Jeffrey O. Greenberg

Increasing pneumococcal vaccination for immunosuppressed patients: A cluster quality improvement trial

OBJECTIVE Pneumococcal vaccination is important for patients taking immunosuppressive medications, but prior studies suggest that most patients do not undergo vaccination. The aim of this study was to evaluate the effects of a point-of-care paper reminder form as a quality improvement (QI) strategy to increase the numbers of immunosuppressed patients being kept up-to-date with pneumococcal vaccination in a rheumatology practice. METHODS Selected rheumatologists at 5 ambulatory practice sites received a point-of-care paper reminder form to be applied to patients who were not up-to-date with pneumococcal vaccination. Interrupted time-series analyses were used to measure the effect of the intervention on the pneumococcal vaccination rates among patients, comparing the rates in the intervention group with those in a control group of rheumatologists who did not receive the intervention. Adjusted Cox proportional hazards models were examined to identify independent predictors of being up-to-date with pneumococcal vaccination. RESULTS We evaluated a total of 3,717 patients (66.0% with rheumatoid arthritis) who were taking immunosuppressive medications (74.1% women, mean age 53.7 years). Rheumatologists who received the intervention had a significant increase in the rate of patients who were up-to-date with pneumococcal vaccination, from 67.6% to 80.0% (P=0.006), in the time period following the intervention, compared to a rate that remained stable, from 52.3% to 52.0% (P=0.90), among patients in the nonintervention control group during this same time period. In regression models, positive predictors of being up-to-date with pneumococcal vaccination at the patient level included the following: having received the intervention (hazard ratio [HR] 3.58, 95% confidence interval [95% CI] 2.46-5.20), having a primary care physician affiliated with Brigham and Womens Hospital (HR 1.68, 95% CI 1.44-1.97), having a diagnosis of diabetes mellitus (HR 1.57, 95% CI 1.02-2.41), and being age 56-65 years at baseline, compared to age≤45 years (HR 1.24, 95% CI 1.01-1.51). CONCLUSION A QI strategy involving a simple point-of-care paper reminder form significantly increased the rate of being up-to-date with pneumococcal vaccination among patients receiving immunosuppressive medications in our rheumatology practices over a 6-month period.

Engaging specialists in performance-incentive programs.

Dr. Jeffrey Greenberg and colleagues argue that to have a meaningful impact on the quality of care, pay-for-performance programs and newer-generation quality-incentive programs must engage more specialists. However, engaging these physicians in such programs is challenging for several reasons.

A Decision-Making Algorithm for Initiation and Discontinuation of RRT in Severe AKI

BACKGROUND AND OBJECTIVES AKI is an increasingly common and devastating complication in hospitalized patients. Severe AKI requiring RRT is associated with in-hospital mortality rates exceeding 40%. Clinical decision making related to RRT initiation for patients with AKI in the medical intensive care unit is not standardized. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a 13-month (November of 2013 to December of 2014) prospective cohort study in an academic medical intensive care unit involving the implementation of an AKI Standardized Clinical Assessment and Management Plan, a decision-making algorithm to assist front-line clinicians caring for patients with AKI. The Standardized Clinical Assessment and Management Plan algorithms provided recommendations about optimal indications for initiating and discontinuing RRT on the basis of various clinical parameters; 176 patients managed by nine nephrologists were included in the study. We captured reasons for deviation from the recommended algorithm as well as mortality data. RESULTS Patients whose clinicians adhered to the Standardized Clinical Assessment and Management Plan recommendation to start RRT had lower in-hospital mortality (42% versus 63%; P<0.01) and 60-day mortality (46% and 68%; P<0.01), findings that were confirmed after multivariable adjustment for age, albumin, and disease severity. There was a differential effect of Standardized Clinical Assessment and Management Plan adherence in low (<50% mortality risk) versus high (≥50% mortality risk) disease severity on in-hospital mortality (interaction term P=0.02). In patients with low disease severity, Standardized Clinical Assessment and Management Plan adherence was associated with lower in-hospital mortality (odds ratio, 0.21; 95% confidence interval, 0.08 to 0.54; P=0.001), but no significant association was evident in patients with high disease severity. CONCLUSIONS Physician adherence to an algorithm providing recommendations on RRT initiation was associated with lower in-hospital mortality.

Cost-related medication underuse: Prevalence among hospitalized managed care patients†

BACKGROUND The affordability of prescription medications continues to be a major public health issue in the United States. Estimates of cost-related medication underuse come largely from surveys of ambulatory patients. Hospitalized patients may be vulnerable to cost-related underuse and its consequences, but have been subject to little investigation. OBJECTIVE To determine impact of medication costs in a cohort of hospitalized managed care beneficiaries. METHODS We surveyed consecutive patients admitted to medical services at an academic medical center. Questions about cost-related underuse were based on validated measures; predictors were assessed with multivariable models. Participants were asked about strategies to improve medication affordability, and were contacted after discharge to determine if they had filled newly prescribed medications. RESULTS One-hundred thirty (41%) of 316 potentially eligible patients participated; 93 (75%) of these completed postdischarge surveys. Thirty patients (23%) reported cost-related underuse in the year prior to admission. In adjusted analyses, patients of black race were 3.39 times (95% confidence interval [CI], 1.05 to 11.02) more likely to report cost-related underuse than non-Hispanic white patients. Virtually all respondents (n = 123; 95%) endorsed at least 1 strategy to make medications more affordable. Few (16%) patients, prescribed medications at discharge, knew how much they would pay at the pharmacy. Almost none had spoken to their inpatient (4%) or outpatient (2%) providers about the cost of newly prescribed drugs. CONCLUSIONS Cost-related underuse is common among hospitalized patients. Individuals of black race appear to be particularly at risk. Strategies should be developed to address this issue around the time of hospital discharge.

Care coordination gaps due to lack of interoperability in the United States: a qualitative study and literature review

BackgroundHealth information technology (HIT) could improve care coordination by providing clinicians remote access to information, improving legibility, and allowing asynchronous communication, among other mechanisms. We sought to determine, from a clinician perspective, how care is coordinated and to what extent HIT is involved when transitioning patients between emergency departments, acute care hospitals, skilled nursing facilities, and home health agencies in settings across the United States.MethodsWe performed a qualitative study with clinicians and information technology professionals from six regions of the U.S. which were chosen as national leaders in HIT. We analyzed data through a two person consensus approach, assigning responses to each of nine care coordination activities. We also conducted a literature review of MEDLINE®, CINAHL®, and Embase, analyzing results of studies that examined interventions to improve information transfer during transitions of care.ResultsWe enrolled 29 respondents from 17 organizations and conducted six focus groups. Respondents reported how HIT is currently used for care coordination activities. HIT is currently used to monitor patients and to align systems-level resources with population needs. However, we identified multiple areas where the lack of interoperability leads to inefficient processes and missing data. Additionally, the literature review identified ten intervention studies that address information transfer, seven of which employed HIT and three of which utilized other communication methods such as telephone calls, faxed records, and nurse case management.ConclusionsSignificant care coordination gaps exist due to the lack of interoperability across the United States. We must design, evaluate, and incentivize the use of HIT for care coordination. We should focus on the domains where we found the largest gaps: information transfer, systems to monitor patients, tools to support patients’ self-management goals, and tools to link patients and their caregivers with community resources.

Validity of physician-reported hospitalized infections in a US arthritis registry

OBJECTIVE In safety studies, events reported as infections may be misclassified and, therefore, affect the validity of estimated risks associated with biologic agents. Using data from the Consortium of Rheumatology Researchers of North America (CORRONA), we evaluated hospitalized infection reports contributed by rheumatologists to establish their validity. METHODS All patients hospitalized with infections from 2002 to 2007 reported to CORRONA were examined and compared with information from hospital discharge summaries and other confirmatory data. Infectious episodes were classified by two physicians as confirmed, empirically treated, possible or unlikely. RESULTS Of 562 reported hospitalized infectious episodes, 9% were classified as unlikely and had minimal or no supporting evidence for infection, leaving 509 hospitalized infectious episodes. Of these, 53% of the infectious episodes were classified as confirmed, 15% empirically treated and 32% possible. The confirmation status of infectious episodes for younger or biologic-exposed participants was similar to older and biologic-unexposed participants. CONCLUSION More than two-thirds of hospitalized infections reported by rheumatologists were confirmed or had evidence that the physician was treating an infection. In almost all cases, there was at least modest evidence for an infection. Future studies should consider case definitions for infections or sensitivity analyses, or both, regarding the certainty of an infection to account for possible misclassification and reduce bias.

Meaningful measurement: developing a measurement system to improve blood pressure control in patients with chronic kidney disease

OBJECTIVES To develop an electronic registry of patients with chronic kidney disease (CKD) treated in a nephrology practice in order to provide clinically meaningful measurement and population management to improve rates of blood pressure (BP) control. METHODS We combined data from multiple electronic sources: the billing system, structured fields in the electronic health record (EHR), and free text physician notes using natural language processing (NLP). We also used point-of-care worksheets to capture clinical rationale. RESULTS Nephrologist billing accurately identified patients with CKD. Using an algorithm that incorporated multiple BP readings increased the measured rate of control (130/80 mm Hg) from 37.1% to 42.3%. With the addition of NLP to capture BP readings from free text notes, the rate was 52.6%. Data from point-of-care worksheets indicated that in 52% of visits in which patients were identified as not having controlled BP, patients were actually at goal based on BP readings taken at home or on that day in the office. CONCLUSIONS Building a method for clinically meaningful continuous performance measurement of BP control is possible, but will require data from multiple sources. Electronic measurement systems need to grow to be able to capture and process performance data from patients as well as in real-time from physicians.

Electronic Consultations in Nephrology: Pilot Implementation and Evaluation

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

Implementation Science Workshop: Implementation of an Electronic Referral System in a Large Academic Medical Center

Division ofGeneral InternalMedicineandPrimaryCare, DepartmentofMedicine, BrighamandWomen’s Hospital, Boston,MA, USA; Brighamand Women’s Physicians Organization, Boston, MA, USA; Par8o Inc., Newton, MA, USA; Department of Health Care Policy, Harvard Medical School, Boston,MA, USA; HoustonVeteransAffairs Center for Innovations inQuality, Effectiveness and Safety,Michael E. DeBakeyVeteransAffairsMedical Center and Baylor College of Medicine, Houston, TX, USA.

Implementation of a Risk Stratification and Management Pathway for Acute Chest Pain in the Emergency Department.

OBJECTIVES Chest pain is a common complaint in the emergency department, and a small but important minority represents an acute coronary syndrome (ACS). Variation in diagnostic workup, risk stratification, and management may result in underuse, misuse, and/or overuse of resources. METHODS From July to October 2014, we conducted a prospective cohort study in an academic medical center by implementing a Standardized Clinical Assessment and Management Plan (SCAMP) for chest pain based on the HEART score. In addition to capturing adherence to the SCAMP algorithm and reasons for any deviations, we measured troponin sample timing; rates of stress test utilization; length of stay (LOS); and 30-day rates of revascularization, ACS, and death. RESULTS We identified 239 patients during the enrollment period who were eligible to enter the SCAMP, of whom 97 patients were entered into the pathway. Patients were risk stratified into one of 3 risk tiers: high (n = 3), intermediate (n = 40), and low (n = 54). Among low-risk patients, recommendations for troponin testing were not followed in 56%, and 11% received stress tests contrary to the SCAMP recommendation. None of the low-risk patients had elevated troponin measurements, and none had an abnormal stress test. Mean LOS in low-risk patients managed with discordant plans was 22:26 h/min, compared with 9:13 h/min in concordant patients (P < 0.001). Mean LOS in intermediate-risk patients with stress testing was 25:53 h/min, compared with 7:55 h/min for those without (P < 0.001). At 30 days, 10% of intermediate-risk patients and 0% of low-risk patients experienced an ACS event (risk difference 10% [0.7%-19%]); none experienced revascularization or death. The most frequently cited reason for deviation from the SCAMP was lack of confidence in the tool. CONCLUSIONS Compliance with SCAMP recommendations for low- and intermediate-risk patients was poor, largely due to lack of confidence in the tool. However, in our study population, outcomes suggest that deviation from the SCAMP yielded no additional clinical benefit while significantly prolonging emergency department LOS.