Improving Transitions to Postacute Care for Elderly Patients Using a Novel Video-Conferencing Program: ECHO-Care Transitions

Purpose

Within 30 days of hospital discharge to a skilled nursing facility, older adults are at high risk for death, re-hospitalization, and high-cost health care. The purpose of this study was to examine whether a novel videoconference program called Extension for Community Health Outcomes-Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at skilled nursing facilities reduces patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.

A prospective,randomized, controlled trial of an emergency department-based atrial fibrillation treatment strategy with low-molecular-weight heparin

STUDY OBJECTIVE: We assess an alternative accelerated clinical pathway approach to the management of patients with newly diagnosed or new-onset atrial fibrillation (AF). METHODS: A prospective, randomized pilot study of 2 AF disease-management strategies was conducted at a single university hospital. A traditional approach of hospital admission versus an accelerated emergency department-based strategy with low-molecular-weight heparin and early cardioversion to sinus rhythm was assessed in a cohort of patients with uncomplicated AF. The primary end points were length of stay and total actual direct costs. RESULTS: Eighteen patients were randomized over a 15-month period. The accelerated treatment strategy in the ED resulted in a substantial decrease in length of stay (2.1+/-2.3 versus <1 day) and a favorable trend toward mean cost reduction ($1,706+/-$1,512 versus $879+/-$394; P =.15). The clinical outcomes (rate of sinus rhythm at discharge and follow-up and complications caused by AF) related to AF were similar in the 2 groups. CONCLUSION: A disease-management strategy for new, uncomplicated AF that uses an ED-outpatient treatment pathway results in a shorter length of stay at potentially lower cost. The results of this pilot study warrant further investigation.     

Impact of practice guidelines on support surface selection, incidence of pressure ulcers, and fiscal dollars

Predicated on a need to control overall hospital costs and to integrate a Level 1 trauma center (Campus A) with a family practice based tertiary care hospital system (Campus B), expenditures associated with rental support surfaces were evaluated. Consistency and appropriateness of support surface selection is necessary to promote positive clinical outcomes, patient comfort, and a healthier bottom line, despite increasing costs. Clinical practice guidelines for therapeutic support surfaces were developed to decrease support surface expenditures and maintain prevalence rates below national averages. Utilizing the Agency for Health Care Policy and Research algorithm for managing tissue loads, along with other guidelines, criteria for prevention, comfort, and treatment were developed to assist nurses and physicians in support surface selections. A prevalence study was conducted before these criteria were implemented and repeated 1 year later. Expenditures for all rental support surfaces were assessed quarterly. Campus A, with a history of higher financial expenditures, was monitored weekly to assess whether support surfaces selections met guideline recommendations. Nursing staff reviewed hospital protocol regarding guidelines before implementation, and a self-administered review test was required during the first year post-implementation. One year later, a modest decrease in annual expenditures for rental support surfaces was noted. Campus A had a decrease in nosocomial pressure ulcers, while Campus B had an increased prevalence rate. Staff selection of support surfaces, within guideline recommendations, improved to 75% on medical/surgical units, and 98.8% in ICUs on Campus A. Although implementing support surface selection guidelines did not result in a significant reduction in cost, it created a framework for monitoring future related decisions.     

Impact of a multidisciplinary day program on disease and healthcare costs in children and adolescents with severe asthma: a two-year follow-up study

For patients whose asthma remains in poor control necessitating high utilization of medical services, a referral to a specialized "center of excellence" is often considered. A decade ago, we evaluated our pediatric asthma program of long-term hospitalization (median stay of 75 days) and found significant decreases in subjects' medical utilization following this intervention. In an effort to contain treatment costs, the former program was markedly altered to one of abbreviated stay with emphasis on family management of asthma. The purpose of the present study was to determine the outcome of children treated in the revised program with regard to disease severity, quality of life, and subsequent utilization of medical resources. Children with severe asthma who were admitted to the program and fulfilled study criteria were consecutively enrolled. Data was obtained concerning disease characteristics, treatment, and quality of life at admission, and at 1 and 2 years following discharge. Medical records for the year prior to program admission and for the 2 years following discharge were coded for medical care encounters. Ninety-eight children, aged 9 months to 18 years (mean age, 10.9 years), were enrolled. They participated in the program for a mean of 15.6 ( +/- 8 SD), median of 15.0, and range of 2-51 treatment days. The group showed significant improvement (P < 0.0001) from admission to 1- and 2-year follow-up in median corticosteroid use, asthma functional severity, perceived competence in asthma management, and quality of life for both caregiver and child. Medical record data showed significant improvement (P < 0.0001) at both 1- and 2-year follow-up in median number of corticosteroid bursts, emergency department visits, hospital days, and overall utilization of medical care encounters. A median total medical encounter cost/patient of $16,250 ($6,972-$25,714 interquartile range (IQR)) for the year prior to program participation was reduced to $1,902 ($505-$6,524 IQR) at 1-year and $690 ($185-$3,550 IQR) at 2- year follow-up (P < 0.0001). We conclude that multidisciplinary care in a short-term, outpatient, day treatment program can significantly contribute to improvement in asthma severity, quality of life, and reduction in healthcare costs.     

Ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia

This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP. Presented at the International Conference on AIDS, Berlin, Germany, June 6 –11, 1993. Supported by grant number HS 06454-03 from the Agency for Health Care Policy and Research. Dr. Curtis is funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein are those of the authors and are not necessarily the views of the Agency for Health Care Policy and Research or the Robert Wood Johnson Foundation.     

The cost of institutional care in Alzheimer's disease: nursing home and hospital use in a prospective cohort.

OBJECTIVE: To assess the nursing home and hospital use of patients with Alzheimer's Type Dementia. DESIGN: A prospective cohort study of 126 patients entered into an Alzheimer's disease registry after diagnosis at a university hospital clinic between 1980 and 1982. Only four patients were in nursing homes at enrollment. MEASUREMENTS AND MAIN RESULTS: Data regarding nursing home use came from the registry and the individual nursing homes themselves. Hospital-use data were obtained using Medicare claims files. Follow-up was obtained on 123 patients (98%). Eighty-five (69%) had died by July 1, 1989. Three-quarters of the cohort (92) eventually resided in nursing homes. The median nursing home length of stay was 2.75 years (mean 2.95, 95% CI = 2.5, 3.4), over 10 times the national median length of stay for all diagnoses. Based on prevailing rates in the region, nursing home charges for the cohort were estimated to be between $4.3 and $6.4 million ($35,000-$52,000 per patient). During the 5-year period 1983-1988, 69 patients filed Part A (hospital) claims to Medicare for 76 admissions and 616 inpatient days. Part A Medicare reimbursement for the cohort totaled $460,000 over 5 years ($3,700 per patient), an expenditure comparable to what a random Medicare cohort might incur. CONCLUSIONS: The combination of a high rate of nursing home entry and lengthy stays makes long-term care the largest determinant of the cost of care in Alzheimer's disease. While Alzheimer's Type Dementia undoubtedly has profound indirect costs, this study demonstrates that the direct institutional costs alone are considerable.     

The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators

PURPOSE: Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.PATIENTS AND METHODS: This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.RESULTS: Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.CONCLUSIONS: The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.     

Clinical guidelines and cost implications — the case of stress urinary incontinence

One goal of the Agency of Health Care Policy and Research (AHCPR) is to improve the quality of medical care by developing and disseminating clinical practice guidelines. An indication of the effectiveness of a clinical guideline is the relationship between the medical benefits gained and the costs of achieving those benefits when the guideline is implemented. Using outpatient and inpatient claims data, this paper reports the current practice patterns, cost variations, and cost implications of implementing a proposed clinical guideline for stress urinary incontinence. The current practice patterns reveal large practice variations for incontinence care, with many basic procedures infrequently used. If the clinical guideline for stress incontinence is implemented as designed, the authors project a total annual cost savings of roughly $36 million in 1992 dollars in the United States.     

A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients

OBJECTIVES: To investigate whether an education program and a reorganization of nursing and medical care improved the outcome for older delirious patients. DESIGN: Prospective intervention study. SETTING: Department of General Internal Medicine, Sundsvall Hospital, Sweden. PARTICIPANTS: Four hundred patients, aged 70 and older, consecutively admitted to an intervention or a control ward. INTERVENTION: The intervention consisted of staff education focusing on the assessment, prevention, and treatment of delirium and on caregiver-patient interaction. Reorganization from a task-allocation care system to a patient-allocation system with individualized care. MEASUREMENTS: The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination on Days 1, 3, and 7 after admission. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. RESULTS: Delirium was equally common on the day of admission at the two wards, but fewer patients remained delirious on Day 7 on the intervention ward (n=19/63, 30.2% vs 37/62, 59.7%, P=.001). The mean length of hospital stay+/-standard deviation was significantly lower on the intervention ward then on the control ward (9.4+/-8.2 vs 13.4+/-12.3 days, P<.001) especially for the delirious patients (10.8+/-8.3 vs 20.5+/-17.2 days, P<.001). Two delirious patients in the intervention ward and nine in the control ward died during hospitalization (P=.03). CONCLUSION: This study shows that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients.     

Programmed Outcome Research Teams (PORTs) and implications for clinical practice

The spiraling cost of health care has created a health care crisis. Concerns about the appropriate use of expensive medical technologies have been heightened by health services research studies that demonstrate widespread and dramatic geographic variability in the use of tests and procedures. The Agency for Health Care Policy and Research has funded 14 Programmed Outcome Research Teams (PORTs) targeted at specific disease entities. The PORT in ischemic heart disease is examining 2 principal decisions—which patients should undergo cardiac catheterization and, following catheterization, how patients should be treated. The PORT in ischemic heart disease combines information from the literature, 18 databases, and patient preference studies in models examining these 2 decisions. The databases have also been used to develop statistical models that estimate outcomes with different therapies. The benefit of a therapy in a population can be illustrated using an empirically derived, marginal value curve that describes the expected improvement in outcome (e.g., survival) that accrues with additional procedures performed in patients who are most likely to benefit.     

Financial impact of a home intravenous antibiotic program on a medicare managed care program.

This study quantitates cost savings achieved by a home intravenous antibiotic (HIVA) program in a Medicare managed health care program. In 1998, 66 treatment courses of HIVA therapy were administered for a total of 1542 patient-days of therapy. The calculated cost of HIVA therapy included the actual costs of drugs, supplies, nursing and therapists' salaries, and laboratory studies. Savings were calculated based on the average daily direct variable cost (DDVC) for hospital acute unit or skilled nursing facility (SNF) care associated with the patient's discharge diagnosis-related-group. The number of days on HIVA therapy was assumed to equal the number of days in the hospital acute unit or hospital-based SNF. The average cost per day of HIVA therapy was $122, whereas average DDVC of hospital acute unit care was $798, and the average DDVC of SNF care was $541. In 1 year, the HIVA program saved our health care system $646,000-$834,000, which demonstrates that HIVA programs are powerful tools to reduce costs in Medicare managed health care programs.     

Initial inappropriate urinary catheters use in a tertiary-care center: incidence, risk factors, and outcomes

OBJECTIVES: To evaluate the epidemiology and outcomes for initiation of inappropriate urinary catheterization (IUC) among hospitalized patients. SETTING: A 450-bed, tertiary-care hospital. PATIENTS: All patients admitted to the hospital from September 1, 2003 to June 12, 2004 with urinary catheter (UC). An independent observer reviewed the patient's chart, interviewed the patient and nursing staff, and assessed the need for the UC daily until the catheter was removed or the patient was discharged. RESULTS: One hundred thirty-one (15%) of 895 patients had initiation of IUC. The median age was 61 (range, 15-92). Medicine (0.52 catheter utilization ratio), surgery (0.24 catheter utilization ratio) and the ICUs (0.32) had the most UC use. Main reasons for initial IUC included no clear indication (28%), inappropriate urine output monitoring (26%), and urinary incontinence (18%). Admission to the medical ICU (adjusted odds ratio [aOR]=2.3; P<0.001), nonambulatory functional status (aOR=2.1; P<0.001), and female sex (aOR=1.9; P=0.001) were independently associated with IUC. Catheter-associated urinary tract infections (CA-UTI) occurred in 129 patients (14%). Patients with IUC had a longer duration of catheterization (12 vs. 3 days; P<0.01) were more likely to develop CA-UTI (82% vs. 8%; P=0.001) and had prolonged hospital length of stay (median, 15 vs. 5 days; P<0.001). The mean monthly cost of antibiotics for treatment of CA-UTI was $3480 (range, $1874-$5584). CONCLUSION: UC were inappropriately used more commonly among female, nonambulatory, and medical ICU patients. Careful attention to this aspect of medical care may reduce the incidence CA-UTI with subsequent decreases in length of stay, cost of hospitalization, and cost for treatment of CA-UTI.     

Determinants of resource utilization for patients admitted for evaluation of acute chest pain

Objective:To identify determinants of resource utilization among patients with suspected acute myocardial infarction. Design:Prospective cohort study, with prospective collection of detailed clinical data and retrospective collection of nonclinical data and resource utilization data. Setting:Urban, tertiary-care, teaching hospital. Patient population:992 consecutive patients over the age of 30 years, admitted from the emergency department for evaluation of acute chest pain unexplained by obvious trauma or chest roentgenographic abnormality, were eligible for the study. After excluding patients who had left against medical advice, who had been transferred to another bospital, or who had incomplete utilization data, 903 patients were included in the analyses. Measurements and outcomes:The authors evaluated the effects of 22 clinical and nonclinical factors on resource use. Resource use was primarily evaluated by length of stay; charges were evaluated in secondary analyses. Results:In the entire study population, increased length of stay was associated with a diagnosis of acute myocardial infarction or angina, severity of complications, use of invasive and noninvasive testing, and initial triage to the coronary care unit. In the 424 (47%) patients who had had completely uncomplicated courses after admission, high coefficients of variability were found for length of stay (0.88) and for total charges (0.78). In these uncomplicated patients, increased length of stay was associated with the use of noninvasive cardiac testing (66% longer for patients undergoing echocardiography or radionuclide ventriculography, and 46% longer for patients undergoing exercise tests or ambulatory arrhythmia monitoring), initial triage to the coronary care unit (23% longer), admission at the end of the week (21% longer), and insurance coverage other than Blue Cross/Blue Shield or a commercial carrier (21% for self-pay, 25% for Medicaid, and 48% for Medicare). Conclusions:These findings indicate that after adjustment for important clinical factors, nonclinical factors had a significant impact on length of stay among a large group of uncomplicated patients. Interventions aimed at reducing logistic difficulties in the performance of noninvasive testing and decreasing the number of low-risk patients who are triaged to coronary care unit beds may decrease resource utilization. Received from the Divisions of Clinical Epidemiology and General Medicine and the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School; and the Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts. Presented in part at the annual meeting of the American Federation for Clinical Research, April 28 – May 2, 1989, Washington, DC. Supported in part by grants from the National Center for Health Services Research (HS 05927), the Robert Wood Johnson Foundation, Princeton, NJ (678105), the John A. Hartford Foundation, New York, NY (83102-2H), and the Agency for Health Care Policy and Research (1-PO1-HS06431-02 and HS 06452-02). Dr. Lee is the recipient of an Established Investigator Award (900119) from the American Heart Association. Dr. Udvarhelyi is the recipient of a Medical Foundation Fellowship award.     

Evaluation of a hospital diabetes specialist nursing service: a randomized controlled trial.

AIMS: To evaluate the effectiveness and cost implications of a hospital diabetes specialist nursing service. METHODS: We conducted a prospective, open, randomized, controlled trial of standard in-patient care for adults with diabetes, with and without the intervention of a diabetes specialist nursing (DSN) service. The setting was a single UK university hospital. SUBJECTS: were unselected patients referred to the hospital DSN service. Primary outcome measures were length of hospital stay and patterns of readmission (frequency and time to first readmission). Secondary outcome measures were subjects' diabetes-related quality of life, diabetes knowledge score, satisfaction with treatment, and GP and community care contacts following discharge. Costs were estimated from the hospital and published sources. RESULTS: Median length of stay was lower in the intervention group (11.0 vs. 8.0 days, P < 0.01). Readmission rates were the same in the two groups (25%), and mean time to readmission was similar in the two groups, although slightly less in the control group (278 vs. 283 days, P = 0.80). The cost per patient for nursing input was 38.94 pounds sterling. However, when the reduced length of stay was accounted for, the intervention produced a mean cost per admission of 436 ponds sterling lower than that of the control group (P = 0.19). Patients in the intervention group were more knowledgeable regarding their diabetes and more satisfied with their care. CONCLUSIONS: Diabetes specialist nurses are potentially cost saving by reducing hospital length of stay (LOS). There was no evidence of an adverse effect of reduced LOS on re-admissions, use of community resources, or patient perception of quality of care.     

Evaluation of a multidisciplinary care program for stroke patients in a day care center.

With funds received by the Rehabilitation Center at Martin Place Hospital East from the Michigan Association of Regional Medical Programs, a Rehabilitation Day Care Center was established. Initially it was called the Stroke Day Care Center (SDCC). Its purpose was to provide comprehensive care to patients with disabilities due to stroke and related diseases according to the "day at the hospital, night at home" concept. A complex of medical and allied services was furnished, based upon the patient's attendance at the SDCC from one to five days a week. The goal was to promote for the patient an earlier return of functional vocational, social and home activities by effectively providing him and his family with multidisciplinary care. In this SDCC program the main emphasis was on testing the feasibility of lowering the cost of stroke-patient care by: a) shortening the hospital stay; b) reducing the need for in-patient care in facilities for non-acute illness; c) shortening the stay in extended care facilities; d) returning younger stroke victims earlier to the labor force; e) identifying the number of stroke patients who could live at home if provided with a modified day care program; and f) assessing the need for purely recreational and social activities in future programs. The evaluation was based on a comprehensive study of 108 patients during the period February 1972 to June 1973. This project is offered as a model for the development and expansion of rehabilitation-recreation day care centers for the handicapped of all ages.     

Hospitalization for congestive heart failure: is it still a cardiology business?

BACKGROUND: Hospital management of CHF and predictors of hospital mortality remain unclear. METHODS: To address these issues, we analyzed the hospital admissions for CHF during 1996 in a large university hospital. Patients discharged with the principal diagnosis of CHF were considered eligible for the study. RESULTS: Among the 1511 patients (3% of all discharges) who satisfied the inclusion criteria, 75% were treated in general medicine departments (GMD) and 22% in cardiology units (CU). Patients admitted to GMD were older than those treated in CU (79+/-10 vs. 68+/-15 years, P<0.001), included a higher proportion of females (56% vs. 37%, P<0.001), and presented a higher rate of hospital mortality (13% vs. 4%, P<0.001). The overall mean length of stay was 11+/-9 days. At multivariate analysis, length of stay was not associated with the department (i.e. GMD/CU) (P=0.273). CONCLUSIONS: CHF is a common lethal condition often requiring treatment in GMD. Length of stay appears to depend more on patients' characteristics than on differences in practice between GMD and CU. Patients admitted to GMD present higher rates of comorbidity and hospital mortality. Strategies are urgently needed to improve hospital management of CHF.     

Impact of hospital and physician characteristics on medical expenditures for acute myocardial infarction hospitalization

This study aims to examine the impact of length of stay, hospital characteristics, physician characteristics and other factors on the expenditures of hospitalization for acute myocardial infarction (AMI) under Taiwan's National Health Insurance program. This study uses data collected from the Taiwan's National Health Research Institute's 2001-2003 National Health Insurance Research Database. We estimated contributors to increased expenditures of hospitalization using three-stage least square regression model. The hospital expenditures for the treatment of AMI averaged NT$126,366 (US$3829, US$1=NT$33) per discharge, with the largest proportion (27%) spent on room expenditures. They were strongly impacted by length of stay, increasing around 4.8% per day. We conclude that hospital expenditures for the treatment of AMI patients may vary widely depending on the characteristics of the hospital and physicians that provide them care.