National Early Warning Scores Following Emergency Hospital Transfer: Implications for Care Home Residents

ObjectiveCare home residents have high rates of hospital admission. The UK National Early Warning Score (NEWS2) standardizes the secondary care response to acute illness. However, the ability of NEWS2 to predict adverse health outcomes specifically for care home residents is unknown. This study explored the relationship between NEWS2 on admission to hospital and resident outcome 7 days later.DesignRepeated cross-sectional study.Setting and ParticipantsData on UK care home residents admitted to 160 hospitals in two 24-hour periods (2019 and 2020).MethodChi-squared and Kruskal-Wallis tests, and multinomial regression were used to explore the association between low (score ≤2), intermediate (3–4), high (5–6), and critically high (≥7) NEWS2 on admission and each of the following: discharge on day of admission, admission and discharge within 7 days, prolonged hospital admission (>7 days), and death.ResultsFrom 665 resident admissions across 160 hospital sites, NEWS2 was low for 54%, intermediate for 18%, high for 13%, and critically high for 16%. The 7-day outcome was 10% same-day discharge, 47% admitted and subsequently discharged, 34% remained inpatients, and 8% died. There is a significant association between NEWS2 and these outcomes (P < .001). Compared with those with low NEWS2, residents with high and critically high NEWS2 had 3.6 and 9.5 times increased risk of prolonged hospitalization [relative risk ratio (RRR) 3.56; 95% CI 1.02–12.37; RRR 9.47; CI 2.20–40.67], respectively. The risk of death was approximately 14 times higher for residents with high NEWS2 (RRR 13.62; CI 3.17–58.49) and 54 times higher (RRR 53.50; CI 11.03–259.54) for critically high NEWS2.Conclusion and ImplicationsHigher NEWS2 measurements on admission are associated with an increased risk of hospitalization up to 7 days duration, prolonged admission, and mortality for care home residents. NEWS2 may have a role as an adjunct to acute care decision making for hospitalized residents.     

Electronic Patient Symptom Management Program to Support Patients Receiving Cancer Treatment at Home During the COVID-19 Pandemic

ObjectivesRemote patient monitoring became critical for patients receiving cancer treatment during the COVID-19 pandemic. We sought to test feasibility of an electronic patient symptom management program implemented during a pandemic. We collected and analyzed the real-world data to inform practice quality improvement and understand the patient experience.MethodsEligible patients had breast, lung, or ovarian cancers, multiple myeloma, or acute myeloid leukemia and 12 weeks of planned chemotherapy. Patients were notified that a symptom survey with common symptoms derived from the National Cancer Institute’s Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events was available to complete using a smart phone, tablet, or computer. Patients recorded their symptoms and results were sent to the provider. Patients received care guidelines for mild/moderate severity symptoms and a phone call from the provider for severe reports.ResultsA total of 282 patients generated > 119 088 data points. Patients completed 2860 of 3248 assigned surveys (88%), and 152 of 282 patients (54%) had symptom reports that generated an immediate notification to the provider. Longitudinal data were analyzed to determine whether previous reports predicted a notification alert and whether symptoms resolved after the alert was addressed.ConclusionsAn electronic patient symptom management program was implemented in the midst of the COVID-19 pandemic. Enrollment of 282 patients and a high survey completion (88%) demonstrated feasibility/acceptance. Patients reported symptoms at severe levels of 54% of the time and received self-management instructions and provider phone calls that resolved or decreased the severity of the symptom. A standard approach and validated instrument provide opportunities for improving and benchmarking outcomes.     

Beyond the drive to satisfy needs: in the context of health care

In the context of health care the aim of the article is to bring another meaning to the concept “need” that goes beyond the human activity; the drive to satisfy needs. Another meaning incorporates an ethical and existential nature of life phenomena. An example from empirical research on living with a chronic disease as seen from the patient’s point of view provides the basis for arguing another meaning of the concept “need”. The meanings and nuances in the life phenomena of hope, doubt and life courage are exemplified in qualitative interviews with chronic sufferers. A combination of empirical research and Danish life philosophy. Research has shown that the interaction between the professional health care provider and the patient and family may lead to a more or less unconscious and inappropriate administration of power. Research also indicates that by overlooking or ignoring the existential qualities in human life and suffering, the professional health care provider may deprive the patient and family of their room for action. To add a deeper understanding of the existential meaning of being a person with an illness, the article shows the different human dimensions concerning life phenomena and needs. Developing sensitive, situation-specific attention offers a response to the challenge faced by health care providers in collaboration with the patient: How can we open our eyes to the most significant features of the situation which arise on the onset of illness.     

The Impact of Patient–Provider Communication and Language Spoken on Adequacy of Depression Treatment for U.S. Women

Many women with depression are untreated or undertreated for their condition. The quality of patient–provider communication may impact the receipt of depression treatment. We examine the relationship between patient–provider communication and receipt of adequate treatment for depression among women. The study sample consisted of women with depression who visited a provider in the previous 12 months in the 2002–2008 Medical Expenditure Panel Survey (N = 3,179). Multivariate regression was used to examine the independent contribution of sociodemographic characteristics, health care factors, patient–provider communication, and respondent language on depression treatment status (none, some, adequate). We found that more than one-third of women with depression in the United States did not receive adequate treatment. Women reporting that providers usually or always listened carefully were more likely to receive adequate treatment (OR = 1.59; 95% CI = 1.10?2.30 and OR = 1.55; 95% CI = 1.07?2.23, respectively). Non-English-speaking women were 50% less likely to receive adequate treatment (OR = 0.49; 95% CI = 0.30?0.80). Having a usual source of care was associated with an increased likelihood of receiving some and adequate treatment (OR = 1.84; 95% CI = 1.24?2.73 and OR = 2.22; 95% CI = 1.61?3.05, respectively). Effective provider listening behaviors may help increase the number of U.S. women with depression who receive adequate treatment. Efforts to improve language access for limited English-proficient women are likely critical for improving treatment outcomes in this population. Additionally, ensuring that women with depression have consistent access to health care services is important for obtaining adequate depression care.     

Visit Patterns for Severe Mental Illness with Implementation of Integrated Care: A Pilot Retrospective Cohort Study

There is increasing interest in models that integrate behavioral health services into primary care. For patients with severe mental illness (SMI), a population with disproportionate morbidity and mortality, little is known about the impact of such models on primary care clinic utilization, and provider panels. We performed a retrospective cohort pilot study examining visit patterns for 1,105 patients with SMI overall, by provider, before, and after the implementation of a primary care behavioral health model which had a ramp up period from May 2006-August 2007. We used 2003–2012 electronic health record data from two clinics of a Federally Qualified Health Center and conducted interrupted time series and chi-square analyses. During the intervention period there was a significant increase in the proportion of visits per month to the clinic for patient with SMI relative to overall visits (0.27; 95% CI 0.22-0.32). After the intervention period, this rate declined (-0.23; -0.19-0.28) but remained above the pre-intervention period. After integration of behavioral health into our primary care clinics, there was a sharp increase in the number of patients with SMI, suggesting patient willingness to explore receiving care under this model. Clinics looking to adopt the model should be mindful of potential changes in patient subpopulations and proactively manage this transition.     

A Population-Based Approach to Asthma Disease Management

Asthma disease management (DM) programmes often focus on patients who are considered to be high resource users, such as those with recent emergency department visits and/or hospitalisations, or patients who have been diagnosed with severe persistent asthma. These programmes often focus on a few patients who have acute needs, but may not identify the populations with the highest future resource use. A population-based approach to disease management focuses on identifying deficiencies in asthma management across the population diagnosed with the disease and establishes a partnership between the patient, provider and healthcare plan to improve the overall quality of asthma care. The disease management approach described in this article is population-based, and is intended to raise the standard of medical care across a spectrum of patients with asthma.     

Impact of Local Resources on Hospitalization Patterns of Medicare Beneficiaries and Propensity to Travel Outside Local Markets

Purpose: To examine how local health care resources impact travel patterns of patients age 65 and older across the rural urban continuum.
Methods: Information on inpatient hospital discharges was drawn from complete 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New York, California, and Florida, and the 2003 hospital discharge file for Pennsylvania. The study population was Medicare patients with admissions for ambulatory care sensitive conditions. Analysis was at the patient-level, and area contextual variables were developed at the Primary Care Service Area (PCSA) level. Local resources considered included inpatient supply, provider supply, supply of international medical graduates, and critical access hospitals (CAHs) in the patient's PCSA.
Findings: Findings generally confirmed enhanced retention of the elderly in local markets with greater availability of community resources, although we observed considerable heterogeneity across states. Community resource variables such as median household income or inpatient hospital capacity were stronger and more consistent predictors along the urban rural continuum than any of the provider or CAH variables. Only in California and New York did we see significant effects for provider supply or CAH, but they were robust across the 2 states and models of travel propensity, always reducing the travel propensity.
Conclusions: Findings support policies aimed at augmenting supplies of critical access hospitals in rural communities, and increasing primary care physicians and hospital resources in both rural and urban communities.     

Increasing home health service referrals, boon or bane?

Discharges to home health services (HHS) increased dramatically for the elderly after Medicare's prospective payment system (PPS) was enacted in October 1983. A longitudinal study of fourth quarter South Carolina discharge abstracts from 68 of 71 short term acute care hospitals in the state were analyzed to appraise hospital responses to implementation of this significant change in Medicare's reimbursement system. PPS caused shifts in hospital practices as financial incentives radically changed from a cost-based system that encourages expenditures to a PPS that evokes conservation of resources within a hospital stay. In so doing, the "output" (i.e., discharge) changed. One of those changes observed was an increase in referrals to HHS. Apparently, capping the amount reimbursed for a particular diagnosis left the more resource-intensive patient vulnerable and in want of care on discharge. Demand for HHS rose significantly (+47% in 1983; +234% by 1985). Though a HHS referral may be appropriate during the recuperative phase of an illness, questions arise as to hospital motivation. The HHS referral represented the most resource-intensive, but arguably unprofitable segment. Had hospitals sought earlier discharges to "protect their bottom line" as reimbursement essentially was capped? Was a referral to HHS appropriate to meet the existing patient-care needs that remained? Did HHS offer a more cost-effective substitution for care formerly provided the patient in the hospital? What provider and consumer characteristics are at risk and why? Both consumer and provider concerns need to be addressed. Answers to these questions are most critical to future health care reform. Allocation decisions of scarce resources need to be grounded in realistic expectations drawn from appraisals of what does and does not work in the health care market.     

Pharmacist's role in an interdisciplinary cardiac rehabilitation team

The purpose of this study was to determine the impact of pharmacist and pharmacy student involvement with an interdisciplinary cardiac rehabilitation program in the outpatient setting. The study included 192 patients who were seen following discharge from an acute care hospital between June 2008 and September 2010. The pharmacy team educated patients on their medications, conducted medication reconciliation, and made patient and provider interventions when appropriate. The pharmacist met with the cardiac rehabilitation team before these sessions to identify areas of focus and concern. The team met again after the sessions to reconcile medication lists and identify areas for follow-up. Of the 192 patients seen, an intervention was initiated in 157 (81.8%), for a total of 467 interventions (mean 2.43 interventions/patient). Medication reconciliation interventions not requiring a physician response comprised 79.9% of total interventions, most commonly involving an over-the-counter medication not initially reported (18%). Seventy-six patient interventions and 18 provider interventions were also made; of these, 92% of the patient interventions were accepted, and 72% of the provider interventions were accepted. The most common patient intervention was changing the administration time of a medication (36.8%), and the most common provider intervention was avoidance of a significant drug interaction (33.3%). Pharmacists can play a vital role as part of an interdisciplinary cardiac rehabilitation team to ensure proper adherence to cardiac medications and patient safety through patient education and interventions.     

From Organizational Awareness to Organizational Competency in Health Care Social Work: The Importance of Formulating a “Profession-in-Environment” Fit

Today’s health care environments require organizational competence as well as clinical skill. Economically driven business paradigms and the principles underlying the Patient Protection and Affordable Care Act of 2010 emphasize integrated, collaborative care delivered using transdisciplinary service models. Attention must be focused on achieving patient care goals while demonstrating an appreciation for the mission, priorities and operational constraints of the provider organization. The educational challenge is to cultivate the ability to negotiate “ideology” or ideal practice with the practical realities of health care provider environments without compromising professional ethics. Competently exercising such ability promotes a sound “profession-in-environment” fit and enhances the recognition of social work as a crucial patient care component.     

Malpractice bill stirs discussion, raises moral questions

Catholic health care providers should raise a number of ethical considerations in the debate surrounding the Moore-Gephardt bill, which would establish an alternative malpractice liability system. The proposal encourages states to enact legislation under which providers and patients would reach settlements that compensate for economic losses resulting from negligent treatment. In states that do not enact such laws, HR 5400 would apply to federal program patients only. Under the proposal, if a health care provider who is potentially liable for malpractice offers to compensate for the patient's actual economic loss, the patient would be forever barred from bringing a malpractice suit against the provider. The recovery would be limited to the individual's net economic loss. Though the bill's sponsors have performed a considerable service in identifying a major problem and generating public discussion, the bill raises several important moral questions. How much "defensive medicine," for example, is actually prudent practice that is in patients' best interests? Will thorough and holistic care be sacrificed in the proposal's attempt to save money? If states do not enact an alternative liability system for all patients and the proposal affects only federal program patients, will the result be disproportionate treatment among categories of patients? And is it fair to deny persons recovery for their emotional distress, physical impairment, pain and suffering, and similar kinds of damages? These are but a few of the issues that Catholic providers should raise in the debate, which otherwise might well be oriented toward fiscal concerns only.     

Risk-adjusted number-between failures charting procedures for monitoring a patient care process for acute myocardial infarctions

Risk-adjusted charts for monitoring a surgical or patient care process have recently gained prominence in the literature. To monitor a patient care process, especially to detect deterioration is crucial in saving patients’ lives. In this paper, a new charting procedure is developed for monitoring a patient care process for patients admitted to a hospital with acute myocardial infarctions. This procedure is based on the number-between failures by taking the patients’ risks into account. When there is a change in the risk distribution of incoming patients, it is demonstrated that this procedure will behave properly while the non-risk-adjusted counterpart will signal incorrectly that the patient care process has changed. The setting up of this chart to monitor a patient care process for patients with acute myocardial infarctions is described in detail.     

NEWS结合GCS评分在颅脑损伤患者病情评估中的应用研究

目的 本研究旨在探讨采用NEWS评分结合GCS评分在颅脑损伤患者病情评估中的应用价值。方法 前瞻性纳入317例确诊为颅脑损伤的患者,动态评估患者的意识状态、生命体征状况、是否进行吸氧干预以及血氧饱和度等情况并计算其NEWS评分和GCS评分结果,利用SPSS19.0绘制受试者工作曲线（ROC曲线）,并计算出两个评分表对判断患者是否需要转入ICU进行更高级别监护的曲线下面积（AUC）和最佳截断值;采用Spearman相关性分析了解NEWS评分和GCS评分与患者的住院天数的关系。结果 NEWS 评分、GCS评分在预测患者是否需要转入ICU的AUC分别为0.912（95%CI:0.881-0.943）、0.950（95%CI:0.927~0.973）;NEWS≥8、GCS≤11为判断患者需要转入ICU的最佳截断值;患者的住院天数与NEWS评分呈正相关（r=0.657,P＜0.05）、与GCS评分呈负相关（r=-0.540,P＜0.05）。 结论 NEWS结合GCS评分能很好的预测颅脑损伤患者是否需要转入ICU进行更高级别监护,值得临床推广使用。     

Heart failure patients¿ experiences with continuity of care and its relation to medication adherence: a cross-sectional study

ABSTRACT: BACKGROUND: A growing number of health care providers are nowadays involved in heart failure care. This could lead to discontinuity and fragmentation of care, thus reducing trust and hence poorer medication adherence. This study aims to explore heart failure patients' experiences with continuity of care, and its relation to medication adherence. METHODS: We collected data from 327 primary care patients with chronic heart failure. Experienced continuity of care was measured using a patient questionnaire and by reviewing patients' medical records. Continuity of care was defined as a multidimensional concept including personal continuity (seeing the same doctor every time), team continuity (collaboration between care providers in general practice) and cross-boundary continuity (collaboration between general practice and hospital). Medication adherence was measured using a validated patient questionnaire. The relation between continuity of care and medication adherence was analysed by using chi-square tests. RESULTS: In total, 53% of patients stated not seeing any care provider in general practice in the last year concerning their heart failure. Of the patients who did contact a care provider in general practice, 46% contacted two or more care providers. Respectively 38% and 51% of patients experienced the highest levels of team and cross-boundary continuity. In total, 14% experienced low levels of team continuity and 11% experienced low levels of cross-boundary continuity. Higher scores on personal continuity were significantly related to better medication adherence (p < 0.01). No clear relation was found between team- or cross-boundary continuity and medication adherence. CONCLUSIONS: A small majority of patients that contacted a care provider in general practice for their heart failure, contacted only one care provider. Most heart failure patients experienced high levels of collaboration between care providers in general practice and between GP and cardiologist. However, in a considerable number of patients, continuity of care could still be improved. Efforts to improve personal continuity may lead to better medication adherence.     

The mental health care context and patient characteristics: implications for provider job satisfaction

This research examines job satisfaction among 282 staff providing mental health care to 574 patients with serious mental illness. The mental health staff worked in 18 Department of Veterans Affairs inpatient and outpatient mental health care units at 12 Veterans Affairs Medical Centers located across the contiguous 48 states. The purpose was to identify (1) aspects of the health care context that were associated with provider job satisfaction and (2) administrative and organizational procedures/interventions that might sustain or improve provider job satisfaction. The association of provider job satisfaction with patients' functional status and symptom severity was tested in multilevel statistical models that accounted for provider and unit characteristics. Provider job satisfaction was found to be greater on smaller units and units with higher patient functioning and lower illness severity. Implications of these results are discussed.     

Who knows best: the patient or the provider? A nursing perspective

Who knows best: the patient or the provider? My opinion, based on a review of the literature and practical experience, is that the patient, the provider and the system each offer a unique perspective that we can draw upon in ensuring quality care across the continuum. Nurses have a unique body of knowledge and skill that they bring to each interaction with the patient. They must have an awareness of the patient's and the system's expectations and interact and negotiate realistic expectations for each. The maintenance of balanced expectations and the measurement of effectiveness will continue to be a challenge. However, patients should be involved in and direct aspects of their care and feel satisfied with the process. Ultimately, nurses and the hospitals in which they work are responsible for providing effective and satisfying care. I would like to end by reinforcing the importance of the patient's voice in the provision of compassionate care. It is disheartening to read about patients' experiences of "discompassionate healthcare" (Holloway 1999). Yet I am reassured when I read or experience examples of compassionate and effective care such as that outlined by Valerie McDonald. (Hospital Quarterly Winter 1999/2000) Ms. McDonald, a former social worker and adult educator, is the mother of three daughters, one who had Burkitt's lymphoma diagnosed in 1994 and a second who had acute lymphostatic leukemia diagnosed in 1997 and who died recently in 1999. McDonald provided a wonderful perspective about her hospital experiences--the good and the bad. There would be no denying from this report that patients know the key qualities necessary for effective and compassionate care and that this mother recognized the energy and time it took to provide this care. "I hope," she states, "as the dust settles from restructuring and cutbacks that hospital staff will still have the time, energy and flexibility to practice the art of healing as they did with my children" (p. 24). I too reinforce that we must ensure nurses (and others) have the resources, the flexibility within their roles and the knowledge and skill to practise both the art and science of nursing.     

“Ticket to ride”: How useful is this new handoff tool?

Patient handoffs come in many forms, some of which are permanent (the provider will not get the patient back) and some of which are temporary (the provider will get the patient back). The danger inherent in temporary handoffs is that the temporary provider will not have sufficient information, or will not have time to gather the necessary information, to provide care for the patient safely. The “ticket‐to‐ride” tool, in addition to the verbal handoff communication, can be used to provide temporary providers of care with a salient synopsis of the patient's condition to protect the patient during an absence from the floor or unit. This article gives guidance on the development of a ticket‐to‐ride form.     

Do the Medicaid and Medicare programs compete for access to health care services? A longitudinal analysis of physician fees, 1998–2004

As the demand for publicly funded health care continues to rise in the U.S., there is increasing pressure on state governments to ensure patient access through adjustments in provider compensation policies. This paper longitudinally examines the fees that states paid physicians for services covered by the Medicaid program over the period 1998–2004. Controlling for an extensive set of economic and health care industry characteristics, the elasticity of states’ Medicaid fees, with respect to Medicare fees, is estimated to be in the range of 0.2–0.7 depending on the type of physician service examined. The findings indicate a significant degree of price competition between the Medicaid and Medicare programs for physician services that is more pronounced for cardiology and critical care, but not hospital care. The results also suggest several policy levers that work to either increase patient access or reduce total program costs through changes in fees.     

Improved Diabetes Control Through a Provider-Based Disease Management Program

Objective: The primary aim of this study was to evaluate the effectiveness of a newly implemented hospital-based diabetes mellitus disease management program. A secondary aim was to determine if relationships existed among variables.Design and setting: Effectiveness was evaluated in terms of glycemic control, post-program acute care resource utilization, adherence with American Diabetes Association (ADA) standards of care, and health-related quality of life. Participants in the Diabetes LifeCare program (DLC) received all standards of care which included diabetes self-management education, medical management by a primary care provider (PCP) supported by an evaluation and recommendations by an Advanced Practice Registered Nurse (APRN), nutritional counseling and at minimum, quarterly follow-up appointments for 1 year.Patients: Patients who were aged ≥18 years and referred to the DLC program with new a diagnosis or history of type 1 or 2 diabetes mellitus.Main outcome measures and results: Results demonstrated that at 3 months after enrollment in the DLC, participants in the study with available data (n = 142) had a mean decrease in predominant glycosylated hemoglobin (HbA_1c) values from 9.31 to 7.21 (p < 0.001). The HbA_1c value for participants with data at the 6-month visit (n = 66) decreased from 9.23 to 7.22 at 3 months and to 6.80 at 6 months (p < 0.001). At baseline, 52 of the 142 participants (36.5%) had HbA1c values less than 8.0, compared with 107 patients (75.4%) at 3 months (p < 0.0001). A total of 185 of 227 patients (81.5%) received eye examinations as per ADA guidelines. A total of 225 of 227 patients (99.1%) were in compliance with the ADA guidelines for nutritional counseling as a result of participation in the program. On the Physical Component Summary, their mean scores were 42.75 [standard deviation (SD) = 11.17] at enrollment, compared with 45.12 (SD = 10.52) at 3 months (p < 0.001). The Mental Component Summary score increased from 47.52 (SD = 11.90) to 50.83 (SD = 10.47) [p < 0.001]. Regarding resource utilization, during the follow-up period only 3 of 227 patients had emergency room visits and there were no inpatient visits for acute problems related to diabetes.Conclusions: Our results show that, in the short term, significant improvement in glycemic control can be achieved through a comprehensive program of patient education and management, that includes collaborative efforts with the patient’s primary care provider. High rates of eye and foot examination can also be attained by reinforcing patient involvement and admissions for acute metabolic complications can be minimized.