Hospitalists and care transitions: the divorce of inpatient and outpatient care

We interviewed hospitalist and nonhospitalist respondents as part of the Community Tracking Study site visits to examine how the growing use of hospitalists has affected care delivery systems. The growth of hospitalist programs contributes to a loss of physicians' participation on hospital medical staffs, which increases the burden of coordination and blurs accountability for the quality of postdischarge care. Arrangements where companies and multispecialty medical groups employ hospitalists are more likely than others to establish routines for ensuring coordinated transitions upon hospital admission and discharge. Policymakers could support the development of guiding principles for care coordination, greater reliance on nonphysicians, and reintegration of inpatient and outpatient providers.     

Patient transitions from inpatient to outpatient: Where are the risks? Can we address them?

Transitions of care from the inpatient to outpatient setting can be dangerous. Studies have shown that almost half of all hospitalized patients experience a medical error after discharge. With efforts to decrease the cost of healthcare, patients are discharged “quicker and sicker” oftentimes leaving families to manage the patient's recovery with little support. Most medical errors can be traced back to communication breakdowns and lack of systems to follow up on needed care. Inpatient and outpatient providers must work together to develop processes to address these deficits or face decreasing reimbursement and malpractice claims.     

Top 25 inpatient procedures driven by new technology, push to outpatient settings

DATA BENCHMARKS: Top 25 inpatient procedures ranked by volume show which procedures are still occurring broadly within hospitals. See how to use the ranking to compare your procedure costs and length of stay with others across the country and to track several health care industry trends.     

Blended learning: emerging best practices in allied health workforce development

To remain dynamic and viable, academic institutions preparing the future workforce need to convert to a more accessible and convenient pathway for students. The need for responsiveness is especially true when considering strategies to prepare an allied health workforce in areas of shortages and to meet the needs of the underserved. A blended or hybrid learning model that strategically uses web-based and face-to-face teaching/learning methods is an innovative and strategic way that promotes learner-centered higher education and facilitates a higher learning experience. A model and emerging best practices for implementation are presented from our experience at the Center for Allied Health Programs at the University of Minnesota.     

Surgical procedures in inpatient versus outpatient settings and its potential impact on follow-up costs

ObjectiveWe examined real-world effects of cantonal legislations to direct surgery patients from the inpatient to the outpatient setting in Switzerland.MethodsAnalyses were based on claims data of the Helsana Group, a leading Swiss health insurance. The study population consisted of 13’145 (in 2014), 12’455 (in 2016), and 12’875 (in 2018) insured persons aged >18 years who had haemorrhoidectomy, inguinal hernia repair, varicose vein surgery, knee arthroscopy/meniscectomy or surgery of the cervix/uterus. We assessed the proportion of inpatient procedures, index costs, length of hospital stays, outpatient costs and hospitalizations during follow-up, stratified by procedure, in-/outpatient setting, and the presence (enacted/effective in 2018) of a cantonal legislation. We used difference-in-differences methods to study the impact of cantonal legislations.ResultsOverall, the proportion of procedures performed in the inpatient setting decreased between 2014 and 2018 (p < 0.001). The decrease between 2016 and 2018 was significantly steeper in cantons with a legislation (p < 0.001; effect size: 0.57; 95% CI: 0.51, 0.64), leading to steeper decreases in healthcare costs of index procedures in cantons with a legislation, with no impact on length of hospital stays. The legislation also had no impact on outpatient costs or hospitalizations during follow-up.ConclusionsThe cantonal legislations achieved the intended effects of inpatient surgery substitution by outpatient surgery, with no evidence suggesting negative effects on costs or hospitalizations during follow-up.     

Organizing healthcare delivery systems for persons with ongoing care needs and their families: a best practices framework

How systems of care delivery are structured can have a major impact on their relative efficiency and on the quality of care provided to individuals. As the population continues to age, as more people are able to continue to live with disabilities or chronic conditions, and as demands continue from consumers and lobby groups to allow individuals to be more fully integrated into customary Canadian life, pressures to deal with the needs of persons with ongoing care requirements will only continue to mount.     

Transitioning from inpatient to outpatient therapy in patients with in-hospital hyperglycemia

Transition from inpatient to outpatient care for patients with type 2 diabetes mellitus is an important aspect of patient management for which there is no guidance. Intensive glucose lowering with insulin is generally favored for seriously ill hospitalized patients, but after discharge, patients often resume their prior regimens, which may include an array of oral or injected glucose-lowering agents. Factors that should be considered in this transition include goals of care/life expectancy, glycated hemoglobin at hospital admission, home medications for other illnesses and their potential for interactions with antidiabetes treatment, comorbidities, nutritional status, physical disabilities, ability to carry out self-monitoring of blood glucose, risk for hypoglycemia, contraindications to oral medications, health literacy, and financial and other resources. Traditional oral therapies that may be used after the patient leaves the hospital include sulfonylureas, α-glucosidase inhibitors, thiazolidinediones, and metformin. α-Glucosidase inhibitors are limited by gastrointestinal adverse events, and thiazolidinediones by fluid retention and increased risk for heart failure. Thiazolidinediones also require a long period of administration for onset glucose lowering and are not suitable for transitioning hospitalized patients who have been receiving insulin to outpatient care. Metformin is contraindicated in patients with renal, cardiac, or pulmonary insufficiency. Incretin-based therapies, glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, have limited use in hospitals, but may be suitable for the transition to outpatient treatment. The most common adverse events with glucagon-like peptide-1 inhibitors involve the gastrointestinal system. More formal studies of treatment regimens for patients with hyperglycemia leaving the hospital are needed to guide care for this group.     

Socioeconomic status and access to care and the incidence of a heart failure diagnosis in the inpatient and outpatient settings

Purpose

Despite well-documented associations of socioeconomic status with incident heart failure (HF) hospitalization, little information exists on the relationship of socioeconomic status with HF diagnosed in the outpatient (OP) setting.

Healthy settings: challenges to generating evidence of effectiveness

This paper starts by briefly reviewing the history, theory and practice of the settings approach to promoting public health--highlighting its ecological perspective, its understanding of settings as dynamic open systems and its primary focus on whole system organization development and change. It goes on to outline perceived benefits and consider why, almost 20 years after the Ottawa Charter advocated the approach, there remains a relatively poorly developed evidence base of effectiveness. Identifying three key challenges--relating to the construction of the evidence base for health promotion, the diversity of conceptual understandings and real-life practice and the complexity of evaluating ecological whole system approaches--it suggests that these have resulted in an ongoing tendency to evaluate only discrete projects in settings, thus failing to capture the 'added value' of whole system working. It concludes by exploring the potential value of theory-based evaluation and identifying key issues that will need to be addressed in moving forward--funding evaluation within and across settings; ensuring links between evidence, policy and practice; and clarifying and articulating the theories that underpin the settings approach generically and inform the approach as applied within particular settings.     

Measuring inpatient and outpatient costs: a cost-function approach

In this article, the authors estimate a multiple-output cost function for a sample of 2,235 hospitals during the period 1984-88 to disaggregate total costs into inpatient and outpatient components. The results suggest that outpatient cost growth is roughly proportional to that of inpatient cost, despite much higher relative growth in revenues and utilization on the outpatient side. The stability in the outpatient/inpatient cost ratio implies that the increase in the outpatient-to-inpatient utilization ratio was offset by a decline in their relative unit costs.     

Recommendations from lead poisoning prevention program participants: best practices

We present a program evaluation of the Phillips Lead Project, a 5-year study of the effectiveness of culture-specific, peer education in maintaining low blood lead levels of children in an inner-city neighborhood. We conducted focus groups to understand how project participants felt about the various strategies employed by the Lead Project. The purpose of this article is to describe their reactions to the project and make recommendations concerning appropriate educational strategies for lead poisoning prevention projects being undertaken in similar communities. Although this project was a research study, many of its methods, and participants' reactions to those methods, are relevant to non-research prevention programs and may be generalizable to other health issues besides lead poisoning.     

Evaluation of working practices and surface contamination with antineoplastic drugs in outpatient oncology health care settings

Purpose

Many antineoplastic drugs are classified as carcinogenic, mutagenic and teratogenic for humans. Therefore, minimization of exposure is required to reduce health risks to employees. The aim of this study was to evaluate working practices and safety measures during drug administration and to assess workplace contamination in outpatient oncology health care settings.

Methods

Questionnaires about working procedures were sent to 137 day hospitals and private practices. Workplace contamination with 5-fluorouracil, platinum, gemcitabine, cyclophosphamide, ifosfamide, methotrexate, docetaxel and paclitaxel was assessed using wipe samples.

Results

Forty institutions participated in the study, and in 28 departments, wipe samples were taken. Depending on the kind of activity, working procedures often (5–80%) were not confirmed with recommendations for safe handling of antineoplastic drugs. Altogether, 60.9% of the sampling results were above the limit of detection (LOD). Most frequent loads were detected with 5-FU (93.5%) and platinum (88.4%). Contamination was detected on all surfaces and the results ranged between <LOD up to 750,000 pg/cm². There was no correlation between the amount of drugs handled and the extent of surface contamination. However, specific working practices resulting in a lower number of positive wipe samples could be identified (e.g., use of closed infusion systems).

Conclusion

Workplace contamination with antineoplastic drugs is still present. As patients have to be considered as a potential source of contamination, surface contamination is difficult to avoid. However, our study revealed that it is possible to administer a large number of preparations without causing high workplace contamination.     

Advocacy evaluation: challenges and emerging trends

Devising, promoting, and implementing changes in policies and regulations are important components of population-level health promotion. Whether advocating for changes in school meal nutrition standards or restrictions on secondhand smoke, policy change can create environments conducive to healthier choices. Such policy changes often result from complex advocacy efforts that do not lend themselves to traditional evaluation approaches. In a challenging fiscal environment, allocating scarce resources to policy advocacy may be particularly difficult. A well-designed evaluation that moves beyond inventorying advocacy activities can help make the case for funding advocacy and policy change efforts. Although it is one thing to catalog meetings held, position papers drafted, and pamphlets distributed, it is quite another to demonstrate that these outputs resulted in useful policy change outcomes. This is where the emerging field of advocacy evaluation fits in by assessing (among other things) strategic learning, capacity building, and community organizing. Based on recent developments, this article highlights several challenges advocacy evaluators are currently facing and provides new resources for addressing them.     

Key challenges and best practices in the coordination of volunteers in healthcare services: A qualitative systematic review

Cooperation between voluntary organisations and volunteers within healthcare services contributes to the development of public welfare. The coordination process between healthcare services and volunteers must therefore be studied to understand associated challenges and best practices. This paper presents a systematic literature review of studies that have used qualitative methods. The review was conducted to identify the knowledge base concerning these issues. The search was performed in 4 April 2019 on five databases: EbscoHost, Ovid, Scopus, Emerald and Svemed+. The selection criteria included papers published between 1 January 2009 and 4 April 2019. In total, 5,340 papers were extracted; after removing duplicates and screening titles and abstracts, 49 papers were independently read by two of the authors. Ten papers addressed the research question and were thus included for further investigation. The Critical Appraisal Skills Programme (CASP) checklist was used to check the eligibility of the papers, all of which were found to be of sufficient quality for analysis. A thematic analysis for synthesising qualitative research was used to identify key challenges in the coordination process and the best practices needed to deal with these challenges. The findings demonstrated the pursuit of a common understanding between employees and volunteers and described challenges in organising the associated work. The main solution applied to these challenges was the involvement of a volunteer coordinator. Although several identified challenges remained unresolved, the papers selected for this review provide an overall picture of volunteer cooperation in health services.     

Verbal autopsy: current practices and challenges

Cause-of-death data derived from verbal autopsy (VA) are increasingly used for health planning, priority setting, monitoring and evaluation in countries with incomplete or no vital registration systems. In some regions of the world it is the only method available to obtain estimates on the distribution of causes of death. Currently, the VA method is routinely used at over 35 sites, mainly in Africa and Asia. In this paper, we present an overview of the VA process and the results of a review of VA tools and operating procedures used at demographic surveillance sites and sample vital registration systems. We asked for information from 36 field sites about field-operating procedures and reviewed 18 verbal autopsy questionnaires and 10 cause-of-death lists used in 13 countries. The format and content of VA questionnaires, field-operating procedures, cause-of-death lists and the procedures to derive causes of death from VA process varied substantially among sites. We discuss the consequences of using varied methods and conclude that the VA tools and procedures must be standardized and reliable in order to make accurate national and international comparisons of VA data. We also highlight further steps needed in the development of a standard VA process.