Effect of Evidence-Based Acute Pain Management Practices on Inpatient Costs

Objectives. To estimate hospital cost changes associated with a behavioral intervention designed to increase the use of evidence-based acute pain management practices in an inpatient setting and to estimate the direct effect that changes in evidence-based acute pain management practices have on inpatient cost.
Data Sources/Study Setting. Data from a randomized "translating research into practice" (TRIP) behavioral intervention designed to increase the use of evidence-based acute pain management practices for patients hospitalized with hip fractures.
Study Design. Experimental design and observational "as-treated" and instrumental variable (IV) methods.
Data Collection/Extraction Methods. Abstraction from medical records and Uniform Billing 1992 (UB92) discharge abstracts.
Principal Findings. The TRIP intervention cost on average $17,714 to implement within a hospital but led to cost savings per inpatient stay of more than $1,500. The intervention increased the cost of nursing services, special operating rooms, and therapy services per inpatient stay, but these costs were more than offset by cost reductions within other cost categories. "As-treated" estimates of the effect of changes in evidence-based acute pain management practices on inpatient cost appear significantly underestimated, whereas IV estimates are statistically significant and are distinct from, but consistent with, estimates associated with the intervention.
Conclusions. A hospital treating more that 12 patients with acute hip fractures can expect to lower overall cost by implementing the TRIP intervention. We also demonstrated the advantages of using IV methods over "as-treated" methods to assess the direct effect of practice changes on cost.     

Measuring Organizational Attributes of Primary Care Practices: Development of a New Instrument

Objective. To develop an instrument to measure organizational attributes relevant for family practices using the perspectives of clinicians, nurses, and staff.
Data Sources/Study Setting. Clinicians, nurses, and office staff ( n =640) from 51 community family medicine practices.
Design. A survey, designed to measure a practices' internal resources for change, for use in family medicine practices was created by a multidisciplinary panel of experts in primary care research and health care organizational performance. This survey was administered in a cross-sectional study to a sample of diverse practices participating in an intervention trial. A factor analysis identified groups of questions relating to latent constructs of practices' internal resources for capacity to change. ANOVA methods were used to confirm that the factors differentiated practices.
Data Collection. The survey was administered to all staff from 51 practices.
Principal Findings. The factor analysis resulted in four stable and internally consistent factors. Three of these factors, "communication,""decision-making," and "stress/chaos," describe resources for change in primary care practices. One factor, labeled "history of change," may be useful in assessing the success of interventions.
Conclusions. A 21-item questionnaire can reliably measure four important organizational attributes relevant to family practices. These attributes can be used both as outcome measures as well as important features for targeting system interventions.     

Older patients in the acute care setting: rural and metropolitan nurses' knowledge, attitudes and practices

ABSTRACT: Many studies reporting nurses' knowledge of and attitudes toward older patients in long-term care settings have used instruments designed for older people. However, nurses' attitudes toward older patients are not as positive as their attitudes toward older people. Few studies investigate acute care nurses' knowledge of and attitudes toward older patients. In order to address these shortcomings, a self-report questionnaire was developed to determine nurses' knowledge of, and attitudes and practices toward, older patients in both rural and metropolitan acute care settings. Rural nurses were more knowledgeable about older patients' activities during hospitalisation, the likelihood of them developing postoperative complications and the improbability of their reporting incontinence. Rural nurses also reported more positive practices regarding pain management and restraint usage. However, metropolitan nurses reported more positive attitudes toward sleeping medications, decision making, discharge planning and the benefits of acute gerontological units, and were more knowledgeable about older patients' bowel changes in the acute care setting.     

Improving Quality Assessment through Multilevel Modeling: The Case of Nursing Home Compare

Objective. To demonstrate how multilevel modeling and empirical Bayes (EB) estimates can improve Medicare's Nursing Home Compare quality measures (QMs).
Data Sources/Study Setting. Secondary data from July 1 to September 30, 2004. Facility-level QMs were estimated from minimum data set (MDS) assessments for approximately 31,000 Minnesota nursing home residents in 393 facilities.
Study Design. Prevalence and incidence rates for 12 nursing facility QMs (e.g., use of physical restraints, pressure sores, and weight loss) were estimated with EB methods and risk adjustment using a hierarchical general linear model. Three sets of rates were developed: Nursing Home Compare's current method, unadjusted EB rates, and risk-adjusted EB rates. Bayesian 90 percent credibility intervals (CIs) were constructed around EB rates, and these were used to flag facilities for potential quality of care problems.
Data Collection/Extraction Methods. MDS assessments were performed by nursing facility staff, transmitted electronically to the Minnesota Department of Health, and provided to the investigators.
Principal Findings. Facility rates and rankings for the 12 QMs differed substantially using the multilevel models compared with current methods. The EB estimated rates shrank considerably toward the population mean. Risk adjustment had a large impact on some QM rates and a more modest impact on others. When EB CIs were used to flag problem facilities, there was wide variation across QMs in the percentage of facilities flagged.
Conclusions. Multilevel modeling should be applied to Nursing Home Compare and more widely in other health care quality assessment systems.     

Effects of Payment Changes on Trends in Post-Acute Care

Objective. To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies.
Data Sources. Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data.
Study Design. We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems.
Data Extraction Methods. A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement.
Principal Findings. Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill.
Conclusions. Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.     

From Pubs to Scrubs: Alcohol Misuse and Health Care Use

Objective. To analyze the relationships between alcohol misuse and two types of acute health care use—hospital admissions and emergency room (ER) episodes.
Data Sources/Study Setting. The first (2001/2002) and second (2004/2005) waves of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC).
Study Design. Longitudinal study using a group of adults (18–60 years in Wave 1, N =23,079). Gender-stratified regression analysis adjusted for a range of covariates associated with health care use. First-difference methods corrected for potential omitted variable bias.
Data Collection. The target population of the NESARC was the civilian noninstitutionalized population aged 18 and older residing in the United States and the District of Columbia. The survey response rate was 81 percent in Wave 1 ( N =43,093) and 65 percent in Wave 2 ( N =34,653).
Principal Findings. Frequent drinking to intoxication was positively associated with hospital admissions for both men and women and increased the likelihood of using ER services for women. Alcohol dependence and/or abuse was related to higher use of ER services for both genders and increased hospitalizations for men.
Conclusions. These findings provide updated and nationally representative estimates of the relationships between alcohol misuse and health care use, and they underscore the potential implications of alcohol misuse on health care expenditures.     

Impact of the Medicare Short Stay Transfer Policy on Patients undergoing Major Orthopedic Surgery

Objective. To examine the impact of the Short Stay Transfer Policy (SSTP) on practice patterns.
Data Sources. This study uses data from the Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review (MEDPAR) file, Home Health Standard Analytical File, 1999 Provider of Service file, and data from the 2000 United States Census.
Study Design. An interrupted time-series analysis was used to examine the length of stay (LOS) and probability of "early" discharge to post acute care (PAC).
Data Collection. Separate 100percent samples of all fee-for-service Medicare recipients undergoing either elective joint replacement (JR) surgery or surgical management of hip fracture (FX) between January 1, 1996 and December 31, 2000 were selected.
Principal Findings. Prior to implementation of the SSTP. LOS had been falling by 0.37 and 0.30 days per year for JR and FX patients respectively. After implementation of the SSTP, there was an immediate increase in LOS by 0.20 and 0.17 days, respectively. Thereafter, LOS remained flat. The proportion of patients discharged "early" to PAC had been rising by 4.4 and 2.6 percentage points per year for JR and FX patients respectively, to a peak of 28.8percent and 20.4percent early PAC utilization in September 1998. Immediately after implementation of the SSTP, there was a 4.3 and 3.0 percentage point drop in utilization of "early" PAC. Thereafter utilization of early PAC increased at a much slower rate (for JR) or remained flat (for FX). There was significant regional variation in the magnitude of response to the policy.
Conclusion. Implementation of the SSTP reduced the financial incentive to discharge patients early to PAC. This was accomplished primarily through longer LOS without meaningful change in PAC utilization. With the recent expansion of the SSTP to 29 DRGs (representing 34percent of all discharges), these findings have important implications regarding patient care.     

Managed Care, Access to Specialists, and Outcomes among Primary Care Patients with Pain

Objective. To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain.
Data Sources/Study Setting. Patient, physician, and office manager questionnaires collected in the Seattle area in 1996–1997, plus data abstracted from patient records and health plans.
Study Design. A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle.
Data Collection. Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines.
Principal Findings. A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians.
Conclusions. Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.     

An Empty Toolbox? Changes in Health Plans' Approaches for Managing Costs and Care

Objective. To examine how health plans have changed their approaches for managing costs and utilization in the wake of the recent backlash against managed care.
Data Sources/Study Setting. Semistructured interviews with health plan executives, employers, providers, and other health care decision makers in 12 metropolitan areas that were randomly selected to be nationally representative of communities with more than 200,000 residents. Longitudinal data were collected as part of the Community Tracking Study during three rounds of site visits in 1996–1997, 1998–1999, and 2000–2001.
Study Design. Interviews probed about changes in the design and operation of health insurance products—including provider contracting and network development, benefit packages, and utilization management processes—and about the rationale and perceived impact of these changes.
Data Collection/Extraction Methods. Data from more than 850 interviews were coded, extracted, and analyzed using computerized text analysis software.
Principal Findings. Health plans have begun to scale back or abandon their use of selected managed care tools in most communities, with selective contracting and risk contracting practices fading most rapidly and completely. In turn, plans increasingly have sought cost savings by shifting costs to consumers. Some plans have begun to experiment with new provider networks, payment systems, and referral practices designed to lower costs and improve service delivery.
Conclusions. These changes promise to lighten administrative and financial burdens for physicians and hospitals, but they also threaten to increase consumers' financial burdens.     

Hospital nurse practice environments and outcomes for surgical oncology patients

Objective. To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery.
Data Sources. Secondary analysis of cancer registry, inpatient claims, administrative and nurse survey data collected in Pennsylvania for 1998–1999.
Study Design. Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelor's degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30-day mortality, complications, and failure to rescue (death following a complication).
Principal Findings. Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07–1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07–2.03). Receipt of care in National Cancer Institute-designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments.
Conclusions. This study is one of the first to examine the predictive validity of the National Quality Forum's endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.     

Risk of Medication Errors at Hospital Discharge and Barriers to Problem Resolution

SUMMARY

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.     

Risk of medication errors at hospital discharge and barriers to problem resolution

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.     

Practice Location Choice by New Physicians: The Importance of Malpractice Premiums, Damage Caps, and Health Professional Shortage Area Designation

Objective. To understand the factors affecting the choice of initial practice location by new physicians.
Data Sources/Study Setting. A unique survey of exiting medical residents in New York State from 1998 to 2003.
Study Design. We estimate conditional logit models to examine the factors affecting the choice of initial practice location by new physicians.
Data Collection/Extraction Methods. We identify all physicians completing their training in obstetrics/gynecology or surgery and primary care physicians (PCPs) (general internal medicine, pediatrics, and family medicine) who had accepted a job in patient care and who provided the location (zip code) of their job. This resulted in 3,758 physicians in our sample.
Principal Findings. Our results indicate that malpractice insurance premiums are a significant deterrent for surgeons, but they do not appear to deter OB/GYNs or PCPs from locating in particular areas. In addition, caps on malpractice damage awards attract surgeons to areas. Shortage area designations attract PCPs without education debt yet deter PCPs with debt, suggesting that subsidies do not outweigh the perceived costs of locating in underserved areas.
Conclusions. In general our results highlight that new physicians are sensitive to the characteristics of the locations in which they could potentially locate when beginning their careers in patient care.     

Acceptability and feasibility of physician-based activity counseling: The PAL project

Background: The continued prevalence of sedentary behavior in older adults underscores the need for physical activity promotion. Physician-delivered activity counseling may be an important avenue of promoting physical activity for these individuals. The Physically Active for Life (PAL) project was a randomized study of the effects of brief physician counseling plus follow-up on physical activity behaviors in older adults.Method: Twelve practices were randomized to the intervention group and 12 to standard care. Physicians in the intervention group participated in a 1-hour training session and received support materials for exercise counseling. Pre-assessment and post-assessment of self-reported exercise counseling behaviors and confidence in providing exercise counseling were obtained from physicians in the study. Patient evaluations of the exercise counseling and support materials were also obtained.Results: Results showed that physicians favorably endorsed the training and the support materials, and reported adherence to delivery of the intervention protocol. Comparisons between the two groups showed significant improvements in confidence for intervention-group physicians, but no significant changes in physician reports of exercise counseling provided to all patients. Patients reported satisfaction with the exercise counseling and support materials.Conclusions: Physicians and patients indicated the PAL project offered an acceptable and feasible approach to promote physical activity in older adults.     

Exploring Differences in Patient-Centered Practices among Healthcare Professionals in Acute Care Settings

There is limited evidence of the extent to which Healthcare professionals implement patient-centered care (PCC) and of the factors influencing their PCC practices in acute care organizations. This study aimed to (1) examine the practices reported by health professionals (physicians, nurses, social workers, other healthcare providers) in relation to three PCC components (holistic, collaborative, and responsive care), and (2) explore the association of professionals’ characteristics (gender, work experience) and a contextual factor (caseload), with the professionals’ PCC practices. Data were obtained from a large scale cross-sectional study, conducted in 18 hospitals in Ontario, Canada. Consenting professionals (n = 382) completed a self-report instrument assessing the three PCC components and responded to standard questions inquiring about their characteristics and workload. Small differences were found in the PCC practices across professional groups: (1) physicians reported higher levels of enacting the holistic care component; (2) physicians, other healthcare providers, and social workers reported implementing higher levels of the collaborative care component; and (3) physicians, nurses, and other healthcare providers reported higher levels of providing responsive care. Caseload influenced holistic care practices. Interprofessional education and training strategies are needed to clarify and address professional differences in valuing and practicing PCC components. Clinical guidelines can be revised to enable professionals to engage patients in care-related decisions, customize patient care, and promote interprofessional collaboration in planning and implementing PCC. Additional research is warranted to determine the influence of professional, patient, and other contextual factors on professionals’ PCC practices in acute care hospitals.     

Intervention targeted at nurses to improve venous thromboprophylaxis.

OBJECTIVE: To assess the effectiveness of an intervention targeting both physicians and nurses vs. physicians only in improving venous thromboprophylaxis for older patients. DESIGN: Cluster randomized trial. SETTING: Fifty hospital-based post-acute care departments in France. PARTICIPANTS: Patients aged 65 years or older. INTERVENTION: A multifaceted intervention to implement a clinical practice guideline addressing venous thromboprophylaxis. MAIN OUTCOME MEASURES: The effectiveness outcomes were elastic stocking use, ambulation or mobilization under the supervision of a physical therapist and anticoagulant-based prophylaxis. Patient outcomes included deep vein thrombosis and anticoagulant-related adverse events. RESULTS: One department allocated to the intervention targeted at physicians only and seven departments allocated to the intervention targeted at both physicians and nurses dropped out of the study. Compared with the intervention targeted at physicians only (n = 497 patients), the intervention targeted at both physicians and nurses (n = 315 patients) was associated with a higher rate of mobilization (62 vs. 37%, P < 0.001) and comparable levels of elastic stocking (32 vs. 39%, P = 0.74) and anticoagulant (55 vs. 48%, P = 0.36) use. The rates of deep vein thrombosis (15 vs. 13%, P = 0.50), bleeding (1 vs. 1%, P = 0.99) and thrombocytopaenia (0 vs. 0.2%, P = 0.99) did not differ between the two groups. CONCLUSIONS: A multifaceted intervention targeting nurses in addition to physicians can increase the frequency of mobilization of older patients to prevent venous thromboembolism but does not alter the use of elastic stockings and anticoagulant. A differential drop-out of departments might have contributed to creating imbalances in baseline characteristics and outcomes in this study.     

Experiences of Agency for Healthcare Research and Quality-Funded Projects That Implemented Practices for Safer Patient Care

Objectives. To synthesize lessons learned from the experiences of Agency for Healthcare Research and Quality-funded patient safety projects in implementing safe practices.
Data Sources. Self-reported data from individual and group interviews with Original, Challenge, and Partnerships in Implementing Patient Safety (PIPS) grantees, from 2003 to 2006.
Study Design. Interviews with three grantee groups ( n =60 total) implementing safe practice projects, with comparisons on factors influencing project implementation and sustainability.
Data Collection. Semi-structured protocols contained open-ended questions on lessons learned and more structured questions on factors associated with project implementation and sustainability.
Principal Findings. The grantees shared common experiences, frequently identifying lessons learned regarding structural components needing to be in place before implementation, components of the implementation process, components of interventions' results needed for sustainability, changes in timelines or activities, unanticipated issues, and staff acceptance/adoption. Also, fewer Original grants had many of the factors related project to implementation/sustainability than the PIPS or Challenge grantees had.
Conclusions. Although much of what was reported seemed like common sense, surprisingly few projects actually planned for or expected many of the barriers or facilitators they experienced during their project implementation. Others implementing practice improvements likely will share the experiences and issues identified by these implementation projects and can learn from their lessons.