of high-risk patients.
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Affiliation(s)
- Kirstin A Manges
- National Clinician Scholar, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA .,Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Roman Ayele
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Chelsea Leonard
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Marcie Lee
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Emily Galenbeck
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Section of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Stutzbach J, Jones J, Taber A, Recicar J, Burke RE, Stevens-Lapsley J. Systems Approach Is Needed for In-Hospital Mobility: A Qualitative Metasynthesis of Patient and Clinician Perspectives. Arch Phys Med Rehabil 2020; 102:984-998. [PMID: 32966808 DOI: 10.1016/j.apmr.2020.09.370] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/21/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To describe how different key stakeholders (ie, interprofessional clinical care team and patients) perceive their role in promoting in-hospital mobility by systematically synthesizing qualitative literature. DATA SOURCES PubMed, Ovid MEDLINE, Ovid PsychInfo, and Cumulative Index to Nursing and Allied Health were searched using terms relevant to mobility, hospitalization, and qualitative research. A total of 510 unique articles were retrieved and screened for eligibility. STUDY SELECTION Eligible qualitative studies included stakeholder perspectives on in-hospital mobility, including patients, nursing staff, rehabilitation staff, and physicians. Eleven articles remained after inclusion/exclusion criteria were applied. DATA EXTRACTION At least 2 authors independently read, coded, and derived themes from each study. We used a team-based inductive approach to thematic synthesis informed by critical realism and the socioecological model. Reciprocal translation unified convergent and divergent constructs across primary studies. Investigator triangulation enhanced interpretation. DATA SYNTHESIS Three primary themes emerged: (1) patient, family, and clinician expectations shape roles in in-hospital mobility; (2) stakeholders' role in mobility depends on hospital environment, infrastructure, culture, and resources; and (3) teamwork creates successful in-hospital mobility, but lack of coordination and cooperation leads to delay in mobilizing. Studies suggested that while mobility is an essential construct in the professional role of clinicians and in the personal identity of patients, the ability of stakeholders to realize their role in mobility is highly dependent on the hospital physical and cultural environment, administrative support, clarity in professional roles, and teamwork. CONCLUSIONS Interventions designed to address the problem of low hospital mobility should take a systems approach and consider allocation of resources, clarity around professional responsibilities, and elevation of patient and clinician expectations surrounding mobility.
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Affiliation(s)
- Julie Stutzbach
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado.
| | - Jacqueline Jones
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Anna Taber
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado; College of Nursing, Nevada State College, Henderson, Nevada
| | - John Recicar
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado; Trauma and Burn Program, Children's Hospital Colorado, Aurora, Colorado
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania; Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Perelman School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado; Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC), Aurora, Colorado
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Park S, Langellier BA, Burke RE, Figueroa JF, Coe NB. Association of Medicare Advantage Penetration With Per Capita Spending, Emergency Department Visits, and Readmission Rates Among Fee-for-Service Medicare Beneficiaries With High Comorbidity Burden. Med Care Res Rev 2020; 78:703-712. [PMID: 32842874 DOI: 10.1177/1077558720952582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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
Rapid growth of Medicare Advantage (MA) plans has the potential to change clinical practice for both MA and fee-for-service (FFS) beneficiaries, particularly for high-need, high-cost beneficiaries with multiple chronic conditions or a costly single condition. We assessed whether MA growth from 2010 to 2017 spilled over to county-level per capita spending, emergency department visits, and readmission rates among FFS beneficiaries, and how much this varied by the comorbidity burden of the beneficiary. We also examined whether the association between MA growth and per capita spending in FFS varied in beneficiaries with specific chronic conditions. MA growth was associated with decreased FFS spending and emergency department visits only among beneficiaries with six or more chronic conditions. MA growth was associated with decreased FFS spending among beneficiaries with 11 of the 20 chronic conditions. This suggests that MA growth may drive improvements in efficiency of health care delivery for high-need, high-cost beneficiaries.
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Affiliation(s)
| | | | - Robert E Burke
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,University of Pennsylvania, Philadelphia, PA, USA
| | - Jose F Figueroa
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard University, Boston, MA, USA
| | - Norma B Coe
- University of Pennsylvania, Philadelphia, PA, USA
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McCreight MS, Rabin BA, Glasgow RE, Ayele RA, Leonard CA, Gilmartin HM, Frank JW, Hess PL, Burke RE, Battaglia CT. Using the Practical, Robust Implementation and Sustainability Model (PRISM) to qualitatively assess multilevel contextual factors to help plan, implement, evaluate, and disseminate health services programs. Transl Behav Med 2020; 9:1002-1011. [PMID: 31170296 DOI: 10.1093/tbm/ibz085] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [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] [Indexed: 01/17/2023] Open
Abstract
There is consensus in dissemination and implementation (D&I) science that addressing contextual factors is critically important for understanding translation of health care delivery interventions but little agreement on which contextual factors are key determinants of implementation outcomes. We describe the application of the Practical Robust Implementation and Sustainability Model (PRISM), which expands the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to identify contextual factors across four diverse programs. Multiple qualitative methods were used to collect multilevel, multistakeholder perspectives from the adopting organizations and staff. We identified measures for evaluating context through the various domains of PRISM to guide health services research across the phases of program implementation. The PRISM domains of Recipients, Implementation and Sustainability Infrastructure, and External Environment identified important multilevel contextual factors, including variability in operational processes and available resources. These domains helped to facilitate planning and implementation phases of the four interventions and guide purposeful adaptations. We found assessments of PRISM domains useful to systematically assess multilevel contextual factors across various content areas as well as phases of program implementation. Additionally, these contextual factors were found to be relevant to RE-AIM outcomes. Lessons learned can be applied to future research as there is a need to investigate the measurement properties of PRISM and continue to test which contextual factors are most important to successful implementation and for which outcomes.
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Affiliation(s)
- Marina S McCreight
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Research Service, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Borsika A Rabin
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Department of Family Medicine and Public Health, School of Medicine, University of California San Diego, La Jolla, CA, USA
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, CO, USA
- Department of Family Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Russell E Glasgow
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, CO, USA
- Department of Family Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Roman A Ayele
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Research Service, VA Eastern Colorado Health Care System, Aurora, CO, USA
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Chelsea A Leonard
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Research Service, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Heather M Gilmartin
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Research Service, VA Eastern Colorado Health Care System, Aurora, CO, USA
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Joseph W Frank
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Research Service, VA Eastern Colorado Health Care System, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Paul L Hess
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Research Service, VA Eastern Colorado Health Care System, Aurora, CO, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA
- Section of Hospital Medicine, Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Catherine T Battaglia
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Research Service, VA Eastern Colorado Health Care System, Aurora, CO, USA
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Burke RE, Canamucio A, Medvedeva E, Manges KA, Ersek M. External Validation of the Skilled Nursing Facility Prognosis Score for Predicting Mortality, Hospital Readmission, and Community Discharge in Veterans. J Am Geriatr Soc 2020; 68:2090-2094. [DOI: 10.1111/jgs.16650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Robert E. Burke
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Anne Canamucio
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Elina Medvedeva
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Kirstin A. Manges
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
- National Clinician Scholars Program University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Mary Ersek
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
- University of Pennsylvania School of Nursing Philadelphia Pennsylvania USA
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Falvey JR, Burke RE, Ridgeway KJ, Malone DJ, Forster JE, Stevens-Lapsley JE. Involvement of Acute Care Physical Therapists in Care Transitions for Older Adults Following Acute Hospitalization: A Cross-sectional National Survey. J Geriatr Phys Ther 2020. [PMID: 29533283 DOI: 10.1519/jpt.0000000000000187] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Recent evidence has suggested physical therapist involvement in care transitions after hospitalization is associated with reduced rates of hospital readmissions. However, little is known about how physical therapists participate in care transitions for older adults, the content of care communications, and the facilitators and barriers of implementing evidence-based care transition strategies into practice. Thus, the purpose of this article is to evaluate participation in care transition activities known to influence readmission risk among older adults, and understand perceptions of and barriers to participation in these activities. METHODS We developed a survey questionnaire to quantify hospital-based physical therapist participation in care transitions and validated it using cognitive interviewing. It was introduced to a cross-sectional national sample of physical therapists who participate in the Academy of Acute Care Physical Therapy electronic discussion board using a SurveyMonkey tool. RESULTS AND DISCUSSION More than 90% of respondents agreed they routinely recommended a discharge location and provided recommendations for durable medical equipment for patients at the time of hospital discharge. Respondents did not routinely initiate communication with therapists in other care settings, or follow up with patients to determine whether recommendations were followed. A majority of respondents agreed their facilities would not consider many key care transition activities to count as productive time.This survey provides a novel insight into how hospital-based physical therapists participate in care transitions. Communications between rehabilitation providers across care settings are infrequent, even though those communications are recommended to help reduce readmissions. However, administrative barriers were elucidated in this study that may help explain lack of therapist involvement. CONCLUSIONS Physical therapists' communications across health care setting about older adults discharging from acute care hospitalization are infrequent, but may represent a meaningful intervention target for future studies. Future research is needed to evaluate best practices for hospital-based physical therapists during care transitions.
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Affiliation(s)
- Jason R Falvey
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora
| | - Robert E Burke
- Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Kyle J Ridgeway
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora
| | - Daniel J Malone
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora
| | - Jeri E Forster
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora.,Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora.,Veterans Affairs Geriatric Research, Education and Clinical Center, Denver, Colorado
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Jones CD, Nearing KA, Burke RE, Lum HD, Boxer RS, Stevens-Lapsley JE, Ozkaynak M, Levy CR. "What Would It Take to Transform Post-Acute Care?" 2019 Conference Proceedings on Re-envisioning Post-Acute Care. J Am Med Dir Assoc 2020; 21:1012-1014. [PMID: 32192872 DOI: 10.1016/j.jamda.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/23/2020] [Accepted: 02/03/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO.
| | - Kathryn A Nearing
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Eastern Colorado VA Geriatric Research Education and Clinical Center, Aurora, CO
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA; Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Eastern Colorado VA Geriatric Research Education and Clinical Center, Aurora, CO
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jennifer E Stevens-Lapsley
- Eastern Colorado VA Geriatric Research Education and Clinical Center, Aurora, CO; Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cari R Levy
- Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO; Division of Health Care Policy and Research, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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Ayele RA, Lawrence E, McCreight M, Fehling K, Glasgow RE, Rabin BA, Burke RE, Battaglia C. Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System. J Hosp Med 2020; 15:133-139. [PMID: 31634102 PMCID: PMC7064299 DOI: 10.12788/jhm.3320] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/13/2019] [Accepted: 08/27/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Veterans with healthcare needs utilize both Veterans Health Administration (VA) and non-VA hospitals. These dual-use veterans are at high risk of adverse outcomes due to the lack of coordination for safe transitions. OBJECTIVES The aim of this study was to understand the barriers and facilitators to providing high-quality continuum of care for veterans transitioning from non-VA hospitals to the VA primary care setting. DESIGN Guided by the practical robust implementation and sustainability model (PRISM) and the ideal transitions of care, we conducted a qualitative assessment using semi-structured interviews with clinicians, staff, and patients. SETTING This study was conducted at a single urban VA medical center and two non-VA hospitals. PARTICIPANTS A total of 70 participants, including 52 clinicians and staff (23 VA and 29 non-VA) involved in patient transition and 18 veterans recently discharged from non-VA hospitals, were included in this study. APPROACH Data were analyzed using a conventional content analysis and managed in Atlas.ti (Berlin, Germany). RESULTS Four major themes emerged where participants consistently discussed that transitions were delayed when they were not able to (1) identify patients as veterans and notify VA primary care of discharge, (2) transfer non-VA hospital medical records to VA primary care, (3) obtain follow-up care appointments with VA primary care, and (4) write VA formulary medications for veterans that they could fill at VA pharmacies. Participants also discussed factors involved in smooth transition and recommendations to improve care coordination. CONCLUSIONS All participants perceived the current transition-of-care process across healthcare systems to be inefficient. Efforts to improve quality and safety in transitional care should address the challenges clinicians and patients experience when transitioning from non-VA hospitals to VA primary care.
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Affiliation(s)
- Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- Corresponding Author: Roman A. Ayele; E-mail: ; Telephone: (720) 857-5907
| | - Emily Lawrence
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Marina McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Kelty Fehling
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Russell E Glasgow
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Borsika A Rabin
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- University of California San Diego, San Diego, California
| | - Robert E Burke
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- VA Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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Kumar A, Rivera-Hernandez M, Karmarkar AM, Chou LN, Kuo YF, Baldwin JA, Panagiotou OA, Burke RE, Ottenbacher KJ. Social and Health-Related Factors Associated with Enrollment in Medicare Advantage Plans in Older Adults. J Am Geriatr Soc 2020; 68:313-320. [PMID: 31617948 PMCID: PMC7015142 DOI: 10.1111/jgs.16202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 03/25/2019] [Revised: 08/29/2019] [Accepted: 09/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We assessed the characteristics of older Mexican American enrollees in traditional fee-for-service (FFS) and Medicare Advantage (MA) plans and the factors associated with disenrollment from FFS and enrollment in MA plans. DESIGN Longitudinal study linked with Medicare claims data. SETTING The Hispanic Established Populations for the Epidemiologic Study of the Elderly. PARTICIPANTS Community-dwelling Mexican American older adults (N = 1455). MEASUREMENTS We examined insurance status using the Medicare Beneficiary Summary File and estimated the association of sociodemographic and clinical factors with insurance plan switching. RESULTS Among Mexican American older adults, FFS enrollees were more likely to be born in Mexico, speak Spanish, have lower levels of education, and have more disability than MA enrollees. Older adults with a larger number of limitations of instrumental activities of daily living (odds ratio [OR] = .50; 95% confidence interval [CI] = .26-.98) and more social support (OR = .70; 95% CI = .45-.98) were less likely to switch from FFS to MA compared with older adults with no limitations and less social support. Additionally, older adults living in counties with a greater number of MA plans were more likely to switch from FFS to MA (OR = 2.1; 95% CI = 1.45-3.16), compared with counties with a lower number of MA plans. In counties with a higher number of MA plans, older adults with more social support had lower odds of switching from FFS to MA (OR = .48; 95% CI = .28-.82) compared with older adults with less social support. CONCLUSION Compared with those enrolled in MA, older Mexican American adults enrolled in Medicare FFS are more socioeconomically disadvantaged and more likely to demonstrate poor health status. Stronger social support and increased physical limitations were strongly associated with less frequent switching from FFS to MA plans. Additionally, increased availability of MA plans at the county level is a significant driver of enrollment in MA plans. J Am Geriatr Soc 68:313-320, 2020.
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Affiliation(s)
- Amit Kumar
- College of Health and Human Services, Northern Arizona University, Flagstaff, AZ
- Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Amol M. Karmarkar
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA
| | - Lin-Na Chou
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Julie A. Baldwin
- College of Health and Human Services, Northern Arizona University, Flagstaff, AZ
- Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ
| | - Orestis A. Panagiotou
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kenneth J. Ottenbacher
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
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Gilmartin HM, Liu VX, Burke RE. Web Exclusive. Annals for Hospitalists Inpatient Notes - The Role of Hospitalists in the Creation of Learning Healthcare Systems. Ann Intern Med 2020; 172:HO2-HO3. [PMID: 31958842 PMCID: PMC7549378 DOI: 10.7326/m19-3873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Vincent X Liu
- Kaiser Permanente Division of Research, Oakland, California (V.X.L.)
| | - Robert E Burke
- Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania (R.E.B.)
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Aimé P, Karuppagounder SS, Rao A, Chen Y, Burke RE, Ratan RR, Greene LA. The drug adaptaquin blocks ATF4/CHOP-dependent pro-death Trib3 induction and protects in cellular and mouse models of Parkinson's disease. Neurobiol Dis 2020; 136:104725. [PMID: 31911115 PMCID: PMC7545957 DOI: 10.1016/j.nbd.2019.104725] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [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: 10/30/2019] [Revised: 12/18/2019] [Accepted: 12/31/2019] [Indexed: 12/19/2022] Open
Abstract
Identifying disease-causing pathways and drugs that target them in Parkinson’s disease (PD) has remained challenging. We uncovered a PD-relevant pathway in which the stress-regulated heterodimeric transcription complex CHOP/ATF4 induces the neuron prodeath protein Trib3 that in turn depletes the neuronal survival protein Parkin. Here we sought to determine whether the drug adaptaquin, which inhibits ATF4-dependent transcription, could suppress Trib3 induction and neuronal death in cellular and animal models of PD. Neuronal PC12 cells and ventral midbrain dopaminergic neurons were assessed in vitro for survival, transcription factor levels and Trib3 or Parkin expression after exposure to 6-hydroxydopamine or 1-methyl-4-phenylpyridinium with or without adaptaquin co-treatment. 6-hydroxydopamine injection into the medial forebrain bundle was used to examine the effects of systemic adaptaquin on signaling, substantia nigra dopaminergic neuron survival and striatal projections as well as motor behavior. In both culture and animal models, adaptaquin suppressed elevation of ATF4 and/or CHOP and induction of Trib3 in response to 1-methyl-4-phenylpyridinium and/or 6-hydroxydopamine. In culture, adaptaquin preserved Parkin levels, provided neuroprotection and preserved morphology. In the mouse model, adaptaquin treatment enhanced survival of dopaminergic neurons and substantially protected their striatal projections. It also significantly enhanced retention of nigrostriatal function. These findings define a novel pharmacological approach involving the drug adaptaquin, a selective modulator of hypoxic adaptation, for suppressing Parkin loss and neurodegeneration in toxin models of PD. As adaptaquin possesses an oxyquinoline backbone with known safety in humans, these findings provide a firm rationale for advancing it towards clinical evaluation in PD.
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Affiliation(s)
- Pascaline Aimé
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University Medical Center, 650 W. 168(th) Street, New York, NY 10032, USA; The Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University, 650 W. 168(th) Street, New York, NY 10032, USA
| | - Saravanan S Karuppagounder
- Burke Neurological Institute, 785 Mamaroneck Ave, White Plains, NY 10605, USA; Feil Family Brain and Mind Research Institute, Weill Medical College of Cornell University, 407 E. 61st Street, New York, NY 10065, USA
| | - Apeksha Rao
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University Medical Center, 650 W. 168(th) Street, New York, NY 10032, USA
| | - Yingxin Chen
- Burke Neurological Institute, 785 Mamaroneck Ave, White Plains, NY 10605, USA; Feil Family Brain and Mind Research Institute, Weill Medical College of Cornell University, 407 E. 61st Street, New York, NY 10065, USA
| | - Robert E Burke
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University Medical Center, 650 W. 168(th) Street, New York, NY 10032, USA; Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Medical Center, 650 W. 168(th) Street, New York, NY 10032, USA
| | - Rajiv R Ratan
- Burke Neurological Institute, 785 Mamaroneck Ave, White Plains, NY 10605, USA; Feil Family Brain and Mind Research Institute, Weill Medical College of Cornell University, 407 E. 61st Street, New York, NY 10065, USA
| | - Lloyd A Greene
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University Medical Center, 650 W. 168(th) Street, New York, NY 10032, USA; The Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University, 650 W. 168(th) Street, New York, NY 10032, USA.
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Burke RE, Leonard C, Lee M, Ayele R, Cumbler E, Allyn R, Greysen SR. Cognitive Biases Influence Decision-Making Regarding Postacute Care in a Skilled Nursing Facility. J Hosp Med 2020; 15:22-27. [PMID: 31433771 PMCID: PMC6932595 DOI: 10.12788/jhm.3273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 03/18/2019] [Revised: 05/28/2019] [Accepted: 06/23/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Decisions about postacute care are increasingly important as the United States population ages, its use becomes increasingly common, and payment reforms target postacute care. However, little is known about how to improve these decisions. OBJECTIVE To understand whether cognitive biases play an important role in patient and clinician decision-making regarding postacute care in skilled nursing facilities (SNFs) and identify the most impactful biases. DESIGN Secondary analysis of 105 semistructured interviews with patients, caregivers, and clinicians. SETTING Three hospitals and three SNFs in a single metropolitan area. PATIENTS Adults over age 65 discharged to SNFs after hospitalization as well as patients, caregivers, and multidisciplinary frontline clinicians in both hospital and SNF settings. MEASUREMENTS We identified potential cognitive biases from prior systematic and narrative reviews and conducted a team-based framework analysis of interview transcripts to identify potential biases. RESULTS Authority bias/halo effect and framing bias were the most prevalent and seemed the most impactful, while default/status quo bias and anchoring bias were also present in decision-making about SNFs. CONCLUSIONS Cognitive biases play an important role in decision-making about postacute care in SNFs. The combination of authority bias/halo effect and framing bias may synergistically increase the likelihood of patients accepting SNFs for postacute care. As postacute care undergoes a transformation spurred by payment reforms, it is increasingly important to ensure that patients understand their choices at hospital discharge and can make high-quality decisions consistent with their goals.
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Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion (CHERP); Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chelsea Leonard
- Center of Innovation for Veteran-Centered and Value-Driven Care; Denver VA Medical Center, Aurora, Colorado
| | - Marcie Lee
- Center of Innovation for Veteran-Centered and Value-Driven Care; Denver VA Medical Center, Aurora, Colorado
| | - Roman Ayele
- Center of Innovation for Veteran-Centered and Value-Driven Care; Denver VA Medical Center, Aurora, Colorado
| | - Ethan Cumbler
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Rebecca Allyn
- Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado
| | - S Ryan Greysen
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Denson JL, Knoeckel J, Kjerengtroen S, Johnson R, McNair B, Thornton O, Douglas IS, Wechsler ME, Burke RE. Improving end-of-rotation transitions of care among ICU patients. BMJ Qual Saf 2019; 29:250-259. [PMID: 31685581 DOI: 10.1136/bmjqs-2019-009867] [Citation(s) in RCA: 2] [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] [Received: 05/30/2019] [Revised: 10/16/2019] [Accepted: 10/20/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Hospitalised patients whose inpatient teams rotate off service experience increased mortality related to end-of-rotation care transitions, yet standardised handoff practices are lacking. OBJECTIVE Develop and implement a multidisciplinary patient-centred handoff intervention to improve outcomes for patients who are critically ill during end-of-rotation transitions. DESIGN, SETTING AND PARTICIPANTS Single-centre, controlled pilot study of medical intensive care unit (ICU) patients whose resident team was undergoing end-of-rotation transition at a university hospital from June 2017 to February 2018. INTERVENTION A 4-item intervention was implemented over two study periods. Intervention 1 included: (1) in-person bedside handoff between teams rotating off and on service, (2) handoff checklist, (3) nursing involvement in handoff, and (4) 30 min education session. Intervention 2 included the additional option to conduct bedside handoff via videoconferencing. MAIN OUTCOME MEASURES Implementation was measured by repeated clinician surveys and direct observation. Patient outcomes included length of stay (LOS; ICU and hospital) and mortality (ICU, hospital and 30 days). Clinician perceptions were modelled over time using per cent positive responses in logistic regression. Patient outcomes were compared with matched control 'transition' patients from 1 year prior to implementation of the intervention. RESULTS Among 270 transition patients, 46.3% were female with a mean age of 55.9 years. Mechanical ventilation (64.1%) and in-hospital death (27.6%) rates were prevalent. Despite high implementation rates-handoff participation (93.8%), checklist utilisation (75.0%), videoconferencing (62.5%), nursing involvement (75.0%)-the intervention did not significantly improve LOS or mortality. Multidisciplinary survey data revealed significant improvement in acceptability by nursing staff, while satisfaction significantly declined for resident physicians. CONCLUSIONS In this controlled pilot study, a structured ICU end-of-rotation care transition strategy was feasible to implement with high fidelity. While mortality and LOS were not affected in a pilot study with limited power, the pragmatic strategy of this intervention holds promise for future trials.
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Affiliation(s)
- Joshua Lee Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA .,Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Julie Knoeckel
- Medicine, Denver Health Medical Center, Denver, CO, United States.,Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Sara Kjerengtroen
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Rachel Johnson
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Bryan McNair
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | | | - Ivor S Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA.,Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Michael E Wechsler
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA.,Pulmonary and Critical Care Medicine, National Jewish Health, Denver, Colorado, USA
| | - Robert E Burke
- Section of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Burke RE, Myers JS. Waiting for Godot: The Quest to Promote Scholarship in Hospital Medicine. J Hosp Med 2019; 14:508-509. [PMID: 31386618 DOI: 10.12788/jhm.3237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 04/30/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer S Myers
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Center for Healthcare Improvement and Patient Safety, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Daddato AE, Dollar B, Lum HD, Burke RE, Boxer RS. Identifying Patient Readmissions: Are Our Data Sources Misleading? J Am Med Dir Assoc 2019; 20:1042-1044. [PMID: 31227472 DOI: 10.1016/j.jamda.2019.04.028] [Citation(s) in RCA: 2] [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] [Received: 07/19/2018] [Revised: 04/24/2019] [Accepted: 04/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND The accuracy of data is vital to identifying hospitalization outcomes for clinical trials. Patient attrition and recall bias affects the validity of patient-reported outcomes, and the growing prevalence of Medicare Advantage (MA) could mean Fee-for-Service (FFS) claims are less reliable for ascertaining hospital utilization. Statewide health information exchanges (HIEs) may be a more complete data source but have not been frequently used for research. DESIGN Secondary analysis comparing identification of readmissions using 3 different acquisition approaches. SETTING Randomized controlled trial of heart failure (HF) disease management in 37 skilled nursing facilities (SNFs). PARTICIPANTS Patients with HF discharged from the hospital to SNF. MEASURES Readmissions up to 60 days post-SNF admission collected by patient self-report, recorded by nursing home (NH) staff during the SNF stay, or recorded in the state HIE. RESULTS Among 657 participants (mean age 79 ± 10 years, 49% with FFS), 295 unique readmissions within 60 days of SNF admission were identified. These readmissions occurred among 221 patients. Twenty percent of all readmissions were found using only patient self-report, 28% were only recorded by NH staff during the SNF stay, and 52% were identified only using the HIE. The readmission rate (first readmission only) based only on patient self-report and direct observation was 18% rather than 34% with the addition of the enhanced HIE method. CONCLUSIONS AND IMPLICATIONS More than one-quarter (34%) of HF patients were rehospitalized within 60 days post SNF admission. Use of a statewide HIE resulted in identifying an additional 153 admissions, 52% of all the readmissions seen in this study. Without use of an HIE, nearly half of readmissions would have been missed as a result of incomplete patient self-report or loss to follow-up. Thus, HIEs serve as an important resource for researchers to ensure accurate outcomes data.
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Affiliation(s)
- Andrea E Daddato
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Blythe Dollar
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Hillary D Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO; Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente, Aurora, CO
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