Efrat Shadmi

Low Mobility During Hospitalization and Functional Decline in Older Adults

OBJECTIVES: To examine the association between mobility levels of older hospitalized adults and functional outcomes.

Hospital‐Associated Functional Decline: The Role of Hospitalization Processes Beyond Individual Risk Factors

To investigate the combined contribution of processes of hospitalization and preadmission individual risk factors in explaining functional decline at discharge and at 1‐month follow‐up in older adults with nondisabling conditions.

Specialty Referral Completion Among Primary Care Patients: Results From the ASPN Referral Study

PURPOSE This study describes referral completion from the perspectives of patients and primary care physicians and identifies predictors of adherence to the referral recommendation. METHODS We observed a cohort of 776 referred patients from the offices of 133 physicians in 81 practices and 30 states. Referring physicians and patients completed self-administered questionnaires at the time of the referral decision and 3 months later. RESULTS Physicians reported that 79.2% of patients referred had a specialist visit, and 83.0% of patients indicated they completed the referral. The most common reasons for not completing the referral were “lack of time” and patient belief that the “health problem had resolved.” The κ statistic for patient-physician agreement on referral completion was 0.34, indicating only fair concordance. Patients in Medicaid plans were less likely than others to complete the referral, and more likely to experience a health plan denial. A longer duration of the patient relationship with the primary care physician and physician/staff scheduling of the specialty appointment were both positive predictors of referral completion. CONCLUSIONS About 8 in 10 patients referred from primary care complete a specialty referral within 3 months. Findings from this study suggest that referral completion rates may be increased by assisting patients with scheduling their specialty appointments and promoting continuity of care.

Predicting 30-day readmissions with preadmission electronic health record data.

Background:Readmission prevention should begin as early as possible during the index admission. Early identification may help target patients for within-hospital readmission prevention interventions. Objectives:To develop and validate a 30-day readmission prediction model using data from electronic health records available before the index admission. Research Design:Retrospective cohort study of admissions between January 1 and March 31, 2010. Subjects:Adult enrollees of Clalit Health Services, an integrated delivery system, admitted to an internal medicine ward in any hospital in Israel. Measures:All-cause 30-day emergency readmissions. A prediction score based on before admission electronic health record and administrative data (the Preadmission Readmission Detection Model—PREADM) was developed using a preprocessing variable selection step with decision trees and neural network algorithms. Admissions with a recent prior hospitalization were excluded and automatically flagged as “high-risk.” Selected variables were entered into multivariable logistic regression, with a derivation (two-thirds) and a validation cohort (one-third). Results:The derivation dataset comprised 17,334 admissions, of which 2913 (16.8%) resulted in a 30-day readmission. The PREADM includes 11 variables: chronic conditions, prior health services use, body mass index, and geographical location. The c-statistic was 0.70 in the derivation set and of 0.69 in the validation set. Adding length of stay did not change the discriminatory power of the model. Conclusions:The PREADM is designed for use by health plans for early high-risk case identification, presenting discriminatory power better than or similar to that of previously reported models, most of which include data available only upon discharge.

In‐Hospital Use of Continence Aids and New‐Onset Urinary Incontinence in Adults Aged 70 and Older

OBJECTIVES: To describe the types of continence aids that older adults hospitalized in acute medical units use and to test the association between use of continence aids and development of new urinary incontinence (UI) at discharge.

Reducing health disparities: strategy planning and implementation in Israel's largest health care organization.

OBJECTIVE To describe an organization-wide disparity reduction strategy and to assess its success in quality improvement and reduction of gaps in health and health care. STUDY SETTING Clalit Health Services, Israels largest non-for-profit insurer and provider serving 3.8 million persons. STUDY DESIGN Before and after design: quality assessment before and 12-month postinitiation of the strategic plan. A composite weighted score of seven quality indicators, measuring attainment of diabetes, blood pressure, and lipid control, lack of anemia in infants, and performance of mammography, occult blood tests, and influenza vaccinations. DATA EXTRACTION METHODS Quality indicator scores, derived from Clalits central data warehouse, based on data from electronic medical records. PRINCIPAL FINDINGS Low-performing clinics, of low-socioeconomic and minority populations, were targeted for intervention. Twelve months after the initiation of the project continuous improvement was observed coupled with a reduction of 40 percent of the gap between disadvantaged clinics, serving ~10 percent of enrollees, and all other medium-large clinics. CONCLUSION The comprehensive strategy, following a quality improvement framework, with a top-down top-management incentives and monitoring, and a bottom-up locally tailored interventions, approach, is showing promising results of overall quality improvement coupled with disparity reduction in key health and health care indicators.

Assessing socioeconomic health care utilization inequity in Israel: impact of alternative approaches to morbidity adjustment

BackgroundThe ability to accurately detect differential resource use between persons of different socioeconomic status relies on the accuracy of health-needs adjustment measures. This study tests different approaches to morbidity adjustment in explanation of health care utilization inequity.MethodsA representative sample was selected of 10 percent (~270,000) adult enrolees of Clalit Health Services, Israels largest health care organization. The Johns-Hopkins University Adjusted Clinical Groups® were used to assess each persons overall morbidity burden based on one years (2009) diagnostic information. The odds of above average health care resource use (primary care visits, specialty visits, diagnostic tests, or hospitalizations) were tested using multivariate logistic regression models, separately adjusting for levels of health-need using data on age and gender, comorbidity (using the Charlson Comorbidity Index), or morbidity burden (using the Adjusted Clinical Groups). Model fit was assessed using tests of the Area Under the Receiver Operating Characteristics Curve and the Akaike Information Criteria.ResultsLow socioeconomic status was associated with higher morbidity burden (1.5-fold difference). Adjusting for health needs using age and gender or the Charlson index, persons of low socioeconomic status had greater odds of above average resource use for all types of services examined (primary care and specialist visits, diagnostic tests, or hospitalizations). In contrast, after adjustment for overall morbidity burden (using Adjusted Clinical Groups), low socioeconomic status was no longer associated with greater odds of specialty care or diagnostic tests (OR: 0.95, CI: 0.94-0.99; and OR: 0.91, CI: 0.86-0.96, for specialty visits and diagnostic respectively). Tests of model fit showed that adjustment using the comprehensive morbidity burden measure provided a better fit than age and gender or the Charlson Index.ConclusionsIdentification of socioeconomic differences in health care utilization is an important step in disparity reduction efforts. Adjustment for health-needs using a comprehensive morbidity burden diagnoses-based measure, this study showed relative underutilization in use of specialist and diagnostic services, and thus allowed for identification of inequity in health resources use, which could not be detected with less comprehensive forms of health-needs adjustments.

Implementing routine outcome measurement in psychiatric rehabilitation services in Israel

Abstract In this article we present the design, development and implementation of the Psychiatric Rehabilitation Routine Outcome Measurement (PR-ROM) project, the first systematic effort to implement mental health routine outcome measures in Israel. The goal of the PR-ROM is to provide updated information about the process and impact of psychiatric rehabilitation services in Israel and to establish a sustainable infrastructure and foundation for routine outcome monitoring of rehabilitation services to improve care, inform policy, generate incentives for service improvement, increase informed decision-making and provide data for research purposes. The rehabilitation services evaluated and the characteristics of the population being served are described and the methods and nature of the collected data as well as some preliminary findings are presented. We discuss the major barriers encountered, our efforts to deal with them and lessons learned during the process. We conclude with a description of the current state of the initiative and plans for the future.

From Research to Reality: Minimizing the Effects of Hospitalization on Older Adults

This review examines ways to decrease preventable effects of hospitalization on older adults in acute care medical (non-geriatric) units, with a focus on the Israeli experience at the Rambam Health Care Campus, a large tertiary care hospital in northern Israel. Hospitalization of older adults is often followed by an irreversible decline in functional status affecting their quality of life and well-being after discharge. Functional decline is often related to avoidable effects of in-hospital procedures not caused by the patient’s acute disease. In this article we review the literature relating to the recognized effects of hospitalization on older adults, pre-hospitalization risk factors, and intervention models for hospitalized older adults. In addition, this article describes an Israeli comprehensive research study, the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR), and outlines the design of a combined intervention model being implemented at the Rambam Health Care Campus. The majority of the reviewed studies identified preadmission personal risk factors and psychosocial risk factors. In-hospital restricted mobility, under-nutrition care, over-use of continence devices, polypharmacy, and environmental factors were also identified as avoidable processes. Israeli research supported the findings that preadmission risk factors together with in-hospital processes account for functional decline. Different models of care have been developed to maintain functional status. Much can be achieved by interdisciplinary teams oriented to the needs of hospitalized elderly in making an impact on hospital processes and continuity of care. It is the responsibility of health care policy-makers, managers, clinicians, and researchers to pursue effective interventions to reduce preventable hospitalization-associated disability.

Impact of Functional Change Before and During Hospitalization on Functional Recovery 1 Month Following Hospitalization

BACKGROUND The functional changes that occur immediately before acute hospitalization and those that occur during hospitalization are pertinent to posthospitalization functional status in older adults. Our primary aim was to estimate the effects of membership in categories that take into account pre- and within-hospital functional changes on the likelihood of functional recovery (FR) 1 month after discharge. METHODS The sample included 691 older (≥70) adults admitted to general-medical inpatient units in two hospitals in Israel. FR was defined as a restoration of functioning 1 month postdischarge to levels reported 2 weeks prior to admission. Patients were classified according to functional decline or stability during the prehospital stage and decline, stability, or improvement between admission and discharge in terms of ability to perform self-care or mobility activities. We performed multivariate logistic regressions to test the association between categories of functional change and FR. RESULTS Patients who remained stable before and during hospitalization had the highest odds of maintaining their premorbid functional levels. Those who experienced functional improvement during hospitalization, despite previous functional loss, were 2.3-2.9 times more likely than persistent decliners to experience FR (p < .05 for all). Comparable patterns were found in the relationship between pre- and in-hospital functional trajectories and recovery, both in self-care and in mobility. CONCLUSIONS Differentiating between pre- and in-hospital functional changes is important for promoting short-term posthospitalization FR. In-hospital function-focused care that takes into account preadmission functional history may help improve posthospitalization FR.