Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease.

BACKGROUND: The appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy. METHODS: Using an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis. RESULTS: A total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]). CONCLUSIONS: In this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily. (Funded by the Patient-Centered Outcomes Research Institute; ADAPTABLE ClinicalTrials.gov number, NCT02697916.).

Days Not at Home: Association of Vulnerability with Healthcare Utilization After Hospitalization for Heart Failure.

BACKGROUND: Heart failure (HF) hospitalizations are characterized by vulnerability in functioning and frequent post-discharge healthcare utilization in both acute and post-acute settings. OBJECTIVE: To determine, in patients hospitalized for decompensated HF, the association of vulnerability with (1) detailed forms of post-discharge healthcare utilization, and (2) days spent away from home after initial hospital discharge. DESIGN: Secondary analysis of a prospective longitudinal cohort study from a single-center academic institution in the USA. PARTICIPANTS: Adults admitted with acute decompensated HF who were discharged alive. MAIN MEASURES: The Vulnerable Elders Survey 13 (VES-13) measured functional vulnerability at baseline. The primary outcome was the Highest Healthcare Utilization (HHU) 90 days post-discharge, from the following ordered categories: at home, emergency room visit, skilled nursing facility stay, hospital readmission, or death. The secondary outcome was the proportion of days not at home (DNAH) within the first 90 days. Analyses were performed using a partial proportional odds model with adjustment for demographics and health characteristics. KEY RESULTS: A total of 806 patients were included with median age 65, interquartile range [IQR] 55-73 years. Fewer than half (N = 345 [43%]) of patients remained alive and at home during 90-day follow-up. There were 286 [35%] hospital readmissions and 70 [8.7%] participants died. The median DNAH was 3 [IQR 0-16]. Increased vulnerability was associated with (1) HHU, (2) higher odds of utilizing healthcare or dying versus being at home alive 90 days post-discharge (OR 1.81 [95% CI, 1.35, 2.42]), and (3) higher odds of DNAH in the first 90 days (OR 1.55 [95% CI, 1.27, 1.89]). CONCLUSIONS: In this cohort of patients hospitalized for decompensated HF, vulnerability predicted higher levels of healthcare utilization, as well as total days not at home in the 90 days following hospitalization. Vulnerability may have clinical applications to identify patients at greatest need for comprehensive, patient-centered discharge planning.

Screening for the high-need population using single institution versus state-wide admissions discharge transfer feed.

BACKGROUND: Access to programs for high-needs patients depending on single-institution electronic health record data (EHR) carries risks of biased sampling. We investigate a statewide admission, discharge, and transfer feed (ADT) in assessing equity in access to these programs. METHODS: This is a retrospective cross-sectional study. We included high-need patients at Vanderbilt University Medical Center (VUMC) 18 years or older, with at least three emergency visits (ED) or hospitalizations in Tennessee from January 1 to June 30, 2021, including at least one at VUMC. We used the Tennessee ADT database to identify high-need patients with at least one VUMC ED/hospitalization. Then, we compared this population with high-need patients identified using VUMC's Epic® EHR database. The primary outcome was the sensitivity of VUMC-only criteria for identifying high-need patients compared to the statewide ADT reference standard. RESULTS: We identified 2549 patients with at least one ED/hospitalization and assessed them as high-need based on the statewide ADT. Of those, 2100 had VUMC-only visits, and 449 had VUMC and non-VUMC visits. VUMC-only visit screening criteria showed high sensitivity (99.1%, 95% CI: 98.7 - 99.5%), showing that the high-needs patients admitted to VUMC infrequently access alternative systems. Results showed no meaningful difference in sensitivity when stratified by patient's race or insurance. CONCLUSIONS: ADT allows examination for potential selection bias when relying upon single-institution utilization. In VUMC's high-need patients, there's minimal selection bias when depending on same-site utilization. Further research must understand how biases vary by site and durability over time.

Concurrent validity of the Arabic version of General Medication Adherence Scale using two validated indirect adherences measures in Saudi patients with non-communicable diseases.

PURPOSE: This study aimed to evaluate the concurrent validity of the Arabic version of the General Medication Adherence Scale (GMAS) using two validated scales namely Adherence to Refills and Medications Scale (ARMS) and Medication Adherence Rating Scale (MARS) in Saudi patients with non-communicable diseases. METHODS: A cross sectional study was conducted for 2 months in out-patient departments at a tertiary care hospital in Khobar, Saudi Arabia. The study collected data from patients with chronic illnesses through convenience sampling. Pearson correlation (ρ) was conducted to report concurrent validity of GMAS. A correlation coefficient value ≥ 0.5 with p-value < 0.01 was considered threshold for establishing concurrent validity. The study was approved by an ethics committee (IRB-2019-05-002). RESULTS: A total of 406 patients responded to the study. The average age was 42.4 ± 5.94 years, and most patients were females (53.7%), married (70%), graduates (65.3%), employed (39.9%) and, had a monthly family income > SAR 10,000, i.e., USD 2666.2 (56.4%). The mean adherence scores obtained from MARS, ARMS and GMAS were 7.09, 19.9, and 27.4. The correlation (ρ) between GMAS and MARS scores was 0.65, and between GMAS and ARMS scores was -0.79, p < 0.01 for both comparisons. CONCLUSION: The concurrent validity of GMAS-AR was established in this study that would further substantiate psychometric properties of the scale in this population.

Impact of a Follow-up Telephone Call Program on 30-Day Readmissions (FUTR-30): A Pragmatic Randomized Controlled Real-world Effectiveness Trial.

BACKGROUND: Telephone call programs are a common intervention used to improve patients' transition to outpatient care after hospital discharge. OBJECTIVE: To examine the impact of a follow-up telephone call program as a readmission reduction initiative. RESEARCH DESIGN: Pragmatic randomized controlled real-world effectiveness trial. SUBJECTS: We enrolled and randomized all patients discharged home from a hospital general medicine service to a follow-up telephone call program or usual care discharge. Patients discharged against medical advice were excluded. The intervention was a hospital program, delivering a semistructured follow-up telephone call from a nurse within 3-7 days of discharge, designed to assess understanding and provide education, and assistance to support discharge plan implementation. MEASURES: Our primary endpoint was hospital inpatient readmission within 30 days identified by the electronic health record. Secondary endpoints included observation readmission, emergency department revisit, and mortality within 30 days, and patient experience ratings. RESULTS: All 3054 patients discharged home were enrolled and randomized to the telephone call program (n=1534) or usual care discharge (n=1520). Using a prespecified intention-to-treat analysis, we found no evidence supporting differences in 30-day inpatient readmissions [14.9% vs. 15.3%; difference -0.4 (95% confidence interval, 95% CI), -2.9 to 2.1; P=0.76], observation readmissions [3.8% vs. 3.6%; difference 0.2 (95% CI, -1.1 to 1.6); P=0.74], emergency department revisits [6.1% vs. 5.4%; difference 0.7 (95% CI, -1.0 to 2.3); P=0.43], or mortality [4.4% vs. 4.9%; difference -0.5 (95% CI, -2.0 to 1.0); P=0.51] between telephone call and usual care groups. CONCLUSIONS: We found no evidence of an impact on 30-day readmissions or mortality due to the postdischarge telephone call program.

The Partnership to Improve Diabetes Education Trial: a Cluster Randomized Trial Addressing Health Communication in Diabetes Care.

BACKGROUND: Effective type 2 diabetes care remains a challenge for patients including those receiving primary care in safety net settings. OBJECTIVE: The Partnership to Improve Diabetes Education (PRIDE) trial team and leaders from a regional department of health evaluated approaches to improve care for vulnerable patients. DESIGN: Cluster randomized controlled trial. PATIENTS: Adults with uncontrolled type 2 diabetes seeking care across 10 unblinded, randomly assigned safety net clinics in Middle TN. INTERVENTIONS: A literacy-sensitive, provider-focused, health communication intervention (PRIDE; 5 clinics) vs. standard diabetes education (5 clinics). MAIN MEASURES: Participant-level primary outcome was glycemic control [A1c] at 12 months. Secondary outcomes included select health behaviors and psychosocial aspects of care at 12 and 24 months. Adjusted mixed effects regression models were used to examine the comparative effectiveness of each approach to care. KEY RESULTS: Of 410 patients enrolled, 364 (89%) were included in analyses. Median age was 51 years; Black and Hispanic patients represented 18% and 25%; 96% were uninsured, and 82% had low annual income level (< $20,000); adequate health literacy was seen in 83%, but numeracy deficits were common. At 12 months, significant within-group treatment effects occurred from baseline for both PRIDE and control sites: adjusted A1c (- 0.76 [95% CI, - 1.08 to - 0.44]; P < .001 vs - 0.54 [95% CI, - 0.86 to - 0.21]; P = .001), odds of poor eating (0.53 [95% CI, 0.33-0.83]; P = .01 vs 0.42 [95% CI, 0.26-0.68]; P < .001), treatment satisfaction (3.93 [95% CI, 2.48-6.21]; P < .001 vs 3.04 [95% CI, 1.93-4.77]; P < .001), and self-efficacy (2.97 [95% CI, 1.89-4.67]; P < .001 vs 1.81 [95% CI, 1.1-2.84]; P = .01). No significant difference was observed between study arms in adjusted analyses. CONCLUSIONS: Both interventions improved the participant's A1c and behavioral outcomes. PRIDE was not more effective than standard education. Further research may elucidate the added value of a focused health communication program in this setting.

Breaking down walls: a qualitative evaluation of perceived emergency department delays for patients transferred with ST-elevation myocardial infarction.

BACKGROUND: Despite regionalization efforts, delays at transferring hospitals for patients transferred with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) persist. These delays primarily occur in the emergency department (ED), and are associated with increased mortality. We sought to use qualitative methods to understand staff and clinician perceptions underlying these delays. METHODS: We conducted semi-structured interviews at 3 EDs that routinely transfer STEMI patients to identify staff perceptions of delays and potential interventions. Interviews were recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to build and refine a list of themes and subthemes, and identify supporting quotes. RESULTS: We interviewed 43 ED staff (staff, nurses, and physicians) and identified 3 major themes influencing inter-facility transfers of STEMI patients: 1) Processes, 2) Communication; and 3) Resources. Standardized processes (i.e., protocols) reduce uncertainty and can mobilize resources. Use of performance benchmarks can motivate staff but are frequently focused on internal, not inter-organizational performance. Direct use ofcommunication between ORGANIZATIONS can process uncertainty and expedite care. Record sharing and regular post-transfer communication could provide opportunities to discuss and learn from delays and increase professional satisfaction. Finally, characteristics of resources that enhanced their capacity, clarity, experience, and reliability were identified as contributing to timely transfers. CONCLUSIONS: Processes, communication, and resources were identified as modifying inter-facility transfer timeliness. Potential quality improvement strategies include ongoing updates of protocols within and between organizations to account for changes, enhanced post-transfer feedback between organizations, shared medical records, and designated roles for coordination.

Developing an Implementation Strategy for Systematic Measurement of Patient-Reported Outcomes at an Academic Health Center.

EXECUTIVE SUMMARY: Patient-reported outcome measures (PROMs) are used in research and have the potential to improve clinical care. We sought to develop a strategy for integrating PROMs into routine clinical care at an academic health center. The implementation strategy consisted of three phases. The first, exploratory phase, focused on engaging leadership and conducting an inventory of current efforts to collect PROMs. The inventory revealed 87 patient-reported outcome efforts, 47 of which used validated PROMs (62% for research, 21% for clinical care, 17% for quality). In the second, preparatory phase, we identified three pilot implementation sites chosen with facilitators determined in the exploratory phase. Using data from local needs assessments at the pilot sites, we constructed a timeline for inclusion of PROM efforts across the clinical enterprise. In the third phase, we adapted a technology platform for capturing PROMs using the electronic health record and began implementing this platform at the pilot sites. We found that integrating PROMs into routine clinical practice is highly complex. This complexity necessitates change management at the enterprise level.

Development of the Initial Surveys for the All of Us Research Program.

BACKGROUND: The All of Us Research Program is building a national longitudinal cohort and collecting data from multiple information sources (e.g., biospecimens, electronic health records, and mobile/wearable technologies) to advance precision medicine. Participant-provided information, collected via surveys, will complement and augment these information sources. We report the process used to develop and refine the initial three surveys for this program. METHODS: The All of Us survey development process included: (1) prioritization of domains for scientific needs, (2) examination of existing validated instruments, (3) content creation, (4) evaluation and refinement via cognitive interviews and online testing, (5) content review by key stakeholders, and (6) launch in the All of Us electronic participant portal. All content was translated into Spanish. RESULTS: We conducted cognitive interviews in English and Spanish with 169 participants, and 573 individuals completed online testing. Feedback led to over 40 item content changes. Lessons learned included: (1) validated survey instruments performed well in diverse populations reflective of All of Us; (2) parallel evaluation of multiple languages can ensure optimal survey deployment; (3) recruitment challenges in diverse populations required multiple strategies; and (4) key stakeholders improved integration of surveys into larger Program context. CONCLUSIONS: This efficient, iterative process led to successful testing, refinement, and launch of three All of Us surveys. Reuse of All of Us surveys, available at http://researchallofus.org, may facilitate large consortia targeting diverse populations in English and Spanish to capture participant-provided information to supplement other data, such as genetic, physical measurements, or data from electronic health records.

Depressed Mood, Perceived Health Competence and Health Behaviors: aCross-Sectional Mediation Study in Outpatients with Coronary Heart Disease.

BACKGROUND: Identifying potential mechanisms that link depressed mood with worse health behaviors is important given the prevalence of depressed mood in patients with coronary heart disease (CHD) and its relationship with subsequent mortality. Perceived health competence is an individual's confidence in his/her ability to successfully engineer solutions to achieve health goals and may explain how depressed mood affects multiple health behaviors. OBJECTIVE: Examine whether or not perceived health competence mediates the relationship between depressed mood and worse health behaviors. DESIGN: A cross-sectional study conducted by the Patient-Centered Outcomes Research Institute-funded Mid-South Clinical Data Research Network between August 2014 and September 2015. Bootstrapped mediation was used. PARTICIPANTS: Patients with coronary heart disease (n = 2334). MAIN MEASURES: Two items assessing perceived health competence, a single item assessing depressed mood, and a Health Behaviors Index including: the International Physical Activity Questionnaire (IPAQ); select items from the National Adult Tobacco Survey and the Alcohol Use Disorder Inventory Test; and single items assessing diet and medication adherence. KEY RESULTS: Depressed mood was associated with lower perceived health competence (a = - 0.21, p < .001) and lower perceived health competence was associated with worse performance on a Health Behaviors Index(b = 0.18, p < .001). Perceived health competence mediated the influence of depressed mood on health behaviors (ab = - 0.04, 95% CI = - 0.05 to - 0.03). The ratio of the indirect effect to the total effect was used as a measure of effect size (PM = 0.26, 95% CI: 0.18 to 0.39). CONCLUSIONS: Depressed mood is associated with worse health behaviors directly and indirectly via lower perceived health competence. Interventions to increase perceived health competence may lessen the deleterious impact of depressed mood on health behaviors and cardiovascular outcomes.

Association of Health Literacy and Numeracy with Interest in Research Participation.

BACKGROUND: There is much attention to recruitment of diverse populations in research, but little is known about the influence of health literacy and numeracy skills. OBJECTIVE: To determine if health literacy and numeracy affect individuals' interest to participate in research studies. DESIGN: Cross-sectional survey data were pooled from 3 large studies conducted in the Mid-South Clinical Data Research Network. PARTICIPANTS: Adult patients enrolled in 1 of 3 Mid-South Clinical Data Research Network studies. MAIN MEASURES: The survey domains included demographic items, the 3-item Brief Health Literacy Screen (range 3-15), and the 3-item Subjective Numeracy Scale (range 3-18). The outcome was a sum index measure of a 7-item instrument (range 7-21) assessing individuals' interest in participating in different types of research, including research that involves taking surveys, giving a blood sample, participating via phone or internet, taking an investigational medication, meeting at a local community center or school, including family, or staying overnight at a hospital. KEY RESULTS: Respondents (N = 15,973) were predominately women (65.5%), White (81.4%), and middle aged (M = 52.8 years, SD = 16.5); 32.4% previously participated in research. Self-reported health literacy was relatively high (M = 13.5 out of 15, SD = 2.1), and subjective numeracy skills were somewhat lower (M = 14.3 out of 18, SD = 3.6). After adjustment for age, gender, race, income, education, and other characteristics, lower health literacy and numeracy skills were each independently associated with less interest in research participation (p < 0.001 for each). Prior research participation was associated with greater interest in future research participation (p < 0.001). CONCLUSIONS: After adjustment for factors known to be predictive of interest, individuals with lower health literacy or numeracy scores were less interested in participating in research. Additional work is needed to elucidate reasons for this finding and to determine strategies to engage these populations.

Patterns of multimorbidity associated with 30-day readmission: a multinational study.

BACKGROUND: Multimorbidity is associated with higher healthcare utilization; however, data exploring its association with readmission are scarce. We aimed to investigate which most important patterns of multimorbidity are associated with 30-day readmission. METHODS: We used a multinational retrospective cohort of 126,828 medical inpatients with multimorbidity defined as ≥2 chronic diseases. The primary and secondary outcomes were 30-day potentially avoidable readmission (PAR) and 30-day all-cause readmission (ACR), respectively. Only chronic diseases were included in the analyses. We presented the OR for readmission according to the number of diseases or body systems involved, and the combinations of diseases categories with the highest OR for readmission. RESULTS: Multimorbidity severity, assessed as number of chronic diseases or body systems involved, was strongly associated with PAR, and to a lesser extend with ACR. The strength of association steadily and linearly increased with each additional disease or body system involved. Patients with four body systems involved or nine diseases already had a more than doubled odds for PAR (OR 2.35, 95%CI 2.15-2.57, and OR 2.25, 95%CI 2.05-2.48, respectively). The combinations of diseases categories that were most strongly associated with PAR and ACR were chronic kidney disease with liver disease or chronic ulcer of skin, and hematological malignancy with esophageal disorders or mood disorders, respectively. CONCLUSIONS: Readmission was associated with the number of chronic diseases or body systems involved and with specific combinations of diseases categories. The number of body systems involved may be a particularly interesting measure of the risk for readmission in multimorbid patients.

A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial.

BACKGROUND: Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients. METHODS: The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status. DISCUSSION: The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities. TRIAL REGISTRATION: This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.

Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.

BACKGROUND: The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1. METHODS: MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient. DISCUSSION: A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients.

Background: Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame. Objective: To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability. Design: Prospective cohort study. Setting: 10 academic medical centers in the United States. Patients: 822 adults readmitted to a general medicine service. Measurements: For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics. Results: Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions. Limitation: Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results. Conclusion: Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions. Primary Funding Source: Association of American Medical Colleges.

Tales from the Trips: A Qualitative Study of Timely Recognition, Treatment, and Transfer of Emergency Department Patients with Acute Ischemic Stroke.

BACKGROUND AND OBJECTIVES: Acute Ischemic stroke (AIS) is a time-sensitive emergency and patients frequently present to, and are transferred from emergency departments (EDs). We sought to evaluate potential factors, particularly organizational, that may influence the timeliness of interfacility transfer for ED patients with AIS. METHODS: We conducted semistructured interviews at 3 EDs that routinely transfer AIS patients. A structured interview guide was developed and piloted prior to use. Staff were asked about perceived facilitators and barriers to timely and high quality emergency care for patients with AIS who require transfer. Each interview was audio recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to build a list of themes and subthemes, and identify supporting quotes. RESULTS: We interviewed 45 ED staff (administrative staff, nurses, and physicians) involved in acute stroke care. We identified 4 major themes influencing the execution of interfacility transfers of AIS patients: (1) processes, (2) historical experiences; (3) communication; and (4) resources. Pre-existing protocols that standardized processes (eg, autoacceptance protocols) and reduced unnecessary communication, combined with direct communication with the neurology team at the comprehensive stroke center, and the flexibility and availability of human and physical resources (eg, staff and equipment) were commonly cited as facilitators. Lack of communication of clinical and operational outcomes back to transferring ED staff was viewed as a lost opportunity for process improvement, interorganization relationship building, and professional satisfaction. CONCLUSIONS: ED staff view the interfacility transfer of AIS patients as highly complex with multiple opportunities for delay. Coordination through the use of protocols and communication pre- and post-transfer represented opportunities to facilitate transfers. Staff and clinicians at transferring facilities identified multiple opportunities to enhance existing processes and ongoing communication quality among facilities involved in the acute management of patients with AIS.

Networks of hospital discharge planning teams and readmissions.

Improving the hospital discharge process to prevent readmission requires a focus on the coordination and communication between interprofessional team members in and outside of the hospital as well as with patients and their caregivers. Yet little is known about how these actors currently communicate and coordinate during the discharge process. Network analysis allows for a direct look at this communication and coordination. This network analysis study utilized retrospective chart review to identify the individuals involved in the discharge planning and their communication with each other for 205 patients. Using this abstracted data, a network was created for each patient wherein a node was any individual involved in the patient's discharge planning process and a tie was any communication documented in the chart related to discharge planning between individuals. Graphical and structural network analyses were used to compare the networks of readmitted patients and non-readmitted patients. Networks of patients not readmitted were more hierarchical, unidirectional, streamlined compared to those readmitted. These findings demonstrate the feasibility and usefulness of conceptualizing discharge planning as a network. Future efforts to understand discharge planning and create interventions to improve the process may benefit by considering network patterns of communication.

Health Literacy and Demographic Disparities in HIV Care Continuum Outcomes.

Studies evaluating the association between human immunodeficiency virus (HIV) infection continuum of care outcomes [antiretroviral (ART) adherence, retention in care, viral suppression] and health literacy have yielded conflicting results. Moreover, studies from the southern United States, a region of the country disproportionately affected by the HIV epidemic and low health literacy, are lacking. We conducted an observational cohort study among 575 people living with HIV (PLWH) at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee). Health literacy was measured using the brief health literacy screen, a short tool which can be administered verbally by trained clinical personnel. Low health literacy was associated with a lack of viral suppression, but not with poor ART adherence or poor retention. Age and racial disparities in continuum of care outcomes persisted after accounting for health literacy, suggesting that factors in addition to health literacy must be addressed in order to improve outcomes for PLWH.

Health literacy, cognition, and urinary incontinence among geriatric inpatients discharged to skilled nursing facilities.

AIMS: To investigate the association between health literacy and cognition and nursing and patient-reported incontinence in a geriatric inpatient population transitioning to skilled nursing facilities (SNF). METHODS: Health literacy, depression, and cognition were assessed via the Brief Health Literacy Screen (BHLS), Geriatric Depression Scale 5-item (GDS) and Brief Interview for Mental Status (BIMS), respectively. Multivariable logistic regression assessed the association between BHLS score and incontinence by: (1) nursing-reported urinary incontinence during hospitalization; and (2) patient self-reported "bladder accidents" in the post-enrollment study interview. RESULTS: A total of 1556 hospitalized patients aged 65 and older met inclusion criteria, of whom 922 (59.3%) were women and 1480 had available BHLS scores. A total of 464 (29.8%) and 515 (33.1%) patients had nursing-reported and self-reported urinary incontinence, respectively. Nursing-reported incontinence was significantly associated with lower BHLS (ie, poorer health literacy) (aOR 0.93, 95%CI 0.89-0.99) and BIMS (ie, poorer cognition) (aOR 0.90, 95%CI 0.83-0.97) scores and need for assistance with toileting (aOR 7.08, 95%CI 2.16-23.21). Patient-reported incontinence was significantly associated with female sex (aOR 1.62, 95%CI 1.19-2.21), increased GDS score (ie, greater likelihood of depression) (aOR 1.22, 95%CI 1.10-1.36) and need for assistance with toileting (aOR 2.46, 95%CI 1.26-4.79). CONCLUSIONS: Poorer health literacy and cognition are independently associated with an increased likelihood of nursing-reported urinary incontinence among geriatric inpatients transitioning to SNF. Practitioners should consider assessment of health literacy and cognition in frail patients at risk for urinary incontinence and that patient and nursing assessment may be required to capture the diagnosis.

Precision Medicine: Familiarity, Perceived Health Drivers, and Genetic Testing Considerations Across Health Literacy Levels in a Diverse Sample.

A clear awareness of a patient's knowledge, values, and perspectives is an important component of effective genetic counseling. Advances in precision medicine, however, have outpaced our understanding of patient perceptions of this new approach. Patient views may differ across the three domains of precision medicine (genetics, behavioral, and environmental determinants of health), ethnic/racial groups, and health literacy levels. This study describes and compares group differences in familiarity, perceptions, and preferences for precision medicine in a diverse sample. Between 2016 and 2017, 252 participants completed a 10-15-min survey in three primary care clinics in Florida and Tennessee. The final sample was 42.5% African American/Black, 25.8% Hispanic/Latino, 25.0% White, and 6.7% other ethnicity/race. Less than a quarter of participants reported being familiar with the term "precision medicine," but were more familiar with basic genetic terms. Participants with higher health literacy reported greater familiarity with terms (p ≤ .003). African Americans/Black participants were more likely to identify ethnicity/race and discrimination as influencing their health (p ≤ .004). When deciding to get a genetic test, individuals across ethnic/racial groups shared similar considerations. Those with higher health literacy, however, gave significantly greater importance to provider trust (p ≤ .008). Given the recent emergence of precision medicine, at present there may be limited differences in patient perceptions across ethnic/racial groups. Culturally sensitive efforts, tailored to health literacy level, may aid equitable precision medicine uptake.