Preventable Hospital Admissions Research Articles

Evaluation of Oritavancin Use at a Community Hospital.

Background: Oritavancin is a lipoglycopeptide antibiotic indicated for the treatment of acute bacterial skin and soft tissue infections. The prolonged half-life of this agent allows for a course of therapy to be completed with a single dose. Oritavancin was added to our formulary as an option for treatment of acute bacterial skin and soft tissue infection to reduce admission and length of stay. Objective: The purpose of this study was to determine whether oritavancin is used appropriately at our hospital and to evaluate the impact to the institution. Methods: A retrospective and concurrent chart review was performed on all patients who had received oritavancin within our health system between June 2015 and December 2016. The primary endpoint was to determine the appropriateness of oritavancin use. Secondary endpoints include documenting readmission rates for patients prescribed oritavancin and assessing potential financial benefits to the institution. Results: In the 67 patients identified, 51 (76%) patients received oritavancin for an appropriate indication. Orders from infectious disease physicians constituted 81% of inappropriate cases of oritavancin use. No patients who received oritavancin required readmission within 14 days of therapy. The estimated potential financial benefit to our institution when using oritavancin to prevent hospital admissions was $653,451. Conclusions: The majority of oritavancin use at our institution is appropriate according to indication. Oritavancin offers an outpatient option for the treatment of acute bacterial skin and soft tissue infections with the potential to decrease hospital cost by reducing admissions and length of stay.

Preventable versus avoidable hospital admissions.

Preventable versus avoidable hospital admissions.

COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update.

Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and chronic airflow limitation, and is associated with exacerbations and comorbidities. Advances in the management of COPD are updated quarterly in the national COPD guidelines, the COPD-X plan, published by Lung Foundation Australia in conjunction with the Thoracic Society of Australia and New Zealand and available at http://copdx.org.au. Main recommendations: Spirometry detects persistent airflow limitation (post-bronchodilator FEV1/FVC < 0.7) and must be used to confirm the diagnosis.Non-pharmacological and pharmacological therapies should be considered as they optimise function (ie, improve symptoms and quality of life) and prevent deterioration (ie, prevent exacerbations and reduce decline).Pulmonary rehabilitation and regular exercise are highly beneficial and should be provided to all symptomatic COPD patients.Short- and long-acting inhaled bronchodilators and, in more severe disease, anti-inflammatory agents (inhaled corticosteroids) should be considered in a stepwise approach.Given the wide range of inhaler devices available, inhaler technique and adherence should be checked regularly.Smoking cessation is essential, and influenza and pneumococcal vaccinations reduce the risk of exacerbations.A plan of care should be developed with the multidisciplinary team. COPD action plans reduce hospitalisations and are recommended as part of COPD self-management.Exacerbations should be managed promptly with bronchodilators, corticosteroids and antibiotics as appropriate to prevent hospital admission and delay COPD progression.Comorbidities of COPD require identification and appropriate management.Supportive, palliative and end-of-life care are beneficial for patients with advanced disease.Education of patients, carers and clinicians, and a strong partnership between primary and tertiary care, facilitate evidence-based management of COPD. Changes in management as result of the guideline: Spirometry remains the gold standard for diagnosing airflow obstruction and COPD. Non-pharmacological and pharmacological treatment should be used in a stepwise fashion to control symptoms and reduce exacerbation risk.

Causes of Hospital Admissions in Domus: A Randomized Controlled Trial of Specialized Palliative Cancer Care at Home

ContextAvoidable hospital admissions are important negative indicators of quality of end-of-life care. Specialized palliative care (SPC) may support patients remaining at home. ObjectivesTherefore, the purpose of this study was to investigate if SPC at home could prevent hospital admissions in patients with incurable cancer. MethodsThese are secondary results of Domus: a randomized controlled trial of accelerated transition to SPC with psychological intervention at home (Clinicaltrials.gov: NCT01885637). Participants were patients with incurable cancer and limited antineoplastic treatment options and their caregivers. They were included from the Department of Oncology, Rigshospitalet, Denmark, between 2013 and 2016. The control group received usual care. Outcomes were hospital admissions, causes thereof, and patient and caregiver perceptions of place of care (home, hospital, etc.) at baseline, four weeks, eight weeks, and six months. ResultsDuring the study, 340 patients were randomized and 322 were included in modified intention-to-treat analyses. Overall, there were no significant differences in hospital admissions between the groups. The intervention group had more admissions triggered by worsened general health (22% vs. 16%, P = 0.0436) or unmanageable home situation (8% vs. 4%, P = 0.0119). After diagnostics, admissions were more often caused by clinical symptoms of cancer without progression in the intervention group (11% vs. 7%, P = 0.0493). The two groups did not differ significantly in overall potentially avoidable admissions. Both groups felt mostly safe about their place of care. ConclusionThe intervention did not prevent hospital admissions. Likely, any intervention effects were outweighed by increased identification of problems in the intervention group leading to hospital admissions. Overall, patients and caregivers felt safe in their current place of care.

1395P - Specialized ambulatory palliative care: (SAPV) 5-year results of a multi-professional care model by HomeCare linker Niederrhein gGmbH (HC) in the Lower Rhine region

Background: In recent times, German legislation has given terminally ill patients the right to receive SAPV, a multi-professional palliative care model which is aimed at prevention of hospital admission and enabling patients to die at home despite severe symptoms and a high need for palliative care. This new type of care raises the question about the best implementation and impact of SAPV. HC provides SAPV to 560.000 inhabitants of the city of Mönchengladbach and the district of Viersen. Methods: Data collected during daily care from 2012 to 2016 are summarized and analysed in order to describe the implementation and results of SAPV. Results: 1798 patients were treated in 5 years. The first contact with SAPV was initiated by a GP in 30% of patients and by a specialist in 4.5%; in 26% through a hospital, in 6% by a palliative care unit and in at least 30% by non-medical participants, such as relatives, nursing services, counseling centers etc. 20% of all patients were treated only temporarily by SAPV. 6% were admitted to a hospice, 14% were transferred to regular care after counseling or crisis intervention. Of the remaining patients, only 3.3% had to be hospitalized at the end and 96.7% were able to remain in their chosen home environment. That was at home for 80%, at a relative’s home for 3%, in a nursing home for 14%, and miscellaneous for the remaining 3% of patients. Sonography, thoracic and abdominal paracentesis, patient-controlled analgesia etc. were performed in the patient's home by the SAPV team. Of all 1798 patients, 112 had to be hospitalized; 64 were subsequently retreated with SAPV and 48 were not. The main reasons for hospitalization were palliative interventions due to ileus and urinary retention in the upper tract, radiation of a fracture, psychosocial decompensation of the supporting relatives and confirmation of the palliative concept. The average treatment duration was 19 days, the median was under 10 days. In detail, 112 patients were treated for less than 24 hours, 271 patients for less than 48 hours, 57 patients were treated for more than 90 days and 4 patients for over 200 days. Conclusions: The wish of patients to die at home and to avoid unnecessary hospitalization can be achieved with this model of specialized care. Further comparative investigations are necessary to identify the optimal implementation and impact of SAPV. Legal entity responsible for the study: Ulrich Grabenhorst Funding: None Disclosure: All authors have declared no conflicts of interest. Keyword: SAPV

From laboratory to bedside: a case report of a concise and pragmatic approach on heart failure

Heart failure is one of the most common and intensely studied diseases in the world. Nevertheless, it is considered a difficult condition to diagnose and manage.This case report, starting from the description of a brief clinical case, aims to directly and concisely explain the most important steps, from laboratory to bedside, in the diagnosis and management of heart failure disease. Physicians can rely on some laboratory tests (e.g., natriuretic peptides) and instrumental exams to diagnose and manage the patients in everyday medical practice. Finally, this article highlights that a multidisciplinary team management can improve the clinical status and the quality of life, thus preventing hospital admission and reducing mortality in patients with heart failure.

Potentially preventable medication-related hospitalizations: A clinical pharmacist approach to assessment, categorization, and quality improvement

ObjectivesThe primary objective of this report is to describe a quality improvement practice designed to identify and categorize potentially preventable medication-related hospital admissions. The secondary objective is to present data collected from this practice and describe how it was used to improve a pharmacist intervention focused on reducing medication-related readmissions. SettingThis practice was developed as part of the quality improvement system supporting a pharmacist-led care transition model that was implemented across rural and urban counties in Hawaii. Practice descriptionPharmacists systematically assessed readmissions of the high-risk patients who were enrolled in the care transition model to determine the reasons for the admission and whether each was potentially preventable and medication related. This information was then used to improve the care transition model. Practice innovationThis admission categorization system is the first based on best practice in pharmaceutical care and identifies indication, effectiveness, safety, and adherence problems, as well as subcategories within each of those domains. EvaluationThis quality improvement practice was applied to 401 readmissions. A chi-square test was used to determine if there were differences between urban and more rural areas regarding percentage of readmissions that were potentially preventable and medication related. ResultsTwenty-six percent of the readmissions were determined to be potentially preventable and medication related. The most common categories were nonadherence due to patient choice (23.8%), untreated condition for which medication is indicated (13.3%), dose too high (10.5%), and dose too low (10.5%). The percentage of readmissions that were potentially preventable and medication related was significantly higher in more rural areas (30%) compared with urban areas (17%). There were no significant rural–urban differences by major category of potentially preventable medication-related admissions. ConclusionThis systematic and actionable approach to reviewing and categorizing potentially preventable medication-related admissions can facilitate improvement in care and document the value of pharmacists serving in patient care roles.

Telehealth Protocol to Prevent Readmission Among High-Risk Patients With Congestive Heart Failure

BackgroundCongestive heart failure is the leading cause of hospital readmissions. We aimed to assess adherence to and effectiveness of a telehealth protocol designed to prevent hospital admissions for congestive heart failure. MethodsWe recruited a random sample of 50 patients with congestive heart failure (mean age 61 years) from a managed care organization. We developed a telehealth platform allowing for daily, real-time reporting of health status and video conferencing. We defined adherence as the percentage of days on which the patient completed the daily check-in protocol. To assess efficacy, we compared admission and readmission rates between the 6-month intervention period and the prior 6 months. Primary outcomes were admissions and readmissions due to congestive heart failure, and secondary outcomes were admissions and readmissions due to any cause. ResultsForty-eight patients (96%) completed the protocol. Approximately half (46%) were at high risk for readmission according to standardized measures. Median 120-day adherence was 96% (interquartile range, 92%-98%), and adherence did not significantly differ across sex, race, age, living situation, depression, cognitive ability, or risk for readmission. Approximately equal proportions of patients were admitted for all causes during the 6-month intervention period versus the comparison period (37% vs 43%; P = .32). Half as many patients were admitted for congestive heart failure during the 6-month intervention period compared with the comparison period (12% vs 25%; P = .11). ConclusionAdherence to this telehealth protocol was excellent and consistent, even among high-risk patients. Future research should test the protocol using a more rigorous randomized design.

The Western Sydney Integrated Care Program (WSICP): Qualitative Evaluation

Introduction : The ageing population together with an increasing prevalence of chronic conditions require a systems wide integrated approach to health care. This includes overcoming barriers between primary and secondary care, physical and mental health, and health and social care in order to provide patient centred care. In Australia, the New South Wales Ministry of Health (NSW MoH) is piloting an innovative Integrated Care Program in Western Sydney (WSICP) focussed on care of those with diabetes, COPD and congestive cardiac failure. Commencing in 2015, WSICP has established multidisciplinary rapid access clinics in two hospitals; initiatives to support General Practices in moving towards a Patient Centred Medical Home model of care as well as establishment of care facilitator roles to coordinate patient care between General Practices and hospitals. Theory/Methods : The NSW MoH is collecting quantitative data on the WSICP that includes hospital admissions and patient and provider engagement. We are undertaking a qualitative evaluation that complements the NSW MoH evaluation to develop an understanding of how the various WSICP strategies are working for all stakeholders. We have conducted the first of two rounds of in-depth semi-structured interviews with 70 participants including patients and carers (20), health care providers from hospitals and the community (40), and management (10). We have analysed the transcribed audio-recorded interviews thematically according to established protocols and will report on themes identified at this early stage of WSICP. Results : We are still analysing the data but expect to be able to report improvements in collaboration and shared care described by health care providers. Patients and their carers have described improved health and health care as well as increased efficacy in self-managing illness and navigating the health system. Rapid clinic access is reported to be preventing hospital admission and reducing waiting times. However, barriers still exist in terms of IT systems and communication, promotion and awareness, and low levels of General Practitioner engagement. Discussions : As WSICP progresses, early successes will enhance engagement with the program. Challenges identified by our evaluation will be addressed. This comprehensive qualitative review in the early phase of the program will not only refine its roll out, but will inform other similar initiatives. Conclusions : The WSICP is facilitating improved patient outcomes and greater health care provider collaboration. Barriers to care integration identified by our evaluation are being addressed. Lessons learned : Our early qualitative evaluation provides opportunities to refine the WSICP and gain understandings of how each element of this comprehensive health services integration pilot is contributing to the intended outcomes. Limitations : Due to the early stage of WSICP implementation, the experiences of stakeholders have varied relative to their length of engagement with the program. Individual program initiatives were also at various stages of operation. Suggestions for future research : The second round of data collection, scheduled for December 2016-February 2017, will provide a comparison against this baseline data. Most interviewees consented to a subsequent interview.

Rifaximin treatment for encephalopathy reduces hospital resource use: real-world data don’t fail to IMPRESS

The adventof rifaximin, a poorly absorbed antibiotic, for recurrent hepatic encephalopathy (HE) represents a major therapeutical advance for a debilitating condition, the treatment of which had remained unchanged for more...

Potentially avoidable hospitalizations in patients with advanced cancer.

e18275 Background: Cancer patients and their clinicians often wish to avoid preventable hospital admissions, but efforts to understand the predictors of avoidable hospitalizations are lacking. We sought to examine reasons for hospital admissions in patients with advanced cancer, identify potentially avoidable hospitalizations (PAH), and explore predictors of PAH. Methods: We prospectively enrolled hospitalized patients with advanced cancer from 9/2014 - 11/2014 as part of a longitudinal data repository to define symptom burden in this population. Upon admission, we assessed patients’ symptom burden (Edmonton Symptom Assessment System [ESAS]; scored 0-10). We created a summated ESAS physical symptom variable. We used consensus-driven medical record review to identify the primary reason for each hospital admission and categorize it as PAH or not based on of an adaptation of Graham’s criteria for PAH. We used mixed multivariable logistic regression analyses to identify predictors of PAH. Results: We assessed 477 hospital admissions in 200 consecutively admitted patients (mean age = 64.6; 47% female; 67% married). Over half of admissions came through the emergency department (56%). The most common reasons for admissions were fever/infection (30%), symptoms (26%), and planned admission for chemotherapy or procedure (10%). We identified 149 (31%) as PAH. Among these PAH, 45 (30%) were readmissions due to failure of timely outpatient follow-up (within 7 days of discharge) and 44 (30%) were due to premature discharge from prior hospitalization. In a mixed logistic regression model, being married (odds ratio [OR] 0.48 [0.28-0.81]; p &lt; 0.01) was associated with lower likelihood of PAH, while higher physical symptom burden (OR 1.02 [1.00-1.04]; p = 0.04) was associated with greater likelihood of PAH. Conclusions: We identified that a substantial proportion of hospitalizations in patients with advanced cancer are potentially avoidable, often related to failure of timely outpatient follow-up and premature hospital discharge. Our results demonstrate that patients’ symptom burden predicts PAH, thus underscoring the need to address patients’ symptoms in order to reduce preventable hospital admissions.

Does Telehealth Monitoring Identify Exacerbations of Chronic Obstructive Pulmonary Disease and Reduce Hospitalisations? An Analysis of System Data.

BackgroundThe increasing prevalence and associated cost of treating chronic obstructive pulmonary disease (COPD) is unsustainable. Health care organizations are focusing on ways to support self-management and prevent hospital admissions, including telehealth-monitoring services capturing physiological and health status data. This paper reports on data captured during a pilot randomized controlled trial of telehealth-supported care within a community-based service for patients discharged from hospital following an exacerbation of their COPD.ObjectiveThe aim was to undertake the first analysis of system data to determine whether telehealth monitoring can identify an exacerbation of COPD, providing clinicians with an opportunity to intervene with timely treatment and prevent hospital readmission.MethodsA total of 23 participants received a telehealth-supported intervention. This paper reports on the analysis of data from a telehealth monitoring system that captured data from two sources: (1) data uploaded both manually and using Bluetooth peripheral devices by the 23 participants and (2) clinical records entered as nursing notes by the clinicians. Rules embedded in the telehealth monitoring system triggered system alerts to be reviewed by remote clinicians who determined whether clinical intervention was required. We also analyzed data on the frequency and length (bed days) of hospital admissions, frequency of hospital Accident and Emergency visits that did not lead to hospital admission, and frequency and type of community health care service contacts—other than the COPD discharge service—for all participants for the duration of the intervention and 6 months postintervention.ResultsPatients generated 512 alerts, 451 of which occurred during the first 42 days that all participants used the equipment. Patients generated fewer alerts over time with typically seven alerts per day within the first 10 days and four alerts per day thereafter. They also had three times more days without alerts than with alerts. Alerts were most commonly triggered by reports of being more tired, having difficulty with self-care, and blood pressure being out of range. During the 8-week intervention, and for 6-month follow-up, eight of the 23 patients were hospitalized. Hospital readmission rates (2/23, 9%) in the first 28 days of service were lower than the 20% UK norm.ConclusionsIt seems that the clinical team can identify exacerbations based on both an increase in alerts and the types of system-generated alerts as evidenced by their efforts to provided treatment interventions. There was some indication that telehealth monitoring potentially delayed hospitalizations until after patients had been discharged from the service. We suggest that telehealth-supported care can fulfill an important role in enabling patients with COPD to better manage their condition and remain out of hospital, but adequate resourcing and timely response to alerts is a critical factor in supporting patients to remain at home.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 68856013; http://www.isrctn.com/ISRCTN68856013 (Archived by WebCite at http://www.webcitation.org/6ofApNB2e)

Support at Home: Interventions to Enhance Life in Dementia (SHIELD) – evidence, development and evaluation of complex interventions

BackgroundDementia is a national priority and this research addresses the Prime Minister’s commitment to dementia research as demonstrated by his 2020 challenge and the new UK Dementia Research Institute. In the UK &gt; 800,000 older people have dementia. It has a major impact on the lives of people with dementia themselves, on the lives of their family carers and on services, and costs the nation £26B per year. Pharmacological cures for dementias such as Alzheimer’s disease are not expected before 2025. If no cure can be found, the ageing demographic will result in 2 million people living with dementia by 2050. People with dementia lose much more than just their memory and their daily living skills; they can also lose their independence, their dignity and status, their confidence and morale, and their roles both within the family and beyond. They can be seen as a burden by society, by their families and even by themselves, and may feel unable to contribute to society. This programme of research aims to find useful interventions to improve the quality of life of people with dementia and their carers, and to better understand how people with dementia can be supported at home and avoid being admitted to hospital.Objectives(1) To develop and evaluate the maintenance cognitive stimulation therapy (MCST) for people with dementia; (2) to develop the Carer Supporter Programme (CSP), and to evaluate the CSP and Remembering Yesterday, Caring Today (RYCT) for people with dementia both separately and together in comparison with usual care; and (3) to develop a home treatment package (HTP) for dementia, to field test the HTP in practice and to conduct an exploratory trial.Methods(1) The MCST programme was developed for people with dementia based on evidence and qualitative work. A randomised controlled trial (RCT) [with a pilot study of MCST plus acetylcholinesterase inhibitors (AChEIs)] compared MCST with cognitive stimulation therapy (CST) only. The MCST implementation study conducted a trial of outreach compared with usual care, and assessed implementation in practice. (2) The CSP was developed based on existing evidence and the engagement of carers of people with dementia. The RCT (with internal pilot) compared the CSP and reminiscence (RYCT), both separately and in combination, with usual care. (3) A HTP for dementia, including the most promising interventions and components, was developed by systematically reviewing the literature and qualitative studies including consensus approaches. The HTP for dementia was evaluated in practice by conducting in-depth field testing.Results(1) Continuing MCST improved quality of life and improved cognition for those taking AChEIs. It was also cost-effective. The CST implementation studies indicated that many staff will run CST groups following a 1-day training course, but that outreach support helps staff go on to run maintenance groups and may also improve staff sense of competence in dementia care. The study of CST in practice found no change in cognition or quality of life at 8-month follow-up. (2) The CSP/RYCT study found no benefits for family carers but improved quality of life for people with dementia. RYCT appeared beneficial for the quality of life of people with dementia but at an excessively high cost. (3) Case management for people with dementia reduces admissions to long-term care and reduces behavioural problems. In terms of managing crises, staff suggested more costly interventions, carers liked education and support, and people with dementia wanted family support, home adaptations and technology. The easy-to-use home treatment manual was feasible in practice to help staff working in crisis teams to prevent hospital admissions for people with dementia.LimitationsGiven constraints on time and funding, we were unable to compete the exploratory trial of the HTP package or to conduct an economic evaluation.Future researchTo improve the care of people with dementia experiencing crises, a large-scale clinical trial of the home treatment manual is needed.ConclusionThere is an urgent need for effective psychosocial interventions for dementia. MCST improved quality of life and was cost-effective, with benefits to cognition for those on AChEIs. MCST was feasible in practice. Both CSP and RYCT improved the quality of life of people with dementia, but the overall costs may be too high. The HTP was useful in practice but requires evaluation in a full trial. Dementia care research may improve the lives of millions of people across the world.Trial registrationsCurrent Controlled Trials ISRCTN26286067 (MCST), ISRCTN28793457 (MCST implementation) and ISRCTN37956201 (CSP/RYCT).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 5. See the NIHR Journals Library website for further project information.

Infectious diseases specialist management improves outcomes for outpatients diagnosed with cellulitis in the emergency department: a double cohort study

Three hospital emergency rooms (ERs) routinely referred all cases of cellulitis requiring outpatient intravenous antibiotics, to a central ER-staffed cellulitis clinic. We performed a retrospective cohort study of all patients seen by the ER clinic in the last 4months preceding a policy change (ER management cohort [ERMC]) (n=149) and all those seen in the first 3months of a new policy of automatic referral to an infectious disease (ID) specialist–supervised cellulitis clinic (ID management cohort [IDMC]) (n=136). Fifty-four (40%) of 136 patients in the IDMC were given an alternative diagnosis (noncellulitis), compared to 16 (11%) of 149 in the ERMC (P<0.0001). Logistic regression–demonstrated rates of disease recurrence were lower in the IDMC than the ERMC (hazard ratio [HR], 0.06; P=0.003), as were rates of hospitalization (HR, 0.11; P=0.01). There was no significant difference in mortality. Automatic ID consultation for cellulitis was beneficial in differentiating mimickers from true cellulitis, reducing recurrence, and preventing hospital admissions.

Efficacy and Effectiveness of High-Dose Influenza Vaccine for Older Adults: A Systematic Review and Meta-Analysis

BackgroundSeasonal influenza epidemics are responsible for significant disease burden each year, especially in adults over the age of 65. Only recently have there been vaccines that are formulated specifically for individuals 65 years of age or older, one of which, Fluzone®High-Dose (IIV3-HD), has received widespread use in the US. This study aims to review the evidence of efficacy and effectiveness of IIV3-HD compared with standard dose influenza vaccine (IIV3) in individuals aged 65 years or older against clinical outcomes plausibly related to influenza.MethodsA systematic review of four electronic databases and other sources was conducted for randomized and observational studies assessing vaccine efficacy or effectiveness (VE) of IIV3-HD against clinical outcomes such as influenza-like illness, hospital admissions and death in adults 65 years of age or older. A meta-analysis was conducted by separately extracting individual VEs reported in the studies and estimating random-effects pooled efficacy against each of the clinical outcomes.Results7 eligible studies (4 randomized trials and 3 observational studies) were identified following the screening of 1,816 studies. All of these studies reported relative VE (rVE) of IIV3-HD vs. IIV3, and not absolute efficacy/effectiveness of IIV3-HD. Of those, 5 studies reported rVE for IIV3-HD vs. IIV3 against influenza-like illness, 6 studies reported rVE against hospital admissions, and 3 studies reported rVE against death. IIV3-HD demonstrated improved protection against influenza-like illness (rVE=18.3%, 95% CI: 7.0 to 28.3%), and was also more effective at preventing hospital admissions due to influenza illness (rVE=19.4%, 95% CI: 6.7 to 30.4%), pneumonia (rVE=22.4%, 95% CI: 5.0 to 36.5%), cardiorespiratory events (rVE=12.0%, 95% CI: 4.9 to 18.6%), and death following a hospital admission for influenza (rVE=22.2%, 95% CI: -18.2 to 48.8%). IIV3 also had a modest but not statistically significant impact on all-cause hospital admissions (rVE= 7.3%, 95% CI: -1.5 to 15.4%) and all-cause death (rVE=0.8%, 95% CI: -4.2 to 5.5%).ConclusionThere is significant evidence demonstrating IIV3-HD is more effective than standard dose influenza vaccine at reducing the clinical outcomes typically associated with influenza infection in older adults.This study was funded by sanofi pasteur.Disclosures J. Lee, sanofi pasteur: Employee, Salary; G. Lam, sanofi pasteur: Employee, Salary; T. Shin, sanofi pasteur: Employee, Salary; J. Kim, sanofi pasteur: Co-op Student, Educational support; A. Krishnan, sanofi pasteur: Co-op Student, Educational support; B. Seet, sanofi pasteur: Employee and Shareholder, Salary; D. Neame, sanofi pasteur: Employee and Shareholder, Salary; D. P. Greenberg, sanofi pasteur: Employee and Shareholder, Salary; A. Chit, sanofi pasteur: Employee, Salary

Technology Enabled Care (TEC) provision for the care home sector in the Scottish Highlands: video conferencing in care homes

Introduction : Public service reform in Scotland is focusing on prevention and early intervention with the aim of breaking cycles of inequality and poverty. Public bodies are expected to play a full part in delivering these improved outcomes with leaders and their teams working collaboratively across organizational boundaries to ensure that services are shaped around the needs and demands of individuals and communities. The Scottish Government's 2020 Vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting. NHS Highland health board in Scotland covers an area of over 32,500 square km. With a population of 320,000 it is one of the largest and most sparsely populated Health Boards in the UK. NHS Highland care home places for older adults are provided by care homes owned and managed by a mixture of local authority/health board, private organisations and the voluntary sector. In the care home sector improved outcomes for individuals are expected to come about by preventing adverse situations through the use of anticipatory care and planned care models. Latest care home census data indicates that close to 57% of care home residents in the NHS Highland area are affected by dementia (both medical and non-medically diagnosed). Access to specialist psychiatric expertise for staff and for residents affected by dementia presents challenges in this rural context due to long gaps between consultant visits and the anxiety and stress related to travel to secondary care for appointments in between consultant visits. TEC psychiatric clinics have been introduced to address these challenges. Practice Change Implemented : Nurse led TEC older adult psychiatry clinics were introduced in three rural care homes in NHS Highland with the aim of providing improved access to psychiatric care services, reducing unnecessary admissions, reducing antipsychotic use for people with dementia and improving the management of behavioural and psychiatric symptoms of dementia. Stakeholder groups involved in the psychiatric clinics included the service provider (NHS Highland), technology enabler and facilitator (Scottish Centre for Telehealth and Telecare, SCTT), care home managers and staff, care home residents/family members, occasional care home users (day care and lunch clubs) and other wider community users such as GPs, social workers, hospital consultants, pharmacists, community nurses. Key Findings and Highlights : The direct impact on residents has been quicker assessment, treatment review and regular monitoring. Residents and family members believe that it is more responsive to their needs. In addition to direct impacts on residents, the development of greater knowledge and understanding by care home staff through access to specialist knowledge, experience and advice has led to increased confidence and skills, enabling staff to feel more confident and be more actively involved in care. Care homes have become more able to manage complex cases and challenging behaviours locally and are less likely to admit patients to hospital. Prevention of hospital admissions has allowed residents to remain within their local care setting. Where hospital admission has been necessary, sooner and more frequent follow up has been possible after discharge back to the care home. Frequent reviews have enabled more rapid adjustment in medication, with some residents becoming managed through behavioural plans only. Overall, participation in the clinics has led to staff feeling more valued in their role. Although the initiative emerged following consultation and collaboration between SCTT and secondary care psychiatric clinicians in response to a redesigning of outreach services, involvement by the care home staff from an early stage facilitated a successful introduction. Provision of training for as wide a group of potential users as possible promoted and enabled use of the technology for applications other than psychiatric clinics. Conclusion : An equivalent level of input and support for residents without utilising TEC would involve a significant amount of time travelling for specialist secondary care staff with associated high travel costs. For care home staff, accessing an equivalent amount of relevant training would be unachievable due to resourcing issues. While residents and their families have clearly benefited directly from individual consultations, a significant impact on residents has come about through the knowledge and confidence gained by care home staff. This has resulted in improved patient outcomes by early intervention through participatory care planning. Wider community impacts are beginning to emerge with the launch of other initiatives using the care home based TEC including polypharmacy review clinics, hospice palliative care and the way the local community are using the equipment to access a range of specialist services (eg weight management classes) in one care home community.

Antithrombotic stewardship: a multidisciplinary team approach towards improving antithrombotic therapy outcomes during and after hospitalisation: a study protocol

IntroductionAntithrombotic therapy carries high risks for patient safety. Antithrombotics belong to the top 5 medications involved in potentially preventable hospital admissions related to medication. To provide a standard for antithrombotic...

Prediction of Hospitalization due to Adverse Drug Reactions in Elderly Community-Dwelling Patients (The PADR-EC Score).

BackgroundAdverse drug reactions (ADRs) are the major cause of medication-related hospital admissions in older patients living in the community. This study aimed to develop and validate a score to predict ADR-related hospitalization in people aged ≥65 years.MethodsADR-related hospitalization and its risk factors were determined using a prospective, cross-sectional study in patients aged ≥65 years admitted to two hospitals. A predictive model was developed in the derivation cohort (n = 768) and the model was applied in the validation cohort (n = 240). ADR-related hospital admission was determined through expert consensus from comprehensive reviews of medical records and patient interviews. The causality and preventability of the ADR were assessed based on the Naranjo algorithm and modified Schumock and Thornton criteria, respectively.ResultsIn the derivation sample (mean [±SD] age, 80.1±7.7 years), 115 (15%) patients were admitted due to a definite or probable ADR; 92.2% of these admissions were deemed preventable. The number of antihypertensives was the strongest predictor of an ADR followed by presence of dementia, renal failure, drug changes in the preceding 3 months and use of anticholinergic medications; these variables were used to derive the ADR prediction score. The predictive ability of the score, assessed from calculation of the area under the receiver operator characteristic (ROC) curve, was 0.70 (95% confidence interval (CI) 0.65–0.75). In the validation sample (mean [±SD] age, 79.6±7.6 years), 30 (12.5%) patients’ admissions were related to definite or probable ADRs; 80% of these admissions were deemed preventable. The area under the ROC curve in this sample was 0.67 (95% CI 0.56–0.78).ConclusionsThis study proposes a practical and simple tool to identify elderly patients who are at an increased risk of preventable ADR-related hospital admission. Further refinement and testing of this tool is necessary to implement the score in clinical practice.

Physician EHR Adoption and Potentially Preventable Hospital Admissions among Medicare Beneficiaries: PanelData Evidence, 2010-2013.

To test for correlation between the growth in adoption of ambulatory electronic health records (EHRs) in the United States during 2010-2013 and hospital admissions and readmissions for elderly Medicare beneficiaries with at least one of four common ambulatory care-sensitive conditions (ACSCs). SK&A Information Services Survey of Physicians, American Hospital Association General Survey and Information Technology Supplement; and the Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013. Fixed effects model estimated the relationship between hospital referral region (HRR) level measures of physician EHR adoption and ACSC admissions and readmissions. Analyzed rates of admissions and 30-day readmissions per beneficiary at the HRR level (restricting the denominator to beneficiaries in our sample), adjusted for differences across HRRs in Medicare beneficiary age, gender, and race. Calculated physician EHR adoption rates as the percentage of physicians in each HRR who report using EHR in ambulatory care settings. Each percentage point increase in market-level EHR adoption by physicians is correlated with a statistically significant decline of 1.06 ACSC admissions per 10,000 beneficiaries over the study period, controlling for the overall time trend as well as market fixed effects and characteristics that changed over time. This finding implies 26,689 fewer ACSC admissions in our study population during 2010 to 2013 that were related to physician ambulatory EHR adoption. This represents 3.2 percent fewer ACSC admissions relative to the total number of such admissions in our study population in 2010. We found no evidence of a correlation between EHR use, by either physicians or hospitals, and hospital readmissions at either the market level or hospital level. This study extends knowledge about EHRs' relationship with quality of care and utilization. The results suggest a significant association between EHR use in ambulatory care settings and ACSC admissions that is consistent with policy goals to improve the quality of ambulatory care for patients with chronic conditions. The null findings for readmissions support the need for improved interoperability between ambulatory care EHRs and hospital EHRs to realize improvements in readmissions.

Preparing for Value-Based Payment: A Stepwise Approach for Cancer Centers.

Most cancer centers are ill-equipped to pursue value-based payment (VBP) because of limited information on their population's cost of care. Herein, we outline the stepwise approach used by Smilow Cancer Hospital at Yale-New Haven in our pursuit of better value care. First, we addressed institutional barriers. A move toward value required demonstration to Yale-New Haven Health System leadership that OCM would improve patient care, fund new infrastructure, and provide the opportunity to gain experience with VBP without a major threat to the financial stability of the health system. We evaluated patterns of care and found that of patients presenting to the emergency department (ED), 88% were admitted, 62% arrived during the workday, and 50% could have been stabilized with urgent care services. Within 30 days of death, 27% were admitted to the intensive care unit, 38% presented to the ED, and 52% were admitted. To quantify total cost of care, we accessed the 5% Medicare Limited Data Set to map out total cost of care for patients receiving chemotherapy at Smilow Cancer Hospital. Costs increased as patients moved through 6-month episodes, used the ED (patients with two or more visits were twice as expensive as those with one or fewer), or died during an episode (costs were twice as high as episodes in which the patient lived). To determine strategic interventions to improve value, we targeted investments in urgent care to reduce ED utilization, care management to prevent hospital admissions, and referral to palliative care for clarification of goals of care and avoidance of costly futile treatment. Developing internal metrics to evaluate success will require monitoring our interventions by having utilization measures for each site of care and individual provider.