Primary Care Physician Follow-up Research Articles

Impact of early primary care physician follow-up on hospital readmission following gastrointestinal cancer surgery.

We sought to examine the association between primary care physician (PCP) follow-up on readmission following gastrointestinal (GI) cancer surgery. Patients who underwent surgery for GI cancer were identified using the Surveillance, Epidemiology and End Results (SEER) database. Multivariable regression was performed to examine the association between early PCP follow-up and hospital readmission. Among 60 957 patients who underwent GI cancer surgery, 19 661 (32.7%) visited a PCP within 30-days after discharge. Of note, patients who visited PCP were less likely to be readmitted within 90 days (PCP visit: 17.4% vs. no PCP visit: 28.2%; p < 0.001). Median postsurgical expenditures were lower among patients who visited a PCP (PCP visit: $4116 [IQR: $670-$13 860] vs. no PCP visit: $6700 [IQR: $870-$21 301]; p < 0.001). On multivariable analysis, PCP follow-up was associated with lower odds of 90-day readmission (OR: 0.52, 95% CI: 0.50-0.55) (both p < 0.001). Moreover, patients who followed up with a PCP had lower risk of death at 90-days (HR: 0.50, 95% CI: 0.40-0.51; p < 0.001). PCP follow-up was associated with a reduced risk of readmission and mortality following GI cancer surgery. Care coordination across in-hospital and community-based health platforms is critical to achieve optimal outcomes for patients.

Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall

Study objectiveFalls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. MethodsThis 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. ResultsOf 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. ConclusionOnly 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions

The benefit of primary care physician (PCP) follow-up as a potential means to reduce readmissions in hospitalized patients has been found in other medical conditions and among patients receiving high-risk surgery. However, little is known about the implications of PCP follow-up for patients with an emergency general surgery (EGS) condition. To evaluate the association between PCP follow-up and 30-day readmission rates after hospital discharge for an EGS condition. This cohort study used data from the Centers for Medicare & Medicaid Services Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for beneficiaries aged 66 years or older who were hospitalized with an EGS condition that was managed operatively or nonoperatively between September 1, 2016, and November 30, 2018. Eligible patients were enrolled in Medicare fee-for-service, admitted through the emergency department with a primary diagnosis of an EGS condition, and received a general surgery consultation during the admission. Data were analyzed between July 11, 2022, and June 5, 2023. Follow-up with a PCP within 30 days after hospital discharge for the index admission. The primary outcome was readmission within 30 days after discharge for the index admission. An inverse probability weighted regression model was used to estimate the risk-adjusted association of PCP follow-up with 30-day readmission. The secondary outcome was readmission within 30 days after discharge stratified by treatment type (operative vs nonoperative treatment) during their index admission. The study included 345 360 Medicare beneficiaries (mean [SD] age, 74.4 [12.0] years; 187 804 females [54.4%]) hospitalized with an EGS condition. Of these, 156 820 patients (45.4%) had a follow-up PCP visit, 108 544 (31.4%) received operative treatment during their index admission, and 236 816 (68.6%) received nonoperative treatment. Overall, 58 253 of 332 874 patients (17.5%) were readmitted within 30 days after discharge for the index admission. After risk adjustment and propensity weighting, patients who had PCP follow-up had 67% lower odds of readmission (adjusted odds ratio [AOR], 0.33; 95% CI, 0.31-0.36) compared with patients without PCP follow-up. After stratifying by treatment type, patients who were treated operatively during their index admission and had subsequent PCP follow-up within 30 days after discharge had 79% reduced odds of readmission (AOR, 0.21; 95% CI, 0.18-0.25); a similar association was seen among patients who were treated nonoperatively (AOR, 0.36; 95% CI, 0.34-0.39). Infectious conditions, heart failure, acute kidney failure, and chronic kidney disease were among the most frequent diagnoses prompting readmission overall and among operative and nonoperative treatment groups. In this cohort study, follow-up with a PCP within 30 days after discharge for an EGS condition was associated with a significant reduction in the adjusted odds of 30-day readmission. This association was similar for patients who received operative care or nonoperative care during their index admission. In patients aged 66 years or older with an EGS condition, primary care coordination after discharge may be an important tool to reduce readmissions.

\u201cShe knows me best\u201d: a qualitative study of patient and caregiver views on the role of the primary care physician follow-up post-hospital discharge in individuals admitted with chronic obstructive pulmonary disease or congestive heart failure

BackgroundPatients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are at high-risk of readmission after hospital discharge. There is conflicting evidence however on whether timely follow-up with a primary care provider reduces that risk. The objective of this study is to understand the perspectives of patients with COPD and CHF, and their caregivers, on the role of primary care provider follow-up after hospital discharge.MethodsA qualitative study design with semi-structured interviews was conducted among patients or their family caregivers admitted with COPD or CHF who were enrolled in a randomized controlled study at three acute care hospitals in Ontario, Canada. Participants were interviewed between December 2017 to January 2019, the majority discharged from hospital at least 30 days prior to their interview. Interviews were analyzed independently by three authors using a deductive directed content analysis, with the fourth author cross-comparing themes.ResultsInterviews with 16 participants (eight patients and eight caregivers) revealed four main themes. First, participants valued visiting their primary care provider after discharge to build upon their longitudinal relationship. Second, primary care providers played a key role in coordinating care. Third, there were mixed views on the ideal time for follow-up, with many participants expressing a desire to delay follow-up to stabilize following their acute hospitalization. Fourth, the link between the post-discharge visit and preventing hospital readmissions was unclear to participants, who often self-triaged based on their symptoms when deciding on the need for emergency care.ConclusionsPatients and caregivers valued in-person follow-up with their primary care provider following discharge from hospital because of the trust established through pre-existing longitudinal relationships. Our results suggest policy makers should focus on improving rates of primary care provider attachment and systems supporting informational continuity.

Follow-Up Care of Distal Radius Buckle Fractures

Source: Colaco K, Willan A, Stimec J, et al. Home management versus primary care physician follow-up of patients with distal radius buckle fractures: a randomized controlled trial. Ann Emerg Med. 2021;77(2):163-173; doi:10.1016/j.annemergmed.2020.07.039Investigators from the University of Toronto conducted a randomized controlled trial to assess outcomes associated with home management versus physician follow-up in children with distal buckle fractures. Children were eligible if they were 5-17 years old and were diagnosed in the study ED within the previous 3 days with a distal radius buckle fracture during the 2018-2019 study period. The standard management for all patients diagnosed with a distal buckle fracture at the study ED is a removable splint. All participants completed a demographic survey at enrollment as well as a baseline modified Activities Scale for Kids-38 (ASKp38) scale that assessed wrist function the week before injury (with the average score for patients with no disabilities being 95%).Participants were randomized to either removal of the splint at home with physician follow-up as needed or to see their primary care physician 1-2 weeks after the ED visit. All participants were advised to wear the splint continuously (except for bathing) for the first week and then as needed to manage pain or swelling symptoms. All participants were advised to restrict activities that could lead to reinjury for 6 weeks.The primary outcome was ASKp38 scores at 3 weeks post-ED visit, assessed via telephone. A secondary outcome was health care resource use and parental expenses related to the child’s injury, assessed by parent report at 3 and 6 weeks post-ED visit and medical records. Total patient health care costs were estimated by multiplying health care resources data by corresponding unit prices. The investigators assessed outcomes by allocation arm using an intention-to-treat analysis.There were 149 participants enrolled, 73 in the home management group and 76 in the primary care physician follow-up group. Follow-up was completed for 90.4% of participants in the home management group and 88.2% of the physician follow-up group at 3 weeks, and 89% and 86.8%, respectively, at 6 weeks. There were no significant differences in baseline demographics or baseline ASKp38 scores. Mean ASKp38 scores at 3 weeks were similar between both groups (95.4% and 95.9% in the home management and physician follow-up groups, respectively). Total mean healthcare and parent costs in the physician follow-up group were greater than in the home management group ($149.10 vs $26.80, respectively).The investigators conclude that home removal of splints for distal buckle fractures is noninferior to physician follow-up and less costly.Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Buckle (torus) fractures of the distal radius are the most common fractures in children.1 There are many ways these fractures can be managed, as they are very stable and have an excellent prognosis. Primary care physicians are becoming the standard of care for follow-up of buckle fractures instead of orthopedic or fracture clinic follow-up. Primary care physician follow-up for distal forearm buckle fractures has demonstrated excellent recovery and management mainly based on patient symptoms rather than frequent radiographic follow-up common to orthopedists or fracture clinics.2 The current investigators sought to determine whether symptomatic home management versus primary care provider follow-up of torus fractures had equivalent functional outcomes in children managed with a removable splint.Indeed, the authors did find that home management was just as efficacious as primary care provider follow-up in terms of functional use scores at 3 weeks. Notably, children who were managed at home had even lower costs and fewer follow-up radiographs obtained than children who had follow-up with their primary care provider. There are, however, 2 significant limitations of the current study that should be noted. The first is that most of the population had post-secondary school education and telephone and electronic access and had a primary care provider. Thus, extrapolating the results to a different population (eg, lower parental education, lack of telephone access or a primary care provider) is not possible at this time. The second limitation is that the population was also primarily English-speaking, so it is likely not practical to expect similar results in a non-English speaking population of caregivers based on the current study.In English-speaking families with telephone and electronic access and a primary care physician, at-home management of children with torus fractures with a removable splint is less costly and just as efficacious as follow-up with a primary care physician.The benefits that accrue with home splint removal are potentially more than financial. Parental time away from employment or other priorities, as well as school absence by affected children, are obviated by home management of distal radius fractures.

Home Management Versus Primary Care Physician Follow-up of Patients With Distal Radius Buckle Fractures: A Randomized Controlled Trial

In patients with a distal radius buckle fracture, we determine whether home removal of a splint and physician follow-up as needed (home management) is noninferior to primary care physician follow-up in 1 to 2 weeks with respect to functional recovery. We also compare groups with respect to health care and patient-level costs. This was a noninferiority randomized controlled trial conducted at a tertiary care children's hospital. Eligible patients were randomized to home management versus primary care physician follow-up and received telephone contact at 3 and 6 weeks after the index ED visit. Functional recovery was measured with the Activities Scale for Kids-performance, and participants reported wrist-injury-related health care interventions and expenses. The primary outcome was a comparison of the performance score between groups at 3 weeks. We enrolled 149 patients with mean age 9.5 years (SD 2.7 years), and 81 (54.4%) were male patients. Of the 133 patients (89.3%) with completed 3-week follow-up, the mean Activities Scale for Kids-performance score was 95.4% in the home management group (n=66) and 95.9% in the primary care physician follow-up group (n=67) (mean difference -0.4%; lower bound of the 95% confidence interval -2.4%). There was a mean costs savings of -$100.10 (95% confidence interval -$130.0 to -$70.20) in health care and -$28.2 (95% confidence interval -$49.6 to -$7.0) in patient costs in the home management versus primary care physician follow-up group. In patients with distal radius buckle fractures, home management is at least as good as primary care physician follow-up with respect to functional recovery. Implementation of the home management strategy also demonstrated significant cost savings.

Missed Opportunities to Diagnose and Intervene in Modifiable Risk Factors for Older Emergency Department Patients Presenting After a Fall

Falls are a major cause of mortality and morbidity in adults aged 65 years and older and a common chief complaint in the emergency department (ED). However, the rate of missed opportunities to diagnose and intervene in modifiable fall-risk factors in the ED is unknown. We hypothesize that although ED providers (defined as ED attendings, residents, and advanced care providers) excel at assessing and ruling out injury, they miss the opportunity to identify a large portion of the modifiable risk factors that contribute to a patient's fall. Our objective is to quantify the number of missed opportunities to identify and reduce fall-risk factors in older adult ED patients presenting after a fall. This secondary analysis used data from a prospective cohort study of older patients at a single academic urban ED. The original study investigated the standard ED evaluation after a fall in older adults. All patients in the original study had a falls evaluation conducted at their ED visit by trained research assistants; this served as the standard fall evaluation. We reviewed the charts of study patients and identified modifiable fall-risk factors. We then determined the number of missed opportunities to intervene in these risk factors during the ED encounter; the primary outcome was the percentage of missed opportunities to identify risk factors in older ED patients who fell. We found that of the 400 patient charts reviewed, 349 patients had a modifiable risk factor for falling. Of those patients with known modifiable risk factors, the ED team missed identifying the factors in 335 patients (96%). The most commonly missed fall-risk factors were visual acuity (147/154; 96%) and the use of high-risk medications (245/259;95%). Gait abnormalities had the lowest rates of missed modifiable risk factors, at 56% of patients (109/196). When a modifiable risk factor was identified and intervened in, it was most commonly done in the ED observation unit by a physician or physical therapist, and often consisted of an outpatient referral or primary care physician follow-up. Providers frequently fail to identify and intervene in modifiable fall-risk factors in older adult patients presenting to the ED after a fall; this is a missed opportunity. Addressing the risk factors that contributed to the fall during a fall-related ED visit may minimize fall risk and promote safer mobility.

Does Scheduling a Postdischarge Visit with a Primary Care Physician Increase Rates of Follow-up and Decrease Readmissions?

Driven in part by Medicare's Hospital Readmissions Reduction Program, hospitals are focusing on improving the transition from inpatient to outpatient care with particular emphasis on early follow-up with a primary care physician (PCP). To assess whether the implementation of a scheduling assistance program changes rates of PCP follow-up or readmissions. Retrospective cohort study. An urban tertiary care center PATIENTS: A total of 20,918 adult patients hospitalized and discharged home between September 2008 and October 2015. A postdischarge appointment service to facilitate early PCP follow-up. Primary outcomes were rates of follow-up visits with a PCP within seven days of discharge and hospital readmission within 30 days of discharge. Our first analysis assessed differences in outcomes among patients with and without the use of the service. In a second analysis, we exploited the fact that the service was not available on weekends and conducted an instrumental variable analysis that used the interaction between the intervention and day of the week of admission. In our multivariable analysis, use of the appointment service was associated with much higher rates of PCP follow-up (+31.9 percentage points, 95% CI: 30.2, 33.6; P < .01) and a decrease in readmission (-3.8 percentage points, 95% CI: -5.2, -2.4; P < .01). In the instrumental variable analysis, use of the service also increased the likelihood of a PCP follow-up visit (33.4 percentage points, 95% CI: 7.9, 58.9; P = .01) but had no significant impact on readmissions (-2.5 percentage points, 95% CI: -22.0, 17.0; P = .80). The postdischarge appointment service resulted in a substantial increase in timely PCP followup, but its impact on the readmission rate was less clear.

Surgical patients’ experiences of information about medication: a qualitative comparative study with a patient-centered medication counseling upon discharge

Background: Medical treatment is often prescribed to patients for acute or chronic conditions during hospital admission. Upon discharge, patients must be prepared to manage their medication at home to promote recovery and avoid readmission. Objective: To investigate the patient experience of information about medication in relation to admission in a general surgical ward when a patient-centered medication counseling upon discharge was compared with usual care. Methods: A comparative study with qualitative interviews (n=10) was performed using a phenomenological-hermeneutic approach. The intervention was performed by 2 pharmaconomists and comprised patient information, medication reconciliation, physician discussion, patient counselling, written information to primary care physician and telephone follow-up after discharge. Results: The study revealed 3 themes: firstly, “who keeps the main thread?” was about patients’ experiences of lack of information and a concern of whether the health professionals collaborated and informed each other about observations and treatment plans; secondly, “being put out of act” reflected patients’ experiences of losing control of the situation due to their illness, health professionals and guidelines; thirdly, “to take the lead” was related to how patients acted to avoid medication errors and continue an ongoing treatment. Conclusion: A patient-centered medication counseling delivered by pharmaconomists upon discharge did not improve patient experiences of information about medication. The patients experienced a series of encounters with unfamiliar health professionals which resulted in patients not requesting the needed information about medication and treatment plans.

101 Adherence to evidence-based care of distal forearm buckle fractures in a tertiary care pediatric emergency department

Pediatric buckle fractures of the distal forearm are a common reason for emergency department (ED) visits. Evidence has clearly demonstrated that a removable splint is as good as a circumferential cast for treatment of these injuries, and may be superior with respect to patient preference and return to activity. Children should be instructed to wear the splint for comfort only, without a specific duration of wear. These injuries are safely managed without primary care physician (PCP) or orthopedic follow-up. Our objective was to assess the adherence to evidence-based recommendations for isolated distal forearm buckle fractures in a tertiary care pediatric ED. Our primary outcome was the proportion of patients treated with a splint. Secondary outcome measures were the proportion of patients a) instructed to wear the splint for comfort only without a specific duration of wear, and b) receiving instructions for no required follow up. A retrospective chart review of all children < 18 years presenting to a pediatric ED between May 1 to July 31, 2017 was conducted. We identified children with fractures of the forearm using ICD-10 codes (S52.500, S52.580, S52.590, S52.600 and S52.800). The electronic medical record was reviewed to identify patients with isolated buckle fractures of the radius and/or ulna as diagnosed by the ED physician and confirmed by radiology report. Of the 274 patients identified by ICD-10 code, 83 had an isolated distal forearm buckle fracture. 93% were treated with a removable splint, and 7% received a cast. For splint wear instructions, 29% were told to wear as needed for comfort, 47% were told to wear continuously and 24% had no documentation of splint instructions. Of children who were told to wear the splint continuously, 6% were instructed to wear it for 7 days, 6% for 10 days, 39% for 14 days, and 49% for ≥ 21 days. 48% of patients were asked to follow up with their PCP, 10% were referred to orthopedics and 31% were told no follow-up was required. Only 17% of patients were managed with all 3 recommendations for evidence-based care. Although good evidence for management of isolated buckle fractures has existed for over a decade, adherence to evidence-based care in our centre varied by measure, ranging from 29% to 93%. Only 17% of patients were managed with full adherence to recommendations. This data lays a foundation for targeted quality improvement initiatives in this area.

56 A Novel Transitional Care Strategy Improving Health Care Utilization in Diabetes Patients

Diabetes is a common chronic disease requiring regular primary care physician (PCP) clinic visits to prevent diabetes-associated complications. Noncompliance of PCP follow-up occurs frequently among chronic diabetic patients. A novel transitional care plan was established in a hospital urgent care center (UCC) adjacent to an emergency department (ED) with the goal of increasing PCP compliance. We aim to investigate the quality improvement role of implementing this novel transitional care strategy. All patients with new-onset diabetes or history of diabetes were enrolled from April 6, 2015 through October 1, 2017. Enrolled patients followed the transitional care protocol; upon disposition, a follow-up PCP clinic appointment was scheduled and given to the patient before discharge. Each patient was also advised to return to diabetic transitional care (within the UCC), if they were unable to keep their PCP appointment. The number of PCP clinic visits, diabetic transitional care visits and ED visits were compared before and after the intervention. The association between PCP clinic/ED visits and such intervention were investigated in a linear multivariate regression model. The number of PCP clinic visits before and after the intervention was compared using paired student t-test. A total of 12,226 patient encounters were included. The average number of PCP clinic visits per patient within 12 months before the intervention was 1.75, in comparison to 2.58 post-intervention PCP clinic visits, after adjusting for the same follow-up duration (p<0.001). The number of PCP visits increased (point estimate=0.015, 95% CI0.006-0.024) and the number of ED visits decreased (point estimate= -0.012, 95% CI -0.018 to -0.007), with the increased number of transitional care visits in a multivariate regression analysis. Additionally, 68% of patients kept their PCP appointment after the transitional care visit. However, this percentage decreased with increased intervals between the initial transitional care and subsequent PCP clinic appointments. A novel diabetic transitional care strategy increased patient compliance for PCP follow-up visits and decreased the number of ED visits. However, patient PCP follow-up compliance decreased with an increased interval between transitional care and subsequent PCP clinic appointments.

Isolated proximal greater saphenous vein thrombosis and the risk of propagation to deep vein thrombosis and pulmonary embolism

ObjectivesGreater saphenous vein (GSV) thrombosis is concerning due to its close proximity to the deep femoral vein. This study sought to identify the risk of propagation to deep vein thrombosis (DVT) or pulmonary embolism (PE) among patients with isolated proximal GSV superficial thrombosis and describe provider practice patterns related to treatment.Materials and methodsThis is an Institutional Review Board-approved retrospective multi-center study. Patients presented to one of three possible emergency departments in a large health system. About 21,716 patients were queried through the electronic medical record. Ninety-five patients or 0.4% of study subjects met inclusion criteria of isolated proximal GSV thrombosis. Forty-five patients were excluded, leaving a final data set of 40 patients. Investigators recorded radiology impressions, patient demographics, past medical history, DVT/PE risk factors, and treatment plans. Propagation of GSV thrombosis to DVT/PE was also noted. Follow-up methods included chart review, primary care physician follow-up, and direct, scripted patient follow-up phone calls. Descriptive statistics were applied to study subjects using SAS for Windows, version 9.3.ResultsThree patients (7.5%) had progression of GSV thrombosis to DVT/PE. Twenty percent of patients without malignancy were treated with anticoagulation compared to 14% of those with preexisting malignancy upon initial diagnosis of isolated GSV thrombosis. Forty-five percent of patients were prescribed some type of supportive therapy to aid in the treatment of GSV thrombosis.ConclusionIsolated proximal GSV thrombosis, while uncommon, may frequently progress to DVT or PE. Our work suggests clinicians should consider anticoagulation for isolated GSV thrombosis.

Impact of the Implementation of Project Re-Engineered Discharge for Heart Failure patients at a Veterans Affairs Hospital at the Central Arkansas Veterans Healthcare System.

Background: Hospitalizations due to chronic diseases such as heart failure (HF) continue to increase worldwide. Fragmentation of care while transitioning from one care setting to another is an important factor contributing to hospitalizations. Fragmented discharge tools have been implemented; however, the impact of a comprehensive interdisciplinary discharge tool has not been previously studied. Objective: The goal of this study is to assess the impact of the implementation of Project Re-Engineered Discharge (RED) on the incidence of hospital readmissions, all-cause mortality, primary care physician follow-up rate, and cost savings for patients with HF. Methods: This was a single-center, retrospective, cohort study of patients admitted with HF exacerbation at the Central Arkansas Veterans Healthcare System (CAVHS). A random sample of 100 patients admitted prior to implementation of Project RED and 50 patients after Project RED intervention were included in the study. The primary end point was 30-day hospital readmission for HF exacerbation. The co-secondary end points were all-cause mortality, cost savings, and rate of primary care physician appointments scheduled as well as attended per postdischarge recommendations. Results: The 30-day hospital readmission rate was 28% in the pre-Project RED group, and it was 18% in the post-Project RED group (P = .18). The all-cause mortality was significantly lower in the post-Project RED group as compared with the pre-Project RED group (18% vs 41%, P = .04). More patients in the post-Project RED group attended an outpatient primary care appointment as recommended per postdischarge instructions (40% vs 19%, P = .006). In addition, with the decrease in hospital 30-day readmission rate in the post-Project RED group, there was a cost savings of $1453 per patient visit for HF exacerbation. Conclusions: Coordination of care using a discharge tool like Project RED should be utilized in institutions to improve patient outcomes as well as patient safety while decrease the overall health care cost.

Abstract WP394: Needs of Stroke Survivors Post Hospital Discharge Stroke Follow-up Call

Background: This project attempts to discover the subjective response needs of 30-day post-acute stroke patients and their family members that were treated in two Northern California hospitals. The goal is to determine the functional level of the Stroke Survivor (SS) as measured by the Modified Rankin Scale (mRS) and to identify post-discharge needs. Purpose: The objective of this project is to identify the patient’s mRS score and post-discharge needs. The study includes stroke education reinforcement, primary care physician follow-up, ancillary services follow-up, discern hospital readmissions rates, and increase patient satisfaction. Methods: A list of discharged acute ischemic stroke patients over a three month period was provided to the Stroke Nurse Champion (SNC). A stroke phone call template was created to elicit the patient’s history, diagnosis, and mRS score. Patients with intracranial hemorrhage diagnosis, patients discharged to Skilled Nursing Facilities, and deceased patients were excluded from the study. The SNC performed chart review to determine patient course of hospitalization and stroke care management; places follow-up phone call to patient or family member; and identify the SS needs. When needs were discovered, they were addressed using electronic in-house messaging to patient’s primary care providers and ancillary staff. Results: Of the 63 participants, nine required stroke resource follow-up. The average mRS score of 1.84 revealed the patient’s knowledge of self-management to be 100%. There were 13 cases that needed outpatient therapy and Home Health therapy with mRS &gt;2. The study outcome includes readmission rate of 0.03% (n=2) and stroke patient satisfaction &gt;12.5%. Conclusions: Based on the mRS score, the SS appropriately met the level of care including rehabilitation needs at home. Post discharge needs of SS included psychosocial support, medication modification and appropriate durable medical equipment. Overall, the SS were satisfied with their care with low incidence of hospital readmission due to their stroke education provided during their hospitalization. Further plans for each hospital facility to consider continuing this project or to change the focus to outpatient support services as well.

Team-based innovations in primary care delivery in Quebec and timely physician follow-up after hospital discharge: a population-based cohort study

Outpatient follow-up has been a key intervention point in addressing gaps in care after hospital discharge. We sought to estimate the association between enrolment in new team-based primary care practices and 30-day postdischarge physician follow-up among older patients and patients with chronic illnesses who were admitted to hospital in Quebec, Canada. Patients were selected into this cohort if a primary care physician enrolled them as a "vulnerable patient" between November 2002 and January 2005. Data for this analysis included province-wide health insurance claims for inpatient and outpatient services delivered between November 2002 and January 2009 in Quebec. The primary analysis examined time to the first outpatient postdischarge follow-up service provided by either a primary care physician or a medical specialist. We used marginal structural models to estimate adjusted rates of follow-up with a primary care physician or with a medical specialist by primary care delivery models. We extracted billing data for 312 377 patients that represented 620 656 index admissions for any cause from 2002 to 2009. Rates of 30-day follow-up were 374 visits to primary care physicians and 422 visits to medical specialists per 1000 discharges. Rates of primary care physician follow-up were similar across primary care delivery models, except for patients with very high morbidity; these patients had significantly higher rates of follow-up with a primary care physician if they were enrolled in team-based primary care practices (30-d rate difference [RD] 13.3 more follow-up visits per 1000 discharges, 95% confidence interval [CI] 6.8 to 19.8). Rates of follow-up with a medical specialist were lower among patients enrolled in team-based practices, particularly within 15 days of hospital discharge (15-d RD 25.1 fewer follow-up visits per 1000 discharges, 95% CI 21.1 to 29.1). Our study found lower rates of postdischarge follow-up with a medical specialist among older patients and patients with chronic illness who were enrolled in team-based primary care practices compared with those enrolled in traditional primary care practices. Future research is needed to better understand the role of primary health care service organization in improving acute postdischarge care.

Hot Off the Press: Do Emergency Department-based Predischarge Educational Interventions for Adult Asthma Patients Improve Outcomes?

Hot Off the Press: Do Emergency Department-based Predischarge Educational Interventions for Adult Asthma Patients Improve Outcomes?

Primary Care Physician Follow-up of Distal Radius Buckle Fractures.

Our main objective was to determine the proportion of children referred to a primary care provider (PCP) for follow-up of a distal radius buckle fracture who subsequently did not deviate from this reassessment strategy. This prospective cohort study was conducted at a tertiary care pediatric emergency department (ED). Eligible children were aged 2 to 17 years with a distal radius buckle fracture treated with a removable splint and referred to the PCP for reassessment. We telephoned families 28 days after their ED visit. The primary outcome was the proportion who received PCP follow-up exclusively. We also measured the proportion who received PCP anticipatory guidance and those children who reported returning to usual activities "always" by 4 weeks. We enrolled 200 children, and 180 (90.0%) received telephone follow-up. Of these, 157 (87.2% [95% confidence interval: 82.3 to 92.1]) received PCP follow-up exclusively. Specifically, 11 (6.1%) families opted out of physician follow-up, 5 (2.8%) self-referred to an ED, and the PCP requested specialty consultation in 7 (3.9%) cases. Of the 164 with a PCP visit, 77 (47.0%) parents received anticipatory guidance on return to activities for their child, and 162 (98.8%) reported return to usual activities within 4 weeks. The vast majority of children with distal radius buckle fractures presented to the PCP for follow-up and did not receive additional orthopedic surgeon or ED consultations. Despite a suboptimal rate of PCP advice on return to activities, almost all parents reported full return to usual activities within 4 weeks.

Discharge instructions for youth sports-related concussions in the emergency department, 2004 to 2012.

To evaluate the effect of the Centers for Disease Control and Prevention (CDC) Heads-Up concussion campaign on appropriateness of discharge instructions for youth sports-related concussion (SRC) patients presenting to a pediatric emergency department (ED). Retrospective cohort study. Pediatric ED. Children up to 18 years. A retrospective chart review was conducted on patients evaluated from 2004 to 2012. Patients were selected by ICD-9 code for having a concussion during a sporting activity. Discharge instructions were reviewed for recommendations for cognitive rest, physical rest, primary care physician follow-up, and referral to a concussion specialist or center. There were 497 youth SRCs from 392 908 total ED visits. Overall, only 66% had appropriate discharge recommendations. This improved to 75% after 2010, which was not statistically significant (odds ratio = 1.02, P = 0.179). Only 4% of patients received a recommendation of cognitive rest, which only increased to 12% of the patients seen after 2010. Finally, referrals to a sports concussion specialist or center dramatically increased from an average of 8% to 43% after 2010. Even with the CDC Heads-Up campaign on concussion education, there is still need to improve appropriateness of discharge instructions for youth SRCs. There have been dramatic increases in referrals to sports concussion specialists and centers after 2010.

Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors.

This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients.

A mixed-methods approach to understanding barriers to postpartum retention in care among low-income, HIV-infected women.

Optimal retention in HIV care postpartum is necessary to benefit the health and wellbeing of mothers and their infants. However, postpartum retention in HIV care among low-income women is suboptimal, particularly in the Southern United States. A mixed-methods study was conducted to identify factors associated with postpartum retention in care among HIV-infected women. Participants (n=35) were recruited during pregnancy at two county clinics and completed self-report demographic and psychosocial surveys. Twenty-two women who returned for a postpartum appointment completed a semi-structured interview about lifestyle factors and retention in care. Of the participants enrolled at baseline, 71.4% completed a follow-up with an obstetrician (OB), while 57.1% completed a follow-up with a primary care physician (PCP). High CD4 count at delivery, low viral load at baseline, low levels of depression, high interpersonal social support, and fewer other children were significantly associated with completion of postpartum follow-up. Barriers and facilitators to retention identified during qualitative interviews included competing responsibilities for time, lack of social support outside of immediate family members, limited transportation access, experiences of institutionalized stigma, knowledge about the benefits of adherence, and strong relationships with healthcare providers. OB and PCP follow-up postpartum was suboptimal in this sample. Findings underscore the importance of addressing depressive symptoms, social support, viral suppression, competing responsibilities for time, institutionalized stigma, and transportation issues in order to reduce the barriers that inhibit women from seeking postpartum HIV care.