Adam Licurse

Renal Ultrasonography in the Evaluation of Acute Kidney Injury Developing a Risk Stratification Framework

BACKGROUND In adult inpatients with acute kidney injury (AKI), clinicians routinely order a renal ultrasonography (RUS) study. It is unclear how often this test provides clinically useful information. METHODS Cross-sectional study, including derivation and validation samples, of 997 US adults admitted to Yale-New Haven Hospital from January 2005 to May 2009, who were diagnosed as having AKI and who underwent RUS to evaluate elevated creatinine level. Pregnant women, renal transplant recipients, and patients with recently diagnosed hydronephrosis (HN) were excluded. Demographic and clinical characteristics were abstracted from the medical records. A multivariable logistic regression model was developed to create risk strata for HN and HN requiring an intervention (HNRI); a separate sample was used for validation. The frequency of incidental findings on RUS was assessed for each stratum. RESULTS In a derivation sample of 200 patients, 7 factors were found to be associated with HN: history of HN; recurrent urinary tract infections; diagnosis consistent with obstruction; nonblack race; and absence of the following: exposure to nephrotoxic medications, congestive heart failure, or prerenal AKI. Among 797 patients in the validation sample (mean age, 65.6 years), 10.6% had HN and 3.3% had HNRI. Of 223 patients in the low-risk group, 7 (3.1%) had HN and 1 (0.4%) had HNRI (223 patients needed to be screened to find 1 case of HNRI). In this group, there were 0 incidental findings on RUS unknown to the clinical team. In the higher-risk group, 15.7% had HN and 4.7% had HNRI. CONCLUSION In adult inpatients with AKI, specific factors can identify patients unlikely to have HN or HNRI on RUS.

An educational intervention to improve cost-effective care among medicine housestaff: a randomized controlled trial.

Purpose High medical costs create significant burdens. Research indicates that doctors have little awareness of costs. This study tested whether a brief educational intervention could increase residents’ awareness of cost-effectiveness and reduce costs without negatively affecting patient outcomes. Method The authors conducted a clustered randomized controlled trial of 33 teams (96 residents) at an internal medicine residency program (2009–2010). The intervention was a 45-minute teaching session; residents reviewed the hospital bill of a patient for whom they had cared and discussed reducing unnecessary costs. Primary outcomes were laboratory, pharmacy, radiology, and total hospital costs per admission. Secondary measures were length of stay (LOS), intensive care unit (ICU) admission, 30-day readmission, and 30-day mortality. Multivariate adjustment controlled for patient demographics and health. A follow-up survey assessed resident attitudes three months later. Results Among 1,194 patients, there were no significant cost differences between intervention and control groups. In the intervention group, 30-day readmission was higher (adjusted odds ratio 1.51, P = .010). There was no effect on LOS or the composite outcome of readmission, mortality, and ICU transfer. In a subgroup analysis of 835 patients newly admitted during the study, the intervention group incurred

Ten Years, Forty Decision Aids, And Thousands Of Patient Uses: Shared Decision Making At Massachusetts General Hospital

163 lower adjusted lab costs per admission (P = .046). The follow-up survey indicated persistent differences in residents’ exposure to concepts of cost-effectiveness (P = .041). Conclusions A brief intervention featuring a discussion of hospital bills can fill a gap in resident education and reduce laboratory costs for a subset of patients, but may increase readmission risk.

Electronic Consultations in Nephrology: Pilot Implementation and Evaluation

Shared decision making is a core component of population health strategies aimed at improving patient engagement. Massachusetts General Hospitals integration of shared decision making into practice has focused on the following three elements: developing a culture receptive to, and health care providers skilled in, shared decision making conversations; using patient decision aids to help inform and engage patients; and providing infrastructure and resources to support the implementation of shared decision making in practice. In the period 2005-15, more than 900 clinicians and other staff members were trained in shared decision making, and more than 28,000 orders for one of about forty patient decision aids were placed to support informed patient-centered decisions. We profile two different implementation initiatives that increased the use of patient decision aids at the hospitals eighteen adult primary care practices, and we summarize key elements of the shared decision making program.

Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial

To the Editor: The care of complex patients is fragmented and poorly coordinated between referring primary care providers (PCPs) and specialists. Systemic issues include ill-defined referral indications, poor communication between physicians, and recommendations from specialists that are thought by PCPs to be unclear. There is a need to improve the efficiency of delivering specialist services; this involves ensuring that patients who benefit most from in-person consultation receive timely care and identifying patients for whom in-person consultation may not be necessary. The electronic health record (EHR) can potentially be leveraged to develop electronic consultation (e-consult) systems that improve specialty referrals by facilitating communication between providers and providing a platform for specialists to determine the need and urgency of a referral. A few health care systems have successfully implemented e-referral and/or e-consult tools. San Francisco General Hospital developed a web-based referral system integrated into the existing EHR. The e-consult tool led to decreased wait times for new appointments, lower rates of avoidable visits, and improved clarity regarding referral indication. Most PCPs thought that it improved overall clinical care. Analyzing e-consult by specialty may improve the efficacy of implementation because certain specialties may be better suited to an e-consult platform than others, based on

A Scalable Program for Customized Patient Education Videos

BackgroundHospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient’s home potentially reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking.ObjectiveDetermine if home hospital care reduces cost while maintaining quality, safety, and patient experience.DesignRandomized controlled trial.ParticipantsAdults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma.InterventionHome hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing.Main MeasuresPrimary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience.Key ResultsNine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%; p = 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19; p < 0.01) and less often received consultations (0% vs. 27%; p = 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%; p < 0.01) lower, with trends toward less use of home-care services (22% vs. 55%; p = 0.08) and fewer readmissions (11% vs. 36%; p = 0.32). Patient experience was similar in both groups.ConclusionsThe use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity. No significant differences in quality, safety, and patient experience were noted, with more definitive results awaiting a larger trial.Trial Registration NCT02864420.

The Impact of Disclosing Financial Ties in Research and Clinical Care: A Systematic Review

PROBLEM DEFINITION Patients must make sense of increasingly complex information to navigate their health and the health care system, with limited opportunity to do so in clinical settings. Patient education videos may help to communicate key information, but they are often impersonal and cumbersome to produce or update with new evidence. To address these limitations, a program was developed to facilitate local video creation to deliver targeted information to patients. APPROACH The Patient Education Video Program was created at a large urban academic medical center. The medical director and two project managers worked with clinicians and patients to create and disseminate short, single-topic videos organized by segments. The videos educated patients on clinical and service topics such as self-care for low back pain and postoperative protocols. Videos were filmed and modified on a user-friendly mobile device application, then prescribed by sharing a link to the online video platform. Video creators were engaged through a learning collaborative, a physician incentive program, and a residency elective in which trainees designed video-based care redesign projects. OUTCOMES The program was introduced to practice sites across 26 departments. Some 269 videos received 19,713 unique views in a two-year period. In an operational survey, 1,034 (86.0%) of 1,203 viewer responses stated that a video helped them understand their health, medical condition, or treatment plan. KEY INSIGHTS A program to facilitate video creation and dissemination is feasible. Clinicians were most receptive to creating and using videos that addressed direct clinical or operational needs.