Juliette T. Liesinger

Effect of Hospital Follow-up Appointment on Clinical Event Outcomes and Mortality

BACKGROUND Decreasing hospital readmission and patient mortality after hospital dismissal is important when providing quality health care. Interventions recently proposed by the Centers for Medicare and Medicaid Services to reduce avoidable hospital readmissions include providing patients with clear discharge instructions and appointments for timely follow-up visits. Although research has demonstrated a correlation between follow-up arrangements and reduced hospital readmission in specific patient populations, the effect of hospital follow-up in general medicine patients has not been assessed. METHODS For this study, we reviewed hospital dismissal instructions for general medicine patients dismissed in 2006 from Mayo Clinic hospitals in Rochester, Minnesota (n = 4989), and determined whether specific appointment details for follow-up were documented. Survival analysis and propensity score-adjusted proportional hazards regression models were developed to investigate the association of follow-up appointment arrangements with hospital readmission, emergency department visits, and mortality at 30 and 180 days after discharge. RESULTS Of the 4989 dismissal summaries, 3037 (60.9%) contained instructions for a follow-up appointment. No difference was found between those with a documented follow-up appointment vs those without regarding hospital readmission, emergency department visits, or mortality 30 days after dismissal. However, those with a documented follow-up appointment were slightly more likely to have an adverse event (hospital readmission, emergency department visit, or death) within 180 days after dismissal. CONCLUSIONS Improved discharge processes, including arrangement of hospital follow-up appointments, do not appear to improve readmission rates or survival in general medicine patients. Therefore, national efforts to ensure follow-up for all patients after hospital dismissal may not be beneficial or cost-effective.

Incidence of Antibiotic-Resistant Escherichia coli Bacteriuria According to Age and Location of Onset: A Population-Based Study From Olmsted County, Minnesota

OBJECTIVE To better understand the epidemiology of drug-resistant Escherichia coli across health care and community settings. PATIENTS AND METHODS We conducted a population-based cohort study of the incidence of antibiotic-resistant E coli bacteriuria among different patient groups. All urine cultures with monomicrobial growth of E coli obtained from Olmsted County, Minnesota, residents from January 1, 2005, through December 31, 2009, were identified. The initial isolate per patient per year was included. Analyses were stratified by patient age and location of infection onset (ie, nosocomial, health care associated, and community associated). RESULTS We evaluated 5619 E coli isolates and the associated patients. During the study period, the incidence of drug-resistant bacteriuria did not change among children but increased significantly among adults of all ages, most markedly among elderly patients older than 80 years. In elderly patients, the incidence of bacteriuria with isolates resistant to fluoroquinolones increased from 464 to 1116 per 100,000 person-years (P<.001), and the incidence of bacteriuria with isolates resistant to fluoroquinolones plus trimethoprim-sulfamethoxazole increased from 274 to 512 per 100,000 person-years (P<.05). When analyzed by location of infection onset, incidence of bacteriuria with isolates resistant to trimethoprim-sulfamethoxazole, fluoroquinolones, trimethoprim-sulfamethoxazole plus fluoroquinolones, extended-spectrum cephalosporins, and more than 3 drug classes increased significantly among community-associated but not among nosocomial or health care-associated cases. CONCLUSION In this population-based study, the incidence of antibiotic-resistant E coli bacteriuria nearly doubled during the 5-year study period among elderly patients and those with community-associated isolates. These patient groups should be targets of interventions to slow the emergence and spread of antibiotic-resistant E coli.

A two-county comparison of the HOUSES index on predicting self-rated health

Background Mortality, incidence of most diseases, and prevalence of adverse health behaviours follow an inverse gradient with social class. Many proxies for socioeconomic status (SES) exist; however, each bears a different relation to health outcomes, probably following a different aetiological pathway. Additionally, data on SES can be quite difficult to gather. Five measures of SES were compared, including a novel measure, the HOUSES index, in the prediction of self-rated health (SRH) in two Midwestern settings, Olmsted County, Minnesota, and Jackson County, Missouri. Methods Using a probability sampling design, a cross-sectional telephone survey was administered to a randomised sample of households. The questionnaire collected a variety of sociodemographic and personal health information. The dependent variable, SRH, was dichotomised into excellent/very good/good versus fair/poor health. Information for the HOUSES index was collected through public property records and corroborated through the telephone questionnaire. Participants were parents/guardians of children aged 1–17 residing in Olmsted County (n=746) and Jackson County (n=704). Results The HOUSES index was associated with adverse SRH in Jackson County adults. All five SES measures were significant predictors in this group. Composite SES indices showed significant associations with SRH in Olmsted County adults. Conclusions The HOUSES index makes a unique contribution to the measurement of SES and prediction of health outcomes. Its utility is qualified by specific social contexts, and it should be used in concert with other SES indices.

Automated detection of follow-up appointments using text mining of discharge records

OBJECTIVE To determine whether text mining can accurately detect specific follow-up appointment criteria in free-text hospital discharge records. DESIGN Cross-sectional study. SETTING Mayo Clinic Rochester hospitals. PARTICIPANTS Inpatients discharged from general medicine services in 2006 (n = 6481). INTERVENTIONS Textual hospital dismissal summaries were manually reviewed to determine whether the records contained specific follow-up appointment arrangement elements: date, time and either physician or location for an appointment. The data set was evaluated for the same criteria using SAS Text Miner software. The two assessments were compared to determine the accuracy of text mining for detecting records containing follow-up appointment arrangements. MAIN OUTCOME MEASURES Agreement of text-mined appointment findings with gold standard (manual abstraction) including sensitivity, specificity, positive predictive and negative predictive values (PPV and NPV). RESULTS About 55.2% (3576) of discharge records contained all criteria for follow-up appointment arrangements according to the manual review, 3.2% (113) of which were missed through text mining. Text mining incorrectly identified 3.7% (107) follow-up appointments that were not considered valid through manual review. Therefore, the text mining analysis concurred with the manual review in 96.6% of the appointment findings. Overall sensitivity and specificity were 96.8 and 96.3%, respectively; and PPV and NPV were 97.0 and 96.1%, respectively. ANALYSIS of individual appointment criteria resulted in accuracy rates of 93.5% for date, 97.4% for time, 97.5% for physician and 82.9% for location. CONCLUSION Text mining of unstructured hospital dismissal summaries can accurately detect documentation of follow-up appointment arrangement elements, thus saving considerable resources for performance assessment and quality-related research.

A telephonic coaching program has more impact when body mass index is over 35

SUMMARY PURPOSE The purpose of this study was to test the theory that two indicators of risk (body mass index (BMI) and overall medical risk at baseline) are correlated with weight change in a telephone employer-provided coaching program. DESIGN A retrospective cohort study with assessments at baseline and six months after program completion. SETTING A large manufacturing employer in the United States. SUBJECTS Adult employees and dependents enrolled in a voluntary weight loss program. INTERVENTION The weight program was based on the Self-Management of Care model. Coaching was based on collaborative goal-setting and included telephonic self-management health education. Clients were staged according to readiness to change. MEASURES Weight change (in kilograms), percent weight change, BMI, health risk indices, readiness to change, and demographic variables. ANALYSIS Age, gender, race, education, income, total health risk, readiness to change, and baseline body mass index (BMI) were included as model covariates in a multiple linear regression analysis. RESULTS Individuals with a BMI >35 at baseline lost more weight than those with normal weight (p = 0.001). Total health risk at baseline was not significantly related to weight loss at p < 0.05. CONCLUSION Our findings suggest that the greatest weight loss could be achieved in this telephone coaching program by targeting morbidly obese employees.

Improvements in Health Behaviors, Eating Self-Efficacy, and Goal-Setting Skills Following Participation in Wellness Coaching.

Purpose: This project examined potential changes in health behaviors following wellness coaching. Design: In a single cohort study design, wellness coaching participants were recruited in 2011, data were collected through July 2012, and were analyzed through December 2013. Items in the study questionnaire used requested information about 11 health behaviors, self-efficacy for eating, and goalsetting skills. Setting: Worksite wellness center. Participants: One-hundred employee wellness center members with an average age of 42 years; 90% were female and most were overweight or obese. Intervention: Twelve weeks of in-person, one-on-one wellness coaching. Method: Participants completed study questionnaires when they started wellness coaching (baseline), after 12 weeks of wellness coaching, and at a 3-month follow-up. Results: From baseline to week 12, these 100 wellness coaching participants improved their self-reported health behaviors (11 domains, 0- to 10-point scale) from an average of 6.4 to 7.7 (p < .001), eating selfefficacy from an average of 112 to 142 (on a 0- to 180-point scale; p < .001), and goal-setting skills from an average of 49 to 55 (on a 16- to 80-point scale; p < .001). Conclusion: These results suggest that participants improved their current health behaviors and learned skills for continued healthy living. Future studies that use randomized controlled trials are needed to establish causality for wellness coaching.

Patterns of Complementary and Alternative Medicine Use in Children With Common Neurological Conditions

Background: Recent literature suggests that one in nine children in the United States uses some type of complementary and alternative medicine (CAM). Children with challenging neurological conditions such as headache, migraine, and seizures may seek CAM in their attempts at self-care. Our objective was to describe CAM use in children with these conditions. Methods: We compared use of CAM among children aged 3 to 17 years with and without common neurological conditions (headaches, migraines, seizures) where CAM might plausibly play a role in their self-management using the 2007 National Health Interview Survey (NHIS) data. Results : Children with common neurological conditions reported significantly more CAM use compared to the children without these conditions (24.0% vs 12.6%, P< .0001). Compared to other pediatric CAM users, children with neurological conditions report similarly high use of biological therapies and significantly higher use of mind-body techniques (38.6% vs 20.5%, P<.007). Of the mind-body techniques, deep breathing (32.5%), meditation (15.1%), and progressive relaxation (10.1%) were used most frequently. Conclusions: About one in four children with common neurological conditions use CAM. The nature of CAM use in this population, as well as its risks and benefits in neurological disease, deserve further investigation.

The asthma ePrompt: a novel electronic solution for chronic disease management.

Objective. This study tested the ability of an electronic prompt to promote an asthma assessment during primary care visits. Methods. We performed a prospective study of all eligible adult patients with previously diagnosed asthma in three geographically distinct ambulatory family medicine clinics within a 4-month period. The usual clinic visit process was performed at two geographically distinct control sites (n = 75 and n = 55 patients, respectively). The intervention group site (n = 64) had an electronic flag embedded in the Patient Check-in Locator field which prompted the distribution of a self-administered Asthma Management Questionnaire (AMQ) in the waiting room. The primary outcome measure was a documented asthma severity assessment. Results. The front desk distributed the AMQ successfully in 100% of possible opportunities and the AMQ was completed by 84% of patients. Providers in the intervention group were significantly more likely than providers in the two non-intervention groups to document asthma severity in the medical record during a non-asthma ambulatory clinic visit (63.3% vs. 18.7% vs. 3.6%; p < .001). Conclusion. The provision of standardized asthma information triggered by an electronic prompt at the time of check-in effectively initiates an asthma assessment during the primary care visits.

Effectiveness of a Quality Improvement Training Course: Mayo Clinic Quality Academy

This study assessed the effectiveness of Quality Academy Teams Training, a team-based process improvement program at Mayo Clinic. The study population consisted of employees who attended the course in 2008 (n = 103). A pretest–posttest design was used to assess learning by participants of the course, and gain score analysis was conducted using paired t test procedures. Electronic surveys were sent to participants 90 days following completion of the course to assess self-reported application of skills and process improvement tools in the work setting. The mean overall score (n = 99) for the posttest was 68%, which was a significant improvement from the pretest mean of 48% (P < .001). Survey results showed that respondents (n = 58) increased their use of 36 specific process improvement tools on the job after attending the training (P < .001). Other health care institutions may benefit from the implementation of quality-related training programs that teach employees to use process improvement tools and methods.

Inclusion of short-term care patients affects the perceived performance of specialists: a retrospective cohort study

BackgroundCurrent publicly reported quality performance measures directly compare primary care to specialty care. Specialists see short-term patients referred due to poor control of their disease who then return to their local provider. Our study looked to determine if outcomes measured in short-term care patients differed from those in long-term care patients and what impact those differences may have on quality performance profiles for specialists.MethodsRetrospective cohort from a large academic medical Center. Performance was measured as “Optimal Care” - all or none attainment of goals. Patients with short-term care (<90 days contact) versus long-term care (>90 days contact) were evaluated for both specialty and primary care practices during the year 2008.ResultsPatients with short-term care had significantly lower “Optimal Care”: 7.2% vs. 19.7% for optimal diabetes care in endocrinology and 41.3% vs. 53.1% for optimal ischemic vascular disease care in cardiology (p < 0.001). Combining short and long term care patients lowered overall perceived performance for the specialty practice.ConclusionsFactors other than quality affect the perceived performance of the specialty practice. Extending current primary care quality measurement to short-term specialty care patients without adjustment produces misleading results.