Post-intervention Cohort Research Articles

Value-based evaluation of gestational diabetes mellitus care pathway redesign by using cost and outcome data

BackgroundGestational diabetes mellitus (GDM) is a common complication of pregnancy. Implementation of Value-Based Healthcare (VBHC) to GDM care is worthwhile as traditional GDM care is fragmented and fails to meet the needs of women with GDM. Value of care can be improved through optimization and redesign of the care pathway and implementation of an outcome-based payment model. This study was conducted to perform a value-based evaluation of GDM care pathway redesign by using cost- and outcome data.MethodsThis study was designed as a single center, prospective, observational cohort study. In January 2022, GDM care was redesigned by substituting GDM care activities from an Internal Medicine Department (IMD) to an Integrated Maternity Care Organization (IMCO) in the Netherlands. Women diagnosed with GDM in 2021 were assigned to a pre-intervention cohort (N = 264) and those diagnosed in 2022 to a post-intervention cohort (N = 407). The impact of the intervention on value of care for women with GDM was evaluated by comparing clinical outcomes, patient-reported experience measures (GDM Responsiveness questionnaire), and costs (Time-Driven Activity-Based Costing) between the cohorts.ResultsReferrals to the IMD for GDM decreased by 84.8% (pre-intervention: 100%, post-intervention: 15.2%, p <.001), patient-reported experiences significantly improved (Mean responsiveness pre-intervention: 3.46, post-intervention: 3.63, p: 0.00). Initiation of insulin treatment decreased by 46.8% (pre-intervention: 25.0%, post-intervention: 13.3%, p <.001). Maternal- and neonatal clinical outcomes were not different after redesign. Weighted average costs per GDM treatment were 9.7% lower post-intervention (pre-intervention: €168,37, post-intervention: €151,97).ConclusionsThe redesign of GDM care positively impacted value through decreased referrals and improved patient-reported experiences while clinical outcomes remained constant. By de-fragmenting GDM care, cost savings were realized. This study contributes to the improvement of care delivery, particularly in pregnancy and childbirth, by promoting the adoption of comprehensive, value-based evaluations of redesign initiatives and supports the further uptake of VBHC in maternity care.

Hospital-to-facility transitions for antithrombosis patients: Perilous junctures requiring focused stewardship

Background To assess the impact of receipt of a comprehensive anticoagulation communication note on need for Antithrombosis Stewardship care transition interventions from the hospital to post-acute care facilities. Methods This was a retrospective, single-center observational analysis of care transitions interventions among patients discharged on therapeutic-intensity anticoagulants from an academic medical center to post-acute care facilities (PACFs). The pre-intervention group followed standard institutional antithrombosis stewardship practices to transmit an ‘Anticoagulation Communication at Discharge’ (ACDC) note plus follow-up call. The post-intervention cohort added a preparatory call to obtain the best contact information for direct transmission of anticoagulation information to the clinical team. Results The final analysis included 712 patients (605 patients in pre-intervention group and 107 patients in post-intervention group). Receipt of the ACDC note was confirmed in 45% (272/605) patients in the pre-intervention cohort compared to 58% (62/107) in the post-intervention cohort (p = 0.013). Of the patients who did not have confirmed receipt in the pre-intervention period, 12% (41/333) required intervention to optimize therapy compared to 5% (14/272) who had confirmed receipt (RR 2.2, p = 0.002). Similarly, in the post-intervention cohort, patients who did not have confirmed receipt required intervention (5/45) more frequently than patients with confirmed receipt (4/62) (11% vs. 6%; p=0.391). Conclusion Focused antithrombosis stewardship efforts to support improved communication of key patient information between facilities may be associated with a reduced need for clinical intervention during care transitions.

Impact of Competency-Based Skills Assessments on Student Performance, Stress, and Preparedness in an Advanced Pharmacy Practice Experience (APPE) Readiness Course.

Impact of Competency-Based Skills Assessments on Student Performance, Stress, and Preparedness in an Advanced Pharmacy Practice Experience (APPE) Readiness Course.

Changing Opioid Prescribing Algorithms in Plastic Surgery.

Changing opiate prescribing practices in surgical fields without guidelines or standardizations can be a daunting task. An encouraging amount of literature has shown the benefits of reducing opioid use, but many plastic surgeons hesitate to initiate this directive. We present a practice modification designed to reduce the number of opiates prescribed and highlight the steps needed to implement a new prescribing algorithm. In October of 2023, we implemented a new opiate algorithm for patients undergoing breast surgery. In the preintervention group, patients received 30 pills of postoperative opiates and recorded their consumption. Following the intervention, patients were given a maximum of 10 pills. To guide this new prescribing practice, we relied on pill consumption analysis from our preintervention group. In each cohort, data were collected on postoperative analgesic use per procedure. Forty-one survey responses were included in our preintervention cohort and 10 in our postintervention cohort. A median of 5.5 pills was consumed by patients who received implant or tissue expanders, 4.75 pills for pedicled flaps, 12 pills for fat grafting, 5 pills for breast reduction, and 12.5 pills for gender affirming mastectomies. Before and after the intervention, median opiate consumption was similar at 6 pills and 5.5 pills, respectively. Patients in both cohorts would consume pills for a median of 4 days. In the preintervention group, patients had a median of 24 unused pills. This was significantly reduced to 0.5 unused pills in the postintervention cohort (P < 0.000). Refill requirements and analgesic use by the 2 groups was not significantly different (P = 0.063 and P = 0.545). We have outlined a pathway for updating opioid prescribing algorithms in plastic surgery. Our opiate intervention significantly diminished opiate excess, reducing the risk for abuse. With growing research demonstrating the benefits of regulating prescriptions, and the best ways to implement change, surgeons can feel confident to just say yes to this meaningful reform.

Small Bite Fascial Closure Technique Associated With Reduction in Fascial Dehiscence.

Small Bite Fascial Closure Technique Associated With Reduction in Fascial Dehiscence.

Cost-effectiveness of Lynch syndrome screening in colorectal cancer: universal germline vs sequential screening.

Cost-effectiveness of Lynch syndrome screening in colorectal cancer: universal germline vs sequential screening.

Impact of an Electronic Medical Record Quality Improvement Intervention on Helicobacter pylori Treatment and Eradication Rates in a U.S. Hospital System.

In this pre- and post-intervention quality improvement (QI) study, the impact of an electronic medical record (EMR) order set for Helicobacter pylori treatment was assessed. We evaluated changes in optimal treatment regimen usage, eradication testing, and successful eradication rates based on the intervention. Data were collected from patients within the Harris Health System (Houston, TX) with H. pylori infection. The pre-intervention cohort included patients with a positive H. pylori test from January to February 2022. An EMR order set for H. pylori treatment implemented in May 2022 included optimal treatment recommendations using local antibiotic resistance patterns and testing for eradication post-treatment. Comparisons of proportions with optimal treatment and eradication rates between the pre-intervention cohort, an early post-intervention group (June-July 2022), and a late post-intervention group (November-December 2022) were evaluated using chi-square tests. We identified 295 patients in the pre-intervention, 414 patients in the early post-intervention, and 320 patients in the late post-intervention cohorts. There was an increase in proportions of optimal treatment (bismuth-quadruple, clarithromycin-quadruple, or rifabutin-triple therapy with a proton pump inhibitor for 14 days) between the pre- and early post-intervention groups from 26.4% to 39.7% (p < 0.01) with a further increase in the late post-intervention group to 85.3% (p < 0.01). The proportion of post-treatment eradication testing within 24 months increased from 56% in the pre-intervention cohort to 65.8% in the early post-intervention cohort (p = 0.01) and 64.9% in the late post-intervention cohort (p = 0.03). In patients with post-treatment eradication testing, there was an increase in successful eradication from 80.6% in the pre-intervention cohort to 88.9% in the early post-intervention cohort (p = 0.03) and 82.6% in the late post-intervention cohort (p = 0.66). An EMR order set for H. pylori treatment and eradication testing significantly increased rates of using optimal, evidence-based treatment, post-treatment eradication testing, and confirmed eradication of H. pylori infection.

Reducing Hospital-Acquired Pressure Injuries in a Cardiothoracic Intensive Care Unit.

Hospital-acquired pressure injuries are a significant patient safety concern. The Centers for Medicare & Medicaid Services tracks hospital-acquired pressure injuries as a patient safety indicator. Health care organizations with higher-than-expected rates may incur penalties. The pressure injury prevalence rate in a cardiothoracic intensive care unit was above the National Database of Nursing Quality Indicators benchmark. The current standard of care-use of the Braden scale for pressure injury risk assessment and the SKIN (surface, keep turning, incontinence care, and nutrition) care bundle-may not adequately address the needs of the intensive care unit population. In addition, cardiac patients present a special challenge because of their disease process and the mechanical support devices used to treat patients in cardiogenic shock, which place them at risk for the development of hospital-acquired pressure injuries. A performance improvement project was carried out in the cardiothoracic intensive care unit to reduce the prevalence and incidence of hospital-acquired pressure injuries. A preintervention convenience cohort was compared with a postintervention cohort. The intervention consisted of use of the Cubbin-Jackson scale, an intensive care unit-specific risk-assessment tool, with linked interventions to prevent pressure injuries. The preintervention and postintervention cohorts consisted of 102 patients each. The pressure injury prevalence and incidence rates decreased by 67.84% and 36.43%, respectively, from before to after the intervention. The use of an intensive care unit-specific risk-assessment tool with linked interventions to prevent pressure injury can help reduce hospital-acquired pressure injuries in an intensive care unit.

P-893. Expedited Transition to Oral Antibiotics in Gram Negative Bacteremia Reduces Hospital Length of Stay

Abstract Background Uncomplicated Gram-negative bloodstream infection (GN-BSI), often originating from the urinary tract, is a common reason for hospitalization in the United States. No high-quality data exist that suggest a specific duration of intravenous treatment is indicated for GN-BSI. As such, we hypothesized that expedited transition to oral antibiotics (at the time of susceptibility testing result availability) may facilitate earlier discharge from the hospital. Efforts to reduce hospital length of stay (LOS) yield benefits to both the patient and the healthcare system and have not been as consistently reported as more traditional stewardship metrics, such as time to optimal treatment. A combination of targeted provider and pharmacist education and formal ASP recommendations documented in the medical record were used to facilitate swift transition to oral antimicrobials. Methods Data was collected prior to (January to July 2023) and after (August 2023 to December 2023) the intervention consisting of targeted physician and pharmacist education and formal documentation of ASP recommendations in the medical record was deployed on August 1, 2023. The post-intervention cohort was stratified by whether formal ASP recommendations were documented in the medical record, which may reflect the impact of the targeted education efforts alone. The three groups were compared using an analysis of variance. Results The average hospital LOS for the pre-intervention (n = 421), post-intervention without ASP recommendations (n = 260), and post-intervention with ASP recommendations (n = 83) groups were 7.13, 6.84, and 5.84 days, respectively (p = 0.63). While not statistically significant, using a conservative estimate of $1,100 per hospital day yields an estimated cost savings due to reduced LOS alone of approximately $187,200 from August to December 2023 that may be attributable to the aforementioned interventions. Conclusion Targeted physician and pharmacist education and documenting formal ASP evidence-based recommendations in the medical record that guide clinicians to transition to oral antibiotics when susceptibility results are available can meaningfully reduce hospital length of stay. The reduction in LOS observed in our study was greatest when the two strategies were combined. Disclosures All Authors: No reported disclosures

Reduction of Pediatric Gastrostomy Tube Healthcare Utilization and Socioeconomic Disparities: Longitudinal Benefits of Quality Improvement

Reduction of Pediatric Gastrostomy Tube Healthcare Utilization and Socioeconomic Disparities: Longitudinal Benefits of Quality Improvement

Evaluating accuracy of cervical spine computed tomography interpretation by emergency trainees with the use of a structured protocol.

Radiological evaluation of cervical spine injury with computed tomography (CT) scanning is a fundamental component of the assessment of major trauma. Accurate interpretation of scans is essential for safe clearance or diagnosis of injuries. However, delays in radiologist reporting often result in prolonged spinal immobilisation. The aim of the present study was to evaluate a simple, structured reporting tool to improve assessment of CTs of the cervical spine by emergency medicine trainees. A prospective pre- and post-intervention cohort study was undertaken within a major metropolitan ED. Participants in the pre-intervention phase interpreted a set of randomly selected cervical spine CTs. The post-intervention phase presented the same task with the additional provision of a structured cervical spine CT reporting template designed in collaboration with radiologists and emergency physicians. Interpretation by trainees was evaluated for concordance with the final radiology report by two blinded assessors. A total of 155 cervical spine CT scans were reported by the 46 participants. Participants in the cohorts were similar with regards to experience and country of primary medical degree. Concordance with the radiology report in the pre-intervention phase was 60% (95% CI 0.48-0.71), compared with a concordance of 54% (95% CI 0.42-0.65) in the post-intervention phase (P = 0.46). Interpretation of cervical spine CT scans by trainees was inferior compared to radiologists and did not improve with a structured reporting template. Other innovative strategies towards timely reporting of CT scans by radiologists of the cervical spine are indicated for earlier definitive diagnosis.

Reducing Blood Loss From Phlebotomy in Adult Neurocritical Care Patients: An Evidence-Based Practice Project.

BACKGROUND : Blood loss from phlebotomy is a significant cause of hospital-acquired anemia. Use of small-volume (Pedi) tubes in adult patients reduces blood loss by 40% and does not increase need for repeated labs. Although this practice is evidencebased, it has not been widely implemented. Using Pedi tubes for phlebotomy is a key component of blood management programs to decrease the incidence of hospital-acquired anemia and blood transfusions in the intensive care unit (ICU). Our aim was to implement the use of Pedi tubes for labs in the adult neurocritical care unit to demonstrate feasibility in this population. METHODS : This was a pre-/postintervention quality improvement project. All consecutive patients admitted to the neurocritical care unit from April 10, 2023, to October 10, 2023, aged 18-99 years, were included in the project. During the intervention period from July 10, 2023, to October 10, 2023, Pedi tubes were used for all laboratory draws except admission and crisis labs. A retrospective chart review from April 10 to July 9, 2024, established standard practice for comparison. We recorded hospital and ICU admission, nadir, and discharge hemoglobin, length of stay, number of rejected specimens, number of blood transfusions, discharge disposition, and 30-day readmission for all subjects. RESULTS : Pedi tube use was successfully implemented with significantly less need for repeat laboratory collections in the postintervention cohort ( P = .001). Although no difference was noted in hemoglobin levels, there was a decrease in both ICU and hospital length of stay by 1 day in the intervention arm. Fewer transfusions were required in the intervention cohort. CONCLUSIONS : Small-volume tube use for phlebotomy in adult neurocritical care patients is feasible and can lead to decreased blood transfusion need in the ICU.

Evaluation of an intervention to decrease length of stay in children with low-risk febrile neutropenia

Abstract Background Febrile neutropenia is one of the most common serious complications of myelosuppressive chemotherapy. For this reason, pediatric oncology patients with FN have traditionally been admitted to the hospital and started on empiric intravenous antibiotics. However, not all FN patients are at high risk of developing subsequent complications, and a low-risk group exists that could safely be discharged early. Methods A retrospective study of 194 FN episodes presenting in pediatric oncology patients at St. Jude Children’s Research Hospital. Outcomes of FN episodes were studied and compared before and after early discharge guidelines for low-risk febrile neutropenic (LRFN) were implemented at St. Jude on May 6, 2020. Results Total length of hospital stay was similar in the pre- and post-intervention groups (median 4 [IQR 3,6] vs. 4 [IQR 3,7] days, P = 0.443). Differences in adverse outcomes were insignificant between the pre- and post-intervention cohorts, with only two ICU admissions after the first 24 hours inpatient in the post-intervention group, one new positive blood culture (&amp;gt; 24 hours – 14 days of admission) in each group, and 36.2% versus 21% new fever after resolution of initial fever in pre- and post-intervention cohorts respectively. Cumulative antibiotic use between the pre- and post-intervention groups was statistically insignificant (median 13.5 [IQR 22.8,8] vs. 14 [IQR 22,9] days, P = 0.537), whereas Levofloxacin use was significantly longer in the post-intervention cohort versus the pre-intervention cohort (median 0 [IQR 0,4] vs. 0 [IQR 0,0] days, P = &amp;lt;0.001). Conclusion The implementation of guidelines for early discharge of LRFN patients showed no reduction in hospital stay. Understanding the optimal strategy for effectiveness of guideline implementation is crucial to improve quality and efficiency of care.

Volume-based Feeds: A Quality Improvement Project for Better Nutrition.

This quality improvement project at a single institution aimed to increase the proportion of prescribed tube feeds delivered to adult patients in the burn population with greater than 20% affected TBSA. A retrospective chart review was performed on all adult patients with burns from January 2018 to July 2022 with greater than 20% TBSA burns to compare quantitative measures such as length of stay, change in weight, and mean tube feeds delivered over hospitalization. Prospective data collection began in August 2022, when the first intervention was implemented, and continued until July 2023 in the same patient population to serve as a postintervention cohort. Using a multidisciplinary approach, the team implemented 8 interventions, which increased the mean proportion of tube feeds delivered to patients from 43% to 78%, marking a significant increase in nutrition delivered to patients, which is critical for wound healing following burn injuries.

Improving the medication literacy at the time of discharge from hospital (the LiMeTiD study)

Improving the medication literacy at the time of discharge from hospital (the LiMeTiD study)

Pediatric cardiac surgical site infections: A single-center quality improvement initiative

Pediatric cardiac surgical site infections: A single-center quality improvement initiative

Implementation of a structured oral hygiene program through nursing assistant education to address non-ventilator hospital-acquired pneumonia: A quasi-experimental study.

Non-ventilator hospital-acquired pneumonia (NV HAP) is a common complication for hospitalized patients. NV HAP develops when patients aspirate oral secretions containing pathogenic bacteria. Appropriate oral hygiene can help mitigate NV HAP development. Hospital staff, including nursing assistants, play an important role in ensuring that these cares are completed. A quasi-experimental pre-post design was used to evaluate outcomes before and after implementation of a structured oral hygiene education program. A structured oral hygiene program was developed and implemented in a large quaternary hospital. Change in NA knowledge, attitudes, and behaviors before and after implementation of the oral hygiene program was evaluated. Retrospective patient outcomes before and after the intervention were analyzed to detect changes in NV HAP rates. Following the education, nursing assistant knowledge of recommended frequency of oral care for patients who are NPO increased (67.2% vs. 82.1%, p = 0.003). NAs were more likely to report oral hygiene tools including oral suctioning (80.8% vs. 90.2%, p = 0.005) and toothbrushes (89.3% vs. 95.3%, p = 0.031). The unadjusted incidence of NV HAP was significantly lower in the post-intervention cohort (0.25%) compared to the pre-intervention cohort (0.74%), p < 0.001. In the adjusted model, non-invasive positive pressure ventilation increased the odds of NV HAP by nearly sevenfold (AOR = 6.88, 95% CI: 3.99, 11.39). Focused education for NAs is an effective strategy to increase knowledge related to oral hygiene. Implementing a structured oral hygiene program for NAs appears to be a promising practice to decrease NV HAP.

Effect of standardized EHR-integrated handoff report on intraoperative communication outcomes.

Effect of standardized EHR-integrated handoff report on intraoperative communication outcomes.

High-Volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy

High-Volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy

Electronic Medical Record-Based Nudge Intervention to Increase Comprehensive Molecular Genotyping in Patients With Metastatic Non-Small Cell Lung Cancer: Results From a Prospective Clinical Trial.

Less than half of the patients with newly diagnosed metastatic non-small cell lung cancer (NSCLC) undergo comprehensive molecular testing. We designed an electronic medical record (EMR)-based "nudge intervention" to prompt plasma-based molecular testing at the time of initial medical oncology consultation. A nonrandomized prospective trial was conducted at the University of Pennsylvania's academic practice and two affiliated community practices. Molecular genotyping was performed by tissue- and/or plasma-based next generation sequencing methods. Comprehensive testing was defined as testing for EGFR, ALK, BRAF, ROS1, MET, RET, KRAS, and NTRK. Guideline-concordant treatment was defined as the use of the appropriate first-line (1L) therapy as per the National Comprehensive Cancer Network (NCCN) guidelines. Proportion of patients with comprehensive molecular genotyping results available at any time, molecular results available before 1L therapy, and guideline-concordant 1L treatment were compared between the preintervention and postintervention cohorts using Fisher's exact test or Pearson's chi-squared test. Five hundred and thirty-three patients were included, 376 in the preintervention cohort and 157 in the postintervention cohort. After implementation of the EMR-based nudge, a higher proportion of patients underwent comprehensive molecular testing in the postintervention versus the preintervention cohort (100% v 88%, P = <.001), had results of comprehensive molecular testing available before initiating 1L treatment (97.3% v 91.6%, P = .026), and received NCCN guideline-concordant care (89.8% v 78.2%, P = .035). Across three practice sites in a large health system, implementation of a provider team-focused EMR-based nudge intervention was feasible, and led to a higher number of patients with NSCLC undergoing comprehensive molecular genotyping. These findings demonstrate that behavioral nudges can promote molecular testing and should be studied further as a tool to improve guideline-concordant care in both community and academic sites.