Sung-Joon Min

Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention

Objectives: To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce rehospitalization rates.

Further Application of the Care Transitions Intervention: Results of a Randomized Controlled Trial Conducted in a Fee-For-Service Setting

The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations—The Care Transitions Intervention—could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.

Trends in fatal motor vehicle crashes before and after marijuana commercialization in Colorado.

BACKGROUND Legal medical marijuana has been commercially available on a widespread basis in Colorado since mid-2009; however, there is a dearth of information about the impact of marijuana commercialization on impaired driving. This study examined if the proportions of drivers in a fatal motor vehicle crash who were marijuana-positive and alcohol-impaired, respectively, have changed in Colorado before and after mid-2009 and then compared changes in Colorado with 34 non-medical marijuana states (NMMS). METHODS Thirty-six 6-month intervals (1994-2011) from the Fatality Analysis Reporting System were used to examine temporal changes in the proportions of drivers in a fatal motor vehicle crash who were alcohol-impaired (≥0.08 g/dl) and marijuana-positive, respectively. The pre-commercial marijuana time period in Colorado was defined as 1994-June 2009 while July 2009-2011 represented the post-commercialization period. RESULTS In Colorado, since mid-2009 when medical marijuana became commercially available and prevalent, the trend became positive in the proportion of drivers in a fatal motor vehicle crash who were marijuana-positive (change in trend, 2.16 (0.45), p<0.0001); in contrast, no significant changes were seen in NMMS. For both Colorado and NMMS, no significant changes were seen in the proportion of drivers in a fatal motor vehicle crash who were alcohol-impaired. CONCLUSIONS Prevention efforts and policy changes in Colorado are needed to address this concerning trend in marijuana-positive drivers. In addition, education on the risks of marijuana-positive driving needs to be implemented.

Postoperative Pain Management in Elderly Patients: Correlation Between Adherence to Treatment Guidelines and Patient Satisfaction

Objectives: To evaluate pain management satisfaction in elderly postoperative patients; to define pain management strategies documented in the medical record (MR) that predict patient satisfaction.

A new tool for identifying discrepancies in postacute medications for community-dwelling older adults

BACKGROUND Despite a national focus on the problem of medication safety, few studies have examined the frequency, causes, and factors contributing to discrepancies between the medications prescribed in acute care settings and what elderly patients (age>or=65 years) actually take after their discharge. OBJECTIVE The aims of this study were to develop a new instrument, the Medication Discrepancy Tool (MDT), for use by multiple practitioners across the continuum of care and to assess the MDTs reliability among nurses, pharmacists, and physicians, all of whom play a part in the formulation and administration of medication regimens for patients in transition. METHODS The study was conducted in a vertically integrated health care system and at a geriatric clinic in an academic health center. We applied the MDT to a series of 20 clinical vignettes based on actual cases involving older patients discharged from a community hospital to home. The interrater reliability of the MDT was assessed by asking clinicians (2 home health care nurses, 2 doctoral-trained geriatric pharmacists, and 2 physicians) to use this tool to rate the clinical vignettes. Reliability comparisons were then made within and across clinical disciplines. Intrarater reliability was also determined. RESULTS Across all 3 clinical disciplines, the mean interrater reliability (kappa) for the 20 vignettes was 0.56 (15% low agreement, 80% good agreement, and 5% excellent agreement). Within disciplines, the kappa statistic was as follows: nurses, 0.68; pharmacists, 0.50; and physicians, 0.64. Intrarater reliability ranged from 0.58 to 0.69. CONCLUSIONS By capturing transition-related medication discrepancies, the MDT fills an important gap in national efforts to promote patient safety. MDT items are actionable at both the patient and system level, suggesting that this tool could be used to foster continuous quality improvement efforts.

Understanding and Execution of Discharge Instructions

Discharge from the acute care hospital is increasingly recognized as a time of heightened vulnerability for lapses in safety and quality. The capacity of patients to understand and execute discharge instructions is critical to promote effective self-care. This study explores factors that predict understanding and execution of discharge instructions in a sample of 237 recently discharged older adults. A study nurse conducted a postdischarge home visit to ascertain patient understanding and assess execution of instructions. Health literacy, cognition, and self-efficacy were important predictors of successful understanding and execution of instructions. Neither discharge diagnosis nor complexity of discharge instructions was found to be a significant predictor of these outcomes. Results indicate a need to implement reliable protocols that identify patients at risk for poor understanding and execution of hospital discharge instructions and provide customized approaches to meet them at their respective levels.

Opioid Prescribing at Hospital Discharge Contributes to Chronic Opioid Use.

ABSTRACTBACKGROUNDChronic opioid therapy for chronic pain treatment has increased. Hospital physicians, including hospitalists and medical/surgical resident physicians, care for many hospitalized patients, yet little is known about opioid prescribing at hospital discharge and future chronic opioid use.OBJECTIVEWe aimed to characterize opioid prescribing at hospital discharge among ‘opioid naïve’ patients. Opioid naïve patients had not filled an opioid prescription at an affiliated pharmacy 1 year preceding their hospital discharge. We also set out to quantify the risk of chronic opioid use and opioid refills 1 year post discharge among opioid naïve patients with and without opioid receipt at discharge.DESIGNThis was a retrospective cohort study.PARTICIPANTSFrom 1 January 2011 to 31 December 2011, 6,689 opioid naïve patients were discharged from a safety-net hospital.MAIN MEASUREChronic opioid use 1 year post discharge.KEY RESULTSTwenty-five percent of opioid naïve patients (n = 1,688) had opioid receipt within 72 hours of discharge. Patients with opioid receipt were more likely to have diagnoses including neoplasm (6.3 % versus 3.5 %, p < 0.001), acute pain (2.7 % versus 1.0 %, p < 0.001), chronic pain at admission (12.1 % versus 3.3 %, p < 0.001) or surgery during their hospitalization (65.1 % versus 18.4 %, p < 0.001) compared to patients without opioid receipt. Patients with opioid receipt were less likely to have alcohol use disorders (15.7 % versus 20.7 %, p < 0.001) and mental health disorders (23.9 % versus 31.4 %, p < 0.001) compared to patients without opioid receipt. Chronic opioid use 1 year post discharge was more common among patients with opioid receipt (4.1 % versus 1.3 %, p < 0.0001) compared to patients without opioid receipt. Opioid receipt was associated with increased odds of chronic opioid use (AOR = 4.90, 95 % CI 3.22-7.45) and greater subsequent opioid refills (AOR = 2.67, 95 % CI 2.29-3.13) 1 year post discharge compared to no opioid receipt.CONCLUSIONOpioid receipt at hospital discharge among opioid naïve patients increased future chronic opioid use. Physicians should inform patients of this risk prior to prescribing opioids at discharge.

Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes

OBJECTIVES Hospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes. DESIGN Retrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003-2009. SETTING The MCBS is a nationally representative survey of beneficiaries matched with claims data. PARTICIPANTS Community-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation. INTERVENTION/EXPOSURE Potential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics. MEASUREMENTS Hospital readmission during the PAC stay, return to community residence, and all-cause mortality. RESULTS Of 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21-7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39-1.92), and for-profit PAC ownership (1.43, 1.21-1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9% vs 8.6%, P < .001) and 100 days (39.9% vs 14.5%, P < .001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60-2.54; 100 days: OR 3.79, 95% CI 3.13-4.59). CONCLUSIONS Hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.

Using Telehealth to Provide Diabetes Care to Patients in Rural Montana: Findings from the Promoting Realistic Individual Self-Management Program

OBJECTIVE The objectives of this study were to demonstrate the feasibility of telehealth technology to provide a team approach to diabetes care for rural patients and determine its effect on patient outcomes when compared with face-to-face diabetes visits. MATERIALS AND METHODS An evaluation of a patient-centered interdisciplinary team approach to diabetes management compared telehealth with face-to-face visits on receipt of recommended preventive guidelines, vascular risk factor control, patient satisfaction, and diabetes self-management at baseline and 1, 2, and 3 years postintervention. RESULTS One-year postintervention the receipt of recommended dilated eye exams increased 31% and 43% among telehealth and face-to-face patients, respectively (p=0.28). Control of two or more risk factors increased 37% and 69% (p=0.21). Patient diabetes care satisfaction rates increased 191% and 131% among telehealth and face-to-face patients, respectively (p=0.51). A comparison of telehealth with face-to-face patients resulted in increased self-reported blood glucose monitoring as instructed (97% vs. 89%; p=0.63) and increased dietary adherence (244% vs. 159%; p=0.86), respectively. Receipt of a monofilament foot test showed a significantly greater improvement among face-to-face patients (17% vs. 35%; p=0.01) at 1 year postintervention, but this difference disappeared in years 2 and 3. CONCLUSIONS Telehealth proved to be an effective mode for the provision of diabetes care to rural patients. Few differences were detected in the delivery of a team approach to diabetes management via telehealth compared with face-to-face visits on receipt of preventive care services, vascular risk factor control, patient satisfaction, and patient self-management. A team approach using telehealth may be a viable strategy for addressing the unique challenges faced by patients living in rural communities.

Telemedicine and the mini-mental state examination: assessment from a distance.

The objective of this study was to determine the reliability of the Mini-Mental State Examination (MMSE) administration via telehealth with a focus on the auditory and visual test components. Reliability was assessed through use of an in-person collaborator and by assessment of faxed test copies. The MMSE was administered via telehealth with the assistance of a face-to-face collaborator. Patient responses were recorded by both the remote and in-person nurse and compared item by item; total scores for each subject were also compared. Visual items were assessed through a blinded separate scoring of a faxed copy. Percent agreement per item and total score were calculated and correlations between scores were determined by Pearson correlation coefficients. Mean score differences and associated 95% confidence intervals were calculated. Eighty percent of individual items demonstrated remote to in-person agreement of >95% and all items were >85.5% in agreement. Pearson correlation coefficients demonstrated high correlations (>0.86) between 80% of the items examined. Mean differences in scored test items were not significantly different from zero. This study demonstrates the utility of using telehealth for cognitive assessment by MMSE. It supports the use of telehealth to improve healthcare access among patients for whom distance, cost, and mobility are potential barriers to attending face-to-face clinical visits. Continued validation and reliability testing is warranted to ensure that all healthcare provided via telehealth maintains an equal quality level to that of in-person care.