Patient Care Episodes Research Articles

End-of-Life Care in an Acute Care Hospital: Linking Policy and Practice

The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acute care hospitals as a means to improve the quality of end-of-life care. If policy is to be effective, health care professionals who provide hospital care will need to respond to its patient-centered purpose. Health services will also be called upon to train health care professionals to work with dying people in a more participatory way and to assist them to develop the clinical processes that support shared decision making. Health professionals who manage clinical workplaces become central in reshaping this practice environment by promoting patient-centered care policy objectives and restructuring health service systems to routinely incorporate patient and family preferences about care at key points in the patient's care episode.

Trying Something New: Episode Payments for Cancer Therapy

Trying Something New: Episode Payments for Cancer Therapy

Effect of 16-Hour Duty Periods on Patient Care and Resident Education

To measure the effect of duty periods no longer than 16 hours on patient care and resident education. As part of our Educational Innovations Project, we piloted a novel resident schedule for an inpatient service that eliminated shifts longer than 16 hours without increased staffing or decreased patient admissions on 2 gastroenterology services from August 29 to November 27, 2009. Patient care variables were obtained through medical record review. Resident well-being and educational variables were collected by weekly surveys, end of rotation evaluations, and an electronic card-swipe system. Patient care metrics, including 30-day mortality, 30-day readmission rate, and length of stay, were unchanged for the 196 patient care episodes in the 5-week intervention month compared with the 274 episodes in the 8 weeks of control months. However, residents felt less prepared to manage cross-cover of patients (P = .006). There was a nonsignificant trend toward decreased perception of quality of education and balance of personal and professional life during the intervention month. Residents reported working fewer weekly hours overall during the intervention (64.3 vs 68.9 hours; P = .40), but they had significantly more episodes with fewer than 10 hours off between shifts (24 vs 2 episodes; P = .004). Inpatient hospital services can be staffed with residents working shifts less than 16 hours without additional residents. However, cross-cover of care, quality of education, and time off between shifts may be adversely affected.

A cost minimisation analysis in teledermatology: model-based approach

BackgroundAlthough store-and-forward teledermatology is increasingly becoming popular, evidence on its effects on efficiency and costs is lacking. The aim of this study, performed in addition to a clustered randomised trial, was to investigate to what extent and under which conditions store-and-forward teledermatology can reduce costs from a societal perspective.MethodsA cost minimisation study design (a model based approach) was applied to compare teledermatology and conventional process costs per dermatology patient care episode. Regarding the societal perspective, total mean costs of investment, general practitioner, dermatologists, out-of-pocket expenses and employer costs were calculated. Uncertainty analysis was performed using Monte Carlo simulation with 31 distributions in the used cost model. Scenario analysis was performed using one-way and two-way sensitivity analyses with the following variables: the patient travel distance to physician and dermatologist, the duration of teleconsultation activities, and the proportion of preventable consultations.ResultsTotal mean costs of teledermatology process were €387 (95%CI, 281 to 502.5), while the total mean costs of conventional process costs were €354.0 (95%CI, 228.0 to 484.0). The total mean difference between the processes was €32.5 (95%CI, -29.0 to 74.7). Savings by teledermatology can be achieved if the distance to a dermatologist is larger (> = 75 km) or when more consultations (> = 37%) can be prevented due to teledermatology.ConclusionsTeledermatology, when applied to all dermatology referrals, has a probability of 0.11 of being cost saving to society.In order to achieve cost savings by teledermatology, teledermatology should be applied in only those cases with a reasonable probability that a live consultation can be prevented.Trail RegistrationThis study is performed partially based on PERFECT D Trial (Current Controlled Trials No.ISRCTN57478950).

Analysing the length of care episode after hip fracture: a nonparametric and a parametric Bayesian approach

Effective utilisation of limited resources is a challenge for health care providers. Accurate and relevant information extracted from the length of stay distributions is useful for management purposes. Patient care episodes can be reconstructed from the comprehensive health registers, and in this paper we develop a Bayesian approach to analyse the length of care episode after a fractured hip. We model the large scale data with a flexible nonparametric multilayer perceptron network and with a parametric Weibull mixture model. To assess the performances of the models, we estimate expected utilities using predictive density as a utility measure. Since the model parameters cannot be directly compared, we focus on observables, and estimate the relevances of patient explanatory variables in predicting the length of stay. To demonstrate how the use of the nonparametric flexible model is advantageous for this complex health care data, we also study joint effects of variables in predictions, and visualise nonlinearities and interactions found in the data.

The Health Care Matrix Formulation: A Tool for Competency Assessment in Psychiatry Residency Training

To assert the importance of the use of the healthcare matrix formulation for competency assessment in psychiatry residency training. We present a case from our inpatient psychiatric facility and format it in the form of the healthcare matrix, which was developed at Vanderbilt University incorporating the Institute of Medicine 'aims' and the Accreditation Council for Graduate Medical Education 'core competencies'. We also analyze the healthcare matrix and elucidate its use in clinical practice. The healthcare matrix provides us with a practical tool to analyze any complex episode of patient care, like the one in our psychiatric setting, and allows us to learn from the shortcomings in order to improve. The optimal utilization of this tool in the competency assessment of psychiatry residents has an enormous practical implication by transforming the case and morbidity and mortality conferences into a well-structured learning and improvement format.

Use and cost of erythropoiesis-stimulating agents in patients with cancer

ABSTRACTObjective: To compare the baseline characteristics, episodes of care, and cost of erythropoiesis-stimulating agents among cancer patients in a US managed-care population.Research design and methods: Retrospective analysis of administrative claims data. Episodes of care for patients with cancer receiving erythropoiesis-stimulating agents between January 1, 2004 and January 17, 2006 included all claims for erythropoiesis-stimulating agents with ≤42 days’ gap between claims, plus the duration of therapeutic benefit based on median days between consecutive doses.Main outcome measures: Main outcome measures were average weekly dose of erythropoiesis-stimulating agents and costs of therapy.Results: A total of 15 007 eligible episodes of care (darbepoetin alfa, 7769 episodes [5587 patients]; epoetin alfa 7238 episodes [5157 patients]) were identified. Fewer claims were observed per episode of care for darbepoetin alfa than for epoetin alfa (mean [SD] 3.7 [4.1] vs. 5.3 [6.4]). The median time between consecutive claims was 15 days (darbepoetin alfa) and 8 days (epoetin alfa). The mean (SD) weekly doses were 105 (56) μg (darbepoetin alfa) and 34 242 (28173) U (epoetin alfa), a dose-comparison ratio of 326 : 1.Dose-comparison ratios were sensitive to assumptions about duration of clinical benefit.The mean (95% CI) weekly costs were significantly lower for darbepoetin alfa ($560 [553–567]) than for epoetin alfa ($645 [630–659], p < 0.0001) when duration of clinical benefit was considered.Conclusions: Significant differences characterize patterns of use of erythropoiesis-stimulating agents. Duration of therapeutic benefit is an important variable in comparing darbepoetin alfa with epoetin alfa; incorporation of this variable in analyses of costs of therapy may have notable effects on calculated treatment costs. Limitations of the study include the potential for database errors or omissions, lack of detailed disease data, and lack of adjustment for differences in the ages and comorbidities of patients.

The Healthcare Matrix: Improving Care by Linking Outcomes to Competencies

Abstract The Healthcare Matrix provides learners with a structured framework to analyze complex episodes of patient care in terms of the Aims for Improvement standards outlined by the Institute of ...

Evaluating prescribing competencies and standards used in nurse independent prescribers’ prescribing consultations

Background Independent prescribing of medicines by nurses is widely considered to be part of advanced nursing practice, and occurs within an episode of patient care that can be completed independently by a nurse. Nurse prescribers therefore require the competencies necessary to manage a consultation—such as history taking and diagnostic skills—and subsequently need to decide on any appropriate medicine to be prescribed. Safe prescribing should also involve an accurate, legible and comprehensive written prescription and documentation of the consultation in the patient’s records. However, the extent to which nurse independent prescribers use prescribing competencies and standards in practice had not been researched prior to this study. Aim To describe the frequency with which nurses use a range of prescribing competencies in their prescribing consultations, in order to provide a measure of the quality and safety of nurses’ independent prescribing practices. Design and methods Across 10 case study sites, 118 nurse independent prescribers’ prescribing consultations were analysed using non-participant observation and a structured checklist of prescribing competencies. Documentary analysis was also undertaken of a) prescriptions written ( n =132) by nurses and b) the record of the prescribing episode in patient records ( n =118). Sample and setting 118 prescribing consultations of 14 purposively selected nurse independent prescribers working in primary and secondary care trust case study sites in England. Findings Nurse independent prescribers were issuing a prescription every 2.82 consultations; nurses used a range of assessment and diagnosis competencies in prescribing consultations, but some were employed more consistently than others; nurses almost universally wrote full and accurate prescription scripts for their patients; nurses recorded each of their prescribing consultations, but some details of the consultation and the prescription issued were not always consistently recorded in the patient records. Conclusion The findings from this observation study provide evidence about the quality and safety of nurses’ prescribing consultations in England.

The clinical initiative nurse: Extending the role of the emergency nurse, who benefits?

Summary Introduction and aim: In 2002, the New South Wales (NSW) Government provided funding to implement a new emergency nursing role, the clinical initiative nurse (CIN), that would target waiting patients. The aims of this study were to evaluate the impact of the clinical initiative nurse role and to identify the areas for change in the role. Methodology: The evaluation of the CIN role included data obtained from the Emergency Department Information System (EDIS™) and a 22-item questionnaire examining role function, professional practice and role satisfaction. Results: There were 55 emergency nurses in the CIN role. CINs triaged 4793 patients and undertook 22,912 episodes of patient care on 9366 patients. The questionnaire response rate was 68% ( n =26). Sixteen (62%) nurses perceived that the role offered greater opportunity for clinical and professional advancement, while 10 (38%) did not. Twenty-three (88%) reported the need for additional clinical guidelines to assist in understanding the role function and independence and 11 (42%) reported the need to extend the scope of CIN practices, while 15 (58%) did not. All CINs perceived the need to have a dedicated orientation program for the role. Conclusions: The CIN role has contributed towards timely patient interventions, investigations and care. Emergency nurses can bring about a quality difference in the delivery of emergency department (ED) services through extended role practices.

Clinical and Economic Outcomes of Staphylococcus aureus Septicemia in ESRD Patients Receiving Hemodialysis

Serious infections are a common problem in patients with end-stage renal disease (ESRD). The purpose of this study is to identify clinical and economic consequences of hospitalizations for septicemia caused by Staphylococcus aureus in hemodialysis patients with ESRD. We conducted a retrospective analysis of data obtained from the US Renal Data System to determine lengths of stay and Medicare paid costs for index hospitalizations and episodes of care for patients with ESRD hospitalized with septicemia caused by S aureus. Factors associated with hospital length of stay and Medicare paid costs were examined in multivariate analysis. A total of 11,572 patient admissions with septicemia caused by S aureus were included; 20.7% of patients developed 1 or more complications. Average length of stay for the index admission was 13.0 days, and 11.8% of patients were readmitted within 12 weeks for care related to S aureus. Average Medicare cost for the index admission was 17,307 dollars. Average episodic cost of care, including the index hospitalization, outpatient visits, and readmissions related to S aureus during the subsequent 12 weeks, was 20,067 dollars. S aureus--related complications were associated with greater episodic costs of care: no complications, 18,476 dollars; one complication, 25,804 dollars (P < 0.05 versus no complications); and 2 or more complications, 32,102 dollars (P < 0.05 versus no complications). In multivariate analysis, complications resulted in increased mean lengths of stay of 4 to 7 days, and complications were among the strongest predictors of total episodic costs. Patients with septicemia caused by S aureus had costly and lengthy hospitalizations, which frequently were associated with clinically and economically important complications, including hospital readmissions.

Electronic Health Records

Forces are aligning to shift American health care into the Information Age: an age which financial institutions, airlines, supermarkets and most manufacturing industries have already entered. The shift, which these institutions have already experienced, will facilitate the establishment and widespread use of standardized databases in health care. The databases are known by the terms electronic medical records (EMRs), electronic health record (EHRs) or personal health records (PHRs). These forces underlie today's shift towards full use of a universally accepted electronic medical record, electronic health record and for a personal health record: An unprecedented revolution in computer and communication technologies The widespread availability of affordable electronic tools Burgeoning interest among patients in having access to their own medical information Rapid progress in understanding the human genome and proteosome The rising cost of health care The increasing administrative burden upon physicians A perception that medical errors are increasing Demands for widely comparable measures of quality care The need for post-marketing surveys of new drugs Our increasingly mobile society Greater emphasis upon evidence-based medicine Reimbursement incentives that pay for using EHRs and for providing quality care Reduced malpractice premiums for physicians that fully employ these technologies. What is an Electronic Health Record? An EMR contains the results of clinical and administrative encounters between a provider (physician, nurse, telephone triage nurse, and others) and a patient that occur during episodes of patient care. Consequently, the EMR reflects the practice style, job function, knowledge and skill of the providers who create it. It necessarily includes data structures and data elements that reflect those providers' systems. In an attempt to bring some structure to this emerging field, in 1991 the Institute of Medicine defined the basic functions of an EMR, then known as the computer-based patient record (CPR). The Institute of Medicine's definition remains the gold standard (see Table 1 on page 58). Table 1. EHR functions To supplement the provider-generated information in the EMR, the personal health record (PHR) is a medical record maintained by the patient. The PHR includes electronic copies of information patients have received from their providers. Finally, the concept of the EHR was formulated to integrate an individual's multiple, physician-generated, electronic medical records and the patient-generated personal health record. Intended to be comprehensive, the EHR should facilitate optimal management of the health of an individual or, when used in aggregate, of a population. EHRs should allow sharing of information about patients between any authorized providers. A patient should be able to enter any health care setting, provide authorization, and then consult with a provider who has ready access to his complete health record. EHRs should be securely linked over the Internet and should be integrated seamlessly with medical information for the education of both providers and patients. Table 2 lists common functions of an EHR divided by practice, clinical, system, and chemotherapy/drug management components. Table 2 lists some common medical and oncology-specific data elements (data fields) for an electronic health record. Table 2. Data elements for personal, provider, and oncology health records

The Clinician???s Role in Medicare Prospective Payment

Pamela Teenier, RN, BSN, MBA, CHCE, COS-C, is Director of Medicare Operations, Gentiva Health Services, Corpus Christi, TX. Correspondence: [email protected]. EDITOR’S NOTE:Under Medicare’s Prospective Payment System (PPS), today’s clinician is expected to manage both clinical and financial aspects of a patient care episode. This is the third in a series of articles to teach clinicians three important PPS elements that affect a home health agency’s ability to successfully manage in the PPS environment: case mix weight, adjustments, and visits per episode. The first article (see HHN August 2004) laid the foundation by outlining definitions of the basic elements, tying in the importance they play in PPS reimbursement. The second article (see HHN November 2004) was about evaluating the case mix weight (CMW) element and creating a plan to improve assessments and overall reimbursement.

The Clinician???s Role in Medicare Prospective Payment

Pamela Teenier, BSN, RN, MBA, CHCE, is Director of Medicare Operations, Gentiva Health Services, Corpus Christi, TX. Address for correspondence: 13806 Doubloon Street, Corpus Christi, TX 78418. Editor’s Note: Under Medicare’s Prospective Payment System (PPS) today’s clinician is expected to manage both clinical and financial aspects of a patient care episode. This is the second in a series of articles to teach clinicians three important PPS elements that affect a home health agency’s ability to successfully manage in the PPS environment; Case Mix Weight (CMW), Adjustments, and Visits per Episode. The first article (see August 2004 HHN) laid the foundation by outlining definitions of the basic elements tying in the importance they play in PPS reimbursement. This month’s column focuses on evaluating the CMW element and creating a plan to improve assessments and overall reimbursement. Subsequent columns in the series will discuss each of the terms in depth, presenting an analysis of the concept and opportunities for you to apply them to patient situations.

Malnutrition screening in hospitalised patients and its implication on reimbursement.

Several studies have cited the incidence of malnutrition in hospitals, which is correlated to negative clinical outcomes, to be up to 60%. Data in Singapore, however, are scarce. Its impact on casemix funding is not known. The aims of the present study were to determine the prevalence of malnutrition, the predisposing risk factors and the impact of documentation and coding of malnutrition on casemix funding in a local population in Singapore. Patients admitted to selected wards over a 1-month period were screened for malnutrition. Those at risk were further assessed using subjective global assessment. Logistic regression was used to ascertain the impact of identified factors on malnutrition. Financial impact analysis of coding of malnutrition as a comorbidity was carried out and tested with Wilcoxon signed rank tests. Six hundred and fifty-eight patients were eligible for screening. The overall prevalence of malnutrition in the selected wards was 14.7% (95% confidence interval (CI): 12.0-17.4%). Old age, the occurrence of cancer and the admitting unit were statistically significant in explaining the occurrence of malnutrition. Coding of malnutrition was found to significantly increase the complexity of 24 of 105 episodes (22.9%) of patient care as measured by expected cost weights (P < 0.001) and expected lengths of stay (P < 0.001). As a result, the expected financing for these 24 patients increased by 59.7%. Malnutrition is prevalent in hospitalised medical and surgical patients. Certain clinical factors should heighten awareness and prompt detection for malnutrition. Coding for malnutrition impacts favourably on casemix funding for a subset of malnourished patients.

Counting health care: is there a F in CE?

The consultant episode is widely used by health economists as a measure of delivery of care. The clinical notes of 174 consecutive patients undergoing elective orthopaedic procedures were reviewed. Just over half of the cases (89/174, 51%) were patients referred by their general practitioner, but under half of the available operating time (47%) was expended on these patients, the remainder being on patients already within the system. Under standard NHS accounting, these latter patients are not registered as new consultant referrals and, thus, the episodes of patient care of which their operation is a part, do not constitute finished consultant episodes. Our view is that the episode of care is an inappropriate measure of health care delivery applied to orthopaedic surgery in general.

Bad Outcomes of Questionable Medical Decisions

Letters18 March 2003Bad Outcomes of Questionable Medical DecisionsTimothy P. Hofer, MD, MS and Rodney A. Hayward, MDTimothy P. Hofer, MD, MSVA Center for Practice Management and Outcomes Research; Ann Arbor, MI 48113 (Hofer, Hayward)Search for more papers by this author and Rodney A. Hayward, MDVA Center for Practice Management and Outcomes Research; Ann Arbor, MI 48113 (Hofer, Hayward)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-138-6-200303180-00029 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:Dr. Kessler argues that in the patient we discussed, a more conservative approach to managing pericardial effusion would have been preferable. The cardiologist in this case (who was also a respected clinician at a respected institution) made a different decision. Our experience in formal studies of physician peer review suggests that reviewers make highly variable assessments in most episodes of patient care (1). Assessments of clinical decision making are not very precise, although there is evidence that they are valid in that they correlate with other measures of quality (2). Dr. Kessler also suggests that errors should be ...

An outcome audit for musculoskeletal patients in primary care

Use of accepted validated measures by physiotherapists to monitor the outcomes of their treatment interventions is not widespread. There is limited published data on the outcomes of physiotherapy intervention or the length of treatment episodes in physiotherapy. One objective of this study was to audit outcome measures at the beginning and end of an episode of physiotherapy care for musculoskeletal patients. A second objective was to evaluate the effectives of the introduction of evidence-based guidelines for the management of musculoskeletal problems. A retrospective review of 1,713 consecutive patients with a range of spinal and extremity problems was used. These patients were referred by General Practitioners (GPs) and seen in primary care. An audit was conducted during normal clinical practice using the Roland-Morris back function questionnaire, the Neck Disability Index, the Croft Shoulder scale, and the Lower Extremity Functional Scale as outcome tools. Patients who were unable to complete the outcome tools were excluded from this study, as were patients with elbow and hand conditions, as no suitable outcome tool for these patients was found. At the start of an episode of physiotherapy the patient was asked to complete a self-report measure of pain (0-10) and function (%). At discharge the patient was asked to complete the same measures. Changes in pain and function were documented as a record of outcome. Before and after data on pain and/or function was available for 914 (53.4%) patients. They had predominantly back (37.7%), neck (22.7%), shoulder (14%), and knee (13%) problems. Most patients' (75%) problems were managed with exercise and advice in an average of four sessions. There was a mean improvement of 3.2 on the pain visual analogue scale and a 20% improvement in function. Audit of outcome using valid and reliable tools is feasible in clinical practice, but substantial subject attrition occurred. Most patients achieved significant and clinically important improvements in pain and function with relatively few treatment episodes.

Describing an episode of home nursing care for elderly postsurgical cancer patients.

This American study focused on the home nursing care received by patients with cancers of the prostate, breast, gastrointestinal tract, head and neck, and lung. The ages of the 148 post-surgical patients in the sample ranged from 60 to 90 years, with a mean age of 68.

Integrated care pathways: outcome from inpatient rehabilitation following nontraumatic spinal cord lesion.

Integrated care pathways (ICPs) map the predicted course of an episode of patient care. They detail the expected interventions during the episode and document departures from the expected pathway (variance). This study describes the use of an ICP to audit the rehabilitation of patients with nontraumatic spinal cord injury admitted between 1997 and 1999. The ICPs and outcomes of 85 patients with nontraumatic spinal cord injury admitted to the Neurorehabilitation Unit at the National Hospital for Neurology and Neurosurgery, Queen Square, London were analysed. Data extracted included diagnosis, level of the lesion and duration of stay. The numbers and categories of goals and the rates of goal achievement were extracted and the variance patterns analysed. An average of 28 patients were admitted each year. The level of disability on admission and the duration of stay decreased over the three-year period, while the average patient age increased from 48 to 54 years. None of these changes were statistically significant. On average each patient had three new goals set each week. Ninety per cent of all goals were achieved; this was not dependent on the category of goal. Sixteen patients (19%) accounted for 58% of all nonachieved goals. These patients tended to have acute-onset disability. The number of variances fell from 15 to 7 over the three-year period. The pathway enables monitoring of the rehabilitation process. As the Unit becomes more experienced there is a trend to shorter, more focused admissions with fewer variances. Specific groups of patients with particular needs can be identified. Future patients benefit from closure of the 'audit loop' and the implementation of clinical change based on information obtained from the ICP.