Honora Englander

Risk Prediction Models for Hospital Readmission: A Systematic Review

CONTEXT Predicting hospital readmission risk is of great interest to identify which patients would benefit most from care transition interventions, as well as to risk-adjust readmission rates for the purposes of hospital comparison. OBJECTIVE To summarize validated readmission risk prediction models, describe their performance, and assess suitability for clinical or administrative use. DATA SOURCES AND STUDY SELECTION The databases of MEDLINE, CINAHL, and the Cochrane Library were searched from inception through March 2011, the EMBASE database was searched through August 2011, and hand searches were performed of the retrieved reference lists. Dual review was conducted to identify studies published in the English language of prediction models tested with medical patients in both derivation and validation cohorts. DATA EXTRACTION Data were extracted on the population, setting, sample size, follow-up interval, readmission rate, model discrimination and calibration, type of data used, and timing of data collection. DATA SYNTHESIS Of 7843 citations reviewed, 30 studies of 26 unique models met the inclusion criteria. The most common outcome used was 30-day readmission; only 1 model specifically addressed preventable readmissions. Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large US populations and had poor discriminative ability (c statistic range: 0.55-0.65). Seven models could potentially be used to identify high-risk patients for intervention early during a hospitalization (c statistic range: 0.56-0.72), and 5 could be used at hospital discharge (c statistic range: 0.68-0.83). Six studies compared different models in the same population and 2 of these found that functional and social variables improved model discrimination. Although most models incorporated variables for medical comorbidity and use of prior medical services, few examined variables associated with overall health and function, illness severity, or social determinants of health. CONCLUSIONS Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly. Although in certain settings such models may prove useful, efforts to improve their performance are needed as use becomes more widespread.

“Did I Do as Best as the System Would Let Me?” Healthcare Professional Views on Hospital to Home Care Transitions

ABSTRACTBACKGROUNDPatients are vulnerable to poor quality, fragmented care as they transition from hospital to home. Few studies examine the discharge process from the perspectives of multiple healthcare professionals.OBJECTIVETo understand care transitions from the perspective of diverse healthcare professionals, and identify recommendations for process improvement.DESIGNCross sectional qualitative study.PARTICIPANTS AND SETTINGClinicians, care teams, and administrators from the inpatient general medicine services at one urban, academic hospital; two outpatient primary care clinics; and one Medicaid managed care plan.APPROACHWe conducted 13 focus groups and two in-depth interviews with participants prior to initiating a hospital-funded, multi-component transitional care intervention for uninsured and low-income publicly insured patients, the Care Transitions Innovation (C-TraIn). We used thematic analysis to identify emergent themes and a cross-case comparative analysis to describe variation by participant role and setting.KEY RESULTSPoor transitional care reflected healthcare system fragmentation, limiting the ability of healthcare professionals to provide optimal patient care. Lack of standardized processes, poor multidisciplinary communication within the hospital, and fragmented communication across settings led to chaotic, unsystematic transitions, poor patient outcomes, and feelings of futility and dissatisfaction among providers. Patients with complex psychosocial needs were especially vulnerable during care transitions. Recommended changes to improve transitional care included improving hospital multidisciplinary hospital rounds, clarifying accountability as patients move across settings, standardizing discharge processes, and providing additional medical staff training.CONCLUSIONSHospital to home care transitions are critical junctures that can impact health outcomes, experience of care, and costs. Transitional care quality improvement initiatives must address system fragmentation, reduce communication barriers within and between settings, and ensure adequate professional training.

Treatment of anemia in patients with heart disease: A systematic review

BACKGROUND The benefits of anemia treatment in patients with heart disease are uncertain. PURPOSE To evaluate the benefits and harms of treatments for anemia in adults with heart disease. DATA SOURCES MEDLINE, EMBASE, and Cochrane databases; clinical trial registries; reference lists; and technical advisors. STUDY SELECTION English-language trials of blood transfusions, iron, or erythropoiesis-stimulating agents in adults with anemia and congestive heart failure or coronary heart disease and observational studies of transfusion. DATA EXTRACTION Data on study design, population characteristics, hemoglobin levels, and health outcomes were extracted. Trials were assessed for quality. DATA SYNTHESIS Low-strength evidence from 6 trials and 26 observational studies suggests that liberal transfusion protocols do not improve short-term mortality rates compared with less aggressive protocols (combined relative risk among trials, 0.94 [95% CI, 0.61 to 1.42]; I2 = 16.8%), although decreased mortality rates occurred in a small trial of patients with the acute coronary syndrome (1.8% vs. 13.0%; P = 0.032). Moderate-strength evidence from 3 trials of intravenous iron found improved short-term exercise tolerance and quality of life in patients with heart failure. Moderate- to high-strength evidence from 17 trials of erythropoiesis-stimulating agent therapy found they offered no consistent benefits, but their use may be associated with harms, such as venous thromboembolism. LIMITATIONS Few trials have examined transfusions in patients with heart disease, and observational studies are potentially confounded by indication. Data supporting iron use come mainly from 1 large trial, and long-term effects are unknown. CONCLUSION Higher transfusion thresholds do not consistently improve mortality rates, but large trials are needed. Intravenous iron may help to alleviate symptoms in patients with heart failure and iron deficiency and also warrants further study. Erythropoiesis-stimulating agents do not seem to benefit patients with mild to moderate anemia and heart disease and may be associated with serious harms. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.

So many options, where do we start? An overview of the care transitions literature.

BACKGROUND Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply. PURPOSE To summarize the health and utilization effects of transitional care interventions, and to identify common themes about intervention types, patient populations, or settings that modify these effects. DATA SOURCES PubMed and Cochrane Database of Systematic Reviews (January 1950-May 2014), reference lists, and technical advisors. STUDY SELECTION Systematic reviews of transitional care interventions that reported hospital readmission as an outcome. DATA EXTRACTION We extracted transitional care procedures, patient populations, settings, readmissions, and health outcomes. We identified commonalities and compiled a narrative synthesis of emerging themes. DATA SYNTHESIS Among 10 reviews of mixed patient populations, there was consistent evidence that enhanced discharge planning and hospital-at-home interventions reduced readmissions. Among 7 reviews in specific patient populations, transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations. In general, interventions that reduced readmission addressed multiple aspects of the care transition, extended beyond hospital stay, and had the flexibility to accommodate individual patient needs. There was insufficient evidence on how caregiver involvement, transition to sites other than home, staffing, patient selection practices, or care settings modified intervention effects. CONCLUSIONS Successful interventions are comprehensive, extend beyond hospital stay, and have the flexibility to respond to individual patient needs. The strength of evidence should be considered low because of heterogeneity in the interventions studied, patient populations, clinical settings, and implementation strategies.

Regardless of age: Incorporating principles from geriatric medicine to improve care transitions for patients with complex needs

ABSTRACTWith its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care “receivers” and tailoring home care to meet patient needs, (3) building “recovery plans” into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.

Planning and designing the care transitions innovation (C-Train) for uninsured and Medicaid patients†

BACKGROUND Uninsured and Medicaid patients are particularly vulnerable as they transition from hospital to home. Transitional care improvement programs require time and capital, incentives for which may be unclear for those lacking a third-party payor. This article describes our experience developing a hospital-funded transitional care program for uninsured and Medicaid patients. METHODS We performed an inpatient needs assessment, convened multi-stakeholder work groups, and engaged institutional change-agents to inform program development and a business case. RESULTS We mapped needs to specific program elements, including a transitional care nurse, pharmacy consult and provision of medications for uninsured patients, medical home linkages including community payment for medical homes, and monthly quality improvement meetings. A business case was informed by local needs and utilization data, and compelled the hospital to invest in up-front resources for this population. DISCUSSION We are studying our programs impact on 30-day readmission and emergency department rates through a clustered, randomized controlled trial. Lessons from our experience may be useful to others aiming to improve care for socioeconomically disadvantaged patients.

Transitioning Toward Competency: A Resident-Faculty Collaborative Approach to Developing a Transitions of Care EPA in an Internal Medicine Residency Program

BACKGROUND Residency training and evaluation are moving toward competency-based models. Managing transitions of care is 1 of 16 entrustable professional activities (EPAs) that signal readiness for independent internal medicine practice. Methods for developing EPAs are evolving within the medical education community. OBJECTIVE We describe a process for developing a transitions-of-care EPA for internal medicine inpatient and ambulatory settings using an iterative, consensus-building, resident-faculty collaborative approach. METHODS We used an independent rank-ordering process and successive consensus group meetings to cull an initial list of 142 developmental Milestones to the 15 most relevant to transitions of care for internal medicine patients in an academic medical center and affiliated Veterans Administration hospital. Four senior internal medicine residents and 4 internal medicine faculty members representing inpatient and ambulatory practice settings identified examples of specific tasks and evaluative techniques for each Milestone. RESULTS We demonstrate a feasible resident-faculty collaboration to develop transitions of care as an EPA for an internal medicine training program. Inclusion of residents along with faculty provided broader insights as well as an important learning opportunity for trainees. CONCLUSIONS Our process demonstrated the feasibility of designing an EPA, but questions remain about how entrustment-based evaluation can be implemented in clinical settings. Our framework may serve as a foundation for EPA development in other areas of clinical practice.

Planning and designing the Improving Addiction Care Team (IMPACT) for hospitalized adults with substance use disorder

&NA; People with substance use disorders (SUD) have high rates of hospitalization and readmission, long lengths of stay, and skyrocketing healthcare costs. Yet, models for improving care are extremely limited. We performed a needs assessment and then convened academic and community partners, including a hospital, community SUD organizations, and Medicaid accountable care organizations, to design a care model for medically complex hospitalized patients with SUD. Needs assessment showed that 58% to 67% of participants who reported active substance use said they were interested in cutting back or quitting. Many reported interest in medication for addiction treatment (MAT). Participants had high rates of costly readmissions and longer than expected length of stay. Community stakeholders identified long wait times and lack of resources for medically complex patients as key barriers. We developed the Improving Addiction Care Team (IMPACT), which includes an inpatient addiction medicine consultation service, rapid‐access pathways to posthospital SUD treatment, and a medically enhanced residential care model that integrates antibiotic infusion and residential addiction care. We developed a business case and secured funding from Medicaid and hospital payers. IMPACT provides one pathway for hospitals, payers, and communities to collaboratively address the SUD epidemic.

Lessons learned from the implementation of a medically enhanced residential treatment (MERT) model integrating intravenous antibiotics and residential addiction treatment

Abstract BACKGROUND: Hospitalizations for severe infections associated with substance use disorder (SUD) are increasing. People with SUD often remain hospitalized for many weeks instead of completing intravenous antibiotics at home; often, they are denied skilled nursing facility admission. Residential SUD treatment facilities are not equipped to administer intravenous antibiotics. We developed a medically enhanced residential treatment (MERT) model integrating residential SUD treatment and long-term IV antibiotics as part of a broader hospital-based addiction medicine service. MERT had low recruitment and retention, and ended after six months. The goal of this study was to describe the feasibility and acceptability of MERT, to understand implementation factors, and explore lessons learned. METHODS: We conducted a mixed-methods evaluation. We included all potentially eligible MERT patients, defined by those needing ≥2 weeks of intravenous antibiotics discharged from February 1 to August 1, 2016. We used chart review to identify diagnoses, antibiotic treatment location, and number of recommended and actual IV antibiotic-days completed. We audio-recorded and transcribed key informant interviews with patients and staff. We conducted an ethnographic analysis of interview transcripts and implementation field notes. RESULTS: Of the 45 patients needing long-term intravenous antibiotics, 18 were ineligible and 20 declined MERT. 7 enrolled in MERT and three completed their recommended intravenous antibiotic course. MERT recruitment barriers included patient ambivalence towards residential treatment, wanting to prioritize physical health needs, and fears of untreated pain in residential. MERT retention barriers included high demands of residential treatment, restrictive practices due to PICC lines, and perceptions by staff and other residents that MERT patients “stood out” as “different.” Despite the challenges, key informants felt MERT was a positive construct. CONCLUSIONS: Though MERT had many possible advantages; it proved more challenging to implement than anticipated. Our lessons may be applicable to future models integrating post-hospital intravenous antibiotics and SUD care.

Transitions of Care: Putting the Pieces Together

Many innovations to improve transitions of care across settings are being implemented at national, regional, and local levels, and many questions remain about which promote affordable, high-quality, patient-centered care.