Impact of inpatient diabetes transitions of care consult on glycemic control

Objective(s)An evaluation of a diabetes consult service for hospitalized patients was completed to determine effect on glycemic control.MethodsThis medical record review was conducted to determine impact of a short-term program on patients with diabetes. The electronic medical record was used to identify patients diagnosed with diabetes mellitus and hospitalized from September 2016 to September 2017. A case-control design was utilized to compare patients with an inpatient order for the diabetes transitions of care service to those receiving usual care. The consultation service consisted of inpatient diabetes education and follow-up post discharge. The HbA1c reduction of adult inpatients those who completed a consult (n = 67) and those who received usual care (n = 67) were compared. Statistical analyses were conducted.ResultsFor the primary outcome of HbA1c reduction at 3 months, absolute difference from baseline to 3 months in the intervention was -2.9 % compared to 0.9 % in the control group (p < 0.001).ConclusionsParticipation in the service reduced HbA1c at 3 months and 6 months post-discharge, reduced 30-day all-cause readmissions, and increased percentage of patients with HbA1c <9.0 % at 6 months post-discharge.Practical implicationsA consult-based diabetes transitions of care service decreased HbA1c versus usual care.     

Use of eConsult to enhance genetics service delivery in primary care: A multimethod study

PurposeElectronic consultation (eConsult) is a freely-available secure online platform connecting primary care providers (PCPs) to geneticists. Our purpose was to determine whether eConsult is effective in improving genetics service delivery in primary care.MethodsPCP questionnaires regarding eConsult’s utility, geneticists’ tracking form assessments of eConsult type and appropriateness, and geneticists’ interviews on implementing eConsult were carried out.ResultsIn 2 regions of Ontario, Canada, from January 2019 to June 2020, there were 305 genetics eConsults. For 169 (55%), PCPs indicated receiving good advice for a new course of action; for 110 (36%), referral was now avoided; and for 261 (86%), eConsult was perceived valuable for patient management. Of the 131 geneticist-completed tracking forms, cancer questions were most common (68, 52%). For 63 (48%), geneticists disagreed/strongly disagreed PCPs should know the answer to the referral question. From the interview data, it was observed that geneticists described eConsult positively and suggested how it might improve access and efficiencies if integrated into genetic service delivery. Dealing with eConsults virtually could reduce waitlists, and suggesting appropriate investigations for PCPs could improve efficiencies.ConclusioneConsult offers a potential solution for receiving timely genetics advice and avoiding unnecessary patient referrals, however, greater effect on access and wait times will need systematic integration into PCP and geneticist practice.     

Mixed Methods Study of Patient and Primary Care Provider Perceptions of Chronic Pain Treatment

ObjectiveA mixed-method study involving patient focus groups and survey of primary care providers (PCPs) sought to compare perspectives about chronic pain (CP) and its treatment. Our goal was to identify needs and barriers for facilitating patient-centered care.MethodsTwo focus groups of CP patients from a single academic medical center explored interactions with PCPs and their understandings, experiences, and expectations of CP treatment. They were also asked their opinions about self-assessment/communication tools. We compared themes with survey data from two PCP research networks.ResultsCP patients understand opioid risks and fear PCP judgement and condescension, while sensing PCP fear and avoidance of opioid prescribing. PCPs are dissatisfied with their ability to provide optimal CP care, despite feeling that patients are generally satisfied with their clinic visits. Evaluation tools, especially assessment of functional activities, are favorably viewed by all, but deemed time prohibitive.ConclusionPatients’ understanding of opioid risks, desire for attention on functional goals and behavioral treatment may be greater than PCPs perceive. Such gaps in understanding and attitudes, if recognized, could support high-quality communication and interventional strategies.Practice ImplicationsThese findings guide patient-PCP communication toward alignment of treatment goals and enhanced coordination of care.     

Detecting the effects of physician training in self-care interviewing skills: Coding of standardized patient (SP) visit recordings versus SP post-visit ratings

ObjectiveTo compare how coder ratings of standardized patient (SP) visit recordings and SP ratings of the visits detect primary care physician (PCP) training in self-efficacy enhancing interviewing techniques (SEE IT).MethodsAnalyses of data from 50 PCPs who participated in a randomized controlled trial of SEE IT training, which led to increased SEE IT use during three SP visits 1–3 months post-intervention. Untrained SPs rated SEE IT use post-visit. Subsequently, three trained coders generated a consensus SEE IT rating from visit audio recordings. SPs and coders were blinded to provider study arm, and coders to SP ratings.ResultsSP and coder ratings were correlated (r = 0.62). In detecting the intervention effect, the areas under the receiver operating characteristic curve were 0.80 (95% CI 0.74–0.87) and 0.76 (95% CI 0.69–0.84) for consensus coder and SP ratings, respectively (difference 0.04, 95% CI −0.04–0.11; z = 1.04, p = 0.30).ConclusionSP ratings were not significantly different from coder ratings of SP visit recordings in detecting PCP SEE IT training.Practice implicationsIf similar findings are observed in larger studies, it would suggest a greater role for SP ratings in detecting provider interviewing skills training, given the relative simplicity, low cost, and non-intrusiveness of the approach.     

An analysis of directly observed weight communication processes between primary care practitioners and overweight patients

ObjectiveTo analyse weight-related communication prevalence and processes (content/context) between primary care practitioners (PCPs) and overweight patients within routine primary healthcare consultations.MethodsConsultations between 14 PCPs and 218 overweight patients (BMI ≥ 25 kg/m²) were video recorded. Weight communication was coded using the Roter Interaction Analysis System (RIAS) and the novel St Andrews Issue Response Analysis System (SAIRAS). Communication code frequencies were analysed.ResultsWeight discussion occurred in 25% of consultations with overweight patients; 26% of these had weight-related consultation outcomes (e.g. weight-related counselling and referrals, stated weight-related intention from patients). Weight discussions were more likely to occur if PCPs provided space to patient attempts to discuss weight (p = 0.013). Longer weight discussions (p < 0.001) and contextualising weight as problematic when PCP/patient-initiated weight discussion (p < 0.001) were associated with weight-related consultation outcomes.ConclusionWeight was rarely discussed with overweight patients, however PCP space provision to patient weight-discussion initiation attempts increased weight discussion. When weight was discussed, increased time and/or contextualising weight as a problem increased the likelihood of weight-related consultation outcomes.Practical implicationPCP use of specific communication approaches when discussing, contextualising and responding to patient weight may facilitate weight-related discussion and consultation outcomes and could lead to more effective patient weight management.     

Verbal communication among Alzheimer's disease patients, their caregivers, and primary care physicians during primary care office visits

Objective

Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions.

Methods

To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed.

Results

PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation.

Conclusion

Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less.

Practice implications

Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.     

Use of cancer susceptibility testing among primary care physicians

Primary care physicians (PCPs) are assuming greater roles in cancer risk assessment and susceptibility testing of patients. The objective of this study was to assess the beliefs and practices of PCPs relative to genetic susceptibility testing for cancer. A cross-sectional survey was mailed to 726 PCPs in community-based practices in southeastern Pennsylvania and southern New Jersey. Data were collected on physician background, cognitive and psychosocial factors, practice environment, and patient factors. The main outcome measure was physician self-reported recommendation or referral of patients for cancer genetic susceptibility testing in a 12-month period prior to the survey. Of those surveyed, 475 (65%) PCPs responded. Complete survey data were available for 433 PCPs. Multivariable analyses show that factors positively associated with PCP recommendation/referral included: patient inquiry about their need for genetic testing for cancer (p < 0.001); PCP belief that patient age is the best predictor of cancer risk (p = 0.01); PCP self-reported frequency of collecting patient diet information (p = 0.01) and medical history information (p = 0.01); and PCP participation in an integrated health system (p = 0.01). PCP use of cancer genetic susceptibility testing may be influenced by patient inquiry, provider beliefs about factors that affect cancer risk, provider collection of risk-assessment data, and provider practice environment.     

Patient and practitioner priorities and concerns about primary healthcare interactions for osteoarthritis: A meta-ethnography

ObjectiveTo explore primary care practitioners’ (PCPs) and patients’ priorities and concerns for healthcare interactions for osteoarthritis (OA) in primary care.MethodsWe searched Embase, CINAHL, Medline, PsychInfo (1990 to present) for primary qualitative and mixed methods studies with findings concerning healthcare interactions for OA symptoms. Patient and PCP perceptions were analysed separately then inter-related using a ‘line of argument’ synthesis.ResultsTwenty-six studies reporting qualitative data from 557 patients and 199 PCPs were synthesised. Our findings suggest that therapeutic interactions for OA can be based on discordant priorities and concerns; some patients perceive that PCPs hold negative attitudes about OA and feel their concerns about impact are not appreciated; some PCPs feel patients have misconceptions about prognosis, and hold pessimistic views about outcomes; and both tend to de-prioritise OA within consultations.ConclusionGreater working in partnership could build mutual trust, facilitate tailored provision of information, and foster a shared understanding of OA upon which to build realistic goals for management.Practice implicationsDeveloping a better shared understanding of OA has the potential to improve the quality of healthcare interactions for both patients and PCPs. The significant impact of OA on everyday life means it should be given higher priority in primary care consultations.     

Impact of a Novel Post-Discharge Transitions of Care Clinic on Hospital Readmissions

BackgroundThe Center for Medicare and Medicaid Services (CMS) has targeted hospital readmissions, which cost $17 billion per year, as one potential solution to reduce rising health care costs. Studies have documented the ability of Transitions of care (TOC) services to reduce readmissions in high risk patients. However, the vast majority of studies have not explored TOC services for all-cause admissions nor TOC clinics led by hospitalists. The goal of this study is to provide preliminary data regarding the potential effectiveness of a hospitalist-led TOC clinic servicing all patients on hospital readmission rates.MethodsThis cross-sectional feasibility study analyzed patients on a tertiary hospital teaching service. All discharged patients from January 2016 to September 2018 were given an appointment at the TOC clinic within 14 days of discharge. The control group consisted of patients assigned to the teaching service from January 2018 to November 2018 that were not offered a TOC appointment.ResultsOverall, 1373 patients (n = 1373) were included in this study between January 2016 and September 2018. The control group consisted of 1000 patients who were not offered follow up in the TOC clinic while the TOC group consisted of 373 patients who did attend a follow up appointment in the TOC clinic. The study participants (n = 1373) included patients admitted to the hospital for any diagnosis and were analyzed for all cause readmission rates. The TOC group consisted of 52% African Americans, 52% Medicare patients and 8% Medicaid patients. Demographic information for the control group was not available. The TOC group had a statistically significant 42% decreased risk of being readmitted within 30 days of discharge (RR = 0.58, 95% CI: 0.40-0.83). These data showed a statistically significant difference between the TOC group and control group in relation to the incidence of 30-day readmissions (p-value = 0.002).ConclusionAmong Medicare and Medicaid beneficiaries and commercial health insurance patients, this hospitalist-led TOC intervention was associated with a statistically significant reduction in 30-day readmissions following discharge for all-cause hospital admissions.     

Primary Care Physicians Beliefs about Prostate-Specific Antigen Evidence Uncertainty,Screening Efficacy,and Test Use

Background/Purpose

Little is known about primary care physicians’ (PCPs) beliefs about prostate cancer screening efficacy, evidence uncertainty, and their actual screening behaviors. We examined factors associated with PCP beliefs about screening efficacy and uncertainty and whether beliefs were associated with prostate specific-antigen (PSA) test use.

Continuing Quality Assessment Program Improves Clinical Outcomes of Hospitalized Community-Acquired Pneumonia: A Nationwide Cross-Sectional Study in Korea

BackgroundPneumonia, which is the third leading cause of death in South Korea, is continuously increasing with the aging society. The Health Insurance Review and Assessment of South Korea conducted a quality assessment (QA) for improving the outcome of community-acquired pneumonia (CAP).MethodsWe conducted a nationwide cross-sectional study of hospitalized CAP in South Korea. First to third QA data were gathered into a single database. The national health insurance database was merged with the QA database for analyzing the medical claims data. Comorbidities, pneumonia severity, and pneumonia care appropriateness were calculated using Charlson comorbidity index (CCI), CURB-65, and core assessment of CAP scores (CAP scores), respectively.ResultsOverall, 54,307 patients were enrolled. The CAP scores significantly improved on QA program implementation (P < 0.001). All the variables demonstrated an association with in-hospital mortality, hospital length of stay (LOS), and 30-day mortality in the univariate analyses. Following the adjustments, higher CCI and CURB-65 scores were associated with higher in-hospital mortality, longer hospital LOS, and higher 30-day mortality. Male sex was associated with higher in-hospital/30-day mortality and shorter hospital LOS. Higher CAP scores were associated with shorter hospital LOS (P < 0.001). Upon QA program implementation, in-hospital mortality (P < 0.001), hospital LOS (P < 0.001), and 30-day mortality (P < 0.001) improved.ConclusionContinuing QA program is effective in improving the clinical outcomes of hospitalized CAP.     

Associations of insomnia symptoms with subsequent health services use among community-dwelling U.S. older adults

Study ObjectivesDetermine the association of insomnia symptoms with subsequent health services use, in a representative sample of U.S. older adults.MethodsParticipants were 4,289 community-dwelling Medicare beneficiaries who had continuous fee-for-service Medicare coverage 30 days before, and 1 year after the National Health and Aging Trends Study (NHATS) Round 1 interview. Participants reported past-month insomnia symptoms (i.e. sleep onset latency >30 min, difficulty returning to sleep) which we categorized as 0, 1, or 2 symptoms. Outcomes were health services use within 1 year of interviews from linked Medicare claims: emergency department (ED) visits, hospitalizations, 30-day readmissions, home health care (all measured as yes/no), and number of hospitalizations and ED visits.ResultsOverall, 18.5% of participants were hospitalized, 28.7% visited the ED, 2.5% had a 30-day readmission, and 11.3% used home health care. After adjustment for demographics, depressive and anxiety symptoms, medical comorbidities, and BMI, compared to participants with no insomnia symptoms, those with two insomnia symptoms had a higher odds of ED visits (odds ratio [OR) = 1.60, 95% confidence interval [CI] = 1.24–2.07, p < 0.001), hospitalizations (OR = 1.29, 95% CI = 1.01–1.65, p < 0.05), and 30-day readmissions (OR = 1.88, 95% CI = 1.88–3.29, p < 0.05). Reporting 2 insomnia symptoms, versus no insomnia symptoms, was associated with a greater number of ED visits and hospitalizations (incidence rate ratio (IRR) = 1.52, 95% CI = 1.23–1.87, p < 0.001; IRR = 1.21, 95% CI = 1.02–1.44, p < 0.05, respectively) after adjusting for demographic and health characteristics.ConclusionsAmong older adults, insomnia symptoms are associated with greater health services use, including emergency department use, hospitalization, and 30-day readmission. Targeting insomnia may lower health services use.     

Incidence and safety profile of outpatient unicompartmental knee arthroplasty

BackgroundOutpatient surgery is an increasingly attractive option for patients undergoing procedures with established, acceptable risk profiles. Benefits of outpatient surgery include cost savings, enhanced patient experience and improved resource allocation at busy hospitals. The purpose of this study was to compare 90-day complication and readmission rates for patients undergoing unicompartmental knee arthroplasty (UKA) in the outpatient as opposed to the inpatient setting.MethodsPatients who underwent UKA (CPT code 27446) between 2007 and 2016 were retrospectively selected from a national private insurance database. Patients were defined as ambulatory if their coded location of procedure was in an ambulatory surgery center or as an in-hospital outpatient. Postoperative complications were identified using the Reportable Center for Medicare Services (CMS) Complication Measures. Risks of complications were compared between the inpatient and outpatient cohorts using multivariate logistic regression controlling for age, gender, and comorbidities.Results2600 patients undergoing ambulatory UKA and 5084 patients undergoing inpatient UKA were identified. The percentage of UKA procedures performed on an outpatient basis significantly increased over the course of the study (14.5% to 58.1%, p < 0.001). After adjusting for age, gender, and comorbidities, ambulatory surgery was found to be associated with a decreased risk of postoperative transfusion (OR 0.28; p < 0.001) and pneumonia (OR 0.23; p = 0.008) and there was a trend towards decreased 90-day readmission risk (OR = 0.83; p = 0.062).ConclusionAmbulatory discharge following UKA is increasing in popularity, does not increase risk for perioperative complications or readmission, and may even portend a safer post-operative course.     

A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital

ObjectiveTransitions from hospital to home are high-risk episodes. Communication problems between patients/carers and their primary healthcare providers are a central part of the risk. This literature review aimed to identify any existing tools or information (including secondary care instruments) that would facilitate designing new communication instruments for primary care to manage and mitigate risk at discharge.MethodFive databases (Pubmed, Embase, Cinahl, Web of Science and Cochrane) were searched using a three stem approach (primary/transitional care, discharge period, communication). A dual reviewer system was used, following PRISMA guidelines.ResultsFrom 61 full text articles a total of ten tools were found, 25 articles contained other useful content, 19 further tools were found in grey literature. Most material originated from the USA and described hospital-based transitional care interventions.ConclusionNo ready-made patient/provider communication tool for the post-discharge period in primary care was found. Future communication tools should enhance education and engagement of patients so they feel able to initiate communication.Practice implicationsCollating post-discharge communication material is of importance to improving the safety of care transitions and will enable creation of new tools specifically designed for primary care. These tools will improve patient activation (‘the knowledge, skills and confidence a person has in managing their own health and care’) with the ultimate aim of reducing error and harm in primary care through improved communication of healthcare decisions.     

Matched cohort analysis of peri-operative outcomes following total knee arthroplasty in patients with and without Parkinson's disease

BackgroundIncreased complication rate has been reported in Parkinson's disease (PD) patients following total knee arthroplasty (TKA). However, this has not previously been studied on a national scale. The purpose of this study was to determine whether PD patients had increased cost, complication, mortality, and length of stay following TKA using a national database.MethodsThe HCUP Nationwide Inpatient Sample was evaluated for the years 2000 to 2012. PD patients were matched 1:10 with non-PD control patients for age, sex, Charlson Comorbidity Index (CCI), and year of admission utilizing a propensity score matching procedure. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort.ResultsBefore matching, TKA patients with PD were significantly older (p < 0.0001), more frequently male (p < 0.0001), and had a greater CCI (p = 0.3058). In the matched cohort, PD was associated with significantly increased length of stay (3.92 vs 3.71 days, p < 0.0001) and total hospital charges ($41,523.52 vs $40,657.00, p = 0.0037). There was no significant difference in in-hospital complication rate (8.28% vs 8.04%, p = 0.4297) or in-hospital mortality (0.164% vs 0.150%, p = 0.8465) between PD patients and matched non-PD patients.ConclusionsMatched cohort analysis demonstrated statistically significant but clinically minor increases in length and cost of hospitalization for TKA in PD patients. Complication rate and in-hospital mortality rate was not higher in PD patients, suggesting that this group may be safely considered for TKA.Level of evidencePrognostic — Level III.     

Targeted BRCA1/2 population screening among Ashkenazi Jewish individuals using a web-enabled medical model: An observational cohort study

PurposeThis study aimed to evaluate uptake and follow-up using internet-assisted population genetic testing (GT) for BRCA1/2 Ashkenazi Jewish founder pathogenic variants (AJPVs).MethodsAcross 4 cities in the United States, from December 2017 to March 2020, individuals aged ≥25 years with ≥1 Ashkenazi Jewish grandparent were offered enrollment. Participants consented and enrolled online with chatbot and video education, underwent BRCA1/2 AJPV GT, and chose to receive results from their primary care provider (PCP) or study staff. Surveys were conducted at baseline, at 12 weeks, and annually for 5 years.ResultsA total of 5193 participants enrolled and 4109 (79.1%) were tested (median age = 54, female = 77.1%). Upon enrollment, 35.1% of participants selected a PCP to disclose results, and 40.5% of PCPs agreed. Of those tested, 138 (3.4%) were AJPV heterozygotes of whom 21 (15.2%) had no significant family history of cancer, whereas 86 (62.3%) had a known familial pathogenic variant. At 12 weeks, 85.5% of participants with AJPVs planned increased cancer screening; only 3.7% with negative results and a significant family history reported further testing.ConclusionAlthough continued follow-up is needed, internet-enabled outreach can expand access to targeted GT using a medical model. Observed challenges for population genetic screening efforts include recruitment barriers, improving PCP engagement, and increasing uptake of additional testing when indicated.     

Effects of Emergency Care-related Health Policies during the COVID-19 Pandemic in Korea: a Quasi-Experimental Study

BackgroundThe purpose of this study was to review the nationwide emergency care-related health policies during the coronavirus disease 2019 (COVID-19) pandemic disaster in Korea and to analyze the effects of the policies on the safety of patients who visit emergency departments (EDs) during this period.MethodsThis study is a quasi-experiment study. The study population was patients who visited all 402 EDs in Korea between December 31, 2019 and May 13, 2020, using the National Emergency Department Information System (NEDIS) database. The study period was classified into 5 phases according to the level of national crisis warning of infectious disease and the implementation of emergency care-related health policies, and all study phases were 27 days. The primary outcome was in-hospital mortality, and the secondary outcome was length of stay (LOS) in the ED during the COVID-19 outbreak.ResultsThe number of ED visits during the study period was 2,636,341, and the in-hospital mortality rate was 1.4%. The number of ED visits decreased from 803,160 in phase 1 to 496,619 in phase 5 during the study period. For in-hospital mortality, the adjusted odds ratio (OR) (95% confidence interval) was 0.77 (0.74–0.79) in phase 5 compared to phase 3. Additionally, by subgroup, the ORs were 0.69 (0.57–0.83) for the patients with acute myocardial infarction and 0.76 (0.67–0.87) for severe trauma in phase 5 compared to phase 3. The ED LOS increased while the number of ED visits decreased as the COVID-19 pandemic progressed, and the ED LOS declined after policy implementation (beta coefficient: −5.3 [−6.5 to −4.2] minutes in phase 5 compared to phase 3).ConclusionImplementing appropriate emergency care policies in the COVID-19 pandemic would have contributed to improving the safety of all emergency patients and reducing in-hospital mortality by preventing excessive deaths.     

Comparison of influenza hospitalization outcomes among adults,older adults,and octogenarians: a US national population-based study

ObjectivesThis study sought to more fully elucidate the age-related trends in influenza mortality with a secondary goal of uncovering implications for treatment and prevention.MethodsIn this retrospective cohort analysis of data from the Nationwide Readmission Database, patients with influenza as a primary or secondary discharge diagnosis were separated into three age groups: 55 638 adults aged 20–64 years, 36 862 adults aged 65–79 years and 41 806 octogenarians aged ≥80 years. Propensity score (PS) weighting was performed to isolate age from other baseline differences. Crude and PS-weighted hazard ratios (HR) were calculated from the in-hospital all-cause 30-day mortality rate. Admission threshold bias was minimized by comparison of influenza with bacterial pneumonia mortality.ResultsAdults aged 20–64 years experienced higher in-hospital 30-day mortality compared with older adults aged 65–79 years (HR 0.66; 95% CI 0.55–0.79). Octogenarians had the highest mortality rate, but this was statistically insignificant compared with the adult cohort (HR 1.09; 95% CI 0.94–1.27). This trend was not explained by admission threshold bias: the 30-day mortality rate due to in-hospital bacterial pneumonia increased consistently with age (older adult HR 1.45; 95% CI 1.32–1.59; octogenarian HR 1.99; 95% CI 1.82–2.18).ConclusionsAdults aged 20–64 years and octogenarians were more likely to experience all-cause 30-day mortality during influenza hospitalization compared with older adults aged 65–79 years. These data emphasize the importance of prevention and suggest the need for more tailored treatment interventions based on risk stratification that includes age.