What matters to patients? A timely question for value-based care.

BACKGROUND: Our healthcare system is moving towards patient-centered and value-based care models that prioritize health outcomes that matter to patients. However, little is known about what aspects of care patients would prioritize when presented with choices of desirable attributes and whether these patient priorities differ based on certain demographics. OBJECTIVE: To assess patients' priorities for a range of attributes in ambulatory care consultations across five key health service delivery domains and determine potential associations between patient priorities and certain demographic profiles. METHODS: Using a What Matters to You survey patients ranked in order of importance various choices related to five health service domains (patient-physician relationship, personal responsibility, test/procedures, medications, and cost). Subjects were selected from two Johns Hopkins affiliated primary care clinics and a third gastroenterology subspecialty clinic over a period of 11 months. We calculated the percentage of respondents who selected each quality as their top 1-3 choice. Univariate and multivariate analyses determined demographic characteristics associated with patient priorities. RESULTS: Humanistic qualities of physicians, leading a healthy lifestyle, shared decision making (SDM) for medications and tests/procedures as well as knowledge about insurance coverage were the most frequently ranked choices. Privately insured and more educated patients were less likely to rank humanistic qualities highly. Those with younger age, higher educational attainment and private insurance had higher odds of ranking healthy lifestyle as a top choice. Those with more education had higher odds of ranking SDM as a top choice. CONCLUSIONS: Identifying what matters most to patients is useful as we move towards patient-centered and Value Based Care Models. Our findings suggest that patients have priorities on qualities they value across key health service domains. Multiple factors including patient demographics can be predictors of these priorities. Elucidating these preferences is a challenging but a valuable step in the right direction.

Does Provider Self-Reporting of Etiquette Behaviors Improve Patient Experience? A Randomized Controlled Trial.

BACKGROUND: There is a glaring lack of published evidence-based strategies to improve the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores on the physician domain. Strategies that have been used are resource intensive and difficult to sustain. OBJECTIVE: We hypothesized that prompting providers to assess their own etiquette-based practices every 2 weeks over the course of 1 year would improve patient experience on the physician domain. DESIGN: Randomized controlled trial. SETTING: 4 acute care hospitals. PARTICIPANTS: Hospitalists. INTERVENTION: Hospitalists were randomized to the study or the control arm. The study arm was prompted every 2 weeks for 12 months to report how frequently they engaged in 7 best-practice bedside etiquette behaviors. Control arm participants received similarly worded questions on quality improvement behaviors. MEASUREMENT: Provider experience scores were calculated from the physician HCAHPS and Press Ganey survey provider items. RESULTS: Physicians reported high rates of etiquette-based behavior at baseline, and this changed modestly over the study period. Self-reported etiquette behaviors were not associated with experience scores. The difference in difference analysis of the baseline and postintervention physician experience scores between the intervention arm and the control arm was not statistically significant (P = 0.71). CONCLUSION: In this 12-month study, biweekly reflection and reporting of best-practice bedside etiquette behaviors did not result in significant improvement on physician domain experience scores. It is likely that hospitalists' self-assessment of their bedside etiquette may not reflect patient perception of these behaviors. Furthermore, hospitalists may be resistant to improvement in this area since they rate themselves highly at baseline. Journal of Hospital Medicine 2017;12:402-406.

The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis.

IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012). We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori. We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks. We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95% CI, 0.06-0.70]; I(2)=0%) and fatal PE (0.09 [0.01-0.81]; I(2)=0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95% CI, 0.50-6.19]; P=.38; I(2)=56.8%) or mortality (0.70 [0.40-1.23]; I(2)=6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95% CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studies may be informative.

Pharmacologic and mechanical strategies for preventing venous thromboembolism after bariatric surgery: a systematic review and meta-analysis.

We sought to assess the comparative effectiveness and safety of pharmacologic and mechanical strategies to prevent venous thromboembolism (VTE) in patients undergoing bariatric surgery. We searched (through August 2012) for primary studies that had at least 2 different interventions. Of 30,902 citations, we identified 8 studies of pharmacologic strategies and 5 studies of filter placement. No studies randomized patients to receive different interventions. One study suggested that low-molecular-weight heparin is more efficacious than unfractionated heparin in preventing VTE (0.25% vs 0.68%, P < .001), with no significant difference in bleeding. One study suggested that prolonged therapy (after discharge) with enoxaparin sodium may prevent VTE better than inpatient treatment only. There was insufficient evidence supporting the hypothesis that filters reduce the risk of pulmonary embolism, with a point estimate suggesting increased rates with filters (pooled relative risk [RR], 1.21 95% CI, 0.57-2.56). There was low-grade evidence that filters are associated with higher mortality (pooled RR, 4.30 95% CI, 1.60-11.54) and higher deep vein thrombosis rates (2.94 1.35-6.38). There was insufficient evidence to support that augmented subcutaneous enoxaparin doses (>40 mg daily or 30 mg twice daily) are more efficacious than standard dosing, with a trend toward increased bleeding. Of note, for both filters and augmented pharmacologic dosing strategies, patients at highest risk for VTE were more likely to receive more intensive interventions, limiting our ability to attribute outcomes to prophylactic strategies used.

A systematic review of venous thromboembolism prophylaxis strategies in patients with renal insufficiency, obesity, or on antiplatelet agents.

BACKGROUND: There is uncertainty about optimal strategies for venous thromboembolism (VTE) prophylaxis among select populations such as patients with renal insufficiency, obesity, or patients taking antiplatelet drugs including aspirin. Their physiologies make prophylaxis particularly challenging. PURPOSE: We performed a comparative effectiveness review of the literature on efficacy and safety of VTE prophylaxis in these populations. DATA SOURCES: We searched MEDLINE, EMBASE, SCOPUS, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library through August 2012. Eligible studies included controlled trials and observational studies. DATA EXTRACTION: Two reviewers evaluated studies for eligibility, serially abstracted data, and independently evaluated the risk of bias and strength of evidence supporting interventions to prevent VTE in these populations. RESULTS: After a review of 30,902 citations, we identified 9 controlled studies, 5 of which were trials, and the other 4 were observational studies. Five articles addressed prophylaxis of patients with renal insufficiency, 2 addressed obese patients, and 2 addressed patients on antiplatelet agents. No study tested prophylaxis in underweight patients or those with liver disease. The majority of observational studies had a high risk of bias. The strength of evidence ranged from low to insufficient regarding the comparative effectiveness and safety of VTE prophylaxis among these patients. CONCLUSION: The current evidence is insufficient regarding optimal VTE prophylaxis for patients with renal insufficiency, obesity, or those who are on antiplatelet drugs including aspirin. High-quality studies are needed to inform clinicians about the best VTE prophylaxis for these patients.

Venous thromboembolism prophylaxis in patients with traumatic brain injury: a systematic review.

OBJECTIVE: There is considerable practice variation and clinical uncertainty about the choice of prophylaxis for preventing venous thromboembolism in patients with traumatic brain injury. We performed a systematic review to assess both the effectiveness and safety of pharmacologic and mechanical prophylaxis, and the optimal time to initiate pharmacologic prophylaxis in hospitalized patients with traumatic brain injury. DATA SOURCES AND STUDY SELECTION: MEDLINE®, EMBASE®, SCOPUS, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library were searched in July 2012 to identify randomized controlled trials and observational studies reporting on the effectiveness or safety of venous thromboembolism prevention in traumatic brain injury patients. DATA EXTRACTION: Paired reviewers extracted detailed information from included articles on standardized forms and assessed the risk of bias in each article. DATA SYNTHESIS: Twelve studies (2 randomized controlled trials and 10 cohort studies) evaluated the effectiveness and safety of venous thromboembolism prophylaxis in patients with traumatic brain injury. Five of the included studies assessed the optimal timing of initiation of pharmacological prophylaxis. Low grade evidence supports the effectiveness of enoxaparin over control in reducing deep vein thrombosis. Low grade evidence also supports the safety of unfractionated heparin over control in reducing mortality in patients with traumatic brain injury. Evidence was insufficient for remaining comparisons and outcomes including the optimal timing of initiation of pharmacoprophylaxis. CONCLUSION: There is some evidence that pharmacoprophylaxis improves deep vein thromboses and mortality outcomes in patients hospitalized with traumatic brain injury. Additional studies are required to strengthen this evidence base.

Educating leaders in hospital management: a pre-post study in Ethiopian hospitals.

Despite recent focus on health systems strengthening, few studies report large-scale efforts to improve hospital management capacity in low-income countries, a central component of improving health care delivery. We sought to assess the contributions of a systems-based approach, the Ethiopian Hospital Management Initiative (EHMI), which established hospital chief executive officers (CEOs) trained through a Masters of Healthcare and Hospital Administration (MHA) degree programme in Ethiopia. We conducted a pre-post study of 24 hospitals that are managed by CEOs in the MHA programme. We measured changes in hospital functioning based on adherence to a set of 86 hospital performance standards across 12 management domains published in the Standards for Hospital Management in Ethiopia. We found that adherence to hospital performance standards increased significantly during the one-year follow-up (27% compared with 51% of standards met at baseline and follow-up, respectively; P-value < 0.001); overall improvement was driven by improvement in seven of the 12 management domains. The EHMI is an example of health systems strengthening with focus on building hospital management capacity. Early evidence suggests that the establishment of hospital CEOs and MHA training to equip them with management skills may promote scalable improvements in health facility functioning.

A brief questionnaire for assessing patient healthcare experiences in low-income settings.

OBJECTIVE: The aim of this study was to develop and to assess the validity and reliability of two brief questionnaires for assessing patient experiences with hospital and outpatient care in a low-income setting. DESIGN: Using literature review and data from focus groups (n = 14), we developed questionnaires to assess patient experiences with inpatient (I-PAHC) and with outpatient (O-PAHC) care in a low-income setting. Questionnaires were administered in person by trained interviewers. Construct validity was assessed with factor analysis; convergent validity was assessed by correlating summary scores for each scale with overall patient evaluations, and reliability was assessed with Cronbach's alpha coefficients. SETTING: Eight health facilities in Ethiopia. PARTICIPANTS: Patients >18 years old who had a hospital stay >1 day (n = 230), and patients who received outpatient care (n = 486). MAIN OUTCOME MEASURES: Patient evaluations of health care experiences. RESULTS: The factor analysis revealed 12 items that loaded on five factors for the I-PAHC questionnaire. The O-PAHC showed similar results with 13 items that loaded on four factors. Summary scores for nearly all factors were significantly associated (P-value < 0.05) with the patient's overall evaluation score. The measure of reliability, Cronbach's alpha coefficients, showed good to excellent internal consistency for all scales. CONCLUSIONS: The I-PAHC on O-PAHC questionnaires can be useful in assessing patients' evaluations of care delivery in low-income settings. The questionnaires are brief and can be integrated into health systems strengthening efforts with the support of leadership at the health facility and the country levels.

Network-based social capital and capacity-building programs: an example from Ethiopia.

INTRODUCTION: Capacity-building programs are vital for healthcare workforce development in low- and middle-income countries. In addition to increasing human capital, participation in such programs may lead to new professional networks and access to social capital. Although network development and social capital generation were not explicit program goals, we took advantage of a natural experiment and studied the social networks that developed in the first year of an executive-education Master of Hospital and Healthcare Administration (MHA) program in Jimma, Ethiopia. CASE DESCRIPTION: We conducted a sociometric network analysis, which included all program participants and supporters (formally affiliated educators and mentors). We studied two networks: the Trainee Network (all 25 trainees) and the Trainee-Supporter Network (25 trainees and 38 supporters). The independent variable of interest was out-degree, the number of program-related connections reported by each respondent. We assessed social capital exchange in terms of resource exchange, both informational and functional. Contingency table analysis for relational data was used to evaluate the relationship between out-degree and informational and functional exchange. DISCUSSION AND EVALUATION: Both networks demonstrated growth and inclusion of most or all network members. In the Trainee Network, those with the highest level of out-degree had the highest reports of informational exchange, chi2 (1, N = 23) = 123.61, p < 0.01. We did not find a statistically significant relationship between out-degree and functional exchange in this network, chi2(1, N = 23) = 26.11, p > 0.05. In the Trainee-Supporter Network, trainees with the highest level of out-degree had the highest reports of informational exchange, chi2 (1, N = 23) = 74.93, p < 0.05. The same pattern held for functional exchange, chi2 (1, N = 23) = 81.31, p < 0.01. CONCLUSIONS: We found substantial and productive development of social networks in the first year of a healthcare management capacity-building program. Environmental constraints, such as limited access to information and communication technologies, or challenges with transportation and logistics, may limit the ability of some participants to engage in the networks fully. This work suggests that intentional social network development may be an important opportunity for capacity-building programs as healthcare systems improve their ability to manage resources and tackle emerging problems.

Educating leaders in hospital management: a new model in Sub-Saharan Africa.

QUALITY ISSUE: The vast majority of health system capacity-building efforts have focused on enhancing medical and public health skills; less attention has been directed at developing hospital managers despite their central role in improving the functioning and quality of health-care systems. Initial ASSESSMENT AND CHOICE OF INTERVENTION: Initial assessment of hospital management systems demonstrated weak functioning in several management areas. In response, we developed with the Ethiopian Ministry of Health (MoH) a novel Master of Hospital Administration (MHA) program, reflecting a collaborative effort of the MoH, the Clinton HIV/AIDS Initiative, Jimma University and Yale University. The MHA is a 2-year executive style educational program to develop a new cadre of hospital leaders, comprising 5% classroom learning and 85% executive practice. IMPLEMENTATION: The MHA has been implemented with 55 hospital leaders in the position of chief executive officer within the MoH, with courses taught in collaboration by faculty of the North and the South universities. EVALUATION AND LESSONS LEARNED: The program has enrolled two cohorts of hospital leaders and is working in more than half of the government hospitals in Ethiopia. Lessons learned include the need to: (i) balance education in applied, technical skills with more abstract thinking and problem solving, (ii) recognize the interplay between management education and policy reform, (iii) remain flexible as policy changes have direct impact on the project, (iv) be realistic about resource constraints in low-income settings, particularly information technology limitations, and (v) manage the transfer of knowledge for longer term sustainability.