Large Healthcare Network Research Articles

Adolescent deliberate self-poisoning in South-East Melbourne.

To describe the characteristics of adolescents presenting with deliberate self-poisoning (DSP) to a large Australian healthcare network. This is a retrospective chart review of 12-17 year olds presenting to three Monash Health EDs with self-poisoning from January 2012 to December 2014. There were 35 207 adolescent presentations in the study period. A total of 721 cases were for DSP (2%), and 501 (1.4%) presented with recreational or accidental self-poisoning. The most common DSP toxicants were paracetamol (28%), non-steroidal anti-inflammatory agents (15%) and serotonin reuptake inhibitors (10%). Of the DSP presentations, 96% were impulsive events; 23% of patients (n = 129) presented on multiple occasions, and 67% of all DSP cases had a past psychiatric history, particularly depression (57%). Disposition for DSP patients included 60% discharged home, 6% short stay unit, 19% medical admission, 13% psychiatric admission and 2% intensive care unit admission. There were no mortalities. Adolescent DSP presentations frequently involved impulsive ingestion of over-the-counter medications, suggesting less access to prescription medications. Additionally, pre-existing mental health history and re-presentation were common. Initiatives to prevent DSP might include an increased focus on the early identification and management of mental health problems in adolescents in the community.

Drug allergies documented in electronic health records of a large healthcare system.

The prevalence of drug allergies documented in electronic health records (EHRs) of large patient populations is understudied. We aimed to describe the prevalence of common drug allergies and patient characteristics documented in EHRs of a large healthcare network over the last two decades. Drug allergy data were obtained from EHRs of patients who visited two large tertiary care hospitals in Boston from 1990 to 2013. The prevalence of each drug and drug class was calculated and compared by sex and race/ethnicity. The number of allergies per patient was calculated and the frequency of patients having 1, 2, 3…, or 10+ drug allergies was reported. We also conducted a trend analysis by comparing the proportion of each allergy to the total number of drug allergies over time. Among 1 766 328 patients, 35.5% of patients had at least one reported drug allergy with an average of 1.95 drug allergies per patient. The most commonly reported drug allergies in this population were to penicillins (12.8%), sulfonamide antibiotics (7.4%), opiates (6.8%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (3.5%). The relative proportion of allergies to angiotensin-converting enzyme (ACE) inhibitors and HMG CoA reductase inhibitors (statins) have more than doubled since early 2000s. Drug allergies were most prevalent among females and white patients except for NSAIDs, ACE inhibitors, and thiazide diuretics, which were more prevalent in black patients. Females and white patients may be more likely to experience a reaction from common medications. An increase in reported allergies to ACE inhibitors and statins is noteworthy.

Mealtime interruptions, assistance and nutritional intake in subacute care

Protected mealtimes is an initiative to support increased nutritional intake for all hospitalised patients, particularly those who are malnourished. The increased focus on maximising independence of patients in the subacute setting may provide a supportive environment for implementing these strategies. The aim of the present study was to gain insight into subacute ward practices at mealtimes under usual conditions (i.e. at baseline) where no protected mealtimes policy was implemented. Participants were patients aged ≥65 years recruited from subacute care facilities at a large healthcare network in Victoria, Australia. Participants were observed at mealtimes and mid meals (i.e. morning tea, afternoon tea and supper) to determine daily energy and protein intake, provision of mealtime assistance and mealtime interruptions. Almost all participants received assistance when it was needed, with positive and negative interruptions experienced by 56.2% and 76.2% of participants, respectively. There was an energy deficit of approximately 2 MJ per day between average intake and estimated requirements. In conclusion, mealtime practices were suboptimal, with particularly high rates of negative interruptions. Protected mealtimes is one strategy that may improve the mealtime environment to support patients' dietary intake. Prospective studies are needed to evaluate its implementation and effects.

On modelling non-linear quantity discounts in a supplier selection problem by mixed linear integer optimization

Applying traditional integer programming techniques in order to solve real logistic problems can be an important challenge. To ensure tractability, real instances are often either simplified in scope or limited in size, given rise to solutions that may not address realistic issues. In this paper we present a novel approach to solve a multicommodity capacitated network flow problem with concave routing costs, considering also outsourcing, overload and underutilization facility costs. It is derived from a real NP production and transportation problem concerning to the processing of biological samples in a large health-care network, with consideration of volume-based price incentives—i.e. economies of scale—on the shipping costs. It is a tactical level model providing the global view of network layout and the coordinating policy among facilities with realistic assessment of long-term operations costs. The goal is to find an efficient resolution procedure in order to integrate it into a Decision Support System used by planners. With this aim, we analyse three alternative methods of linearizing the involved modified all-units discount cost function. Performance of the different modelling techniques is shown through extensive computations.

Multidisciplinary Support for Healthcare Transitioning Across an Urban Healthcare Network

A successful transition from pediatric to adult oriented health care is a vital process in maintaining a patient-centered medical home for youth with special health care needs (YSHCNs). We assessed practices of pediatric providers who transition YSCHNs to adult-oriented medical care in a large urban academic healthcare network. A cross-sectional Web-based survey was distributed to 376 generalist and subspecialist pediatric providers. Survey assessed provider-reported utilization of 11 Essential Steps adapted from the 2002 Consensus Statement on Health Care Transitions for YSHCNs, and recent transitioning literature. Compliance score (CS11) was calculated as a sum of steps completed. Additional items assessed knowledge of transitioning literature and respondent demographics. Survey achieved a 28% response rate (n=105), of whom 84 reported assisting transitioning YSHCNs. Only 16.7% of these respondents were compliant with 7 or more of the 11 Essential Steps. Respondents who identified social work or nursing were more likely to have CS11 scores ≥7 compared to those without and were more likely to be compliant with specific steps. We found limited and incomplete utilization of recommended transitioning steps for YSHCNs by pediatric providers within a large urban healthcare network. Access to support from social work and nursing was associated with greater utilization of specific recommended steps, and with more optimal compliance. Further research needs to assess the transitioning practices of all members of the multidisciplinary team and whether operationalizing healthcare transition for YSHCNs as a multidisciplinary activity impacts the transitioning process and patient outcomes.

Electronic medical record analysis of emergency room visits and hospitalizations in individuals with epilepsy and mental illness comorbidity.

Epilepsy is a chronic neurological condition that significantly increases risk of injury and premature death. Rates of mental illness are also disproportionately high in those with epilepsy, which can be attributed in part to the stress and stigma associated with epilepsy. Psychiatric conditions generally complicate the management of epilepsy, and understanding how psychiatric comorbidity affects use of crisis-based health resources could inform care approaches that help improve epilepsy care. To better understand effects of psychiatric comorbidity on epilepsy burden, we conducted a 5-year retrospective analysis of data from a large safety-net healthcare network and compared the occurrence of negative health events (NHEs), defined as emergency department (ED) visits and hospitalizations, among individuals with epilepsy and mental illness (E-MI) vs. those with epilepsy alone (E). Electronic health record (EHR) data from a large Midwestern U.S. safety-net healthcare system were queried to identify a study population of adults ≥18years with a diagnosis of epilepsy, with or without mental illness. We assessed demographic and clinical characteristics for each of the 5years and compared NHEs between subgroups with E-MI vs. E. An additional analysis focused on those individuals who remained in the healthcare system over the entire 5-year study time frame (January, 2010 to December, 2014). Annual and cumulative NHE counts and hospital length of stay for individuals with E-MI and E were assessed, as were hospital discharge diagnoses. The number (approximately 2000) and demographic characteristics of individuals with epilepsy who received care each year of the study period was relatively consistent. In 2014, mean age of individuals with epilepsy was 48 (range: 18-95), 48.2% were women, 51.5% were White, 37.9% were African-American, and 8.6% were Hispanic. In 2014, there were 1616 (78.6%) individuals in the subgroup with E and 439 (21.4%) in the subgroup with E-MI. Most clinical and demographic variables between the subgroups with E-MI and E were similar, except that individuals with E-MI were less likely to be employed or commercially insured. Overall, NHEs were common, with over 1/4 (27.5%) of all individuals with epilepsy having an ED visit during the year, 13.7% having hospitalization, and 34.2% having either an ED visit or hospitalization. Individuals with E-MI had significantly more NHEs compared to individuals with epilepsy only, as evidenced by higher rates of any NHE (p<.001), ED visits (p<.001), and hospitalizations (p<.001). The cumulative differential in ED and hospital use between subgroups with E-MI and E was substantial over a 5-year time period. While most NHEs were directly related to seizures for the overall group, substance-use complications appeared as a top reason for hospitalization only in the group with E-MI. Individuals with E-MI made up just over 20% of all people with epilepsy in a safety-net system and had higher rates of NHEs than those without mental illness. Better and earlier identification of individuals with E-MI, assistance with self-management including helping individuals to optimize ambulatory care settings as opposed to the ED, and treatment for substance use disorders could eventually reduce NHEs in this vulnerable subgroup of individuals with epilepsy.

Development, implementation and evaluation of an evidence-based program for introduction of new health technologies and clinical practices in a local healthcare setting.

BackgroundThis paper reports the process of establishing a transparent, accountable, evidence-based program for introduction of new technologies and clinical practices (TCPs) in a large Australian healthcare network. Many countries have robust evidence-based processes for assessment of new TCPs at national level. However many decisions are made by local health services where the resources and expertise to undertake health technology assessment (HTA) are limited and a lack of structure, process and transparency has been reported.MethodsAn evidence-based model for process change was used to establish the program. Evidence from research and local data, experience of health service staff and consumer perspectives were incorporated at each of four steps: identifying the need for change, developing a proposal, implementation and evaluation. Checklists assessing characteristics of success, factors for sustainability and barriers and enablers were applied and implementation strategies were based on these findings. Quantitative and qualitative methods were used for process and outcome evaluation. An action research approach underpinned ongoing refinement to systems, processes and resources.ResultsA Best Practice Guide developed from the literature and stakeholder consultation identified seven program components: Governance, Decision-Making, Application Process, Monitoring and Reporting, Resources, Administration, and Evaluation and Quality Improvement. The aims of transparency and accountability were achieved. The processes are explicit, decisions published, outcomes recorded and activities reported. The aim of ascertaining rigorous evidence-based information for decision-making was not achieved in all cases. Applicants proposing new TCPs provided the evidence from research literature and local data however the information was often incorrect or inadequate, overestimating benefits and underestimating costs. Due to these limitations the initial application process was replaced by an Expression of Interest from applicants followed by a rigorous HTA by independent in-house experts.ConclusionThe program is generalisable to most health care organisations. With one exception, the components would be achievable with minimal additional resources; the lack of skills and resources required for HTA will limit effective application in many settings. A toolkit containing details of the processes and sample materials is provided to facilitate replication or local adaptation by those wishing to establish a similar program.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1178-4) contains supplementary material, which is available to authorized users.

Strategic role of a flag hospital in a large healthcare network

The Gruppo Villa Maria Care & Research (GVM c & r ), a network of >30 hospitals spread across 4 different countries in Europe, represents a major player in the setting of healthcare providers. Identifying a hospital to represent the philosophy of care and management of the Group (a ‘flag’ hospital) in the national and international scenario is a strategic decision taken at top management level. The need to adapt to a healthcare ecosystem that increasingly puts priority on better health outcomes and effective cost-containment calls for a change in the models of care management and a different relationship …

Relationship between PatientÂ’s Demographics and Stone Composition in Men and Women

Purpose: To detect the differences in age, weight and height between three major stone groups. Materials and Methods: We retrospectively reviewed all patients with a diagnosis of nephrolithiasis in a large healthcare network from January 2000 to July 2014, for whom information on stone composition, age, sex, weight and height was available. Patients less than 18 years were excluded. Patients were characterized by gender and the major component of their stone analysis. We used Wilcoxon rank-sum test for continuous variables to detect the significant differences and multiple logistic regression analysis to evaluate the relative risk between stone groups. Results: 14,961 adult patients were identified. The Distribution of pure (≥ 90%) calcium oxalate, phosphate and uric acid stones in men, was (71%), (7%) and (22%) while in women it was (65%), (19%) and (16%) respectively. Males with calcium oxalate stones were taller than those with calcium phosphate by 2 cm (p=0.0006). Women with calcium phosphate stones were younger than those with calcium oxalate stones by 5 years (p=0.0001). Conclusions: Calcium phosphate stone composition is associated with a shorter stature in men and younger age in women in relation to those with calcium oxalate stones.

Implementation of Sarah Cannon national and international multidisciplinary cancer tumor boards: Initial results.

138 Background: Optimal cancer care is achievable when input is available from specialists in all related disciplines. To exploit the breadth and depth of clinical expertise within a large healthcare network, regularly scheduled web-based multidisciplinary tumor boards related to complex GI and breast cancers have been established. Methods: Monthly national and quarterly international multispecialty tumor boards were held in 2014. Each center presented a case for discussion and suggested management on a predetermined solid tumor subtype or clinical scenario. A web-based interface was used to show key information to the group in real time, including imaging, pathology, and laboratory results. Subspecialty participation included well known centers of excellence in radiation oncology, medical oncology, clinical research, surgical oncology and interventional oncology. A process to assure HIPPA compliance was implemented, and CME awarded. Results: Sarah Cannon centers in Nashville, Kansas City, Denver, San Antonio, Austin and London participated. An average attendance of ten physicians per center (range 4-18) was seen. Survey results demonstrated significant value as reported by participants in improving patient care leading to the development of a prospective clinical trial in one instance. Therapeutic options not available in the US but offered in the London center were discussed and a mechanism for direct referral to the London facility was developed. Improved rates of breast conservation (18% increase), breast reconstruction (31% increase) and use of AJCC staging (24% increase) were the product of breast conferences in each market. Conclusions: Physicians overwhelmingly supported and valued multidisciplinary tumor boards for GI and breast cancers. Consensus development, sharing of best practices, and promotion of the latest evidence based management led to changes in patient care. Additional centers will be invited to join meetings this year, with planned expansion to initiate similar meetings in blood and thoracic malignancies.

The ongoing evolution of the core curriculum of a clinical fellowship in pathology informatics

The Partners HealthCare system's Clinical Fellowship in Pathology Informatics (Boston, MA, USA) faces ongoing challenges to the delivery of its core curriculum in the forms of: (1) New classes of fellows annually with new and varying educational needs and increasingly fractured, enterprise-wide commitments; (2) taxing electronic health record (EHR) and laboratory information system (LIS) implementations; and (3) increasing interest in the subspecialty at the academic medical centers (AMCs) in what is a large health care network. In response to these challenges, the fellowship has modified its existing didactic sessions and piloted both a network-wide pathology informatics lecture series and regular “learning laboratories”. Didactic sessions, which had previously included more formal discussions of the four divisions of the core curriculum: Information fundamentals, information systems, workflow and process, and governance and management, now focus on group discussions concerning the fellows’ ongoing projects, updates on the enterprise-wide EHR and LIS implementations, and directed questions about weekly readings. Lectures are given by the informatics faculty, guest informatics faculty, current and former fellows, and information systems members in the network, and are open to all professional members of the pathology departments at the AMCs. Learning laboratories consist of small-group exercises geared toward a variety of learning styles, and are driven by both the fellows and a member of the informatics faculty. The learning laboratories have created a forum for discussing real-time and real-world pathology informatics matters, and for incorporating awareness of and timely discussions about the latest pathology informatics literature. These changes have diversified the delivery of the fellowship's core curriculum, increased exposure of faculty, fellows and trainees to one another, and more equitably distributed teaching responsibilities among the entirety of the pathology informatics asset in the network. Though the above approach has been in place less than a year, we are presenting it now as a technical note to allow for further discussion of evolving educational opportunities in pathology informatics and clinical informatics in general, and to highlight the importance of having a flexible fellowship with active participation from its fellows.

An Initiative to Improve the Management of Clinically Significant Test Results in a Large Health Care Network

The failure of providers to communicate and follow up clinically significant test results (CSTR) is an important threat to patient safety. The Massachusetts Coalition for the Prevention of Medical Errors has endorsed the creation of systems to ensure that results can be received and acknowledged. In 2008 a task force was convened that represented clinicians, laboratories, radiology, patient safety, risk management, and information systems in a large health care network with the goals of providing recommendations and a road map for improvement in the management of CSTR and of implementing this improvement plan during the sub-force sequent five years. In drafting its charter, the task broadened the scope from "critical" results to "clinically significant" ones; clinically significant was defined as any result that requires further clinical action to avoid morbidity or mortality, regardless of the urgency of that action. The task force recommended four key areas for improvement--(1) standardization of policies and definitions, (2) robust identification of the patient's care team, (3) enhanced results management/tracking systems, and (4) centralized quality reporting and metrics. The task force faced many challenges in implementing these recommendations, including disagreements on definitions of CSTR and on who should have responsibility for CSTR, changes to established work flows, limitations of resources and of existing information systems, and definition of metrics. This large-scale effort to improve the communication and follow-up of CSTR in a health care network continues with ongoing work to address implementation challenges, refine policies, prepare for a new clinical information system platform, and identify new ways to measure the extent of this important safety problem.

A Decision-Making Tool for a Regional Network of Clinical Laboratories

For healthcare systems that operate in large, geographically dispersed areas, the quality of the services provided requires the effective management of a complex transportation problem. We present a decision support system to help healthcare managers improve the delivery of biological samples collected from patients in hospitals and outpatient clinics to laboratories that perform tests on them. We develop an optimization model for supporting strategic decisions on the transport of samples and the assignment of work in a large healthcare network with geographically dispersed hospitals, clinics, and testing laboratories. We embed our model in a Web-based tool to provide planners with interactive functions, enabling them to explore solutions and interactively access data to facilitate the analysis of what-if scenarios. The tool proved invaluable in helping the Andalusian Healthcare System obtain significant improvements in efficiency, quality of service, and outsourcing costs.

Discursive Recontextualization in a Public Health Setting

The authors discuss discursive recontextualization as a process of discursive change in which stable referents may be recombined. As such, discursive recontextualization recognizes the interplay of both stability and instability without necessarily privileging the latter. Drawing on intertextual document analysis of a series of public reports published in the wake of a major health policy initiative in Victoria, Australia— Health to 2050—the authors identify a discursive pattern in which descriptions of a disaggregation from large Health Care Networks to smaller Metropolitan Health Services echo those of an earlier aggregation of individual hospitals into the Health Care Networks. The authors suggest that future research into discourse and organizational change will benefit from greater attention to stabilization and such recontextualization as well as to fluidity and instability. They examine implications for change agents and for researchers in the field.

Development and Implementation of a Comprehensive Strategic Plan for Medical Education at an Academic Medical Center

Despite their vital contributions to the training of future physicians, many academic teaching hospitals have grown operationally and financially distinct from affiliated medical schools because of divergent missions, contributing to the erosion of clinical training. Some institutions have responded by building hybrid organizations; others by creating large health care networks with variable relationships with the affiliated medical school. In this case, the authors wished to establish the future educational mission of their medical center as a core element of the institution by creating data-driven recommendations for reorganization, programs, and financing. They conducted a self-study of all constituents, the results of which confirmed the importance of education at their institution but also revealed the insufficiency of incentives for teaching. They underwent an external review by a committee of prominent educators, and they involved administrators at the hospital and the medical school. Together, these inputs composed an informed assessment of medical education at their teaching hospital, from which they developed and actualized an institution-wide strategic plan for education. Over the course of three years, they centralized the administrative structure for education, implemented programs that cross departments and reinforce the UME-GME continuum, and created transparency in the financing of medical education. The plan was purposefully aligned with the clinical and research strategic plans by supporting patient safety in programs and the professional development of faculty. The application of a rigorous strategic planning process to medical education at an academic teaching hospital can focus the mission, invigorate faculty, and lead to innovative programs.

The Effect of Statins on Viral Load in Patients with Chronic Hepatitis C

Purpose: There is some evidence that HMG-CoA reductase inhibitors (statins) have an effect on hepatitis C virus (HCV) replication in vitro, but there is no in vivo data. We conducted a retrospective review from one large healthcare network database to evaluate the effect of statins on viral loads (VLs) in patients chronically infected with HCV. Methods: We identified all patients seen between 2000–06 who had chronic HCV, were prescribed a statin, and had HCV VLs measured before and after the initiation of statins (N = 16). We excluded patients with chronic hepatitis B or HIV infection or those receiving active treatment for HCV. We collected data on age, gender, ethnicity, BMI, self-reported alcohol use, specific statin medication and dose, HCV serology and genotype, LFTs and lipid profile. We compared the change in HCV VLs before and after initiation of statins by Wilcoxon Signed Rank test. All significant P values reported for P < .05. Results: In our study, patients were males (100%) of Caucasian ethnicity (80%) with mean age 55.5 yrs and BMI 29.7. The median log10VL prior to initiation of statin was 6.094. Most patients had genotype 1 (80%). Majority of patients were prescribed simvastatin (87.5%) with mean dose of 35.4 mg. Patients were taking statins for mean 430.4 days prior to having HCV VL rechecked with median log10VL 6.103 at that time. There was no significant difference between HCV VL before and after initiation of statin (P= .96), and there was also no significant change in LFTs after statins were started. However, there was a significant decrease in total cholesterol after statins were started (P < .001).FigureConclusion: Our review did not demonstrate a significant change in HCV levels after initiation of statin. However, larger, prospective studies are required.[figure1]Table. Results

Implementing the Hospital Emergency Incident Command System: An Integrated Delivery System's Experience

Hospital disaster manuals and response plans often lack formal command structure; instead, they rely on the presence of key individuals who are familiar with hospital operations, or who are in leadership positions during routine, day-to-day operations. Although this structure occasionally may prove to be successful, it is unreliable, as this leadership may be unavailable at the time of the crisis, and may not be sustainable during a prolonged event. The Hospital Emergency Incident Command System (HEICS) provides a command structure that does not rely on specific individuals, is flexible and expandable, and is ubiquitous in the fire service, emergency medical services, military, and police agencies, thus allowing for ease of communication during event management. A descriptive report of the implementation of the HEICS throughout a large healthcare network is reviewed. Implementation of the HEICS provides a consistent command structure for hospitals that enables consistency and commonality with other hospitals and disaster response entities.

Birthweight-adjusted mortality rates for assessing the effectiveness of neonatal intensive care.

Mortality rates for very-low-birthweight infants vary significantly among different neonatal intensive care units (NICUs). Computational models and computer simulation are used to predict the performance of an algorithm for identifying individual NICUs within a network that have greater than 110% of the expected birthweight-adjusted mortality risk. The algorithm maintains high sensitivity and specificity with as few as three moderately heterogeneous risk categories when applied to large health care networks; the model parameters were based on preliminary data from a real NICU network. The performance of the algorithm depends on the number of admissions at the individual NICU. A NICU with a center-specific risk 130% of the network average would be correctly identified as an outlier 50% of the time if it had 35 admissions, 59% of the time if it had 70 admissions, and 77% of the time if it had 280 admissions. A NICU with average risk would be incorrectly identified as an outlier 16%, 12%, or 2% of the time if it had 35, 70, or 280 admissions, respectively. Severity-of-illness casemix adjustment did not improve these results. It is concluded that the sensitivity and specificity of the algorithm in determining which facilities have higher-than-expected mortality will be less in typical NICU networks than in large health care networks that treat adult patients. It is unlikely that severity-of-illness adjustments will overcome the problem of the small numbers of admissions at individual NICUs.