Referral Rate Of Patients Research Articles

Using behaviour change and implementation science to address low referral rates in oncology

BackgroundPatients undergoing surgery for bowel cancer now have a routine screening test to assess their genetic predisposition to this and other cancers (Lynch syndrome). A result indicating a high risk should trigger referral to a genetic clinic for diagnostic testing, information, and management. Appropriate management of Lynch syndrome lowers morbidity and mortality from cancer for patients and their family, but referral rates are low. The aim of this project was to increase referral rates for patients at high risk of Lynch syndrome at two Australian hospitals, using the Theoretical Domains Framework (TDF) Implementation approach.MethodsMultidisciplinary teams at each hospital mapped the referral process and discussed barriers to referral. A 12-month retrospective audit measured baseline referral rates. The validated Influences on Patient Safety Behaviours Questionnaire was administered to evaluate barriers using the TDF. Results were discussed in focus groups and interviews, and interventions co-designed, guided by theory. Continuous monitoring audits assessed change in referral rates.ResultsTeams (n = 8, 11) at each hospital mapped referral processes. Baseline referral rates were 80% (4/5) from 71 screened patients and 8% (1/14) from 113 patients respectively. The questionnaire response rate was 51% (36/71). Most significant barrier domains were: ‘environmental context;’ ‘memory and decision making;’ ‘skills;’ and ‘beliefs about capabilities.’ Focus groups and interviews with 19 healthcare professionals confirmed these domains as significant. Fifteen interventions were proposed considering both emerging and theory-based results. Interventions included: clarification of pathology reports, education, introduction of e-referrals, and inclusion of genetic status in documentation.Audits continued to December 2016 showing a change in pathology processes which increased the accuracy of screening. The referral rate remained low: 46% at Hospital A and 9% Hospital B. Results suggest patients who have their referral deferred for some reason are not referred later.ConclusionLynch syndrome is typical of low incidence problems likely to overwhelm the system as genomic testing becomes mainstream. It is crucial for health researchers to test methods and define generalizable solutions to address this problem. Whilst our approach did not improve referrals, we have deepened our understanding of barriers to referral and approaches to low frequency conditions.

Declining Rates of Referral for Irritable Bowel Syndrome Without Constipation at a Tertiary Care Center.

Irritable bowel syndrome (IBS) is a common chronic disorder of the gastrointestinal tract. Several treatments have been developed, including rifaximin for the treatment of IBS without constipation (non-IBS-C), but no studies have evaluated the effect of these therapies on patient referral rates to tertiary care gastroenterology clinics. To assess referral patterns for IBS patients at a tertiary motility clinic over a 10-year period. Data from consecutive patients referred to the clinic during 2006-2016 were analyzed. Trends in the proportion of referrals and prior rifaximin use in IBS-C versus non-IBS-C groups were compared. A total of 814 adult patients were referred to a single physician panel for IBS-related symptoms. Of these, 776 were included in the study [528 females (68%), average age 45.7 ± 15.9years), comprising 431 IBS-C (55.5%) and 345 non-IBS-C (44.5%) patients. The proportion of non-IBS-C referrals declined significantly from 53.0% in 2006 to 27.3% in 2016 (Chi-square, p < 0.0001, Cochran-Armitage trend test p = 0.0001), and the proportion of IBS-C referrals increased significantly from 46.9% in 2006 to 72.7% in 2016 (Chi-square, p < 0.0001, Cochran-Armitage trend test p = 0.0004). Non-IBS-C referrals with prior rifaximin use significantly increased from 22.7% in 2006 to 66.7% in 2016 (Cochran-Armitage trend test, p = 0.008). The results indicate a significantly declining tertiary care referral rate for non-IBS-C over the past decade. While not directly linked, there has been an increase in rifaximin use in the same population during the same time interval.

The relationship between indicators of drug users detection and the population referral to drug treatment services

To examine the relationship between the results of drug users' identification through medical examination for drug intoxication and the rates of primary population' referral for drug treatment. The data of the state federal statistical observation for period of 2009-2013 were used. Methods of descriptive statistics and regression analysis were applied. It has been established that the identification of drug users during medical examination of citizens for the state of drug intoxication has a statistically significant effect on the population' drug treatment referral rates. According to linear regression equations, out of each 100 cases identified through medical examination, only 15 patients referred to drug treatment services. From practical point of view, the influence of the first indicator on the second one is not high: an increase in the number of identified drug users for each 100 cases leads to an increase in referral rate of patients with drug dependence syndrome for 2 cases, while the referral rate of drug users with established diagnosis of the harmful use of drugs increases for 10 patients. The results of the study highlight the urgent need for developing secondary prevention programs for those diagnosed with the harmful use of drugs. There is also a question of further improvement of legislation in the field of law-governed motivation of exposed drug users to seek drug treatment.

Use of the Electronic Medical Record to Facilitate Intervention for Patients With Rising Prostate-Specific Antigen Values After Radical Prostatectomy: A Feasibility Study.

Salvage radiotherapy (SRT) is the standard of care offered when postprostatectomy prostate-specific antigen (PSA) levels are ≥ 0.2 ng/mL. However, emerging evidence suggests that early SRT (ie, SRT delivered at PSA values < 0.2 ng/mL, but generally ≥ 0.05 ng/mL) improves oncologic outcomes. We evaluated the feasibility of improving referral rates for discussion of early SRT by using a dynamic registry that identifies through the electronic medical record patients with rising postprostatectomy PSA levels. We developed an iteratively updated registry that identifies patients who fall within two postoperative PSA strata: ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL. We compared referral rates to radiation oncology during a 3-year period before use of this registry with those during a 1-year period after promotion of the registry in multidisciplinary tumor board settings. Before promotion of the registry, referral rates for patients with PSA values ≥ 0.05 to < 0.1 ng/mL and ≥ 0.1 to < 0.2 ng/mL were 35% and 65%, respectively. After promotion of the registry, referral rates within each stratum increased significantly to 82% and 94%, respectively ( P < .05 for both by Fisher's exact test). The overall rate of referral for patients with PSA values ≥ 0.05 to < 0.2 ng/mL rose from 48% to 90% ( P < .001). The creation of a registry of patients with rising postprostatectomy PSA values can facilitate increased referral rates for early SRT without burdening providers with a clinical support tool embedded within the EMR itself. This is true even in the case of already high baseline rates of referral for early SRT. The changes reported herein most likely reflect a Hawthorne effect wherein the ability to track referrals rather than a direct function of the registry influenced practice patterns. Nonetheless, the registry provided an integral framework to allow for tracking.

National Health Service Healthcare Staff Experience and Practices Regarding Complementary and Alternative Medicine: An Online Survey

The use of complementary and alternative medicine (CAM) is increasing. The most common reported reason for CAM use is dissatisfaction with conventional healthcare. Several studies have reported factors influencing CAM usage and beliefs in the general public but the beliefs of healthcare staff are less well known. This paper reports the results of an online survey of 537 healthcare staff. Our study demonstrated an increased rate of patient referral for CAM from both personal CAM users and those trained in CAM. There was a high level of optimism amongst respondents as to the role CAM may play in patient care with mental health, depression and palliative care cited as the areas with highest expected benefit. Doctors were generally less optimistic about the likelihood of benefit compared to other healthcare staff. Implications for clinical practice, future research and staff education are discussed.

Web-based consultation between general practitioners and nephrologists: a cluster randomized controlled trial.

Consultation of a nephrologist is important in aligning care for patients with chronic kidney disease (CKD) at the primary-secondary care interface. However, current consultation methods come with practical difficulties that can lead to postponed consultation or patient referral instead. This study aimed to investigate whether a web-based consultation platform, telenephrology, led to a lower referral rate of indicated patients. Furthermore, we assessed consultation rate, quality of care, costs and general practitioner (GPs') experiences with telenephrology. Cluster randomized controlled trial with 47 general practices in the Netherlands was randomized to access to telenephrology or to enhanced usual care. A total of 3004 CKD patients aged 18 years or older who were under primary care were included (intervention group n = 1277, control group n = 1727) and 2693 completed the trial. All practices participated in a CKD management course and were given an overview of their CKD patients. The referral rates amounted to 2.3% (n = 29) in the intervention group and 3.0% (n = 52) in the control group, which was a non-significant difference, OR 0.61; 95% CI 0.31 to 1.23. The intervention group's consultation rate was 6.3% (n = 81) against 5.0% (n = 87) (OR 2.00; 95% CI 0.75-5.33). We found no difference in quality of care or costs. The majority of GPs had a positive opinion about telenephrology. The data in our study do not allow for conclusions on the effect of telenephrology on the rate of patient referrals and provider-to-provider consultations, compared to conventional methods. It was positively evaluated by GPs and was non-inferior in terms of quality of care and costs.

Rehabilitation of Discharged Patients With Chronic Obstructive Pulmonary Disease-Are New Strategies Needed?

Background:Rehabilitation after hospital stay implies several benefits for patients with chronic obstructive pulmonary disease (COPD); still few patients are referred and participate in rehabilitation programs. We conducted a case study to investigate the effects of interventions targeting the referral, uptake, and completion for a program of early rehabilitation in the primary health-care sector.Methods:We undertook targeted initiatives to make patients participate in an individualized rehabilitation program with gradual increased intensity. After discharge, primary care COPD nurses and physiotherapists guided patients through progressing exercises in small groups online. Patients proceeded to class-based exercises, patient education and/or leisure activities, or continued telerehabilitation. We evaluated the effects of the intervention by assessing referral rates, completion, and readmission.Results:Sixteen (23% of discharged patients) patients were referred to rehabilitation. In comparison, only 1 (0.8%) in 131 patients from Vejle hospital was referred to Vejle hospital. Twelve patients completed rehabilitation, all having severe COPD. All started the program within 2 weeks and proceeded to the online-guided exercises within 4 weeks. Study data showed that after 30 days, 1 (6.3%) of the 16 patients in the rehabilitation program had been readmitted compared to 8 (14.8%) of 55 patients who were not referred. After 90 days, 2 (12.5%) and 11 (20.0%) patients were readmitted, respectively. The readmission rate showed a nonsignificant decline in patients participating in rehabilitation.Conclusion:This case study showed that the referral rate of patients with COPD to early municipal rehabilitation is extremely low without a targeted effort and still insufficient in spite of a focused intervention. We showed that completion of a municipal rehabilitation program shortly after discharge is possible even for patients with severe COPD. The findings from our pilot study can guide further investigations into the effect of implementation strategies for handovers between health-care sectors to secure early-onset rehabilitation of patients with COPD.

Epidemiology of uveal melanomas in Moscow

Rationale: Melanoma of the uveal tract of the eye is among the most prevalent malignant intraocular tumors. Aim: To identify epidemiological characteristics of uveal melanoma in Moscow. Materials and methods : We performed a retrospective analysis of out-patient files and follow-up charts of patients with uveal melanoma in the Ophthalmological Clinical Hospital of the Department of Healthcare, Moscow, from 1977 to 2012. Results: Within 36 years, 2547 patients with uveal melanoma have been registered, at the age of 16 to 92 years. The male to female ratio was 1:1.5. The rate of patient referrals with subsequent diagnosis of uveal melanoma has not changed from 1977 to 2000 and was on average 1.07 persons per 100,000 of the adult population. From 2001 to 2012, there was some decline in the number of referrals with uveal melanoma to the average of 0.9 persons per 100,000 of the adult population. We analyzed survival among 359 patients with uveal melanoma after enucleation surgery of the eye; 37% of them were men (63.2 ± 1.8 years) and 63% women (69.5 ± 2.7 years). Their 5-year metastasis-free survival was 65 ± 3%, whereas the 7-year survival was 60 ± 4%. The mean time to death was 5.5 years. There were no association between the life longevity and patients gender, but their survival was associated with the age of patients. The risk of death from metastatic uveal melanoma among patients above 60 years of age was on average 10% higher. After the enucleation surgery, patients with Т4 melanoma lived significantly less than those with Т1-3 tumor (5 and 6.5 years, respectively; р = 0.05). Conclusion: The rates of diagnosis of uveal melanoma at referrals within 36 years did not increased. Epidemiology of uveal melanoma in Moscow is characterized by a high proportion of elderly women. Shorter overall and metastasis-free survival of patients with uveal melanoma after the enucleation surgery depends from a higher proportion of elderly people in the regional population and late diagnosis of the disease.

An odd couple: A large public hospital working with a small private general practice group to integrate care

An odd couple: A large public hospital working with a small private general practice group to integrate care

Mass-gathering Events: The Role of Advanced Nurse Practitioners in Reducing Referrals to Local Health Care Agencies.

Introduction: The introduction of advanced practitioner roles has challenged the traditional boundaries of health care. While studies have been undertaken to understand the role of physicians in respect of mass-gathering medicine, the role of advanced nurse practitioners (ANPs) has not been investigated. Problem Does the presence of an ANP reduce the referral rates of patients presenting for medical care at mass-gathering events to external health care resources? A prospective observational study was undertaken to determine whether the presence of an ANP would reduce the patient referral rate to external health care services by first aiders and paramedics working within an event medical team. Patients identified as requiring referral were reviewed by an ANP as part of the on-site medical provision for four mass-gathering events in the south of England. Additionally, information was gathered identifying which patients would have been transported to hospital by ambulance compared to those actually transported following ANP review. Statistical analysis was undertaken for three key measures (referrals to all local health resources, referrals to hospital-based acute services, and transfers to hospital by ambulance). A rounded total of 842,000 people attended four mass-gathering events held over 14 days. Of these, 652 presented for medical care, many self-referring. Using a one-tailed Fisher's Exact Test and Phi analysis, this study demonstrated statistically significant reductions in the overall referral of patients to all external health care resources (P<.001; φ=0.44), to the emergency department (ED; P<.001; φ=0.43), and a reduction in ambulance transport (P<.001; φ=0.42). Effect size analysis demonstrated a medium-sized effect evident for all of the above, which was also demonstrated in economic terms. The event medical team would have referred 105 (16.3%) of the 652 patient presentations to external health care services; 47 (7.2%) would have been transported by ambulance. In comparison, the ANP referred 23 patients (3.5%) with 11 (1.7%) being transported by ambulance. It also was noted that the first aiders and paramedics could be more selective in their referral habits that were focused primarily on the ED. Appropriately trained and experienced ANPs working within event medical teams have a positive impact on referral rates from mass-gathering events.

Psychological factors explaining the referral behavior of Iranian family physicians.

Background:The recently developed policy of the family practice program in rural regions of Iran faced some challenges such as inefficient referral system. The health insurance organizations (purchaser) and health policy makers are concerned about the high rate of patient referrals from family physicians to specialists due to imposing unnecessary services and costs.Objectives:This study examined utility of the theory of planned behavior to explain intention of Iranian family physicians to reduce referral rate of patients with respiratory diseases to medical specialist.Patients and Methods:An exploratory cross-sectional study, employing a correlational design directed by the theory of planned behavior was conducted. A questionnaire was developed based on an eliciting study and review of literature. One hundred and seventy-four family physicians working at primary care centers in two provinces of Iran completed the questionnaire (response rate of 86%).Results:The finding revealed that intention of family physicians to reduce referral rate of patients to specialists was significantly related to two theory-based variables of subjective norms (r = 0.38, P < 0.001) and perceived behavioral control (r = 0.43, P < 0.001), and not to attitudes. A stepwise regression entering direct measures of the theory variables explained 35% of the variance on the intention, with perceived behavioral control being the strongest predictor. Adding background variables to the model achieved further 5% by variables of practice size and past referral rate behavior.Conclusions:The results indicated that psychological variables of the theory of planned behavior could explain a noticeable proportion of variance in family physician's intention to decrease the rate of referring patients with respiratory diseases to medical specialists. The intention is primarily influenced by normative and control considerations. These findings contribute to a better understanding of referral decisions by family physicians and are of great value in developing interventions to reduce the variation in referral rate of patients to medical specialists at primary care health centers.

Impact of a Guidelines-Based Educational Program on Heart Failure Readmissions to a Medical Teaching Service

Introduction: The literature supports successful reductions in readmissions and improved outcomes with nurse practitioner (NP)-led outpatient HF programs, however readmission rates in the U.S. have remained at 25% for the past decade. Little is known, however, about the impact of an inpatient NP-dedicated program facilitating the management of HF patients directed at advanced HF (NYHA class IIIIV). This study assesses the initiation of an inpatient NP-led HF program and the resulting readmission, mortality, and hospice referral rates Hypothesis/Aim: To review the impact of a comprehensive inpatient NP led HF program that included a rapid patient referral service to a heart transplant/ left ventricular assist device (LVAD) center. Methods: A retrospective cohort record review of HF patients admitted to a regional hospital within a large hospital system in north Texas. An inpatient NP-led HF program was initiated that included clinical management, patient/staff education, discharge programming, hospice and tertiary center referrals. All-cause readmission, mortality, and hospice referral rates for patients admitted with a primary diagnosis of HF from December 2011-January 2013 were assessed via the hospital’s electronic medical record system. Readmission rates and outcomes for advanced HF patients referred to a tertiary HF transplant/LVAD program within the same hospital system were also assessed. Results: From December 2011-January 2013, there were 651 patients with a primary diagnosis of HF admitted. The 30 -day readmission rates from December 2011-February 2012 ranged from 19-22%. The HF program was implemented in February 2012. Readmission rates began to trend downward and remained at or below 15% starting in March 2012-January 2013. Mortality rates remained unchanged at 3.5%, Hospice referrals however increased from 3% in 2011 to 7.9% in 2012. Eleven (NYHA class III-IV) HF patients deemed appropriate for advanced HF treatments were referred to the tertiary transplant/LVAD center starting in March 2012. Three patients were successfully transplanted within an average of 5 months of transfer date. Additionally, 1 patient was successfully implanted with an Heartmate II LVAD within 1 month of transfer. The 30-day readmission rate for this patient subset was 20% prior to referral and there were no 30day readmissions post referral. The mortality rate was 27%. Conclusions: After the implementation of this NP HF program there was a O4-7% decrease in 30-day readmission rates. These programs should continue to be evaluated in their ability to reduce HF readmissions.

Does the Integration of Personalized Ultrasound Change Patient Management in Critical Care Medicine? Observational Trials

Objective. To test the influence of personalized ultrasound (PersUS) on patient management in critical care. Design of the Study. Prospective, observational, and critical care setting. Four substudies compared PersUS and mobile ultrasound, work distribution, and diagnostic and procedural quality. Patients and Interventions. 640 patient ultrasound exams including 548 focused diagnostic exams and 92 interventional procedures. Main Outcome Measures. Number of studies, physician's judgement of feasibility, time of usage per patient, and referrals to echo lab. Results. Randomized availability of PersUS increased its application in ICU work shifts more than twofold from 33 to 68 exams mainly for detection and therapy of effusions. Diagnostic and procedural quality was rated as excellent/very good in PersUS-guided puncture in 95% of cases. Integrating PersUS within an initial physical examination of 48 randomized cases in an emergency department, PersUS extended the examination time by 100 seconds. Interestingly, PersUS integration into 53 randomized regular ward rounds of 1007 patients significantly reduced average contact time per patient by 103 seconds from 8.9 to 7.2 minutes. Moreover, it lowered the patient referral rate to an echo lab from 20% to 2% within the study population. Conclusions. We propose the development of novel ultrasound-based clinical pathways by integration of PersUS.

Abstract 259: Myocardial Perfusion Imaging has Markedly Lower Sensitivity after Accounting for Verification Bias

Introduction Estimates of myocardial perfusion imaging (MPI) performance are often derived from convenience cohorts of patients undergoing coronary angiography, who are selectively referred for this invasive test because of high-risk clinical characteristics, high-risk test results, or both. While clinically appropriate, this approach distorts estimates of MPI's test performance, since sensitivity and specificity are only assessed in patients who are referred for angiography. This verification bias, sometimes called “work-up” or “referral” bias, compromises physicians' ability to appropriately use noninvasive testing since test performance data may be inaccurate. We sought to examine the impact of verification bias on MPI's performance, to provide clinicians with a more accurate assessment of its diagnostic characteristics. Hypothesis We hypothesized that the bias-adjusted performance of MPI will show significantly lower sensitivity and significantly higher specificity compared to published estimates derived from convenience cohorts undergoing invasive angiography. Methods We used a comprehensive meta-analysis of MPI performance (14 studies totaling 3,500 patients based on angiographic referral) to assess the reported (biased) sensitivity and specificity of MPI. We then computed unbiased sensitivity and specificity rates using published methods, combining the meta-analysis estimates with other published data giving angiography referral rates for patients with both positive and negative MPI results (48% and 6%, respectively). Finally, we validated the unbiased performance estimates using a recent multi-center study (Coronary Obstruction Detection by Molecular Personalized Gene Expression [COMPASS]) of MPI that was not subject to verification bias, since all subjects had angiographic referral to use as the gold standard. Results The meta-analysis reported (biased) MPI sensitivity was 81% and specificity was 65%. After appropriate correction for verification bias, the unbiased estimate of sensitivity was 35% (95% CI = 27% to 45%) and specificity was 94% (95% CI = 91% to 96%). These estimates were very similar to the observed values in the unbiased COMPASS trial (N=431 patients): core laboratory MPI sensitivity was 36% (95% CI = 24% to 50%) and specificity was 90% (95% CI = 87% to 93%). Conclusions In conclusion, after correction for verification bias or when estimated in a population without bias, MPI is markedly less sensitive and more specific than most published estimates would indicate. The biased estimates of test performance would tend to encourage referral to angiography compared to corrected estimates. Future studies of non-invasive imaging modalities in patients with suspected or diagnosed CHD should report performance estimates that are either corrected for verification bias or use unbiased cohorts, to provide an accurate assessment of test performance for clinical decision making.

SP3-65 Mission impossible? Evaluating the effectiveness of highly radical cancer surgery with insights from a prospective study of pelvic exenteration

IntroductionPolicy makers, clinicians and patients need robust evidence of the effectiveness of healthcare interventions to inform decision-making. Highly aggressive cancer surgery has major implications for patients and requires substantial healthcare...

The changing pattern of referral in acute kidney injury

Acute kidney injury (AKI) is not only managed by nephrologists, but also by several other subspecialists. The referral rate to nephrologists and the factors influencing it are unknown. To determine the referral rate, factors affecting referral and outcomes across the spectrum of AKI in a population based study. We identified all patients with serum creatinine concentrations ≥150 µmol/l (male) or ≥130 µmol/l (female) over a 6-month period. AKI was defined according to the RIFLE classification (risk, injury, failure, loss, end stage renal disease [ESRD]). Clinical information and outcomes were obtained from each patient's case records. A total of 562 patients were identified as having AKI (incidence 2147 per million population/year [pmp/y]). One hundred and sixty-four patients (29%) were referred to nephrologists-referral rate 627 pmp/y. Forty-nine percent of patients whose serum creatinine rose to >300 µmol/l were referred compared with 22% in our previous study of 1997. Forty-eight patients required renal replacement therapy-incidence 184 pmp/y in comparison to 50 pmp/y in our previous study of 1997. Patients had higher odds of referral if they were male, of younger age and were in the F category of the RIFLE classification. Patients had lower odds of referral if they had multiple co-morbid conditions or if they were managed in a hospital without a nephrology service. There has been a significant rise in the referral rate of patients with AKI to nephrologists but even during our period of study only one-third of such patients were being referred. With rising incidence and increased awareness, the referral rate will certainly rise putting a significant burden on the nephrology services.

Why does the general practitioner refer patients with chest pain not-urgently to the specialist or urgently to the emergency department? Influence of the certainty of the initial diagnosis

Background — Chest pain is an initial symptom for several minor diseases but acute myocardial infarction (AMI) should not be missed.Aim — To assess the influence of initial diagnosis and degree of certainty of this initial diagnosis on the referral decision and the referral method (urgent – non-urgent) in patients contacting their GP with chest pain.Study design — Observational study.Setting — The study was performed in a sentinel network of general practices in Belgium, covering almost 1.6% of the population.Subjects — All patients attending their GP and complaining of chest pain during 2003.Method — The relationships were reported as proportions and in odds ratios (OR) with their 95% confidence intervals.Results — 1996 patients were included (men 52%). Men were referred more often (OR = 1.44; 95% CI: 1.13-1.82). Age shows no relation to referral (OR = 1.06; 95% CI: 0.83-1.35) but predicts urgent referral (OR = 1.46; 95% CI: 1.02-2.08). Odds ratios in case of serious heart disease were high with 11.58 (95% CI: 5.72-23.44) when the GP was certain of his diagnosis and 2.96 (95% CI: 1.59-5.51) if not. If the GP was uncertain, in all disease categories 54% (95% CI: 48-59) of the patients were referred non-urgently.Conclusion — Referral rates for patients with chest pain were influenced by the initial diagnosis and the degree of certainty of this initial diagnosis.

A Coordinator Program in Post-Fracture Osteoporosis Management Improves Outcomes and Saves Costs

The orthopaedic unit at a university teaching hospital hired an osteoporosis coordinator to identify patients with a fragility fracture and to coordinate their education, assessment, referral, and treatment of underlying osteoporosis. We report the results of an analysis of the cost-effectiveness of the use of a coordinator (in comparison with the use of no coordinator) in avoiding future costs of subsequent hip fracture. A one-year decision-analysis model was developed. The health outcome was subsequent hip fracture; only direct hospital costs were considered. With use of patient-level data from a previously described coordinator program and data from the literature, the expected annual incidence of subsequent hip fracture was calculated, on the basis of the type of index fracture (wrist, hip, humerus, other), attribution to osteoporosis, age, and gender. The rate of patient referral, the initiation of osteoporosis treatment, and adherence to therapy were modeled to modify the expected incidence of future hip fracture in the presence of a coordinator (with use of data from the program) and in the absence of a coordinator (with use of data from the literature). Sensitivity analysis modeling techniques were used to assess variable uncertainty and to evaluate coordinator cost-effectiveness. Deterministic cost-effectiveness analysis showed that a tertiary care center that hired an osteoporosis coordinator who manages 500 patients with fragility fractures annually could reduce the number of subsequent hip fractures from thirty-four to thirty-one in the first year, with a net hospital cost savings of C$48,950 (Canadian dollars in year-2004 values), with use of conservative assumptions. Probabilistic sensitivity analysis indicated a 90% probability that hiring a coordinator costs less than C$25,000 per hip fracture avoided. Hiring a coordinator is a cost-saving measure even when the coordinator manages as few as 350 patients annually. Greater savings are anticipated after the first year and when additional costs such as rehabilitation and dependency costs are considered. Employment of an osteoporosis coordinator to manage outpatients and inpatients who have fragility fractures is predicted to reduce the incidence of future hip fractures and to save money (a dominant strategy). A probabilistic sensitivity analysis showed a high probability of cost-effectiveness of this intervention from the hospital cost perspective.

A Randomized Trial of Depression Assessment Intervention in Home Health Care

To determine whether an educational intervention would improve depression assessment and appropriate referral. Secondary analyses tested whether referral led to depression improvement. Training in the Assessment of Depression (TRIAD) was a three-group, nurse-randomized trial. Researchers interviewed randomly selected patients at baseline and 8 weeks. Three certified home healthcare agencies in Westchester County, New York. Fifty-three medical/surgical nurses were randomized within agency to three intervention groups: full, minimal, or control. Research contact with nurses' patients (aged >65; N=477) yielded 256 (53.7%) enrolled subjects, 84 (17.6%) ineligibles, and 120 (25.2%) refusals; 233 of the 256 (87.1%) enrolled patients completed follow-up interviews. Nurse training in clinically meaningful use of depression sections of Medicare's mandatory Outcome and Assessment Information Set (OASIS). Nurse-assessed mood or anhedonia (OASIS) versus research assessments using the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Disorders (SCID); referrals for mental health evaluation (agency records), and depression severity (24-item Hamilton Depression Rating Scale; HDRS). Referral rates for patients with (SCID) depressed mood or anhedonia (n=75) varied according to nurse group: 50.0% full intervention, 18.5% minimal, 21.4% control (P=.047). Rates for nondepressed patients (n=180) did not differ (4.9%, 2.0%, 5.8%, respectively; P=.60). In patients with major or minor depression (n=37), referral was associated with symptom improvement. Change in HDRS was 5 points greater in referred patients than others (P=.04). Concordance between OASIS and SCID did not differ between intervention groups. TRIAD showed that training nurses to assess for depression using an approach developed in partnership with home healthcare agencies led to appropriate referral and care for depressed patients.

Knowledge Translation of the American College of Emergency Physicians Clinical Policy on Hypertension

To determine if dissemination of the American College of Emergency Physicians clinical policy on hypertension to emergency physicians would lead to improvements in blood pressure reassessment and referral of emergency department (ED) patients with elevated blood pressure. Two academic centers implemented a pre-post intervention design, with independent samples at pre and post phases. ED staff were blinded to the investigation. A total of 377 medical records were reviewed before policy dissemination and 402 were reviewed after policy dissemination. Medical records were eligible for review if the patient was at least 18 years of age, was not pregnant, was discharged from the ED, and had a triage systolic blood pressure > or = 140 mm Hg or diastolic blood pressure > or = 90 mm Hg. Patient records with a chief complaint of chest pain, shortness of breath, or neurologic complaints were excluded. Demographics, blood pressures, and evidence of discharge referral were abstracted from the medical record. The policy was disseminated after the initial medical record review. Post-policy dissemination medical record review was conducted within two weeks. A total of 779 medical records were reviewed. The mean age of patients was 45 years, 55% were male, and 46% were white, 13% Hispanic, 35% African American, and 6% other. No differences in reassessment or referral rates were found between study phases. Blood pressure reassessments were low during both phases: 33% (pre) and 37% (post). Referral rates of patients with elevated blood pressure were very low: 13% (pre) and 7% (post). Knowledge of guidelines did not translate into changes in physician practice. Additional systems-based approaches are necessary to effectively translate guidelines into clinical practice.