Luke O. Hansen

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.

BACKGROUND Rehospitalization is a prominent target for healthcare quality improvement and performance-based reimbursement. The generalizability of existing evidence on best practices is unknown. OBJECTIVE To determine the effect of Project BOOST (Better Outcomes for Older adults through Safe Transitions) on rehospitalization rates and length of stay. DESIGN Semicontrolled pre-post study. SETTING/PARTICIPANTS Volunteer sample of 11 hospitals varying in geography, size, and academic affiliation. INTERVENTION Hospitals implemented Project BOOST-recommended tools supported by an external quality improvement physician mentor. METHODS Pre-post changes in readmission rates and length of stay within BOOST units, and between BOOST units and site-designated control units. RESULTS The average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P = 0.010), reflecting an absolute reduction of 2% and a relative reduction of 13.6%. Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P = 0.831). The mean absolute reduction in readmission rates in BOOST units compared to control units was 2.0% (P = 0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site-matched control units). CONCLUSIONS Participation in Project BOOST appeared to be associated with a decrease in readmission rates.

Project BOOST implementation: Lessons learned

Objectives Enhancing care coordination and reducing hospital readmissions have been a focus of multiple quality improvement (QI) initiatives. Project BOOST (Better Outcomes by Optimizing Safe Transitions) aims to enhance the discharge transition from hospital to home. Previous research indicates that QI initiatives originating externally often face difficulties gaining momentum or effecting lasting change in a hospital. We performed a qualitative evaluation of Project BOOST implementation by examining the successes and failures experienced by six pilot sites. We also evaluated the unique physician mentoring component of this program. Finally, we examined the impact of intensification of the physician mentoring model on adoption of BOOST interventions in two later Illinois cohorts (27 hospitals). Methods Qualitative analysis of six pilot hospitals used a process of methodological triangulation and analysis of the BOOST enrollment applications, the listserv, and content from telephone interviews. Evaluation of BOOST implementation at Illinois hospitals occurred via mid-year and year-end surveys. Results The identified common barriers included inadequate understanding of the current discharge process, insufficient administrative support, lack of protected time or dedicated resources, and lack of frontline staff buy-in. Facilitators of implementation included the mentor, a small beginning, teamwork, and proactive engagement of the patient. Notably, hospitals viewed their mentors as essential facilitators of change. Sites consistently commented that the individualized mentoring was extremely helpful and provided significant accountability and stimulated creativity. In the Illinois cohorts, the improved mentoring model showed more complete implementation of BOOST interventions. Conclusions The implementation of Project BOOST was well received by hospitals, although sites faced substantial barriers consistent with other QI research reports. The unique mentorship element of Project BOOST proved extremely valuable in helping sites overcome their distinctive challenges and identify facilitators for success. The findings from this qualitative study should contribute to future BOOST implementation success and others’ efforts to optimize hospital discharge transitions.

Effect of patient-centred bedside rounds on hospitalised patients’ decision control, activation and satisfaction with care

Importance Though interprofessional bedside rounds have been promoted to enhance patient-centred care for hospitalised patients, few studies have been conducted in adult hospital settings and evidence of impact is lacking. Objective To evaluate the effect of patient-centred bedside rounds (PCBRs) on measures of patient-centred care. Design and setting Cluster randomised controlled trial involving four similar non-teaching hospitalist service units in a large urban hospital. Participants Hospitalised general medical patients. Intervention We assembled working groups on two intervention units, consisting of professionals and patient/family members, to determine the optimal timing, duration and format for PCBR. Nurses and hospitalists rounded together in PCBR using a communication tool to provide a framework for discussion and unit leaders joined PCBR to provide coaching during initial weeks of implementation. Main outcomes Using patient interviews, we assessed preferred and experienced roles in medical decision-making using the Control Preferences Scale, activation using the Short Form of the Patient Activation Measure, and satisfaction. We also compared postdischarge patient satisfaction survey items related to teamwork, involvement in decisions and overall care. We assessed nurses’, physicians’ and advanced practice providers’ (APP) perceptions of PCBR using a survey developed for this study. Results Overall, 650 patients were approached for structured interview during hospitalisation: 284 were excluded because of disorientation, 54 were excluded because of non-English language, 72 declined to participate and 4 withdrew from the study after enrolment. Interview data were available for 236 (122 control and 114 intervention unit) patients, and postdischarge satisfaction survey data were available for 493 (274 control and 219 intervention unit) patients. We found no significant differences in patients’ perceptions of shared decision-making, activation or satisfaction with care. Results were similar in analyses based on whether PCBR had been performed (ie, per protocol). We also found no difference in postdischarge patient satisfaction items. Results were similar in multivariate analyses controlling for patient characteristics and clustering of patients within study units. A majority of nurses (78.6%), but only about half of hospitalist physicians and APPs felt that PCBR improved communication with patients (47.4%). A minority of nurses (46.4%) and physicians and APPs (36.8%) agreed that PCBR had improved the efficiency of their workday. Conclusions PCBR had no impact on patients’ perceptions of shared decision-making, activation or satisfaction with care. Additional research is needed to identify optimal approaches that can be reliably implemented in hospital settings to improve patient-centred care.

The physician mentored implementation model: a promising quality improvement framework for health care change.

Quality improvement (QI) efforts hold great promise for improving care delivery. However, hospitals often struggle with QI implementation and fail to sustain improvement in either process changes or patient outcomes. Physician mentored implementation (PMI) is a novel approach that promotes the success and sustainability of QI initiatives at hospitals. It leverages the expertise of external physician mentors who coach QI teams to implement interventions at their local hospitals. The PMI model includes five core components: (1) a hospital self-assessment tool, (2) a face-to-face training session including direct interaction with a physician mentor, (3) a guided continuous quality improvement and systems approach, (4) yearlong individual physician mentoring, and (5) a learning community supported by a resource center, listserv, and webinars. Mentors provide content and process expertise, rather than offering “one-size-fits-all” technical assistance that might not be sustained after the mentoring year ends. Mentors support and motivate QI teams throughout the planning and implementation phases of their interventions, help to engage hospital leadership, garner local physician buy-in, and address institutional barriers. Mentors also guide hospitals to identify opportunities for the adaptation and customization of original evidence-based models of care while ensuring the fidelity of those models. More than 350 hospitals have used the PMI model to implement successful national and statewide QI initiatives. Academic medical centers are charged with improving the health of patients and reengineering care delivery; thus, they serve as the ideal source for physician mentors and can act as leaders in implementing QI projects using the PMI model.

National quality campaigns: who benefits?

Background The use of national quality campaigns to foster evidence-based hospital practices is increasing. Because campaigns typically do not limit access to their resources, they may influence non-enrolled hospitals as well. Objective To examine the relative impact of a national campaign, the Door-to-Balloon (D2B) Alliance, on enrolled and non-enrolled hospitals. Methods In this prospective cohort study, we compared the use of D2B Alliance resources (eg, webinars, online community, mentor network), changes in the use of strategies recommended by the D2B Alliance, and perceived impact of the D2B Alliance between hospitals that enrolled in the D2B Alliance (n=264) and hospitals that declined enrolment (n=101). Results More than half (53.2%) of non-enrolled hospitals reported using at least some of the resources made available by the D2B Alliance to improve door-to-balloon times. This compared with 83.5% of enrolled hospitals reporting that they used D2B Alliance resources (p<0.01). Both enrolled and non-enrolled hospitals significantly increased their use of recommended hospital strategies between 2005 and 2008, although the use of strategies remained incomplete (35.5–91.5% use). There was no significant difference between the use of these strategies between enrolled and non-enrolled hospitals at follow-up (p≥0.51), adjusted for baseline use. About half of all hospitals reported that door-to-balloon times would have been worse at their hospital without the existence of the D2B Alliance. Conclusions This research suggests that national quality campaigns with open access to campaign resources may have substantial spillover effects on non-enrolled hospitals.

The effect of hospitalist discontinuity on adverse events

BACKGROUND Patient-physician continuity is difficult to achieve in hospital settings because of the need to provide care continuously. The impact of hospital physician discontinuity on patient safety is unknown. OBJECTIVE To determine the association between hospital physician continuity and the incidence of adverse events (AEs). DESIGN Retrospective observational study using multivariable models to adjust for patient characteristics. PARTICIPANTS Patients admitted to a nonteaching hospitalist service in a large academic hospital between March 1, 2009 and December 31, 2011. MAIN MEASURE(S) Two measures of continuity were used. The Number of Physicians Index (NPI) was the total number of unique hospitalists caring for a patient. The Usual Provider of Care (UPC) Index was the proportion of encounters with the most frequently encountered hospitalist. Outcome measures were AEs detected by automated queries of information systems and confirmed by 2 physician researchers. KEY RESULTS Our analysis included data from 474 hospitalizations. In unadjusted models, each 1-unit increase in the NPI (ie, less continuity) was significantly associated with the incidence of 1 or more AEs (odds ratio = 1.75; P < 0.001). However, UPC was not associated with incidence of AEs. Across all adjusted models, neither NPI nor UPC was significantly associated with the incidence of AEs. The direction of the effect of discontinuity on AEs was also inconsistent across models. CONCLUSIONS Hospitalist physician continuity does not appear to be associated with the incidence of AEs. Because hospital care is provided by teams of clinicians, future research should evaluate the impact of team complexity and dynamics on patient outcomes.

Patient, Caregiver, and Physician Work in Heart Failure Disease Management: A Qualitative Study of Issues That Undermine Wellness

OBJECTIVE To identify factors underlying heart failure hospitalization. METHODS Between January 1, 2012, and May 31, 2012, we combined medical record reviews and cross-sectional qualitative interviews of multiple patients with heart failure, their clinicians, and their caregivers from a large academic medical center in the Midwestern United States. The interview data were analyzed using a 3-step grounded theory-informed process and constant comparative methods. Qualitative data were compared and contrasted with results from the medical record review. RESULTS Patient nonadherence to the care plan was the most important contributor to hospital admission; however, reasons for nonadherence were complex and multifactorial. The data highlight the importance of patient education for the purposes of condition management, timeliness of care, and effective communication between providers and patients. CONCLUSION To improve the consistency and quality of care for patients with heart failure, more effective relationships among patients, providers, and caregivers are needed. Providers must be pragmatic when educating patients and their caregivers about heart failure, its treatment, and its prognosis.

You get caught up: youth decision-making and violence.

Violence is a major cause of morbidity and mortality among adolescents. We conducted serial focus groups with 30 youth from a violence prevention program to discuss violence in their community. We identified four recurrent themes characterizing participant experiences regarding peer decision-making related to violence: (1) youth pursue respect, among other typical tasks of adolescence; (2) youth pursue respect as a means to achieve personal safety; (3) youth recognize pervasive risks to their safety, frequently focusing on the prevalence of firearms; and (4) as youth balance achieving respect in an unsafe setting with limited opportunities, they express conflict and frustration. Participants recognize that peers achieve peer-group respect through involvement in unsafe or unhealthy behavior including violence; however they perceive limited alternative opportunities to gain respect. These findings suggest that even very high risk youth may elect safe and healthy alternatives to violence if these opportunities are associated with respect and other adolescent tasks of development.

Outpatient follow-up after traumatic injury: Challenges and opportunities

Background: It has been shown that rates of ambulatory follow-up after traumatic injury are not optimal, but the association with insurance status has not been studied. Aims: To describe trauma patient characteristics associated with completed follow-up after hospitalization and to compare relative rates of healthcare utilization across payor types. Setting and Design: Single institution retrospective cohort study. Materials and Methods: We compared patient demographics and healthcare utilization behavior after discharge among trauma patients between April 1, 2005 and April 1, 2010. Our primary outcome of interest was outpatient provider contact within 2 months of discharge. Statistical Analysis: Multivariate logistic regression was used to determine the association between characteristics including insurance status and subsequent ambulatory and acute care. Results: We reviewed the records of 2906 sequential trauma patients. Patients with Medicaid and those without insurance were significantly less likely to complete scheduled outpatient follow-up within 2 months, compared to those with private insurance (Medicaid, OR 0.67, 95% CI 0.51-0.88; uninsured, OR 0.29, 95% CI 0.23-0.36). Uninsured and Medicaid patients were twice as likely as privately insured patients to visit the Emergency Department (ED) for any reason after discharge (uninsured patients (Medicaid, OR 2.6, 95% CI 1.50-4.53; uninsured, OR 2.10, 94% CI 1.31-3.36). Conclusion: We found marked differences between patients in scheduled outpatient follow-up and ED utilization after injury associated with insurance status; however, Medicaid seemed to obviate some of this disparity. Medicaid expansion may improve outpatient follow-up and affect patient outcome disparities after injury.

Hospital-based violence intervention programs targeting adult populations: an Eastern Association for the Surgery of Trauma evidence-based review

Background Violent injury and reinjury take a devastating toll on distressed communities. Many trauma centers have created hospital-based violent injury prevention programs (HVIP) to address psychosocial, educational, and mental health needs of injured patients that may contribute to reinjury. Objectives To evaluate the overall effectiveness of HVIPs for violent injury prevention. We performed an evidence-based review to answer the following population, intervention, comparator, outcomes (PICO) question: Are HVIPs attending to adult patients (age 18+) treated for intentional injury more effective than the usual care at preventing: intentional violent reinjury and/or death; arrest and/or incarceration; substance abuse and/or mental issues; job and/or school attainment? Data sources PubMed, Web of Science, Google Scholar, and the Cochrane Library were queried for salient articles by a professional librarian on two separate occasions, and related articles were identified from references. Study eligibility criteria, participants, interventions Eligible studies examined adult patients treated for intentional injury in a hospital-based violence prevention program compared to a control group. Study appraisal and synthesis methods We used the Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the evidence. Results 71 articles were identified. After discarding duplicates, reviews, and those articles that did not address our PICO questions, we ultimately reviewed 10 articles. We found insufficient evidence to recommend adult-focused HVIP interventions. Limitations There was a relative paucity of data, and available studies were limited by self-selection bias and small sample sizes. Conclusions We make no recommendation with respect to adult-focused HVIP interventions.