Outpatient Follow-up Visits Research Articles

215EMF Development of a Brief Motivational Interview Intervention to Promote Advance Care Planning for Older Adults After Leaving the Emergency Department

The majority of older adults with serious illnesses visit the ED near the end of life, yet most do not have advance directives. In the time-pressured ED environment, the lack of a feasible method to facilitate advance care planning (ACP) constrains our current practice. We sought to develop and refine a brief motivational interview (BMI) intervention for older adults to engage in ACP conversations with their primary outpatient clinician. We conducted iterative cognitive interviews to refine our BMI intervention. We adapted a well-established BMI intervention previously designed for alcohol dependence to empower older adults to seek ACP conversations with their primary outpatient clinicians. Using an expert panel consisting of palliative care researchers and BMI researchers, we created a prototype to meet the needs of older adults with serious illness. The prototype was refined using mock clinical encounters and iterative cognitive interviews. Emergency medicine clinicians administered the intervention to the patient family advisory council members (prior ED patients who volunteered to improve the care we deliver) and standardized patients. After the mock encounters, individual cognitive interviews were performed to understand both the clinician and patient perspectives. An acceptability Likert-scale survey was administered to all participants. The scripted text was refined based on participants’ inputs, and the iterative refinements were reviewed by a second, blinded, attending emergency physician and the expert panel to ensure feasibility in the ED and maintenance of BMI and serious illness communication principles. This process was deemed when >75% of participants rated the intervention acceptable. We conducted 16 mock clinical encounters with 11 attending emergency physicians, 3 physician assistants, and 7 patients. 71% of the clinicians were male. Clinicians had broad range of clinical experience (57% with <5 years, 7% with 5 to 10 year, and 36% with >10 years of experience after training). Patients were 50% male, including 3 standardized patients. The mean acceptability Likert scale (0 not acceptable, 1-4 somewhat unacceptable, 6-9 somewhat acceptable and 10 completely acceptable) was 7. Clinicians spent mean of 6.8 minutes administering the BMI intervention. Examples of refinement included explicit stating the need for goals of care in the setting of worsening serious illness, using patient-centered language, eliminating readiness numerical scale, focusing to prepare for ACP conversation at the follow-up outpatient visit, allowing administering clinicians to use their judgment to avoid redundancy, and including specific actionable items that patients can take home to prepare for their follow-up visit. Participants also recommended shortening the script in concern for time, including caregiver (if present), and offering an opt-out process for patients to refuse the intervention if necessary can further improve the intervention acceptability. An ED BMI intervention for ACP conversations has been developed and refined. This intervention may improve the rate of ACP conversations for older adults after leaving the ED. Further study is needed to understand how older adults in the ED perceive this intervention.

Return to Work after Surgical Treatment of Coxarthrosis by Total Cementless Hip Arthroplasty

Total hip arthroplasty is currently commonly used in surgical treatment of advanced hip osteoarthritis of various aetiologies. Studies show that the number of these procedures has been growing every year, which is associated with global population ageing. The aim of the study was to assess return to work in patients after surgical treatment by arthroplasty due to hip osteoarthritis. The study assessed 114 patients of productive age who underwent surgery due to advanced hip osteoarthritis. The mean age was 49.9 years in women and 52.2 years in men. All patients included in this retrospective study underwent clinical and radiographic assessment prior to arthroplasty and at the last out-patient follow-up visit. The patients' occupational status and the time of return to work after surgery were also assessed. The results of this clinical study were analysed according to the Merle d'Aubigne-Postel classification (modified by Charnley). Preoperative radiographs were assessed according to the Kellgren-Lawrence classification. The radiographs served to assess the position of the endoprosthesis, including both the acetabular component and the stem. The results were statistically analysed. Pre-operative assessment classified all cases as poor both clinically and radiographically. The post-operative outcomes were excellent in 71 cases (61.7%), good in 37 cases (32.2%) and fair in 7 cases. No case was classified as poor. The mean improvement was 6.6 points and reached the level of statistical significance. Radiographic evaluation did not reveal evidence of aseptic implant loosening and confirmed a normal seat of endoprosthetic components within the Lewinnek safe zone in each case. Only 75 (65.8%) of the study participants worked before the procedure. After the treatment was completed, 67 (58.8%) study patients took up employment. The mean duration of sick leave was 138.6 days and 21 patients were receiving rehabilitation benefits. 1. Total hip arthroplasty is a valuable method of surgical treatment of advanced coxarthrosis of various aetiologies in patients of productive age. 2. Most patients who worked before the surgery return to work in the same position and work time. 3. Only dysplastic coxarthro-ses have an unfavourable prognosis with respect to starting or resuming work after surgery.

The association of post-discharge adverse events with timely follow-up visits after hospital discharge.

ObjectiveThere has been little research to examine the association of post-discharge adverse events (AEs) with timely follow-up visits after hospital discharge. We aimed to examine whether having a timely follow-up outpatient visit would reduce the risk for post-discharge AEs.MethodsThis was a methods study of patients at risk for post-discharge AEs from December 2011 through October 2012. Five hundred and forty-five patients who were under the care of hospitalist physicians and were discharged home from a community hospital, spoke English, and could be contacted after discharge were evaluated. The aim of the study was to examine the association of post-discharge AEs with timely follow-up visits after hospital discharge based on structured telephone interviews, health record review, and adjudication by two blinded, trained physicians using a previously established methodology.ResultsWe observed a higher incidence of AEs with patients that had their first follow-up visit within 7 days after hospital discharge (33.5% vs. 23.0%, p = 0.007). This effect was attenuated somewhat but remained significant when adjusted for several patient factors (adjusted OR 1.33, 95% confidence interval 1.16–2.71).ConclusionThis observational study paradoxically showed an increase in post-discharge AEs with early follow-up, likely a result of confounding by indication and/or information bias that could not be completely adjusted for. This study illustrates the potential hazards with conducting observational studies to determine the efficacy of various transitional care interventions, such as early follow-up, where risk for confounding by indication is high.

The association of SCN1A p.Thr1067Ala polymorphism with epilepsy risk and the response to antiepileptic drugs in Slovenian children and adolescents with epilepsy

PurposeThe voltage-gated sodium channel SCN1A mutations are involved in epileptogenesis and may be associated with different epilepsy phenotypes. The SCN1A channel is also an important antiepileptic drug (AED) target. The aim of this study was to investigate if the SCN1A c.3184A>G/p.Thr1067Ala polymorphism modifies the epilepsy risk or is associated with the responsiveness to AEDs in Slovenian children and adolescents with epilepsy. MethodsIn total, 216 paediatric patients with epilepsy were consecutively recruited during routine outpatient follow-up visits between January 2011 and December 2014. All patients and 95 healthy controls, all Central European Caucasians, were genotyped for the SCN1A c.3184A>G/p.Thr1067Ala polymorphism. Clinical data on all patients were collected retrospectively. The response to AEDs was classified as seizure remission (a minimum of one year of seizure freedom before inclusion) or no remission. Univariate and multivariate logistic regression was used to determine the association of genotypes with binary outcomes. Results114 patients (52.8%) had achieved remission, while 102 (47.2%) had failed to do so. Carriers of at least one polymorphic SCN1A c.3184A>G/p.Thr1067Ala G allele tended to have a lower epilepsy risk (OR=0.38, 95% CI=0.18–0.79, P=0.010) and were significantly more likely to achieve remission (OR=2.00, 95% CI=1.16–3.46, P=0.013). Girls were less likely to achieve remission (P=0.055). Patients in remission tended to be older at first seizure in comparison to the group failing to achieve remission (OR=1.06, 95% CI=0.99–1.14, P=0.099), but this association did not reach statistical significance. ConclusionThe polymorphic SCN1A c.3184A>G/p.Thr1067Ala G allele was associated with a lower risk of epilepsy and a higher remission rate in Slovenian children and adolescents with epilepsy.

Outpatient Follow-Up Care and Risk of Hospital Readmission in Schizophrenia and Bipolar Disorder

Although outpatient care within 30 days of mental health hospital discharge is an established quality indicator, little is known about the clinical implications of not receiving such care. This study evaluated whether receipt of outpatient care within 30 days of discharge was associated with a reduced risk of readmission during days 31-120 postdischarge among adult inpatients with schizophrenia or bipolar disorder. Retrospective longitudinal cohort analyses were performed with Truven MarketScan Commercial (2010-2014) and Medicaid (2010-2013) databases. Among inpatients with schizophrenia (N=25,401) or bipolar disorder (N=46,375), overall and stratified associations were examined between receipt of an outpatient follow-up visit in the 30 days postdischarge and hospital readmission during days 31-120 postdischarge. Receipt of a follow-up visit within 30 days of discharge was associated with a slightly lower adjusted odds ratio (AOR) of hospital readmission during days 31-120 postdischarge (schizophrenia, AOR=.88, 95% confidence interval [CI]=.81-.96; bipolar disorder, AOR=.91, CI=.85-.98). For patients with schizophrenia, the strongest observed inverse association of follow-up care with readmission risk was among inpatients whose index admissions were 13 to 30 days long (AOR=.73, CI=.61-.89). For patients with bipolar disorder, the strongest corresponding inverse association was among those in the manic phase of illness at the index discharge (AOR=.73, CI=.63-.86). Outpatient visits during the 30 days after discharge were associated with a lower hospital readmission risk during the following 90 days. Assertive hospital discharge planning to secure outpatient visits after hospital discharge is needed for these patient populations.

Evaluating Retention of Skin Cancer Education in Kidney Transplant Recipients Reveals a Window of Opportunity for Re-education

BackgroundSkin cancer is the most common malignancy after solid organ transplant and can lead to significant morbidity. The likelihood of developing squamous cell carcinomas and melanomas is 100 and 2.4 times more likely, respectively, in kidney transplant recipients when compared with the general population. There are few data regarding the assessment and influence of solid organ transplant recipient (SOTR) knowledge of skin cancer and its effect on short- and long-term awareness and behavior. MethodsThe purpose of this study was to assess the baseline knowledge of SOTR immediately after transplantation, and then to reassess their knowledge following a 5-minute educational video. We also wanted to determine whether lifestyle modifications had been implemented 4 to 8 months after the intervention. ResultsForty patients were enrolled within 2 months of transplantation. Eighty-seven percent of patients were renal transplant recipients, and 75% of patients were available for long-term follow-up. There was a significant increase in knowledge in the immediate postintervention period, which was sustained at 4- to 8-month follow-up, as assessed by patient questionnaire. Patients appeared to be applying this knowledge by participating in lifestyle risk modification and positive sun-protective behavior. ConclusionsOur study suggests that incorporating additional skin cancer education into the early transplant timeline (perhaps in the first one or two outpatient follow-up visits) with an easy to administer educational video and question and answer form increases patient knowledge and influences positive sun-protective behavior.

Assessing Quality and Safety in Pediatric Supracondylar Humerus Fracture Care.

Recently, there has been an emphasis on improving quality, safety, and value in the delivery of health care in the United States. The American Board of Orthopedic Surgery (ABOS) has developed a performance improvement questionnaire (PIQ) for orthopaedic surgeons managing pediatric supracondylar humerus fracture (PSCHF). Using the supracondylar PIQ as a guide, this study evaluates the process of measuring the outcomes and variations in care to PSCHF patients among pediatric orthopaedic surgeons. An 88-question survey incorporating the ABOS PIQ was administered to 35 pediatric orthopaedic surgeons at 3 institutions. A retrospective chart review of patients who received operative management of a PSCHF during 2013 was performed. Each of the 17 eligible surgeons supplied 5 patients for a total of 85 patients. Medical records and radiographic imaging were reviewed using the ABOS PIQ data collection sheet. This data collection sheet encompasses the preoperative assessment, intraoperative treatment and assessment, and clinical and radiographic outcomes of patients with PSCHF. A total of 35 surgeons from 6 hospitals completed the online PSCHF survey. Uniform consensus among all 35 surgeons was identified in 21/79 of the questions (27%). Consensus among surgeons within a hospital group but not with surgeons from the other groups was identified in 39/79 (49%) of the questions. No consensus among the surveyed surgeons could be identified in 19/79 (24%) of the questions. For the 85 PSCHF patients the average age was 6 years, and 37% of fractures were type II, 57% of fractures were type III, and there was 1 flexion type. Ninety percent of the patients received a preoperative dose of antibiotics and the postoperative immobilization placed in the operating room was changed in the clinic before pin removal in 58% of the cases. Pins were removed at 3 weeks in 60%, 4 weeks in 30%, 5 weeks in 7%, and after 5 weeks in 3% of the patients and no malunions occurred. Pin tract infection occurred in 2 patients (2.4%). The procedure time ranged from 13 to 171 minutes, with a median time of 37 minutes. Total anesthesia time ranged from 32 to 233 minutes, with a median of 72 minutes. The number of outpatient follow-up visits ranged from 2 to 7 visits, with a median of 3 visits. The number of postoperative radiographs obtained ranged from 1 to 14, with a median of 3 studies. Four patients (5%) returned to the operating room for a repeat surgery. The survey responses from the surgeons at 6 different hospitals demonstrate that there is still considerable variation in care among surgeons, even for such a routine injury. Our chart review also revealed substantial variation in care with subsequent quality and cost-implications. The variations in operating room time, anesthesiology time, number of postoperative visits, number of radiographs ordered, and the initial intraoperative immobilization, all point to opportunities for standardization and lowering of costs. Level IV.

Predictive Validity of Outpatient Follow-up After Detoxification as a Quality Measure.

Care coordination for substance use disorder (SUD) treatment is a persistent challenge. Timely outpatient follow-up after detoxification from alcohol and opiates is associated with improved outcomes, leading some care systems to attempt to measure and incentivize this practice. This study evaluated the predictive validity of a 7-day outpatient follow-up after detoxification quality measure used by the Veterans Health Administration (VHA). A national sample of patients who received detoxification from alcohol or opiates (N = 25,354) was identified in VHA administrative data. Propensity score-weighted mixed-effects regressions modeled associations between receiving an outpatient follow-up visit within 7 days of completing detoxification and patient outcomes, controlling for facility-level performance and clustering of patients within facilities. Baseline differences between patients who did (39.6%) and did not (60.4%) receive the follow-up visit were reduced or eliminated with propensity score weighting. Meeting the quality measure was associated with significantly more outpatient treatment for SUD (b = 1.07 visits) and other mental health conditions (b = 0.58 visits), and higher inpatient utilization for SUD (b = 0.75 admissions) and other mental health conditions (b = 0.76 admissions). Notably, meeting the quality measure was associated with 53.3% lower odds of 2-year mortality (P < 0.001 for all). These findings support the predictive validity of 7-day follow-up after detoxification as a care coordination measure. Well-coordinated care may be associated with higher outpatient and inpatient utilization, and such engagement in care may be protective against mortality in people who receive detoxification from alcohol or opiates.

The use of a chitosan dressing with silver in the management of paediatric burn wounds: a pilot study.

Traditional burn dressings demonstrate unfavourable tendencies of shrinking when wet and failing to maintain their integrity when manipulated. To overcome these obstacles, gel-forming fibre dressings have emerged as an alternative. Our objective was to observe the clinical properties and healing ability in the setting of burn wounds in a paediatric centre of a chitosan-based dressing containing silver. A sample of 12 partial-thickness burns in 10 children were identified for treatment with the chitosan-based silver dressing. The dressings were moistened before application, and monitored for any shrinkage on application. Patients were monitored for healing at outpatient follow-up visits and the dressings were allowed to separate as healing occurred. We treated 12 burns in 10 children with an average age of 5.2 years. The burns had an average proportion of total body surface area (TBSA) of 3.6 % and involved the trunk and all extremities. Wounds healed mostly or completely in an average of 8.3 days. Dressings retained their size when wet and integrity when removed. No burns were found to be infected at any point in the study. The chitosan-based dressing offered an optimal environment for moist wound management, and did not demonstrate the shrinkage or disintegration that diminishes the clinical usability of widely used hydrofibre dressings. The burns healed within an expected period of time, and did not undergo any infectious processes. Based on the results of this pilot study, the chitosan-based silver dressing is deserving of further study as an alternative to traditional burn dressings.

EPICOG-SCH: A brief battery to screen cognitive impact of schizophrenia in stable outpatients

Brief batteries in schizophrenia, are needed to screen for the cognitive impact of schizophrenia. We aimed to validate and co-norm the Epidemiological Study of Cognitive Impairment in Schizophrenia (EPICOG-SCH) derived brief cognitive battery. A cross-sectional outpatient evaluation was conducted of six-hundred-seventy-two patients recruited from 234 centers. The brief battery included well-known subtests available worldwide that cover cognitive domains related to functional outcomes: WAIS-III-Letter-Number-Sequencing-LNS, Category Fluency Test-CFT, Logical-Memory Immediate Recall-LM, and Digit-Symbol-Coding-DSC. CGI-SCH Severity and WHO-DAS-S were used to assess clinical severity and functional impairment, respectively. Unit Composite Score (UCS) and functional regression-weighted Composite Scores (FWCS) were obtained; discriminant properties of FWCS to identify patients with different levels of functional disability were analyzed using receiver-operating characteristic (ROC) technique. The battery showed good internal consistency, Cronbach's alpha=0.78. The differences between cognitive performance across CGI-SCH severity level subscales ranged from 0.5 to 1 SD. Discriminant capacity of the battery in identifying patients with up to moderate disability levels showed fair discriminant accuracy with areas under the curve (AUC)>0.70, p<0.0001. An FWCS mean cut-off score≥100 showed likelihood ratios (LR) up to 4.7, with an LR+ of 2.3 and a LR− of 0.5. An FWCS cut-off≥96 provided the best balance between sensitivity (0.74) and specificity (0.62).The EPICOG-SCH proved to be a useful brief tool to screen for the cognitive impact of schizophrenia, and its regression-weighted Composite Score was an efficient complement to clinical interviews for confirming patients' potential functional outcomes and can be useful for monitoring cognition during routine outpatient follow-up visits.

Virtual Visits for Acute, Nonurgent Care: A Claims Analysis of Episode-Level Utilization.

BackgroundExpansion of virtual health care—real-time video consultation with a physician via the Internet—will continue as use of mobile devices and patient demand for immediate, convenient access to care grow.ObjectiveThe objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions.MethodsA cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy.ResultsA total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, P<.001; UCC: 39.01%, P<.001; ED: 53.15%, P<.001; PCP: 37.40%, P<.001), and imaging rates for virtual visits (6.62%) were typically lower than in-person locations (RHC: 5.97%, P=.11; UCC: 8.77%, P<.001; ED: 43.06%, P<.001; PCP: 11.26%, P<.001). RHC, UCC, ED, and PCP were estimated to be $36, $153, $1735, and $162 more expensive than virtual visit episodes, respectively, including medical and pharmacy costs.ConclusionsVirtual care appears to be a low-cost alternative to care administered in other settings with lower testing rates. The similar follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care.

Health Literacy in Orthopaedic Trauma Patients.

This study aimed to determine the level of health literacy in a postoperative orthopaedic trauma population and to evaluate the efficacy of a simple predischarge discussion strategy, targeted at improving health literacy. A pre-post intervention study was conducted from April 2014 to January 2015. Academic Level 1 trauma center. One hundred ninety consecutive orthopaedic trauma patients with operatively managed lower limb fractures were recruited. All eligible participants agreed to participate. The first ninety-nine patients received usual care (UC). The following 91 patients received a structured predischarge discussion, including x-rays, written and verbal information, from the orthopaedic staff (DG). Patients were then randomized into health literacy evaluation before first outpatient review or after first outpatient review. The primary outcome measure was a questionnaire determining health literacy. Ninety-six (97%) of the UC patients and 87 (96%) of the discussion patients (DG) completed the interview. UC preoutpatient (n = 46) demonstrated a mean score of 4.67 of a maximum 8. UC postoutpatient (n = 50) demonstrated a mean score of 5.42. DG preoutpatient (n = 47) demonstrated a mean score of 6.70. DG postoutpatient (n = 40) demonstrated a mean score of 7.08. Australian orthopaedic trauma patients demonstrate poor health literacy, with this not showing improvement after their first outpatient follow-up visit. The use of a time efficient, structured predischarge discussion improved patient health literacy. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Deficits in oral health behavior and oral health status in patients after lung transplantation.

Dental status has been implicated in several systemic inflammatory diseases and is a potential focus for systemic infections. Therefore, most lung-transplant centers have recommendations regarding pre-transplant dental care and follow-up, but there are no official clinical guidelines. To date there is little information on oral health status in lung transplant (LTx) recipients. The aim of this study was to systematically assess oral health status in LTx recipients. The aim of this study was to assess oral health status, including periodontal disease, oral health behavior, and awareness of the need for good oral health after LTx. LTx recipients were recruited during follow-up outpatient visits at a university clinic transplant unit. Oral health status was quantified using the count of Decayed, Missing, and Filled Teeth (DMF-T) and the grade of periodontal disease was measured by probing depth. Patients' oral health behavior was assessed using a questionnaire. Seventy-three patients were included at 5.8 ± 3.4 years after lung transplantation. The mean DMF-T was 21.9 ± 5.5. Patients with cystic fibrosis as the indication for transplantation had a significantly lower DMF-T than patients with chronic obstructive pulmonary disease as the transplant indication. Of the 66 patients with teeth, 97% had moderate or severe periodontal disease. The prevalence of moderate or severe periodontal disease was significantly higher in LTx recipients (mean age 55.9 years) compared with older individuals (age 65-74 years) from the German general population (P < .005). This single center study shows deficits in oral health and oral health behavior in patients after LTx. There is a strong need for interdisciplinary collaboration and clinical guidelines to foster better oral health education of the transplant recipient and better oral health.

Pre-Existing Right Bundle Branch BlockIncreases Risk for Death After Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve.

The aim of this study was to determine the impact of pre-existing right bundle branch block (RBBB) on clinical outcomes after transcatheter aortic valve replacement (TAVR). The impact of pre-existing RBBB on clinical outcomes after TAVR is unknown. Between October 2013 and August 2015, 749 patients undergoing TAVR using the Edwards SAPIEN XT prosthesis were prospectively enrolled in the OCEAN-TAVI (Optimized Transcatheter Valvular Intervention) registry from 8 Japanese centers. Electrocardiograms were obtained at baseline. After the procedure, follow-up outpatient visits or telephone interviews were conducted at 30 days, 6 months, and yearly. A total of 102 patients (13.6%) had pre-existing RBBB. The incidence of new pacemaker implantation was significantly higher in the RBBB group (17.6% vs. 2.9%; p< 0.01). The Kaplan-Meier analysis revealed that cardiovascular survival probability was significantly lower in the RBBB group than the no-RBBB group (log-rank p< 0.01). Patients with RBBB and without pacemakers were at higher risk for cardiovascular mortality in the early phase after discharge, and patients with RBBB and pacemakers had higher cardiovascular mortality at mid-term follow-up (log-rank p= 0.01). Amultivariate Cox regression model indicated that pre-existing RBBB (hazard ratio: 2.59; 95% confidence interval: 1.15 to 5.85; p< 0.01) was an independent predictor of cardiovascular mortality. Patients with RBBB demonstrated an increased risk for cardiovascular mortality after TAVR, and patients with RBBB and without pacemakers were at higher risk for cardiac death early after discharge. Patients withprior RBBB should be carefully monitored after undergoing TAVR.

Provider Feedback: A Potential Method to Reduce Readmissions.

There is growing emphasis on improving hospital discharge planning and transitional care for children.1 Many of the potential elements, such as medication reconciliation, patient education, scheduling of outpatient follow-up visits, and postdischarge telephone or home nursing outreach, can be added or improved through process change and new resource allocation. In adult and elderly patients, poor quality-of-care transitions have been linked to higher readmission rates, and bundled transitional care interventions have decreased readmissions in these patients.2 There is less published evidence on the impact of such interventions in hospitalized children.3 The value of readmissions as a metric of pediatric hospital care quality and the potential impact of interventions aimed at improving hospital discharge remains in question.4–6 Despite this uncertainty, pediatric readmission metrics are being incorporated into quality and payment reform, which drives efforts to further understand the etiologies of pediatric readmissions.7 As part of a broader quality improvement initiative to reduce readmissions, we notified inpatient providers about their patients’ readmissions and sought their perceptions about the preventability and causes of readmissions. In this study, we analyzed their responses to describe (1) the preventability of 30-day readmissions, and (2) causes of potentially avoidable readmissions as judged by inpatient clinicians. ### Population and Setting This work occurred at Children’s Hospital Colorado, a free-standing tertiary care center with more than 20 000 hospital discharges per year. The project was performed by our readmissions team within the context of a national quality improvement collaborative.8 We developed a process of e-mail notification for providers of children with unplanned 30-day readmissions between June and December 2013. E-mails were sent to the discharging provider from the index admission and the readmitting provider. Children discharged from all hospital services and units were included. The project was approved as quality improvement by the Children’s Hospital Organizational Research …

Psychiatric Inpatient Discharge Planning Practices and Attendance at Aftercare Appointments.

This study examined discharge planning practices by hospital providers for 17,053 psychiatric discharges in New York's statewide Medicaid program. Claims data were linked to information reported to New York State by managed behavioral health care organizations (MBHOs) conducting inpatient utilization reviews. MBHOs documented hospital providers' reports of the presence of three discharge planning practices for each discharge: communicating with an outpatient provider prior to discharge, scheduling an aftercare appointment, and forwarding a discharge summary. Hospital providers reported completing at least one of the three discharge planning practices for 85% of discharges. Individuals who received all three discharge planning practices had a higher likelihood of follow-up and kept their first outpatient follow-up visit at almost twice the speed compared with individuals who received none of the practices (hazard ratio=1.96, p<.001). This study provided baseline information concerning routine discharge planning practices and their relationship to timeliness of care transitions.

Does Pay-For-Performance Program Increase Providers Adherence to Guidelines for Managing Hepatitis B and Hepatitis C Virus Infection in Taiwan?

BackgroundMany people are concerned about that the quality of preventive care for patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is suboptimal. Taiwan, a hyperendemic area of chronic HBV and HCV infection, implemented a nationwide pay-for-performance (P4P) program in 2010, which aimed to improve the preventive care provided to HBV and HCV patients by increasing physicians’ adherence to guidelines through financial incentives. The objective of this study was to evaluate the early effects of the P4P program on utilization of preventive services by HBV and HCV patients.MethodsUsing a quasi-experimental design with propensity score matching method, we matched the HBV and HCV patients enrolled in the P4P program with non-enrollees in 2010, resulting in 21,643 patients in each group. Generalized estimating equations was applied to examine the difference-in-difference effects of P4P program enrollment on the utilization of three guideline-recommended preventive services (regular outpatient follow-up visits, abdominal ultrasonography (US) examinations, and aspartate aminotransferase and alanine aminotransferase (AST/ALT) tests by HBV and HCV patients.ResultsThe P4P program enrollees were significantly more likely to attend twice-annual follow-up visits, to receive recommended US examinations and AST/ALT tests, than non-enrollees.ConclusionsThe results of our preliminary assessment indicate that financial incentives offered by the P4P program was associated with a modest improvement in adherence to guidelines for better chronic HBV and HBC management.

Timing of First Postdischarge Follow-up and Medication Adherence After Acute Myocardial Infarction.

The use of evidence-based medication therapy in patients after acute myocardial infarction (AMI) improves long-term prognosis, yet the current rates of adherence are poor. To determine whether earlier outpatient follow-up after AMI is associated with higher rates of medication adherence. A retrospective analysis was conducted of 20 976 Medicare patients older than 65 years discharged alive after an AMI between January 2, 2007, and October 1, 2010, from 461 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines hospitals in the United States. Patients were grouped based on the timing of first follow-up clinic visit within 1 week, 1 to 2 weeks, 2 to 6 weeks, or more than 6 weeks after hospital discharge. Data analysis was conducted from September 26, 2014, to April 22, 2015. Medication adherence was defined as the proportion of days with more than 80% coverage using Medicare Part D prescription fill records and was examined at 90 days and 1 year after discharge for β-blockers, platelet P2Y12 receptor inhibitors, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Among 20 976 Medicare-insured patients discharged alive after acute MI, 10 381 (49.5%) were men; mean (SD) age was 75.8 (7.5) years. The median time to the first outpatient follow-up visit after hospital discharge was 14 days (interquartile range, 7-28 days). Overall, the first follow-up clinic visit occurred 1 week or less after discharge in 5542 (26.4%) patients, 1 to 2 weeks in 5246 (25.0%), 2 to 6 weeks in 6830 (32.6%), and more than 6 weeks in 3358 (16.0%) individuals. Rates of medication adherence for secondary prevention therapies ranged from 63.4% to 68.7% at 90 days and 54.4% to 63.5% at 1 year. Compared with patients with follow-up visits within 1 week, those with follow-up in 1 to 2 weeks and 2 to 6 weeks had no significant difference in medication adherence; however, patients with follow-up more than 6 weeks after discharge had lower adherence at both 90 days (56.8%-61.3% vs 64.7%-69.3%; P < .001) and 1 year (49.5%-57.7% vs 55.4%-64.1%; P < .001). Patients with delayed follow-up more than 6 weeks were more likely to reside in communities with lower household incomes and educational levels (both P < .001); however, their clinical characteristics were similar to those of patients with earlier follow-up. After adjusting for these differences, delayed follow-up of more than 6 weeks remained associated with lower medication adherence at 90 days (odds ratio [OR], 0.74 [95% CI, 0.70-0.78]) and 1 year (OR, 0.79 [95% CI, 0.73-0.85]) compared with follow-up of 6 weeks or less. Delayed outpatient follow-up beyond the first 6 weeks after AMI is associated with worse short-term and long-term patient medication adherence. These data support the concept that medication adherence is modifiable via improved care transitions.

Early outpatient follow-up and 30-day outcomes in patients hospitalized with cirrhosis.

Preventing readmission has been the focus of numerous quality improvement efforts across many conditions. Early outpatient follow-up has been proposed as the best mechanism for reducing readmissions. The extent to which early outpatient follow-up averts readmission or improves outcomes in cirrhosis is not known. We evaluated the relationship between early outpatient follow-up and short-term readmission and mortality in patients with cirrhosis. We conducted a retrospective cohort study of patients with cirrhosis who were hospitalized with a liver-related diagnosis and discharged to home from 122 Veterans Administration hospitals between 2010 and 2013. We defined early follow-up as an outpatient visit with a clinician within 7 days after discharge. We propensity matched patients who received early visit with those who did not have any visit and examined the associations between early follow-up and all-cause readmission and mortality within 8-30 days after discharge. Of 25,217 patients hospitalized with cirrhosis, 8,123 (32.2%) had an early follow-up visit within 7 days of discharge. A total of 3,492 (13.8%) patients were readmitted and 1,185 (4.6%) died between 8 and 30 days after discharge. In the propensity-matched sample (N = 16,238), patients with early outpatient follow-up visit had a slightly higher risk of readmission (15.3% vs. 13.8%; hazard ratio [HR] =1.10; 95% confidence interval [CI] = 1.02-1.19), but significantly lower risk of mortality (3.2% vs. 5.2%; HR = 0.60; 95% CI = 0.51-0.70) than those without early visit. The findings persisted in several subgroup and sensitivity analyses. Early outpatient follow-up after discharge was associated with a small increase in readmissions but lower overall mortality in patients with cirrhosis. Transitional care may be effective in improving short-term outcomes in patients with cirrhosis, but readmission performance measures would miss this effect. (Hepatology 2016;64:569-581).

Components and Quality Measures of DIME (Devitalized Tissue, Infection/Inflammation, Moisture Balance, and Edge Preparation) in Wound Care.

ABSTRACTOBJECTIVES:To discuss how patient considerations and the initial wound environment can affect wound treatment and summarize the way in which the initial US Wound Registry measures capture aspects of the DIME (Debridement/devitalized tissue, Infection or inflammation, Moisture balance, and wound Edge preparation/wound depth) principles.DISCUSSION:The treatment of chronic wounds often involves extended hospital stays and long-term outpatient follow-up visits with costly advanced therapeutic interventions. As complex care is required for chronic wounds, treatment guidelines such as DIME have evolved to include consideration of patient-centered concerns and etiology, as well as features of wound bed preparation. The US healthcare system is in the midst of transitioning to a quality-based system. However, as wound care is not yet a recognized specialty, it is poorly represented in the current approved quality-based measures.CONCLUSION:This article helps to identify the practice guidelines that are not currently represented by quality metrics.