Suicide assessment: Clinical interview vs. self-report

This study examined whether patients disclosed the same information about suicidal behaviors on a self-report instrument that they conveyed to a clinician in a face-to-face interview. The results indicated a generally high level of agreement between these two forms of suicide assessment. The one exception was the question that concerns recent suicidal ideation, where patients tended to disclose more on the self-report form.     

Racial/Ethnic Differences in Emergency Department Utilization and Experience

BackgroundPrevious work has demonstrated racial/ethnic differences in emergency department (ED) utilization, but less is known about racial/ethnic differences in the experience of care received during an ED visit.ObjectiveTo examine differences in self-reported healthcare utilization and experiences with ED care by patients’ race/ethnicity.DesignAdult ED patients discharged to community (DTC) were surveyed (response rate: 20.25%) using the Emergency Department Patient Experience of Care (EDPEC) DTC Survey. Linear regression was used to estimate case-mix-adjusted differences in patient experience between racial/ethnic groups.Participants3122 survey respondents who were discharged from the EDs of 50 hospitals nationwide January–March 2016.Main MeasuresSix measures: getting timely care, doctor and nurse communication, communication about medications, receipt of sufficient information about test results, whether hospital staff discussed the patient’s ability to receive follow-up care, and willingness to recommend the ED.Key ResultsBlack and Hispanic patients were significantly more likely than White patients to report visiting the ED for an ongoing health condition (40% Black, 30% Hispanic, 28% White, p<0.001), report having visited an ED 3+ times in the last 6 months (26% Black, 25% Hispanic, 19% White, p<0.001), and report not having a usual source of care (19% Black, 19% Hispanic, 8% White, p<0.001). Compared with White patients, Hispanic patients more often reported that hospital staff talked with them about their ability to receive needed follow-up care (+7.2 percentile points, p=0.038) and recommended the ED (+7.2 points, p=0.037); Hispanic and Black patients reported better doctor and nurse communication (+6.4 points, p=0.008; +4 points, p=0.036, respectively).ConclusionsHispanic and Black ED patients reported higher ED utilization, lacked a usual source of care, and reported better experience with ED care than White patients. Results may reflect differences in care delivery by staff and/or different expectations of ED care among Hispanic and Black patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06738-0.KEY WORDS: emergency department, patient experience, utilization, race, communication     

Impact of a Dyadic Intervention on Family Supporter Involvement in Helping Adults Manage Type 2 Diabetes

BackgroundFamily support for adults’ diabetes care is associated with improved self-management and outcomes, but healthcare providers lack structured ways to engage those supporters.ObjectiveAssess the impact of a patient-supporter diabetes management intervention on supporters’ engagement in patients’ diabetes care, support techniques, and caregiving experience.DesignMultivariate regression models examined between-group differences in support-related measures observed as part of a larger trial randomizing participants to a dyadic intervention versus usual care.ParticipantsA total of 239 adults with type 2 diabetes and either A1c >8% or systolic blood pressure >160mmHg enrolled with a family supporter.InterventionHealth coaches provided training on positive support techniques and facilitated self-management information sharing and goal-setting.Main MeasuresPatient and supporter reports at baseline and 12 months of supporter roles in diabetes care and caregiving experience.ResultsAt 12 months, intervention-assigned patients had higher odds of reporting increased supporter involvement in remembering medical appointments (AOR 2.74, 95% CI 1.44, 5.21), performing home testing (AOR 2.40, 95% CI 1.29, 4.46), accessing online portals (AOR 2.34, 95% CI 1.29, 4.30), deciding when to contact healthcare providers (AOR 2.12, 95% CI 1.15, 3.91), and refilling medications (AOR 2.10, 95% CI 1.14, 3.89), but not with attending medical appointments or with healthy eating and exercise. Intervention-assigned patients reported increased supporter use of autonomy supportive communication (+0.27 points on a 7-point scale, p=0.02) and goal-setting techniques (+0.30 points on a 5-point scale, p=0.01). There were no differences at 12 months in change scores measuring supporter distress about patients’ diabetes or caregiving burden. Intervention-assigned supporters had significantly larger increases in satisfaction with health system support for their role (+0.88 points on a 10-point scale, p=0.01).ConclusionsA dyadic patient-supporter intervention led to increased family supporter involvement in diabetes self-management and increased use of positive support techniques, without increasing caregiver stress.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06946-8.KEY WORDS: diabetes, social support, self-management, caregiving     

An Intensive Intervention to Reduce Readmissions for Frequently Hospitalized Patients: the CHAMP Randomized Controlled Trial

BackgroundA small number of patients are disproportionally readmitted to hospitals. The Complex High Admission Management Program (CHAMP) was established as a multidisciplinary program to improve continuity of care and reduce readmissions for frequently hospitalized patients.ObjectiveTo compare hospital utilization metrics among patients enrolled in CHAMP and usual care.DesignPragmatic randomized controlled trial.ParticipantsInclusion criteria were as follows: 3 or more, 30-day inpatient readmissions in the previous year; or 2 inpatient readmissions plus either a referral or 3 observation admissions in previous 6 months.InterventionsPatients randomized to CHAMP were managed by an interdisciplinary team including social work, physicians, and pharmacists. The CHAMP team used comprehensive care planning and inpatient, outpatient, and community visits to address both medical and social needs. Control patients were randomized to usual care and contacted 18 months after initial identification if still eligible.Main MeasuresPrimary outcome was number of 30-day inpatient readmissions 180 days following enrollment. Secondary outcomes were number of hospital admissions, total hospital days, emergency department visits, and outpatient clinic visits 180 days after enrollment.Key ResultsThere were 75 patients enrolled in CHAMP, 76 in control. Groups were similar in demographic characteristics and baseline readmissions. At 180 days following enrollment, CHAMP patients had more inpatient 30-day readmissions [CHAMP incidence rate 1.3 (95% CI 0.9–1.8) vs. control 0.8 (95% CI 0.5–1.1), p=0.04], though both groups had fewer readmissions compared to 180 days prior to enrollment. We found no differences in secondary outcomes.ConclusionsFrequently hospitalized patients experienced reductions in utilization over time. Though most outcomes showed no difference, CHAMP was associated with higher readmissions compared to a control group, possibly due to consolidation of care at a single hospital. Future research should seek to identify subsets of patients with persistently high utilization for whom tailored interventions may be beneficial.Trial RegistrationClinicalTrials.gov identifier: {"type":"clinical-trial","attrs":{"text":"NCT03097640","term_id":"NCT03097640"}}NCT03097640; https://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT03097640","term_id":"NCT03097640"}}NCT03097640KEY WORDS: care transitions, readmissions, care models, continuity of care, randomized controlled trial

A small number of patients account for a disproportionate number of hospital readmissions.¹ While medically diverse, many patients who are frequently hospitalized have behavioral or social needs that require holistic care models emphasizing more than medical care alone.² This population challenges a system of care that fragments hospital-based care and ambulatory care, creating systematic discontinuity for patients who may require longitudinal relationship-based care to meet their complex needs.³ In qualitative studies, patients who are frequently hospitalized report frustration with care fragmentation, causing them to perceive a lack of continuity and a loss of trust with the medical system.⁴Innovative care models have sought to reduce readmissions through redesigning care delivery, improving care coordination, and connecting patients to existing resources.^5–8 A systematic review of interventions for frequently hospitalized patients found a heterogeneous group of care models.⁹ Importantly, the majority of studies were observational. Many patients experience a reduction in utilization after an initial period of frequent admissions,¹⁰ limiting the ability of observational studies to measure a specific program’s effect due to the natural decline in readmissions over time. A randomized trial of a “healthcare hotspotting” intervention for patients in Camden, NJ, reported no change in hospitalization rates compared to a control group.¹¹ Though this intervention was an intensive interdisciplinary effort that enrolled patients while still hospitalized, it focused primarily on connecting patients to existing outpatient resources. Other intensive outpatient-only interventions have failed to reduce healthcare utilization.¹² Interventions that focus on improving care across clinical settings (i.e., both inside and outside of the hospital) may have a different effect.We created the Complex High Admission Management Program (CHAMP) as a quality improvement initiative to improve inpatient and outpatient care and reduce inpatient readmissions of patients frequently admitted to our hospital. The CHAMP multidisciplinary team works to foster longitudinal relationships with patients who suffer from systematic discontinuity. A pilot pre-post analysis of CHAMP observed reductions in readmission;¹³ however, results may have been confounded by the aforementioned tendency for utilization to decline over time.¹⁰ In this study, we conducted a randomized trial of CHAMP compared with usual care to accurately assess the program’s effect on hospital readmissions.