Impact Care Delivery Research Articles

Hospital personnel perspectives on factors influencing acute care patient outcomes: a qualitative approach to model refinement

BackgroundHealth systems have long been interested in the best practices for staffing in the acute care setting. Studies on staffing often focus on registered nurses and nurse-to-patient staffing ratios. There were fewer studies on the relationship between interprofessional team members or contextual factors such as hospital and community characteristics and patient outcomes. This qualitative study aimed to refine an explanatory model by soliciting hospital personnel feedback on staffing and patient outcomes.MethodsWe conducted a qualitative study using semi-structured interviews and thematic analysis to understand hospital personnel’s perspectives and experiences of factors that affect acute care inpatient outcomes. Interviews were conducted in 2022 with 38 hospital personnel representing 19 hospitals across Washington state in the United States of America.ResultsFindings support a model of characteristics impacting patient outcomes to include the complex and interconnected relationships between community, hospital, patient, and staffing characteristics. Within the model, patient characteristics were positioned into hospital characteristics, and in turn these were positioned within community characteristics to highlight the importance of setting and context when evaluating outcomes. Together, these factors influenced both staff characteristics and patient outcomes, but these two categories also share a direct relationship.ConclusionFindings can be applied to hospitals and health systems in a variety of contexts to examine how external factors such as community resource availability impact care delivery. Future research should expand on this work with specific attention to how staffing changes and interprofessional team composition can improve patient outcomes.

The contribution of household income to rectal cancer patient characteristics, treatment, and outcomes from 2010 to 2020

BackgroundThere is a paucity of recent literature investigating the sole effect of income level on the treatment and survival of patients with rectal cancer. MethodsWe analyzed all cases of rectal cancer in the Rectal Cancer PUF of the NCDB from 2010 to 2020. We utilized the Median Income Quartiles 2016–2020 to define our income levels. The two lower quartiles were combined to create a lower income group, with the upper two quartiles creating the higher income group. The total cohort included 201,329 patients, with 116,843 and 84,486 in the higher and lower income groups, respectively. ResultsLower income patients were more often black (17 % vs 6 %), lived farther from the nearest hospital (33.5 miles vs 25.7 miles) despite being more likely to live in urban areas (25 % vs 7 %), and had lower levels of private insurance (36 % vs 49 %). They underwent more APRs (17 % vs 14 %) and had a 13 % higher chance of undergoing an open operation (OR 1.13, CI 1.09–1.17). Higher income patients had a 12 % reduction in 90-day (OR 0.88, 95 % CI 0.82–0.96) and overall mortality (OR 0.88, 95 % CI 0.86–0.89). ConclusionsClinicians should be aware that lower income patients are often faced with unique challenges that may impact care delivery.

Abstract PO5-09-06: Outcomes of breast cancer in a minority-enriched population treated at a large safety-net system: Is site of care a predictor of poor outcomes?

Abstract Background: Breast cancer outcomes in the United States continue to improve, but sociodemographic disparities remain prevalent and impact care delivery and outcomes in vulnerable populations. Safety-net health systems are intended to address inequities by providing access to care for the uninsured/underinsured. Care delivery in a safety-net setting is often inherently complicated by limited resources at these institutions. Here, we present the overall survival (OS) data of breast cancer patients treated at a large safety-net system, compared to the national average. Methods: Parkland Health (PH) is the safety-net system for Dallas County and is affiliated with the University of Texas Southwestern Harold C. Simmons Comprehensive Cancer Center (NCI-CCC). Electronic medical records of patients diagnosed with invasive breast cancer between 2018 to 2020 at PH were reviewed and data on demographics, treatment, and outcomes were collected. Categorical data was summarized with counts and percentages and continuous data was summarized with median and interquartile range. Statistical comparisons used Chi-square test for categorical data and rank sum test for continuous data with a significance level of 0.05. Survival data was analyzed using Cox proportional hazard model. Data from the National Cancer Database (NCDB) for the same period was used for comparison. Results: Of the 657 patients included in the study, the majority (82.5%) belonged to racial and ethnic minorities (Hispanic 50.2%; Black 32.3%). Compared to the NCDB, PH patients were more often uninsured (67% vs 1.6%) or enrolled on Medicaid (14.5% vs 6.9%), and less often on Medicare (8.5% v. 43%) (p< 0.01). Triple negative breast cancer (TNBC) phenotype and late-stage diagnosis (stage III/IV) rates were higher at PH compared to NCDB (TNBC 22.8% vs 10.7%, p< 0.01; late stage 30.6% vs 13.2%, p< 0.01). At a median follow up of 33 (range 24-43) months in PH and 28 (range 21-36) months in NCDB, the unadjusted OS for the PH population was 86.3% vs 92.6% for the NCDB population (p < 0.01). Within the PH population, Black race, higher stage, and TNBC were associated with decreased OS. There was a significant interaction between Black race and TNBC. When combining all patients (PH+NCDB), site of care (PH) was associated with a higher risk of death from breast cancer (HR 1.467, 95% CI 1.192-1.805, p< 0.0005), however, multivariate analysis did not show a significant difference based on site of care. Factors associated with a significantly increased risk of death in this multivariate analysis (corrected for interaction between Black race and TNBC phenotype) included age, late-stage diagnosis, TNBC, Black race, and uninsured status (Table 1). Conclusions: Breast cancer patients treated at PH were more likely to have adverse disease characteristics compared to the NCDB population. When accounting for these risk factors in multivariate analysis, patients treated at PH had similar outcomes compared to the national average. Our findings reinforce the critical role of safety-net systems in promoting health equity and eliminating disparities. Table 1 Citation Format: Sarah Kashanian, Shifa Kanjwal, L. Steven Brown, Andrea Semlow, Mary Hodges, Robyn Cobb, Brad Walsh, Umber Dickerson, Navid Sadeghi. Outcomes of breast cancer in a minority-enriched population treated at a large safety-net system: Is site of care a predictor of poor outcomes? [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-06.

Interprofessional Global Health Education and Credentialing for Higher Ed

Global health issues, including population health disparities, government policy, and pandemics, impact care delivery at all levels. Healthcare is interconnected in ways never seen before, and interprofessional collaboration is imperative for individual and population health and wellness. Nursing and health professions programs have a noticeable gap in global health coverage across the curriculum. Purposeful global health competency integration in healthcare programs can address this gap and prepare healthcare providers with the knowledge needed to address health disparities on a global level. This paper highlights the process developed by a nursing program to embed interprofessional global health competencies in undergraduate and graduate nursing curricula, data dashboard development to streamline competency tracking, and digital badging to showcase competency attainment.

Investigating health disparities in vestibular rehabilitation.

Health disparities (HD) impact care delivery and health outcomes in individuals with vestibular disorders (IVD). The purpose of this study is to identify whether health disparities (HD) exist in Vestibular Rehabilitation (VR) between individuals identifying as Caucasians or racial or ethnic minorities (REM). This study was a retrospective chart review of IVD who attended outpatient VR between 1/2014 and 9/2020. Data recorded included age, gender, race/ethnicity, vestibular diagnosis, VR interventions, and pre-post outcome measures such as Dizziness Handicap Inventory (DHI), and Activities-Specific Balance Confidence Scale (ABC), Gait speed (GS), and Functional Gait Assessment (FGA). Chi-squared tests, one-tailed, and two-tailed t-tests (α= 0.05) were utilized to compare Caucasian and REM groups. Three hundred and forty-three charts (N = 343) met inclusion/exclusion criteria. REM demonstrated higher median DHI scores (46 vs. 38, p = 0.008) and lower ABC scores (53.10% vs. 66.30%, p < 0.001) at VR evaluation compared to Caucasians. There were no statistically significant differences in DHI, ABC, FGA, and GS scores between Caucasians and REM at discharge. VR was able to equalize HD in DHI and ABC which initially existed between REM and Caucasians. VR therapists should work with public health and policy researchers to improve access to VR.

Insomnia among Intensive Care Unit Nurses in the United Arab Emirates and its Association to Work Productivity and Quality of Life

Background: A healthy workforce is essential for sustainable healthcare systems, disease control, and the provision of quality and safe healthcare services. Insomnia is a common problem among critical care nurses attributed to the hard nature of their work, long and irregular shifts, high levels of stress and tension, and exposure to traumatic situations associated with critical care environments. These issues compromise their professional and personal lives, have financial consequences for health organizations, and may reduce the quality of care provided to patients. Aim: To assess the prevalence of insomnia among ICU nurses and determine its impact on their Quality of Life (QoL) and work productivity. Methods: This cross-sectional study involved 430 ICU nurses working in three major governmental hospitals in the United Arab Emirates. Nurses were selected via convenient sampling. Data collected included nurses’ demographic characteristics, insomnia levels using the Athens Insomnia Scale, work productivity using the workability index, and QoL using the World Health Organization Quality of Life Scale-Brief questionnaire Results: Approximately 237 (55%) of participants reported moderate to severe levels of insomnia, and 195 (45.3%) had moderate productivity levels. However, the majority of participants reported low QoL levels in physical, psychological, social, and environmental QoL domains (61.4%, 60.2%, 47.2%, and 70.5%), respectively. Bivariate correlations demonstrated a significant negative relationship; correlation coefficient of -0.517, between participants' insomnia levels and work productivity levels. Additionally, significant negative relationships were found between insomnia levels and the QoL domains, with correlation coefficients of -0.629, -0.568, -0.469, and -0.485, respectively. Conclusion: This study found that insomnia has a negative relationship with ICU nurses’ work productivity and QoL. This may impact care delivery patient care and safety.Regular counseling sessions, better working hours, less overtime, and a better work-life balance may contribute to increased productivity and improved QoL among ICU nurses in the UAE.

Nurses' perceptions about bereavement care in critical care units: A qualitative study.

To explore critical care nurses' perceptions of bereavement nursing care in critical care settings at a tertiary hospital in Singapore. Grief and bereavement are stressful life experiences associated with significant health problems. Critical care nurses play important roles in supporting bereaved family members, and their self-competence affects the quality of the care they deliver. Exploring critical care nurses' perceptions of bereavement nursing care is thus essential. An exploratory descriptive qualitative study design was adopted. A total of 16 nurses were recruited. One-on-one interviews were conducted using a semi-structured interview guide and were audio-recorded. The data collected were analysed using thematic analysis. This study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. Five themes surfaced in the study, namely, family responses, holistic care, psychological impact, self-competence and organisational dynamics. This study highlighted the key roles of critical care nurses in providing bereavement care, how their self-competence impacts care delivery and the significant impacts of organisational policies on their capacity to provide care. Nursing administrators should provide enhanced organisational support to critical care nurses who provide bereavement nursing care, and implement training work plans to ensure nurses are adequately prepared to provide culturally appropriate care. Strategies should be introduced to reduce administrative burden, expand the role of critical care nurses in providing bereavement nursing care, and establish and enlist role models as drivers of bereavement nursing care.

Comparison of 30-day Readmission Rates and Inpatient Cardiac Procedures for Weekday Versus Weekend Hospital Admissions for Heart Failure

BackgroundWhether the timing of hospital presentation impacts care delivery and clinical outcomes for patients hospitalized for heart failure (HF) remains a matter of debate. In this study, we examined all-cause and HF-specific 30-day readmission rates for patients who were admitted for HF on a weekend vs admitted for HF on a weekday. Methods and ResultsWe conducted a retrospective analysis using the 2010–2019 Nationwide Readmission Database to compare 30-day readmission rates among patients who were admitted for HF on a weekday (Monday to Friday) vs patients who were admitted for HF on a weekend (Saturday or Sunday). We also compared in-hospital cardiac procedures and temporal trends in 30-day readmission by day of index hospital admission. Among 8,270,717 index HF hospitalizations, 6,302,775 were admitted on a weekday and 1,967,942 admitted on a weekend. For weekday and weekend admissions, the 30-day all-cause readmission rates were 19.8% vs 20.3%, and HF-specific readmission rates were 8.1% vs 8.4%, respectively. Weekend admissions were independently associated with higher risk of all-cause (adjusted odds ratio [aOR] 1.04, 95% confidence interval [CI] 1.03–1.05, P < .001) and HF-specific readmission (aOR 1.04, 95% CI 1.03–1.05, P < .001). Weekend HF admissions were less likely to undergo echocardiography (aOR 0.95, 95% CI 0.94–0.96, P < .001), right heart catheterization (aOR 0.80, 95% CI 0.79–0.81, P < .001), electrical cardioversion (aOR 0.90, 95% CI 0.88–0.93, P < .001), or receive temporary mechanical support devices (aOR 0.84, 95% CI 0.79–0.89, P < .001). The mean length of stay was shorter for weekend HF admissions (5.1 days vs 5.4 days, P < .001). Between 2010 and 2019, 30-day all-cause (18.5% to 18.2%, trend P < .001) and HF-specific (8.4% to 8.3%, trend P < .001) readmission rates decreased among weekday HF admissions. Among weekend HF admissions, the HF-specific 30-day readmission rate decreased (8.8% to 8.7%, trend P < .001), but the all-cause 30-day readmission rate remained stable (trend P = .280). ConclusionsAmong patients hospitalized for HF, weekend admissions were independently associated with excess risk of 30-day all-cause and HF-specific readmission and a lower likelihood of undergoing in-hospital cardiovascular testing and procedures. The 30-day all-cause readmission rate has decreased modestly over time among patients admitted on weekdays, but has remained stable among patients admitted on weekends.

Blueprints for well-being: Modeling the way through Human-Centered Leadership and Pathway to Excellence.

Blueprints for well-being: Modeling the way through Human-Centered Leadership and Pathway to Excellence.

Paycheck Protection Program (PPP) COVID-19 relief funding for veteran-, minority-, and women- owned dental businesses: A cross-sectional study.

The Covid-19 pandemic exacerbated dental staffing shortages, which impact care delivery and ultimately oral health equity. Federal funding efforts like the Paycheck Protection Program (PPP) sought to aid traditionally underserved businesses including those owned by veterans, minority racial and ethnic groups, and women. (1) To examine differences in PPP funding between veteran- and nonveteran-owned dental care delivery businesses and organizations and (2) to analyze other relevant factors associated with variation in PPP funding levels for dental businesses. Using publicly available PPP data, we ran unadjusted bivariable and adjusted multivariable linear regression models to estimate associations between loan approval amount and forgiveness amount, veteran status, and relevant covariates. Minority racial and ethnic groups and women received less PPP funding and less loan forgiveness, on average, compared with non-minority groups. In the adjusted model with no missing self-reported demographic observations at p < 0.10, veterans received more PPP funding and loan forgiveness, on average, compared to non-veterans. To our knowledge, this is the first comprehensive analysis of all dental recipients of PPP funding throughout the United States. Despite PPP program intentions and strategies, traditionally underserved dental businesses did not receive increased funding to support employment.

Team Communication and Expectations Following Pediatric Cardiac Surgery: A Multi-Disciplinary Survey.

Patients and families desire an accurate understanding of the expected recovery following congenital cardiac surgery. Variation in knowledge and expectations within the care team may be under-recognized and impact communication and care delivery. Our objective was to assess knowledge of common postoperative milestones and perceived efficacy of communication with patients and families and within the care team. An 18-question survey measuring knowledge of expected milestones for recovery after four index operations and team communication in the postoperative period was distributed electronically to multidisciplinary care team members at 16 academic pediatric heart centers. Answers were compared to local median data for each respondent's heart center to assess accuracy and stratified by heart center role and years of experience. We obtained 874 responses with broad representation of disciplines. More than half of all respondent predictions (55.3%) did not match their local median data. Percent matching did not vary by care team role but improved with increasing experience (35.8% < 2years vs. 46.4% > 10years, p = 0.2133). Of all respondents, 62.7% expressed confidence discussing the anticipated postoperative course, 78.6% denoted confidence discussing postoperative complications, and 55.3% conveyed that not all members of their care team share a common expectation for typical postoperative recovery. Most respondents (94.6%) stated that increased knowledge of local data would positively impact communication. Confidence in communication exceeded accuracy in predicting the timing of postoperative milestones. Important variation in knowledge and expectations for postoperative recovery in pediatric cardiac surgery exists and may impact communication and clinical effectiveness.

Analysis of 372 Adult Allograft Recipients Reveals Associations between Non-European Ancestry, Low Socioeconomic Status, and Receipt of HLA-Disparate Grafts

Introduction: While both race/ ethnicity & socioeconomic status (SES) impact care delivery for allograft candidates & recipients, the associations between ancestry & SES, & their interaction with donor type are not fully established. We hypothesized that low SES disproportionately impacts non-European (non-EURO) recipients of HLA-disparate grafts (cord blood, haploidentical, or 4-7/8 unrelated donor [mmURD]). Methods: We examined surrogates of SES in consecutive adults undergoing allograft 3/2020-2/2022 stratified by recipient ancestry & donor type. A 3/2020 analysis commencement was selected as Social Work (SW) philanthropic financial support for vulnerable patients increased at the onset of the COVID-19 pandemic. As household income was not collected, surrogates of low SES were defined as: 1) an area deprivation index (ADI) national percentile ≥ 60; 2) Medicaid as the primary insurance at BMT referral; &/ or 3) received SW philanthropic financial support to cover cost-of-living expenses within 6 months of transplant. We also assessed mean fold differences in the funding amount/ patient receiving philanthropic support. Results: Of 372 patients (pts, median 62 years, range 19-81; 73% myeloid malignancy), 257 (69%) had European (EURO) and 115 (31%) non-EURO ancestry (including 31 White Hispanic, 40 African, 34 Asian, 4 Middle Eastern, and 6 mixed non-EURO pts). 53 (14%) received matched sibling donor, 191 (51%) 8/8 unrelated donor, 38 (10%) cord blood, 47 (13%) haploidentical, and 43 (12%) mmURD transplants. More than half (67/115, 58%) of non-EURO ancestry pts received an HLA-disparate graft compared to 24% (61/257) of EURO pts (p < 0.001). Median ADI was 14 (range 1-100). Eighteen (5%) patients had low SES by ADI ≥ 60; 22 (6%) by Medicaid insurance; and 71 (19%) by receipt of financial support. A higher proportion of pts received financial support if they had Medicaid (13/22, 59%) compared to Medicare/ private insurance (58/350, 17%), p < 0.001, or if their ADI was ≥ 60 (7/18, 38%) compared to < 60 (64/354, 18%), p = 0.028. Conversely, only one pt with ADI ≥ 60 had Medicaid. Notably, the 3 SES classifications resulted in different pts being classified as low SES (Figure 1). Only 20 pts had low SES by two of these measures, & only 1 by all three. When analyzing by ancestry, compared to EUROs, non-EUROs had a similar ADI distribution but over double the proportion on Medicaid (12/115, 10% vs 10/257, 4%, p = 0.013). Non-EUROs also had almost twice the proportion receiving financial support (33/115, 29% vs 38/257, 15%, p = 0.002), & those who did were granted a mean of 40% more funds relative to EUROs. African ancestry pts had the highest proportions on Medicaid (5/40, 12.5%) & receiving financial support (17/40, 42.5%), with the highest mean fold increase in funds (58% more) relative to EUROs. When stratifying by both ancestry & graft source, because very few EURO HLA-disparate graft recipients had low SES, all EURO ancestry pts were combined. Relative to EUROs, non-EUROs who received HLA-disparate grafts (n = 67 including 15 White Hispanic, 31 African, 20 Asian, & 1 mixed non-EURO pts) had triple the proportion on Medicaid (8/67, 12% vs 10/257, 4%, p = 0.015) with more than double receiving financial support (22/67, 33% vs 38/257, 15%, p = 0.001). Also, those who received support were granted a mean of 50% more funds relative to EUROs (Table 1). By contrast, differences between EUROs & non-EURO HLA-matched graft recipients were not significant. African ancestry pts who received HLA-disparate grafts had the highest proportions on Medicaid (5/31, 16%) & receiving financial support (14/31, 45%) with the highest mean fold increase in funds (75% more) relative to EURO pts. Conclusions: We demonstrate an intersectionality between ancestry & SES, & an association with donor type, with the most vulnerable patients (non-EUROs with low SES, especially African ancestry pts) receiving the most complex (ie HLA-disparate) transplants. Successful extension of transplant access to minority pts will be contingent on addressing this financial hardship. Moreover, as the different SES classification systems result in different assignment of SES, interventions to advance equity will require better SES classifications or detailed recording of household income. Access to expensive post-transplant medications may be another surrogate of low SES & analysis of this is underway at our Center. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Building Compassionate Experience Through Compassionate Action: Qualitative Behavioral Analysis.

The acceleration of technology-based primary care during the COVID-19 pandemic outpaced the ability to understand whether and how it impacts care delivery and outcomes. As technology-based care continues to evolve, focusing on the core construct of compassion in a primary care context will help ensure high-quality patient care and increased patient autonomy and satisfaction. The ability to successfully operationalize the use of technology in patient-clinician interactions hinges on understanding not only how compassionate care is experienced in this context but also how clinicians can create it. The objectives of this study were to understand whether and how compassionate behaviors are experienced in technology-based primary care interactions and identify the individual and contextual drivers that influence whether and how these behaviors occur. We conducted a series of qualitative one-on-one interviews with primary care physicians, nurses, and patients. Qualitative data were initially analyzed using an inductive thematic analysis approach to identify preliminary themes for each participant group independently. We then looked across participant groups to identify areas of alignment and distinction. Descriptions of key behaviors that participants identified as elements of a compassionate interaction and descriptions of key drivers of these behaviors were inductively coded and defined at this stage. A total of 74 interviews were conducted with 40 patients, 20 nurses, and 14 primary care physicians. Key behaviors that amplified the experience of compassion included asking the patient's modality preference, using video to establish technology-based presence, sharing the screen, and practicing effective communication. Participants' knowledge or skills as well as their beliefs and emotions influenced whether or not these behaviors occurred. Contextual elements beyond participants' control influenced technology-based interactions, including resource access, funding structures, culture, regulatory standards, work structure, societal influence, and patient characteristics and needs. A high-yield, evidence-based approach to address the identified drivers of compassion-focused clinician behavior includes a combination of education, training, and enablement. Much of the patient experience is influenced by clinician behavior; however, clinicians need a supportive system and adequate supports to evolve new ways of working to create the experience of compassionate care. The current state of technology-based care operationalization has led to widespread burnout, societal pressure, and shifting expectations of both clinicians and the health system more broadly, threatening the ability to deliver compassionate care. For clinicians to exhibit compassionate behaviors, they need more than just adequate supports; they also need to receive compassion from and experience the humanity of their patients.

Predictors of Emergency Department service outcome for people brought in by police: A retrospective cohort study

BackgroundPeople brought in by police (BIBP) to the emergency department (ED) can present with complicated health conditions that may impact care delivery. We sought to identify factors predictive of an ED length of stay (LOS) ≥4 hours and hospital admission for presentations BIBP. MethodsThis retrospective cohort study comprised a sample of all adults (aged ≥ 18 years old) BIBP to public hospital EDs across Queensland, Australia between 1 January 2018 and 31 December 2020. Univariate and multivariate logistic regression were used to identify predictors of an ED LOS ≥4 hours and hospital admission for presentations BIBP. ResultsOf the 42,502 presentations BIBP, independent predictors of an ED LOS ≥4 hours included higher priority triage categories, hospital transfer/admission, evening/night shift arrival, an Emergency Examination Authority (EEA), (i.e. an involuntary presentation), and a non-descript mental health diagnosis. Independent predictors of hospital admission included higher priority triage categories, increasing age, day/evening shift arrival, a ‘mental or behavioural issues’ diagnosis, and an ED LOS ≥4 hours. ConclusionsNoted predictors of a LOS ≥4 hours and hospital admission indicate further need to support intra and inter-agency interventions to optimise patient outcomes.

The impact of physician-hospital integration on spending and quality of oncology care.

1584 Background: There has been increasing hospital and health system ownership of physician practices in recent years, particularly in oncology. However, relatively little is known about how this impacts care delivery for patients with cancer, who use many hospital-based services that may be impacted by integration. We evaluated the impact of physician-hospital integration in oncology on spending and quality of care for Medicare beneficiaries with cancer. Methods: We used Medicare Fee-for-Service claims from 2005-2019 linked with a unique Health System and Provider Database, developed by National Bureau of Economic Research and Harvard University researchers, to track practice ownership relationships over time. We used a stacked event study to assess outcomes for patients three years before and after oncologists move from independent practices to hospital- or system- owned practices. We compared outcomes to a control group with oncologists who shifted from independent to hospital- or system-owned practices in later years. We focused on two cohorts of patients. The first cohort included cancer patients with presumed incident or recurrent cancer based on ≥2 visits to an oncologist and no visit in the past year. For these patients, we evaluated the impact of physician-hospital integration on the likelihood of receiving chemotherapy following the visit. The second cohort included 6-month episodes for patients receiving chemotherapy. For these patients we evaluated the impact of physician-hospital integration on spending, utilization, and quality. Quality measures included receipt of timely chemotherapy (within 60 days) following surgery, inpatient readmissions, non-use of tamoxifen + strong CYPD26 inhibitors, and end-of-life intensity of care measures. Results: There was no change in the likelihood of receiving chemotherapy with an initial oncology consultation following an oncologist’s transition to hospital-based employment. Total spending during six-month chemotherapy episodes increased by $1391 (95%CI: $465, $2316). The primary contributors to this growth were increases in spending on inpatient care, chemotherapy administration, and office visits. Spending growth, where observed, was driven primarily by higher Medicare prices for care in hospital outpatient settings. We found no positive impact of physician-hospital integration on timeliness of chemotherapy initiation, readmissions, concurrent use of tamoxifen+strong CYPD26 inhibitors, or intensity of end-of-life care. Conclusions: Physician-hospital integration resulted in higher prices and thus higher spending, but had limited impact on utilization and no detectable impacts on measures of quality. These results suggest that claims of quality improvements and concerns regarding overuse associated with physician-hospital integration may be overstated. Our results also support continued movement towards site-neutral payments.

Exploring barriers to stroke coordinator roles in Australia: A national survey

<h2>ABSTRACT</h2><h3>Background</h3> Coordinator roles are integral to delivering best practice stroke care. Evidence related to the challenges faced by clinicians working in these positions is lacking. <h3>Aim</h3> To explore the barriers to working in acute stroke coordinator roles. <h3>Methods</h3> Self-administered online national survey (including closed and open-text questions) of clinicians in coordinator roles in Australia. Non-physician health professionals who worked in a formal or informally recognised clinical leadership position for acute stroke were eligible. Participants were identified from the National Audit (Australia), and advertising via national networks/associations. Quantitative data were analysed descriptively, inductive thematic analysis was used for open-text responses, with all results triangulated. <h3>Findings</h3> A total of 141 eligible clinicians were identified; 105 in coordinator roles responded (103 hospitals); and 96 answered questions related to barriers (91% female, 89% registered nurses). Having insufficient time to perform the role was a major barrier. In particular, having too many responsibilities (55%) and limited staffing allocation (45%) was perceived to impact care delivery. Inequity in classifications and remuneration, both within and across different states of Australia, were common concerns. Environmental barriers, particularly related to managerial support (31%), and associated acknowledgement and recognition of the role especially from executive/management, were frequently raised. Other challenges included limited professional development opportunities and funding support for ongoing education, and inadequate orientation to the role (27%). <h3>Conclusion</h3> To develop and retain clinicians in coordinator roles for optimising stroke care, hospitals should address the modifiable barriers faced by those working in these positions, including greater formal recognition and sufficient employment fractions.

Reduced Cognitive Burden and Increased Focus: A Mixed-methods Study Exploring How Implementing Scribes Impacted Physicians.

Understanding how medical scribes impact care delivery can inform decision-makers who must balance the cost of hiring scribes with their contribution to alleviating clinician burden. The objective of this study was to understand how scribes impacted provider efficiency and satisfaction. This was mixed-methods study. Internal and family medicine clinicians were included. We administered structured surveys and conducted unstructured interviews with clinicians who adopted scribes. We collected average days to close charts and quantity of after-hours clinical work in the 6 months before and after implementation using electronic health record data. We conducted a difference in difference (DID) analysis using a multilevel Poisson regression. Three themes emerged from the interviews: (1) charting time is less after training; (2) clinicians wanted to continue working with scribes; and (3) scribes did not reduce the overall inbox burden. In the 6-month survey, 76% of clinicians endorsed that working with a scribe improved work satisfaction versus 50% at 1 month. After implementation, days to chart closure decreased [DID=0.38 fewer days; 95% confidence interval (CI): -0.61, -0.15] the average minutes worked after hours on clinic days decreased (DID=-11.5 min/d; 95% CI: -13.1, -9.9) as did minutes worked on nonclinical days (DID=-24.9 min/d; 95% CI: -28.1, -21.7). Working with scribes was associated with reduced time to close charts and reduced time using the electronic health record, markers of efficiency. Increased satisfaction accrued once scribes had experience.

“Some version, most of the time”: The surgical safety checklist, patient safety, and the everyday experience of practice variation

BackgroundThis study investigated checklist compliance to highlight where assumptions about the Surgical Safety Checklist might not be met in practice. MethodsWe used ethnographic methods to investigate the practice of the Surgical Safety Checklist in one hospital. Fifty-one observation days, eight semi-structured interviews, and two surveys of operating room staff over two years were conducted. Data were collected and analyzed iteratively. ResultsDespite the near 100% compliance rates reported to the Ministry of Health, practice of the Surgical Safety Checklist varied widely: 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings included some sort of team huddle. Gaps between policy and practice were identified at four different levels: compliance with the stages and items; responsibility for the checklist; documentation of adherence; and interprofessional teamwork. ConclusionsChecklist compliance data are insufficient to understand how complex interventions impact care delivery. Greater and continued attention to practice in healthcare is needed.

Care at the end of life during the COVID-19 pandemic: A CancerLinQ Discovery (CLQD) analysis.

310 Background: For patients with cancer approaching end-of-life (EOL) during the COVID-19 pandemic, the changes in service availability and transition to telehealth may impact care delivery. Little is known about how the COVID-19 pandemic impacted EOL encounters with the healthcare system, particularly for vulnerable patient populations. Methods: This retrospective cohort study included patients with cancer who died from 1/2019-9/2020 in the CLQD electronic health record-based dataset. Descriptive statistics were generated for demographic characteristics and for clinical encounters (telehealth/in person/no encounter) in the last 3 months of life (EOL) among patients deceased in the year. Results were stratified by age, race, ethnicity, and geographic region. Results: Among the 49,688 deceased patients, 27% were under 65, 29% were 65-74, and 44% were 75+. The majority were Non-Hispanic White, with 5% Hispanic, 12% Black. In 2020, patients who were age 75+, White, Non-Hispanic, and/or living in the Midwest or Northeast had lower rates of in person encounters and higher rates of no encounter at EOL than those &lt;65, Black, Hispanic, and/or living in the South (Table). Telehealth use at EOL increased from 2019 to 2020, with highest use amongst those in the West and Hispanic patients (Table). Conclusions: During the pandemic, telehealth use was limited at EOL compared to the 14% reported use for all cancer patients (data not shown). Black and Hispanic patients had slightly higher provider encounters at EOL, which may be due to differences in intensity of EOL care or death capture within the database. Further research is needed to evaluate the quality of EOL care and to assess opportunities to leverage telehealth where patients are unable to access outpatient services.[Table: see text]

Retaining VA Women’s Health Primary Care Providers: Work Setting Matters

When an experienced provider opts to leave a healthcare workforce (attrition), there are significant costs, both direct and indirect. Turnover of healthcare providers is underreported and understudied, despite evidence that it negatively impacts care delivery and negatively impacts working conditions for remaining providers. In the Veterans Affairs (VA) healthcare system, attrition of women's health primary care providers (WH-PCPs) threatens a specially trained workforce; it is unknown what factors contribute to, or protect against, their attrition. Based on evidence that clinic environment, adequate support resources, and workload affect provider burnout and intent to leave, we explored if such clinic characteristics predict attrition of WH-PCPs in the VA, to identify protective factors. This analysis drew on two waves of existing national VA survey data to examine predictors of WH-PCP attrition, via logistic regression. All 2,259 providers from 140 facilities VA-wide who were WH-PCPs on September 30, 2016. The dependent variable was WH-PCP attrition in the following year. Candidate predictors were clinic environment (working in: a comprehensive women's health center, a limited women's health clinic, a general primary care clinic, or multiple clinic environments), availability of co-located specialty support resources (mental health, social work, clinical pharmacy), provider characteristics (gender, professional degree), and clinic workload (clinic sessions per week). Working exclusively in a comprehensive women's health center uniquely predicted significantly lower risk of WH-PCP attrition (adjusted odds ratio 0.40; CI 0.19-0.86). A comprehensive women's health center clinical context may promote retention of this specially trained primary care workforce. Exploring potential mechanisms-e.g., shared mission, appropriate support to meet patients' needs, or a cohesive team environment-may inform broader efforts to retain front-line providers.