Complex Chronic Patients Research Articles

Observational Study of Complexity in a Psychiatric Hospital Unit

ABSTRACT
 Objectives: 1. Describe the possible variables that may be related to a psychiatric complex patient at the Acute Psychiatric Unit of Santa Creu i Sant Pau Hospital. 2. Determine the usefulness of the standard concept of chronic complex patient in a psychiatric patient.
 Methods: Cross sectional, observational, and quantitative study were conducted in Hospital Santa Creu i Sant Pau, Barcelona. 46 patients admitted at the Acute Psychiatric Ward from March to May 2018 were included in the study. The scales used were: PANSS, HDRS, YMRS, EEAG, FAST, CGI, EQ-VAS and Zarit Burden. The number of extended stays in health institutions, need for social assistance, previous admissions and duration of hospital stay were also evaluated.
 
 Results: There is no difference in the need for social assistance between chronic complex patient (11%) and non-chronic complex patient (18.9%). Also, no difference was noted among the scales FAST, CGI, EEAG, EQ-VAS and Zarit Burden. Upon analysis of the variables, the result of the quality of life is correlated with: 1. PANSS_N (p<0.0044) 2. FAST finances (p<0.0027) 3. FAST cognitive (p<0.0018).
 
 Conclusion: The standard definition of a Chronic Complex Patient does not fit the needs of complexity in a psychiatric patient.
 
 DeCS: quality of life, multimorbidity, caregiver, psychiatric

Clinical Implications of "Tailored" Antiplatelet Therapy in Patients With Chronic Total Occlusion.

BackgroundClopidogrel nonresponsiveness is a prognostic marker after percutaneous coronary intervention. Prasugrel and ticagrelor provide a better platelet inhibition and represent the first‐line antiplatelet treatment in acute coronary syndrome. We sought to assess the prognostic impact of high platelet reactivity (HPR) and the potential clinical benefit of a “tailored” escalated or changed antiplatelet therapy in patients with chronic total occlusion.Methods and ResultsFrom Florence CTO‐PCI (chronic total occlusion‐percutaneous coronary intervention) registry, platelet function assessed by light transmission aggregometry, was available for 1101 patients. HPR was defined by adenosine diphosphate test ≥70% and optimal platelet reactivity by adenosine diphosphate test <70%. The endpoint of the study was long‐term cardiac survival. Patients were stratified according to light transmission aggregometry results: optimal platelet reactivity (82%) and HPR (18%). Means for the adenosine diphosphate test were 44±16% versus 77±6%, respectively. Three‐year survival was significantly higher in the optimal platelet reactivity group compared with HPR patients (95.3±0.8% versus 86.2±2.8%; P<0.001). With the availability of new P2Y12 inhibitors, a deeper platelet inhibition (46±17%) and similar survival to the optimal platelet reactivity group were achieved in patients with HPR on clopidogrel therapy after escalation. Conversely, HPR on clopidogrel therapy “not switched” was associated with cardiac mortality (hazard ratio 2.37; P=0.003) after multivariable adjustment.ConclusionsHPR on treatment could be a modifiable prognostic marker by new antiaggregants providing a deeper platelet inhibition associated with clinical outcome improvement in complex chronic total occlusion patients. A “tailored” antiplatelet therapy, also driven by the entity of platelet inhibition, could be useful in these high risk setting patients.

COVID-19 pandemic and management of patients with chronic neurological conditions in low-middle income countries: the added burden

In the Era of SARS-COV2 pandemic, management of non-COVID-19 patients remained heterogenous, particularly in Low-Middle Income Countries where the majority of resources have been allocated to COVID-19 and where managing complex chronic patients with multiple comorbidities such as Neurologic patients is already challenging due to the vulnerability of these patient category, scarce qualified human resources and lack of adapted health structures. We expose a locally developed algorithm aiming to better manage chronic neurological patients, help reduce their exposition level to SARS-COV2 disease while ensuring care continuity without increasing the costs of the preventive measures. This procedure was based on two main pillars: telemedicine as a useful tool for avoiding the necessity of patient’s physical presence at the hospital while ensuring an effective clinical follow up. In five weeks, we performed over 300 WhatsApp® consultations, received 450 vocal messages and 262 written questions; Protectives measures dependent on the patient’s risk assessment which could varies from the simple mask wearing instruction to the strict protective isolation protocol.

Intervention effectiveness by pharmacists integrated within an interdisciplinary health team on chronic complex patients.

Nowadays, it is difficult to establish a specific method of intervention by the pharmacist and its clinical repercussions. Our aim was to identify interventions by pharmacists integrated within an interdisciplinary team for chronic complex patients (CCPs) and determine which of them produce the best results. A systematic review (SR) was performed based on PICO(d) question (2008-18): (Population): CCPs; (Intervention): carried out by health system pharmacists in collaboration with an interdisciplinary team; (Comparator): any; (Outcome): clinical and health resources usage outcomes; (Design): meta-analysis, SR and randomized clinical trials. Nine articles were included: one SR and eight randomized clinical trials. The interventions consisted mainly in putting in order the pharmacotherapy and the review of the medication adequacy, medication reconciliation in transition of care and educational intervention for health professionals. Only one showed significant improvements in mortality (27.9% vs. 38.5%; HR = 1.49; P = 0.026), two in health-related quality of life [according to EQ-5D (European Quality of Life-5 Dimensions) and EQ-VAS (European Quality of Life-Visual Analog Scale) tests] and four in other health-related results (subjective self-assessment scales, falls or episodes of delirium and negative health outcomes associated with medication). Significant differences between groups were found in hospital stay and frequency of visits to the emergency department. No better results were observed in hospitalization rate. Otherwise, one study measured cost utility and found a cost of €45 987 per quality-adjusted life year gained due to the intervention. It was not possible to determine with certainty which interventions produce the best results in CCPs. The clinical heterogeneity of the studies and the short follow-up of most studies probably contributed to this uncertainty.

Risk of Long-Term Mortality for Complex Chronic Patients with Intracerebral Hemorrhage: A Population-Based e-Cohort Observational Study.

Over recent years there has been growing evidence of increased risk of mortality associated with hemorrhagic stroke among older patients. The main objective of this study is to propose and validate a prognostic life table for complex chronic patients after an intracerebral hemorrhage (ICH) episode in primary care settings. This was a multicenter and retrospective study (April1, 2006-December31, 2016) of a cohort from the general population presenting an episode of ICH from which a predictive model of mortality was obtained using a Cox proportional hazards regression model. In addition, Kaplan-Meier survival curves, the log-rank test, receiver operating characteristic (ROC) curves, and area under the ROC curve (AUC) were used to evaluate the ability to stratify patients according to vital prognosis. We proceeded to external validation of the model through prospective monitoring (January1, 2013-December31, 2017) of the population of complex chronic patients with an episode of ICH. A total of 3594 people aged ≥ 65years were identified as complex chronic patients (women 55.9%; mean age, 86.1 ± 8.4years) of whom 161 suffered hemorrhagic stroke during the study period (January 1, 2013-December 31, 2017). The primary outcome was death from any cause within 5years of follow-up after an ICH episode. The independent prognostic factors of mortality were age > 80years (HR 1.048, 95% CI 1.021-1.076, p < 0.001) and HAS-BLED score (HR 1.369, 95% CI 1.057-1.774, p = 0.017). Compared to the general population, the incidence density/1000 person per year (15 vs 0.22) was significantly higher with a significantly lower annual lethality rate (17% vs 49.2%); and both the prognostic factors and the risk of stratified mortality showed different epidemiological patterns. The internal validation of the model was optimal (log-rank < 0.0001) in the general population, but its external validation was not significant in the complex chronic patient population (log-rank p = 0.104). The ICH-AP is a clinical scale that can improve the prognostic prediction of mortality in primary care after an episode of ICH in the general population, but it was not significant in its external validation in a population of complex chronic patients. ClinicalTrials.gov ID: NCT03247049.

Efectividad de una intervención educativa enfermera en pacientes crónicos complejos

To evaluate whether a training intervention performed by nursing professionals in complex chronic patients, during hospitalisation in an internal medicine service, can modify the pattern of readmissions or reduce their number.Pragmatic clinical trial of a nursing training intervention vs. habitual performance. For the intervention group, a training plan in care was designed, personalised for each patient, according to the needs detected in a first interview. The intervention was extended during the time of admission and a contact phone was available after discharge to resolve doubts.Among the 498 patients interviewed initially, 131 were excluded because they were not a complex chronic patient or because they found no deficiencies in their training or care. One patient (.20%) did not agree to participate and there were no dropouts. Of the 366 participants, 190 were included in the intervention group and 176 in the control group. In the first 8 days after discharge, 2 (1.05%) patients from the intervention group and 8 (4.54%) from the control group were re-admitted (p=.05). In the first 30 days after discharge, 26 patients (13.70%) and 33 patients (18.75%) respectively (p=.10) were readmitted.This study shows how a nursing training intervention during hospitalisation in Internal Medicine in complex chronic patients reduces short-term readmissions.

Changes in inflammatory plasma proteins from patients with chronic pain associated with treatment in an interdisciplinary multimodal rehabilitation program - an explorative multivariate pilot study.

It has been suggested that alterations in inflammation molecules maintain chronic pain although little is known about how these factors influence homeostatic and inflammatory events in common chronic pain conditions. Nonpharmacological interventions might be associated with alterations in inflammation markers in blood. This study of patients with chronic pain investigates whether an interdisciplinary multimodal rehabilitation program (IMMRP) was associated with significant alterations in the plasma pattern of 68 cytokines/chemokines 1 year after rehabilitation and whether such changes were associated with clinical changes. Blood samples and self-reports of pain, psychological distress, and physical activity of 25 complex chronic pain patients were collected pre-IMMRP and at 12-month follow-up. Analyses of inflammatory proteins (cytokines/chemokines/growth factors) were performed directly in plasma using the multiplex immunoassay technology Meso Scale Discovery. This explorative pilot study found that 12 substances, mainly pro-inflammatory, decreased after IMMRP. In two other relatively small IMMRP studies, four of these proinflammatory markers were also associated with decreases. The pattern of cytokines/chemokines pre-IMMRP was associated with changes in psychological distress but not with pain or physical activity. The present study cannot impute cause and effect. These results together with the results of the two previous IMMRP studies suggest that there is a need for larger and more strictly controlled studies of IMMRP with respect to inflammatory markers in blood. Such studies need to consider responders/non-responders, additional therapies, involved pain mechanisms and diagnoses. This and the two other studies open up for developing biologically measurable outcomes from plasma. Such biomarkers will be an important tool for further development of IMMRP and possibly other treatments for patients w ith chronic pain.

A self-management system for complex chronic patients

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Connected care for complex chronic patients in Lleida

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Utilizing Data to Improve Sepsis Identification in Targeted Populations

Background: Children’s Memorial Hermann Hospital (CMHH) joined the Improving Pediatric Sepsis Outcomes (IPSO) collaborative in July 2016 with successful data importation beginning Summer 2017. At the beginning of the collaborative, generalized triage screening provided a 30% positive screening rate, and the baseline mortality at 30 days per 1,000 admissions for patients admitted from the Emergency Center (EC) to the pediatric intensive care unit was 0.67. Extensive data analysis revealed that 37% of the patients seen in the emergency department with intent to treat and 100% of attributable deaths related to sepsis at CMHH were identified as complex chronic children who were technology dependent. Methods: Based on the collected data and variable regression analysis utilizing Six Sigma methodology, the problem was defined as the risk for sepsis in the chronic complex patient population who are technology dependent indicated the need for accurate screening. As part of the IPSO collaborative goals of increasing early identification, the CMHH IPSO team worked with the EC nurses to create a triage algorithm to improve the identification of sepsis in this population (Fig. 1). Education was done, and Plan–Do–Study–Act cycle implementation began in January 2018 with the final rollout of the algorithm in the EC of March 2018. Results: Accurate screening of this population increased from a mean of 30%–75% after intervention, resulting in a decrease in mortality for inpatients admitted from the EC to the pediatric intensive care unit to zero/1,000 through the last reported data cycle of December 2018 (Fig. 2). Conclusion: Utilization of data analysis resulted in a defined problem and a targeted intervention resulting in the elimination of sepsis attributed mortality in the targeted population.Fig. 1.: Sepsis triage algorithm.Fig. 2.: Sepsis mortalities per 1,000 admissions—day 3.

RECALMIN. Four years of growth of the internal medicine units of the Spanish National Health System (2013–2016)

ObjectivesTo compare the structure, resources and activity of the internal medicine units (IMUs) of the Spanish National Health System (SNHS) in 2013 and 2016. To analyze the differences between IMUs in 2016 by hospital size. Material and methodsWe conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System, with data referring to 2013 and 2016. The variables were collected via an ad hoc questionnaire (RECALMIN survey). ResultsBetween 2013 and 2016, the demand for care increased dramatically (with an annual average of 11% in hospital discharges and 16% in first consultations), and comorbidity slightly increased (2%). During this period, the mean productivity of IMUs increased 16.7% (0.6±0.3 vs. 0.7±0.3; p=.09), and the mean stay decreased 10% (9±2.2 vs. 8.1±2.1 days; p=.001). Progress in implementing good practices and systematic care for complex chronic patients was scarce. Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes. ConclusionsIMUs responded to the increased burden of care they supported during 2013–2016 by improving their efficiency and productivity; however, advances in implementing good practices, including care for chronic complex patients, were scare. The significant variability in the indicators of structure, activity and management models found in 2013 remained in 2016.

Healthcare staff perceptions of integrated care in a programme for complex chronic patients admitted to hospital because of heart failure (ProMIC)

Introduction Patients with heart failure are usually a frail population characterised by complex care needs. To ensure an integrated care approach, it is necessary to work collaboratively across organisational boundaries. The purpose of this study is to measure and understand the perception of collaboration between clinicians participating in a comprehensive care programme for patients with heart failure, known as PROMIC. Methods A sequential mixed-method study design was used. A sample of PROMIC clinicians completed a survey in which they evaluated 10 dimensions of collaboration in 2010 and in 2014. The perspectives of clinicians were studied more in depth in a focus group in 2012, which was analysed using content analysis. Outcomes: Professionals’ perception of collaboration showed an improvement by 1.18 points (53%) over the period 2010–14. The comprehensive programme proved to be of major support to the professionals. Sometimes, the study participants did not feel prepared to manage cases due to the complexity of the situations with regard to patients’ care. Both, the quantitative and the qualitative methods, showed up a congruent information about the positive perception of participants of the programme itself and the collaboration. Discussion The complexity of care processes and the need for continuity of care mean that large-scale collaboration is necessary between care levels as well as major interdisciplinary teamwork, to achieve the best possible outcomes in terms of health. ProMIC intervention has helped to improve professionals’ perception in terms of collaboration between levels.

RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016)

ObjectivesTo compare the structure, resources and activity of the internal medicine units (IMUs) of the Spanish National Health System (SNHS) in 2013 and 2016. To analyse the differences between IMUs in 2016 by hospital size. Material and methodsWe conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System, with data referring to 2013 and 2016. The variables were collected via an ad hoc questionnaire (RECALMIN survey). ResultsBetween 2013 and 2016, the demand for care increased dramatically (with an annual average of 11% in hospital discharges and 16% in first consultations), and comorbidity slightly increased (2%). During this period, the mean productivity of IMUs increased 16.7% (0.6±0.3 vs. 0.7±0.3; P=.09), and the mean stay decreased 10% (9±2.2 vs. 8.1±2.1 days; P=.001). Progress in implementing good practices and systematic care for complex chronic patients was scarce. Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes. ConclusionsIMUs responded to the increased burden of care they supported during 2013-2016 by improving their efficiency and productivity; however, advances in implementing good practices, including care for chronic complex patients, were scare. The significant variability in the indicators of structure, activity and management models found in 2013 remained in 2016.

EIP on AHA Ontology for adherence: Knowledge representation advanced tools.

Nowadays diseases tend to chronicle, mainly due to the increase in life expectancy and this leads to a state of polypharmacy. More than 1.5% of Spain's GDP is spent on pharmaceuticals and healthcare products. Complex chronic patients (pluripathological and polymedicated) account for most of the expenditure. The "Action Group A1" of the European Innovation Partnership develops in the "Active and Healthy Ageing" programme actions to improve the quality of life and health outcomes of these patients. On the other hand, the PITeS TIiSS project develops decision support tools to improve this scenario. An ontology has been developed as a tool on adherence. The domain of this ontology is mainly focused on medication adherence and measurement methods. This ontology gathers the necessary knowledge about the domain allowing the use of the ontology as part for is possible.

Program to improve the discharge process : TRANSICIONA

Introduction : High-quality coordination during transitions across different setting is especially important for older adults with multiple chronic conditions and complex needs. Evidence suggests an increased risk of decompensations of chronic conditions, hospital readmissions and death, following transitions. For example, in complex chronic patients, 30-days readmissions can reach 20-25%, according to the literature. Although several factors have been associated with “unsafe transition”, mostly uni-dimensional interventions have been designed. We implemented a multidimensional patient-centered intervention program, aimed to increase patient's empowerment on self-management and improve the coordination among the different settings of care. Objectives : Main outcome: reduction of 30-days readmissions. Intermediate outcomes: to promote early follow-up by primary care. Methods : We include all the patients admitted to our intermediate care hospital who meet at least 2 of the following criteria’s: ≥2 chronic conditions, polypharmacy ≥ 8 drugs, cognitive impairment, previous hospital admission The intervention is carried out on 5 domains: a Medication patient-center conciliation and education, b Physical activity encourage and promote the practice of physical activity, according to physical function, c Patients’ empowerment encourage and promote the incorporation of healthy habits, improve the patients’ knowledge of their disease and treatments, d Identification of other risks of hinder patients’ empowerment and confidence e Coordination of different settings primary care, nursing homes, etc. . The multidisciplinary team includes: two nurses leaders of the project, a social worker and a geriatrician. In order to improve patients’ empowerment, the two nurses have received training on motivational interview and specific techniques such as “teach-back”. We collected demographic, clinical and health process variables in order to performed quantitative analyses, as well as 30-days readmissions using the shared IS3 platform available in all Catalonia. Results : After 12 months, a total of 182 patients were included mean age 82 years and 54% females; 24 patients were missing during the intervention due to early discharge. The intervention was done mainly on the medication domain 77.1%, N=140, patients’ empowerment 78.8%, N=143 and physical activity 76%, N=138 Coordination and contact with primary care was done mainly through telephone calls, followed by email and written pre-discharge notifications. Regardless the method use for coordination, a high percentage of patients 47%, N=60 of 128 de patients from Home Care ATDOM; 67%, N= 86 de 128 patients of Primary Care of patients had a follow-up visit soon Futures steps : We plan to complete the assessment looking at patient’s adherence to recommendations pharmacological and no-pharmacological as well as to analyze qualitative feedback of patients and staff about the program implementation.

Impact on the use of services and quality of life of a continuity of care unit for multi-pathological patients

Introduction: Bidasoa Integrated Health Organisation was the first integrated health care organization IHO created in the Basque Country in January 2011. It comprises the hospital 96 beds and 3 primary care centres. The IHO catchment population is around 90,000 citizens. As has happened in other organisations, care delivery in Bidasoa area was fragmented, with poor communication between primary and secondary care professionals. This fragmentation affected especially chronic patients with several pathologies. Description: In answer to this problem and focused on the management of complex chronic patients, Continuity of Care Unit CCU was created in Bidasoa IHO. Nowadays more than 200 patients are being taken care there. CCU worked as follows: the referral internist RI, one for each health centre, is responsible for the admission of patients with complex or multiple conditions in the event that they require admission to hospital. The mission of CCU is to stabilize patients and facilitate continuity of care by the general practitioner GP. These patients have a continuity of care plan between levels of care and they are admitted to the hospital through a special circuit not A&E when needed. The role of the liaison nurse is to support the patient in the transition from hospital to home, where they are followed up by the GP. The RI visits the health center every other week to undertake clinical sessions. Aim: The aim is to improve the quality of life and care provided to complex chronic patients, by a multidisciplinary team, based on a patient-centred care and collaborative work among primary care, hospital care and social services. Targeted population: Patients with two or more chronic conditions who have been admitted at hospital more than two times in the last year. Timeline: CCU was created in 2011.Since 2016 the quality of life of patients that are incorporated in CCU is evaluated Highlights: All patients n=247 included in the unit between 1st January 2011 and 31st December 2014, with a minimum one year follow up are analysed. These patients have an average age of 84.1 years. 56.4% are man. It is observed 45.5% reduction in emergency department visits and 41.9% in hospital admissions. Simultaneously, the number of nurse home visits increased significantly after patient CCU inclusion. Furthermore, analyzing a sample of these patients it is observed a significant improvement in the self-perceived health status that is related to age greater improvement in the youngest. Sustainability: The change in the care model has been made with the reorganization of existing resources. Transferability: That model could be transferred to a care model based on primary care as patients referral. Conclusions: A care model based on a multidisciplinary team between primary and hospital care has improved the quality of care of chronic complex patients and their self-perceived health status Discussions: The implementation of this practice involves a cultural change among professionals, new functional roles nurse, RI and a greater collaboration. Lessons learned: The necessary cultural change is a slow process. The existence of shared areas plays are key role to get it.

Patient empowerment in connecare

Background: In a context of growing incidence of chronic diseases and aging populations, there is the need to research and find new solutions to shift resources into the community in an effort to deal more effectively with chronic conditions. In that direction, patient empowerment plays an important role. Approaches to increase patient empowerment vary from patient self-management programs to promoting patient involvement in treatment shared decision-making, to facilitating the clinician-patient cooperation. Methods: In the CONNECARE project ID: 689802, we focus on patient’s monitoring with the final goal of providing self-management features to people in needs, such as chronic patients. To be modular and scalable and to allow us to have a disease-independent system, the proposed solution is based on the software-engineering concept of microservices. They are modularization concepts that may be developed independently of each other, possess their own data storage, and can bring their own support service. In CONNECARE, each microservice is in charge of performing a simple task; whereas a complex task is achieved by the collaboration, interaction, and coordination of one or more simple microservices. In so doing, the proposed solution allows a better maintenance and bugs fixing. Seemly, scalability is obtained by dividing each task into less complex ones. Thus, when changes are needed in a microservice, they do not affect the rest of the system. Moreover, when a new functionality is required, a new microservice or set of microservices collaborating together may be defined and simply added to the system. In so doing, the proposed solution is robust to changes and improvements. Right now, 9 microservices have been defined and developed, each one aimed at providing a functionality to provide self-management to the patients. Patient’s monitoring is performed through the following microservices: physical activity, self-checked questionnaires, sleeping, and health status. Also 5 further functionalities are provided, each one by a specific microservice: notifications, alerts, recommendations, third-party integration, and messaging. Results: According to a co-design approach with clinicians of the 4 sites in the project i.e., Barcelona, Lleida, Israel, and Groningen, clinical studies have been designed for field-testing the self-management system in real clinical practice. Those studies will be carried out during 18 months starting in March 2018 and will focus on 3 use cases: community-based management of chronic complex patients, integrated management of patients undergoing surgical procedures, and pre-habilitation of high-risk candidates for complex abdominal surgical procedures the latter only in Barcelona. Currently, a feasibility test with selected clinicians and patients is running in the 4 sites. Conclusions: The first release of the presented system is under testing to be ready to be evaluated and refined in 4 sites throughout clinical studies next March. CONNECARE will consequently help to improve real practice deployment of integrated care in those sites and will be able to bring practical insight to the potential of transferability of new methods and technologies to other regions in Europe and beyond.

Impact of a complex chronic care patient case conference on quality and utilization.

There is need for effective venues to allow teams to coordinate care for high-risk or high-need patients. In addition, health systems need to assess the impact of such approaches on outcomes related to chronic health conditions and patient utilization. We evaluate the clinical impact of a novel case conference involving colocated trainees and supervisors in an interprofessional academic primary care clinic. The study utilized a prospective cohort with control group. Intervention patients (N = 104) were matched with controls (N = 104) from the same provider's panel using propensity scores based on age, gender, risk predictors, and prior utilization patterns. Clinical outcomes and subsequent utilization patterns were compared prior to and up to 6 months following the conference. In terms of utilization, intervention patients demonstrated increased visits with primary care team members (p = .0002) compared with controls, without a corresponding increase in the number of primary care providers' visits. There was a trend towards decreased urgent care and emergency visits (p = .07) and a significant decrease in the rate of hospitalizations (p = .04). Patients with poorly-controlled hypertension saw significant decreases in mean systolic blood pressure from 167 to 146 mm Hg. However, there were no differences between the intervention and control groups. Intervention patients with diabetes demonstrated a nonsignificant trend towards decreased hemoglobin A1c from 9.8 to 9.4, when compared with controls. Interprofessional case conferences have potential to improve care coordination and may be associated with improved disease management, decreased unplanned care, and overall reduced hospitalizations.

Home Visit-Based Community Paramedicine and Its Potential Role in Improving Patient-Centered Primary Care: A Grounded Theory Study and Framework.

Community paramedicine (CP) is a model of community-based health care being used around the world. Our objective was to study the patient perspective and valuation of this type of program to understand its potential value for primary care innovation in the future. The EPIC community paramedicine program is a partnership between primary care physicians and specially trained community paramedics, designed to provide in-home support for complex chronic disease patients in Ontario, Canada. As part of an ongoing clinical trial we designed an embedded qualitative evaluation using constructionist grounded theory methodology. Data collection included in-depth interviews with 30 patients and/or family members and 60hours of observation. The health care needs of this complex population are largely attributes that impact a patient's quality of life-including recognition of their vulnerability, providing a safety-net in times of exacerbation and health education and accountability. This seems to be facilitated by a relationship with a dedicated provider that increases continuity of care. Home-based community paramedicine programs like EPIC appear to be able to create a patient-centered, safe, responsive therapeutic relationship that is often not possible within the standard primary health care system.

Orthopedic resident education on postoperative pain control: bridging knowledge gaps to enhance patient safety

As the United States population continues to age, the number of orthopedic procedures continues to grow.1 Not infrequently, many of these patients who are admitted for orthopedic surgical procedures are already on complex pain regimens preoperatively. This is due not only to the increasing comorbid state of our aging population but also the wide variety of analgesic management strategies employed throughout the nation amid chronic opioid use.2 Expanding surgical volumes, particularly when involving increasingly complex and opioid-tolerant chronic pain patients, pose significant challenges for perioperative management. Inpatient hospital pain services3,4 can be of tangible benefit for these complex pain patients.5 Miaskowski and colleagues found that patients cared for by an acute pain service were discharged sooner, had lower pain intensity scores, lower incidences of pruritis, sedation and nausea compared to those without the anesthesia service involvement.5 With a growing number of surgical cases, pain management consultations have increased to a number that is not always sustainable, leading some hospitals to adopt a nurse care model.6 There is minimal medical literature assessing the types of pain management consultations.4 A local and unpublished study on resource utilization at Mayo Clinic Rochester demonstrated that orthopedic surgeons place roughly 40% of all surgical specialty consultation requests for acute postoperative pain management. The majority of these consultations are requests for pharmacologic analgesia management, such as titrating oral narcotic medications. A smaller number of these requests are focused on interventional pain procedures, such as joint injections. Since not all hospitals have dedicated inpatient pain services, this places additional pressure on surgeons in the perioperative period, making pain education for these specialties even more important. To improve postoperative pain management, the inpatient pain medicine service at Mayo Clinic, a subspecialized physician practice with credentials specifically in Pain Medicine, founded an educational seminar for the incoming orthopedic surgery residents. The purpose of this program was to optimize their understanding of the role that the inpatient pain service plays in managing postoperative pain, as well as to educate them in the founding principles of pharmacologically-directed pain management. Educational Seminar In 2011, the Orthopedic Staff Leadership Committee (OSLC) at the Mayo Clinic, which consists of a core group of staff nurses and nursing leadership, participated in an educational seminar with new orthopedic residents to help guide them through the dynamic perioperative hospital course to ensure safe, satisfactory patient care. These residents received clinical education from various hospital groups, including physical and occupational therapy, social services and pharmacy. The seminars guided them through clinical techniques, such as surgical wound management, pressure ulcer prevention, and proper application of splints and casts. As an extension of this training, the OSLC, in conjunction with the Anesthesiology Division of Pain Medicine, developed a seminar to orient the resident trainees to common strategies of postoperative pain management. The training seminar consists primarily of a one-day, three-hour discussion and didactic lecture. This lecture is presented by a core faculty member of the division of Pain Medicine. The core principles it addresses are the nuances of the functions of the Anesthesia Acute Pain Management Hospital Service, as well as the pharmacodynamic and pharmacokinetic principles of a number of common medications used in the postoperative setting. These include medications such as oral and IV narcotics, NSAIDs, Tylenol, topical local anesthetics, and Tramadol. Specific information on opioid titration, parenteral to oral opioid conversion, and postoperative opioid weaning strategies (once healed from surgery) was also provided. The content consisted of defining the concept of multimodal analgesia, reviewing opioid pharmacokinetics and pharmacodynamics, demonstrating how to calculate oral morphine equivalents, understanding the utility of regional anesthesia, and reviewing methadone and pharmacokinetics and pharmacodynamics. A pre and post-assessment, audience response system test was given to improve attention and retention.