Christiana Care Health System Research Articles

Hospitality to healthcare: Patient Experience Academy, a successful alliance between the ChristianaCare Health System and the University of Delaware

This exemplary case study describes a successful collaboration between a healthcare system and a hospitality management program to bring hospitality to healthcare. ChristianaCare Health System (CCHS) and University of Delaware’s Hospitality and Sport Management partnered to create Patient Experience Academy. The program focused on a training intervention, supported by leadership to enhance the patient and guest experience at the ChristianaCare Health System (CCHS). The highlights of the program included Managing Expectations;Service Recovery; Power of Listening & Empathy in Healthcare Setting; Healthcare Theatre (HT) Interactive Training Platforms & Delivery Systems for Sim Sessions; Transformation; and Achievement Stories. Total participants included 32 Cohorts (nearly 1000 participants), and each cohort was comprised of 25–30 attendees selected by CCHS. Cohorts included Physicians, LPNs, RNs, NAs, MAs, OAs, frontline and other support staff. The results were measured at three levels: 1) Learning outcomes, 2) Application of training to practice, and 3) Patient satisfaction scores. Scores in all three areas showed significant improvements.

Do Adult Medicaid Benefits for Oral Health Reduce ED Visits?

The previous ChristianaCare Health System (CCHS) study that examined the financial burden of dental-related Emergency Department (ED) visits within the ChristianaCare Health System between June 1, 2013, and June 22, 2018, provided evidence to support the claim that a large percentage of patients utilizing the ED for dental-related disease were uninsured, as well as the fact that the treatment the patients received was more costly and less effective than definitive dental care in a dental/oral surgery office. On October 1, 2020, adults (19-65) living in Delaware who were eligible for medical Medicaid coverage were enrolled in dental Medicaid coverage as part of their plans. This study aims to compare the previous study's results to the same population between the dates of October 1, 2020, and March 1, 2021, following the approval of adult Medicaid dental coverage and to determine if there was an increased utilization of dental benefits and a subsequent reduction in ED-related dental visits, as patients opted to seek care at dental/oral surgery offices.Data were retrospectively collected on all non-traumatic, dental-related problems presenting to the Wilmington and Christiana Emergency Departments between October 1, 2020, and March 1, 2021. Patients were categorized by the diagnostic code (ICD-10) used during their ED visits. Patient demographics and insurance coverage were obtained. The data were analyzed, and the treatment provided was determined for each visit based on the CPT code used. These results were then extrapolated and compared to the previous study's statistics to determine: 1) if the insurance coverage types and 2) subsequent volume of ED visits had significantly changed as compared to the pre-Medicaid dental coverage time period.After extrapolating the results of the 6-month time period (October 1, 2020, to March 1, 2021), it was determined that the overall distribution of insurance coverage types of those patients presenting to the ED did not significantly change when compared to the previous study (June 1, 2013, to June 22, 2018). Overall, the percentage of patients utilizing Medicaid insurance for ED-related dental visits was 56% before and after the institution of the dental benefits through Medicaid. However, the volume of patients presenting to the ED for dental-related concerns decreased following the addition of dental benefits within adult Medicaid.Based on the results exhibited in this study, since the addition of dental benefits to adult Medicaid in Delaware, the number of dental-related ED visits appears to have decreased as compared to those exhibited in the previous study, while the overall distribution of insurance coverage types did not appear to significantly change. This reduction in total volume of dental-related ED visits is suspected to be related to improved access to care with the addition of dental benefits to adult Medicaid. It is believed that with this improved access to care, along with continued community outreach and dental education, the volume of future dental-related ED visits can effectively continue to be reduced, and the shift toward the use of dental/oral surgery offices for more effective and definitive dental care can be promoted. Furthermore, this trend is suspected to lead to improved oral health throughout the community and a decrease in the total cost of care.

One-year Outcomes of Selective Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Initial Results at Christiana Care Health System

One-year Outcomes of Selective Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Initial Results at Christiana Care Health System

Examining the relationship between food environment and gestational diabetes

Studies have shown an association between the incidence of gestational diabetes and living in neighborhoods oversaturated with unhealthy foods. This study sought to determine if the food environment also affects the management of gestational diabetes. We hypothesized that living in areas with a higher quality of food decreased the risk of requiring medication to treat gestational diabetes. This was a retrospective cohort study of singleton births at the Christiana Care Health System between 2015 and 2018. Patients with gestational diabetes who live in Delaware (N=1327) were geocoded and classified according to their census tract food environment. The food environment was assessed using the modified Retail Food Environment Index, which measures the percentage of healthy food retailers among all food retailers within a half-mile radius of the census tract boundaries. The modified Retail Food Environment Index scores were divided into 3 categories: poor (modified Retail Food Environment Index score, 0-3), average (modified Retail Food Environment Index score, 4-10), and good or above average (modified Retail Food Environment Index score, ≥11) food environments. The primary outcome was the prevalence of A2 gestational diabetes mellitus. Several neonatal and obstetrical outcomes were also examined including type II diabetes mellitus (defined as a 2-hour glucose tolerance test with at least 1 value above the threshold), cesarean delivery, shoulder dystocia, admission to the neonatal intensive care unit, neonatal hypoglycemia, neonatal hyperbilirubinemia, neonatal respiratory distress syndrome, and macrosomia. A total of 689 (52%) women were diagnosed as having A2 gestational diabetes mellitus. Women in the average or good or above average food environment groups had a lower prevalence of A2 gestational diabetes mellitus than women in the poor food environment group (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.92] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.56; 95% confidence interval, 0.40-0.82]). They also had a lower prevalence of type II diabetes mellitus (modified Retail Food Environment Index score, 4-10 [adjusted odds ratio, 0.25; 95% confidence interval, 0.09-0.72] and modified Retail Food Environment Index score, ≥11 [adjusted odds ratio, 0.48; 95% confidence interval, 0.27-0.86]). There were no differences in the other secondary outcomes of interest. The food environment affects the requirement for medication to obtain glycemic levels that are within the target range for those with gestational diabetes.

Rapid Development and Validation of a Novel Laboratory-Derived Test for the Detection of SARS-CoV-2.

ObjectivesTo increase testing capability for SARS-CoV-2 during a rapidly evolving public health emergency, we aimed to deploy a validated laboratory-developed real-time reverse transcription polymerase chain reaction (RT-PCR) diagnostic test for SARS-CoV-2 on an accelerated timeline and using reagent supply chains that were not constrained.MethodsA real-time RT-PCR assay that detects the structural envelope (E) gene of SARS-CoV-2 was developed and validated on the Roche cobas 6800 instrument platform with the omni Utility channel reagents, which performs automated nucleic acid extraction and purification, PCR amplification, and detection. In silico analysis was performed for both inclusivity of all SARS-CoV-2 variants and cross reactivity with other pathogenic organisms. Positive control material was used to determine the Limit of Detection (LOD) and patient samples (positive and negative) confirmed by another authorized assay were used for clinical validation. Experiments were carried out at the Christiana Care Health System’s Molecular Diagnostics Laboratory (Newark, DE) between April 1 and April 4, 2020.ResultsA real-time RT-PCR assay for SARS-Cov-2 was developed and validated in just two weeks. For all oligonucleotides, 100% homology to the available SARS-CoV-2 sequences was observed. Greater than 80% homology between one or more oligonucleotides was observed for SARS-Cov (Urbani strain) and Influenza A, however risk of cross reactivity was deemed to be low. The limit of detection (LOD) of the assay was 250 copies/mL. The assay identified 100% of positive patient samples (30/30) and 100% of negative patient samples (29/29 patient negatives and 1/1 saline). Up to 92 samples can be run on a single plate and analysis takes approximately 3.5 hours.ConclusionsIn this work, we demonstrate the development and validation of a single target laboratory-developed test for SARS-CoV-2 in two weeks. Key considerations for complementary supply chains enabled development on an accelerated timeline and an increase in testing capability.

Treating a patient who has been "tasered".

Kristopher T. Starr is an attorney at law in Wilmington, Del.; an NP at Christiana Care Health System in Wilmington, Del., Nanticoke Memorial Hospital in Seaford, Del., and US Acute Care Solutions in Elkton, Md; and adjunct faculty, at the School of Nursing, University of Delaware in Newark, Del. He is also a member of the Nursing2019 editorial board. The author has disclosed no financial relationships related to this article.

The value of missing information in severity of illness score development.

We aim to investigate the hypothesis that using information about which variables are missing along with appropriate imputation improves the performance of severity of illness scoring systems used to predict critical patient outcomes. We quantify the impact of missing and imputed variables on the performance of prediction models used in the development of a sepsis-related severity of illness scoring system. Electronic health records (EHR) data were compiled from Christiana Care Health System (CCHS) on 119,968 adult patients hospitalized between July 2013 and December 2015. Two outcomes of interest were considered for prediction: (1) first transfer to intensive care unit (ICU) and (2) in-hospital mortality. Five different prediction models were employed. Indicators were utilized in these prediction models to identify when variables were missing and imputed. We observed statistically significant gains in prediction performance when moving from models that did not indicate missing information to those that did. Moreover, this increase was higher in models that use summary variables as predictors compared to those that use all variables. When developing prediction models using longitudinal EHR data, researchers should explore the incorporation of indicators for missing variables along with appropriate imputation.

Four Decades of Epidemiologic Science on HIV Infection and Disease, and Its Impact on Public Health Practice and Policy for Sexual and Gender Minority Persons.

Even at the cusp of the second decade of the new millennia, HIV continues to be a significant public health challenge for sexual and gender minorities (SGM). Men who have sex with men and transgender women, in particular, continue to report higher rates of HIV incidence compared to their heterosexual counterparts, while facing significant barriers to comprehensive sexual healthcare. In Delaware, HIV infection impacts a substantial number of individuals with approximately 14.5 incident cases per 100,000. This ranks Delaware as the 14th highest for HIV incidence among U.S. states. However, the largest healthcare provider in Delaware, Christiana Care Health System, has created many health initiatives to support the health needs of SGM and those living with HIV. The current sustained rate of HIV infection indicates the need for enhanced epidemiologic work to identify HIV cases in subgroups of diverse sexuality and gender identity, collaboration within and across research institution and community organizations, as well as engagement in creative solutions that target the multiple levels of factors contributing to HIV incidence. In addition, it is imperative that local agencies and health organizations continue to support these communities of SGM individuals during the current sociopolitical climate of the national U.S. government.

Improving Efficiency and Standardization in a Robotics Program: A Quality Improvement Project.

After an evaluation of the growing robotics program at Christiana Care Health System in Newark, Delaware, perioperative leaders identified needs related to a lack of instrument set standardization and inconsistent workflow processes; these deficiencies were causing higher-than-anticipated turnaround time (ie, 59 minutes) and an excessive inventory of sterilized robotic instruments. A workgroup was created to review the results of the evaluation and develop solutions for the robotic surgery program. Goals included a 40-minute procedure turnaround time and a 35% reduction in sterilized robotic instrument set inventory one year after project initiation. By developing a team training program, improving operational efficiencies, and improving standardization, the robotics program achieved a 10-minute TAT reduction and a 54% reduction in sterilized robotic instrument inventory. Personnel considered the project to be a huge success because it laid the groundwork for improving efficiency and standardization in Christiana Care Health System's robotics program.

Expanding care for patients infected with Hepatitis C through community partnership in Delaware.

BackgroundHepatitis C virus (HCV) is the most common blood-borne pathogen in the U.S., and Delaware has one of the highest sero-prevalence rates in the country. As a cause of significant morbidity and mortality, it is a public health priority to identify and link individuals with HCV to care. The demand of patients with HCV far exceeds the current availability of providers in Delaware that offer HCV management. ObjectiveTo propose a framework for enabling non-specialist providers within Westside Family Healthcare to manage patients with HCV.MethodsAs a recipient of a Harrington Value Institute Community Partnership grant, the HIV Community Program of Christiana Care Health System (CCHS) started working together with the NE Wilmington pilot site of Westside in July 2018 to: 1) provide HCV education to Westside, 2) implement an HCV care model at Westside, and 3) conduct programmatic evaluation of this framework’s effectiveness. Our goal is to improve Westside rates of HCV knowledge amongst patients and staff, as well as to improve the HCV care continuum, starting with universal HCV screening.Results and ConclusionsResults from the first year of collaboration will be available in August 2019. Implementation of this partnership will enable future expansion and continuation of HCV management amongst Westside sites.

Health system's urgent care centers benefit from pharmacist input on antimicrobial stewardship.

Recently published research indicates that there is an urgent need to apply antimicrobial stewardship interventions to urgent care centers—and one major health system can attest to the benefit of involving pharmacists in those interventions. Jillian Dougherty Laude, an infectious diseases pharmacist at Christiana Care Health System in Delaware, said she helped to create the education that the antimicrobial stewardship team delivered to healthcare providers at her employer’s 5 urgent care centers and has been a sounding board for the centers’ lead physician, Harold P. Kramer. A recent examination of the urgent care centers’ electronic medical records revealed that the number of antibiotics prescribed per 100 patient visits in June was 40% less than the number prescribed in December 2016, before interventions began, Laude said. The antimicrobial stewardship team also found “a pretty whopping over-80% decrease” in the number of azithromycin prescriptions per 100 patient visits, she said. Kramer expressed similar enthusiasm in his July 13 message at the Safe Healthcare Blog, hosted by the Centers for Disease Control and Prevention (CDC). He reported results compiled through March 2018.

Teaching Global Health at an Academic Health Center in Delaware:: The evolution of a Global Health curriculum and Global Health Residency Tracks at Christiana Care Health System.

Teaching Global Health at an Academic Health Center in Delaware:: The evolution of a Global Health curriculum and Global Health Residency Tracks at Christiana Care Health System.

Self-report measure as a useful tool to identify prenatal substance use and predict adverse birth outcomes

Objectives The purpose of the current study was to examine whether a self-report measure identifies prenatal substance use and predicts resulting adverse birth outcomes in a large cohort using electronic medical records. Methods Pregnant patients who were admitted between 2014 and 2015 at Christiana Care Health System and delivered singleton birth were included in the analyses ( N = 11,020). Participant demographic information, pregnancy comorbidities, self-reported substance use, and birth outcomes were retrieved from electronic medical records. Detailed descriptive analyses of prenatal substance use were conducted, and logistic models were evaluated for the associations between substance use and each birth outcome (preterm birth, low birth weight, neonatal intensive care unit admission). Results The average maternal age was 30 years (standard deviation: 6), 37% receiving Medicaid. Over 58% were White, 26% were Black, and 13% were Hispanic. Cigarette smoking only showed the highest prevalence among substance users (53%). Self-reported cigarette smoking and illicit drug use other than marijuana significantly predicted all three adverse birth outcomes (Adjusted Odds Ratio [AOR] range: 1.33 (95% Confidence Interval [CI]: 1.08–1.64)–3.09 (95% CI: 2.03–4.67)). Nonresponders to the cigarette smoking question also significantly predicted two adverse birth outcomes of preterm birth delivery (AOR: 4.16; 95% CI: 1.27–14.71) and having low birth weight babies (AOR: 3.50; 95% CI: 1.04–12.61). Conclusions/Importance: Prenatal cigarette smoking only had the highest prevalence, and co-use with illicit drugs was also high, leading to significant associations with adverse birth outcomes. The study findings indicate that the self-report measurement is a useful tool to identify prenatal substance use and predict resulting adverse birth outcomes.

Cross-cultural comparison of predictors for self-care behaviors in patients with type 2 diabetes.

The aim of the present study was to evaluate how culture moderates the behavioral and psychosocial predictors of diabetes self‐care activities. Patients with type 2 diabetes were recruited in the outpatient department at two sites: Kyoto University hospital in Japan and the Christiana Care Health System in the USA. The data were collected by survey using questionnaires including questions on the frequency of self‐care activities, behavioral and psychosocial predictors, and other background information from 149 Japanese patients and 48 American patients. The cultural impact was observed by multiple regression analyses with interaction terms on the association between emotional support and self‐care activities in diet in female patients. The findings of the present study serve as an example of how cultural context can affect patients with diabetes, and lead to a better understanding of culturally sensitive behavioral intervention.

Dantrolene for Treatment of Suspected Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening neurologic disorder caused by neuroleptic medications (ie, antipsychotics). Although there is no confirmatory laboratory test, NMS has a distinct clinical presentation that includes changes in mental status, muscle rigidity, hyperthermia, and autonomic nervous system manifestations such as tachycardia, high blood pressure, or increased respiration rate. NMS has an incidence of roughly 0.2% and is challenging to diagnose, with mortality rates estimated at 5.6%. 1 Caroff SN Mann SC Neuroleptic malignant syndrome. Med Clin North Am. 1993; 77: 185-202 Crossref PubMed Scopus (455) Google Scholar , 2 Modi S Dharaiya D Schultz L Varelas P Neuroleptic malignant syndrome: complications, outcomes, and mortality. Neurocrit Care. 2016; 24: 97-103 Crossref PubMed Scopus (51) Google Scholar Faster recognition and diagnosis have likely been the cause of decreased mortality rates over the past decades; however, morbidity is still a significant factor in a patient’s recovery, owing to rhabdomyolysis and organ failure. We report a case of suspected NMS in a patient on multiple neuroleptic medications, successfully treated with dantrolene. Colleen J. Whyte is PGY2 Critical Care Pharmacy Resident, Christiana Care Health System, Newark, DE. Jamie M. Rosini is Emergency Medicine Clinical Pharmacy Specialist, Christiana Care Health System, Newark, DE.

Prone Positioning in Moderate-Severe ARDS: Preliminary Data From a Community-Based Teaching Hospital

SESSION TITLE: ARDS and Acute Lung Injury SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: In 2013, after publication of a randomized controlled trial that demonstrated a mortality benefit to ventilation in the prone versus supine position in ARDS, critical care physicians at our institution began to implement this approach. Prior to this, we rarely used prone positioning in our medical ICU and we did not know if the mortality and low complication rate observed in the trial, at centers with >5 years of experience with proning, could be replicated at our institution or what impact this intervention would have on functional outcomes. METHODS: We conducted a retrospective cohort study of all proned patients from June 2013 to November 2014 at Christiana Care Health System. Patients were identified by respiratory care data. We collected demographic data, pre- and post- proning data, respiratory mechanics, diagnoses, complications, and outcomes including mortality, length of stay, and distance walked prior to discharge. Descriptive statistics are used to describe our cohort. RESULTS: Thirty seven patients underwent ventilation in the prone position. Of these, 23 (62%) survived to hospital discharge. The mean age was 56.3 years and 60% were male. The mean sequential organ failure score was 8.6. Immediately prior to proning, the mean positive end expiratory pressure was 14, mean driving pressure was 14 centimeters of water, mean partial pressure of arterial oxygen to fraction of inspired oxygen was 100 and mean tidal volume was 5.5 ml/kg of predicted body weight. Patients were proned for a mean of 41 hours. One patient received extracorporal membrane oxygenation, 31 (84%) received neuromuscular blocking agents, 6 (16.2%) received inhaled nitric oxide, and 21(57%) received steroids. None developed ventilator associated pneumonia or had cardiac arrests while proned. In terms of complications, 6 patients had dependent edema, 7 had dislodged devices, and 2 had skin breakdown. The mean hospital and ICU length of stays were 23 and 14, respectively. A total of 23 patients were able to ambulate a mean of 138 feet prior to hospital discharge. CONCLUSIONS: Hospital mortality was higher in this cohort than the 28-day mortality reported in the trial. However, serious complications from prone positioning were uncommon. The higher mortality rate could be due to differences in clinical care including use of adjuvent therapies or differences in patient selection. Additionally, during our study period in December 2013, we implemented a protocol for ventilation in the prone position. We plan additional data collection and analysis to determine is outcomes differ before and after protocol implementation.All of the survivors were ambulatory prior to hospital discharge. CLINICAL IMPLICATIONS: It is feasible to implement a proning protocol at a community hospital with limited prior experience; however, close monitoring of outcomes is needed to determine whether expected benefits are achieved. DISCLOSURE: The following authors have nothing to disclose: Fahmida Khan, Christa Fistler, Jefferson Mixell, Patricia McGraw, Michael Vest No Product/Research Disclosure Information

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OBJECTIVES/SPECIFIC AIMS: As part of a larger effort to create a longitudinal record of care for patients with chronic kidney disease (CKD) in Delaware, we assessed transitions of care from pediatric to adult care. This study examined the length of time between last pediatric contact and first contact in the adult system in order to determine characteristics associated with delayed transition to adult care. METHODS/STUDY POPULATION: Patients who receive pediatric care at the Nemours/Alfred I. duPont Hospital for Children (Nemours) are transitioned to adult care between the ages of 18 and 21. Our study population consists of all patients seen in the Nephrology unit at Nemours for CKD, hypertension (HTN), or diabetes who turned 21 years old between 2007 and 2013. Records of office visits from Nemours, Christiana Care Health System (CCHS), and Nephrology Associates, P.A. (NAPA) were transformed into the OMOP common data model and merged. Patients who had at least 1 record in the Nemours EHR of pediatric care before age 21 and had at least 1 record in the CCHS or NAPA adult EHRs were considered transitioned. To identify characteristics associated with delayed transition to adult care, we compared gender, race, ethnicity, age, comorbidities, and level of kidney function at the last pediatric visit between patients whose transition gap was less than 1 year and patients whose gap was 1 year or more. Kidney function was estimated by calculating glomerular filtration rate (GFR). Nemours estimates GFR in children using the revised Schwartz equation, which is based on serum creatinine and height. To calculate adult GFR, we used the CKD-Epi equation, which is based on serum creatinine, age, sex, and race and is widely used to derive adult GFR. As kidney function declines, GFR decreases. We used Fisher exact test to compare categorical variables and t-test to compare age and GFR. RESULTS/ANTICIPATED RESULTS: We found only 109 (25%) patients who had records in our adult offices out of the 440 Nemours patients in our data set. Of the 109 transitioned patients, 54 had office visits at CCHS, 37 at NAPA, and 18 at both locations. Examining the office visits of the 109 transitioned patients, 34 (31%) had an overlap in visits defined as an office visit at CCHS or NAPA before the last office visit at Nemours, and 75 (69%) did not have an overlap. The median gap between last pediatric and first adult office visit for the 75 patients without an overlap was 615 days (range 8–3495 d). Only 6 (6%) of the 109 transitioned patients had overlapping GFR measurements from pediatric to adult care, and all of the adult GFR calculations (CKD-Epi) were greater than the pediatric GFR calculations (Schwartz). The difference between child and adult GFR ranged from 8.2 to 87.1 mL/minute per 1.72 m2. DISCUSSION/SIGNIFICANCE OF IMPACT: During the transition from pediatric care to adult care, many young adults with CKD experience declines in health outcomes and comorbidities such as diabetes and HTN complicate self-management. Lack of overlap between pediatric and adult care office visits indicates a delay in executing this transition. In our population of 109 transitioned patients, 69% did not have an overlap in care, and 50% of those without overlap had a gap of more than 615 days (1 y, 8 mo). Our analysis suggests that young adults who are younger at last pediatric office visit are more likely to delay transitioning to adult care. Transitioning from the nurturing environment of pediatric care to adult care is a complex process and could be challenging for young adults with CKD. Transition clinics may be necessary to improve the coordination of care and help these young adults keep their physician appointments.

Pediatric Cardiogenic Shock in a 7-Day-Old With Poor Feeding and Tachypnea: Case Review

Neonatal cardiac emergencies are often considered masters of disguise. There is inherent difficulty in recognizing and managing congenital heart disease (CHD) in neonates. The incidence of CHD is about 8 per 1000 live births, and the defects are generally classified into cyanotic and acyanotic CHD. According to the Centers for Disease and Control and Prevention, CHDs are a leading cause of birth defect–associated infant illness and death. 1 Centers for Disease Control and Prevention US Department of Health and Humans Services Congenital heart defects (CHDs). http://www.cdc.gov/ncbddd/heartdefects/data.html Google Scholar Infant deaths due to CHDs often occur when the baby is younger than 28 days old. The prevalence of critical cardiac disease in infants is higher than the prevalence of infant sepsis. 2 Anderson-Berry A Neonatal sepsis. http://emedicine.medscape.com/article/978352 Google Scholar Kaci A. Rainey, Member, Delaware ENA Chapter, is ED Staff Nurse, Christiana Care Health System, Newark, DE, and Adjunct Nursing Faculty, University of Delaware, Newark, DE.

Innovative Information Technology–Powered Population Health Care Management Improves Outcomes and Reduces Hospital Readmissions and Emergency Department Visits

Patients with chronic conditions are often the most frequent users of health care. Moreover, adapting to developments in one's illness, understanding how to self-manage a chronic illness, and sharing information between primary care and specialty providers, can be a full-time job for someone with a chronic illness. In response to these challenges, Christiana Care Health System (Wilmington, Delaware) developed Care Link, an information technology (IT)-enhanced care management support to enable populations of patients to achieve better clinical outcomes at lower cost. In 2012 Christiana Care received a grant to design a generalizable, scalable, and replicable IT-driven care model that would integrate disparate clinical and registry data generated from routine care to support longitudinal care management for patients with ischemic heart disease. The single-disease care management program was expanded beginning in mid-2015 to serve risk-based models for many diseases and chronic conditions. More than 8,600 patients in several surgical and medical populations, including joint replacement, cervical spine surgery, and congestive heart failure, have been supported by Care Link. For example, preoperative assessment of patients with elective joint replacement to predict post-acute care needs led to an increase in the volume of patients discharged to home with self-care or with home health care by 30%-from 61% to 80%. Care Link IT functions can be replicated to address the unique longitudinal care needs of any population. Care Link's next steps are to continue to increase the number of patients served throughout the region and to expand the scope of care management programming.

Abstract 217: Prediction Outcomes Using Other People’s Models

Introduction: Predictive models of adverse outcomes are developed to identify combinations of variables that can be used to identify at-risk patients. Prediction accuracy of the model is assessed by discrimination - how well the model discriminates those experiencing the outcome vs. those who don’t, and calibration - how well the predicted probabilities of the model correspond to the observed probabilities of the outcome. The ultimate test of a model is applying it to a different cohort. Typically, models developed from the same cohort tend to be overfit, that is, they apply well to the cohort on which they were developed, but less well to a different cohort. We show that re-calibration can result in a valid and useful model. Methods: The Society of Thoracic Surgeons (STS) established the National Adult Cardiac Surgery Database (NCD) in response to inadequately risk-adjusted hospital mortality released by the former Health Care Financing Administration (now the Centers for Medicare and Medicaid Services). Subsequently, the STS published models of several adverse outcomes including in-hospital mortality for patients undergoing coronary artery bypass grafting surgery (CABG). We applied the regression coefficients of the risk factors from their model to a different cohort of CABG patients (patients who underwent CABG at Christiana Care Health System) and assessed discrimination and calibration with the c-index and correlation of observed probabilities to predicted probabilities of in-hospital death. As the model resulted in poor calibration, we then re-estimated the regression coefficients for our cohort by applying penalized logistic regression and calculated discrimination and calibration statistics for the re-calibrated model. Results: While discrimination was good (0.827), the STS model was not well-calibrated (Figure 1A) when applied to our cohort. When the model was re-calibrated, discrimination and calibration statistics indicated good discrimination (0.835) and calibration (Figure 1B). Conclusion: When predictive models of adverse outcomes developed on one cohort of patients are applied to a different cohort of patients, the model needs to be re-calibrated to obtain a useful model.