Shreya Kangovi

Hospital Readmissions—Not Just a Measure of Quality

HOSPITALREADMISSIONSARECOMMONANDCOSTLY.POLIcies fromtheCenters forMedicare&MedicaidServices (CMS) will soon penalize hospitals when its patientsare frequently readmittedwithin30daysof discharge.Asaresult, clinicians,healthcare leaders, andpolicy makers are searching for ways to reduce readmissions. The current understanding of what drives readmission focuses on the quality of the inpatient discharge process and on patients’ health status (FIGURE). Health care administrators have relied on this narrow framework to conclude that the best approach to reduce readmission rates is to improve the discharge process for medically high-risk patients. This strategy may yield disappointing results because it misses important factors that contribute to readmission. In this Commentary, we propose a broader framework that can be used to identify alternative strategies to reduce readmissions.

Challenges Faced by Patients with Low Socioeconomic Status During the Post-Hospital Transition

ABSTRACTBACKGROUNDPatients with low socioeconomic status (low-SES) are at risk for poor outcomes during the post-hospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients.OBJECTIVEWe explored low-SES patients’ perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition.DESIGNWe conducted a qualitative study using in-depth semi-structured interviewing.PARTICIPANTSWe interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals.APPROACHOur interview guide investigated patients’ perceptions of hospitalization, discharge and the post-hospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients’ ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis.KEY RESULTSWe identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients’ ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors.CONCLUSIONSLow-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.

Perceptions of Readmitted Patients on the Transition From Hospital to Home

BACKGROUND Hospital leaders have had mixed success reducing readmissions Little is known about the readmitted patients perspective. METHODS A cross-sectional 36-item survey was administered to 1084 readmitted inpatients of The Hospital of the University of Pennsylvania (an urban academic medical center) and Penn Presbyterian Medical Center (an urban community hospital) between November 10, 2010 and July 5, 2011. The survey response rate was 32.9%. RESULTS The most commonly reported issues contributing to readmission were: 1) feeling unprepared for discharge (11.8%); 2) difficulty performing activities of daily living (ADLs) (10.6%); 3) trouble adhering to discharge medications (5.7%); 4) difficulty accessing discharge medications (5.0%); and 5) lack of social support (4.7%). Low-socioeconomic status (SES) (defined as uninsured or Medicaid) patients were more likely than high-SES patients to report difficulty understanding (odds ratio [OR] 2.7; 95% confidence interval [CI] 1.1, 6.6) and executing (OR 2.2; 95% CI 1.1, 4.4) discharge instructions, difficulty adhering to medications (OR 1.8; 95% CI 1.2, 3.0), lack of social support (OR 2.0; 95% CI 1.2, 3.6), lack of basic resources (OR 2.6; 95% CI 1.1, 6.1), and substance abuse (OR 6.7; 95% CI 2.3, 19.2). CONCLUSIONS Patients reported transition challenges which they believe contribute to illness relapse and readmission. Interventions designed to address these challenges, and tailored for patient characteristics such as SES, may better address the root causes of readmission.

The use of participatory action research to design a patient-centered community health worker care transitions intervention.

BACKGROUND Policymakers, patients and clinicians are increasingly eager to foster patient involvement in health care innovation. Our objective was to use participatory action research with high-risk hospitalized patients to design a post-hospital transition intervention. METHODS We conducted qualitative interviews with sixty-five low-income, recently hospitalized patients exploring their perceptions of barriers to post-hospital recovery and ideas for improvement. We then used a modified grounded theory approach to design an intervention that would address each barrier using patients׳ suggestions. RESULTS Five key themes were translated into design elements. First, patients wished to establish a relationship with healthcare personnel to whom they could relate. The intervention was provided by an empathic community health worker (CHW) who established rapport during hospitalization. Second, patients suggested tailoring support to their needs and goals. CHWs and patients designed individualized action plans for achieving their goals for recovery. Third, patient goals were misaligned with those of the inpatient team. CHW facilitated patient-provider discharge communication to align goals. Fourth, patients lacked post-discharge support for predominantly psychosocial or financial issues that undermined recovery. CHWs provided support tailored to patient needs. Finally, patients faced numerous barriers in obtaining post-hospital primary care. CHWs helped patients to obtain timely care with a suitable provider. CONCLUSIONS Low-income hospitalized patients voiced needs and suggestions that were directly translated into the design of a scalable patient-centered CHW intervention. IMPLICATIONS The approach of using participatory action research to tightly mapping patient input into intervention design is rapid and systematic strategy for operationalizing patient involvement in innovation.

From Rhetoric to Reality — Community Health Workers in Post-Reform U.S. Health Care

Community health workers may become instrumental members of future U.S. health care teams, addressing upstream contributors to health and illness, but CHW programs must address some key implementation barriers to succeed in the post-reform era.

A Classification and Meta-analysis of Community-based Directly Observed Therapy Programs for Tuberculosis Treatment in Developing Countries

In many developing countries, Directly Observed Therapy (DOT) for tuberculosis has been undertaken mainly in the clinic setting. However, clinic-based DOT may create a high patient load in already overburdened health facilities and increase barriers to care by requiring patients to travel to clinic frequently for therapy. Community-based DOT (CBDOT) may overcome some of these problems. This aims of this review are (a) to describe the main features of CBDOT programs, and (b) to compare features and outcomes of CBDOT programs that do and do not offer financial reward for CBDOT providers. Ten major features define CBDOT program structure and function. Programs that paid their CBDOT providers tended to differ from unpaid programs based on all of these features. CBDOT programs in which providers received financial reward had success rates of 85.7 versus 77.6% in programs without financial reward for providers. This difference was not statistically significant. CBDOT programs fall into two major archetypes, which differ in their structure and possibly in their outcomes.

Atherosclerotic Plaque Inflammation Varies Between Vascular Sites and Correlates With Response to Inhibition of Lipoprotein‐Associated Phospholipase A2

Background Despite systemic exposure to risk factors, the circulatory system develops varying patterns of atherosclerosis for unclear reasons. In a porcine model, we investigated the relationship between site‐specific lesion development and inflammatory pathways involved in the coronary arteries (CORs) and distal abdominal aortas (AAs). Methods and Results Diabetes mellitus (DM) and hypercholesterolemia (HC) were induced in 37 pigs with 3 healthy controls. Site‐specific plaque development was studied by comparing plaque severity, macrophage infiltration, and inflammatory gene expression between CORs and AAs of 17 DM/HC pigs. To assess the role of lipoprotein‐associated phospholipase A2 (Lp‐PLA2) in plaque development, 20 DM/HC pigs were treated with the Lp‐PLA2 inhibitor darapladib and compared with the 17 DM/HC untreated pigs. DM/HC caused site‐specific differences in plaque severity. In the AAs, normalized plaque area was 4.4‐fold higher (P<0.001) and there were more fibroatheromas (9 of the 17 animals had a fibroatheroma in the AA and not the COR, P=0.004), while normalized macrophage staining area was 1.5‐fold higher (P=0.011) compared with CORs. DM/HC caused differential expression of 8 of 87 atherosclerotic genes studied, including 3 important in inflammation with higher expression in the CORs. Darapladib‐induced attenuation of normalized plaque area was site‐specific, as CORs responded 2.9‐fold more than AAs (P=0.045). Conclusions While plaque severity was worse in the AAs, inflammatory genes and inflammatory pathways that use Lp‐PLA2 were more important in the CORs. Our results suggest fundamental differences in inflammation between vascular sites, an important finding for the development of novel anti‐inflammatory therapeutics.

Patients in transition: avoiding detours on the road to HIV treatment success.

To fully benefit from antiretroviral therapy (ART), people living with HIV (PLWH) need to be aware of their HIV infection, linked to and engaged in regular HIV care, and must receive and adhere to ART [1,2]. Completion of all these steps is often unsuccessful, with only 28% of all PLWH in United States achieving viral suppression [3]. Our current understanding for improving health behaviors (linkage to care, retention in care, ART receipt and adherence) and outcomes (viral suppression, prevention of AIDSdefining conditions, transmission of HIV, and survival) relies on modifying patient and environmental factors [1]. (Fig. 1) However, this framework is static and does not account for patients in transition.

Patient financial responsibility for observation care

BACKGROUND As observation care grows, Medicare beneficiaries are increasingly likely to revisit observation care instead of being readmitted. This trend has potential financial implications for Medicare beneficiaries because observation care-although typically hospital based-is classified as an outpatient service. Beneficiaries who are readmitted pay the inpatient deductible only once per benefit period. In contrast, beneficiaries who have multiple care episodes under observations status are subject to coinsurance at every stay and could accrue higher cumulative costs. OBJECTIVES We were interested in answering the question: Do Medicare beneficiaries who revisit observation care pay more than they would have had they been readmitted? DESIGN We used a 20% sample of the Medicare Outpatient Standard Analytic File (2010-2012) to determine the total cumulative financial liability for Medicare beneficiaries who revisit observation care multiple times within a 60-day period. PARTICIPANTS Participants were fee-for-service Medicare beneficiaries who had Part A and Part B coverage for a full calendar year (or until death) during the study period. MEASUREMENTS Our primary measure was beneficiary financial responsibility for facilities fees. RESULTS On average, beneficiaries with multiple observation stays in a 60-day period had a cumulative financial liability of

Perspectives of Older Adults of Low Socioeconomic Status on the Post- hospital Transition

947.40 (803.62), which is significantly lower than the