Perceptions of video-based appointments from the patient's home: a patient survey.

BACKGROUND: We examined patient interest in a telehealth model in which the patient supplies the hardware and Internet connectivity to meet with a healthcare provider from his or her home via video call (video appointment). We hoped to understand prospectively the desirability, feasibility, and viability from the patient perspective. MATERIALS AND METHODS: A phone survey was conducted of a random sample of patients who had been seen in the outpatient setting at a single institution. The sample was stratified by proximity to the local institution with oversampling for patients living outside a 120-mile radius. RESULTS: Out of 500 total patients, 301 patients responded, and 263 met the inclusion criteria. Of those 263 respondents, 38% indicated "very likely" to accept an invitation to see their provider via video, 28.1% "somewhat likely," and 33.8% "not at all likely." Of respondents, 75% have broadband, although only 36% reported having a Web camera. The primary factors affecting willingness to participate in a video appointment include comfort in setting up a video call, age, and distance participants would have traveled for an in-clinic appointment. CONCLUSIONS: Patient survey data indicate that most patients are likely to be accepting of telehealth care to the home using video call and that most have the required technology. Nevertheless, there are still significant hurdles to effectively implement this adaptation of telehealth care as part of mainstream practice.

Cost comparison between home telemonitoring and usual care of older adults: a randomized trial (Tele-ERA).

BACKGROUND: From 1992 to 2008, older adults in the United States incurred more healthcare expense per capita than any other age group. Home telemonitoring has emerged as a potential solution to reduce these costs, but evidence is mixed. The primary aim of the study was to evaluate whether the mean difference in total direct medical cost consequence between older adults receiving additional home telemonitoring care (TELE) (n=102) and those receiving usual medical care (UC) (n=103) were significant. Inpatient, outpatient, emergency department, decedents, survivors, and 30-day readmission costs were evaluated as secondary aim. MATERIALS AND METHODS: Multivariate generalized linear models (GLMs) and parametric bootstrapping method were used to model cost and to determine significance of the cost differences. We also compared the differences in arithmetic mean costs. RESULTS: From the conditional GLMs, the estimated mean cost differences (TELE versus UC) for total, inpatient, outpatient, and ED were -$9,537 (p=0.068), -$8,482 (p =0.098), -$1,160 (p=0.177), and $106 (p=0.619), respectively. Mean postenrollment cost was 11% lower than the prior year for TELE versus 22% higher for UC. The ratio of mean cost for decedents to survivors was 2.1:1 (TELE) versus 12.7:1 (UC). CONCLUSIONS: There were no significant differences in the mean total cost between the two treatment groups. The TELE group had less variability in cost of care, lower decedents to survivors cost ratio, and lower total 30-day readmission cost than the UC group.

Association between value-based purchasing score and hospital characteristics.

BACKGROUND: Medicare hospital Value-based purchasing (VBP) program that links Medicare payments to quality of care will become effective from 2013. It is unclear whether specific hospital characteristics are associated with a hospital's VBP score, and consequently incentive payments.The objective of the study was to assess the association of hospital characteristics with (i) the mean VBP score, and (ii) specific percentiles of the VBP score distribution. The secondary objective was to quantify the associations of hospital characteristics with the VBP score components: clinical process of care (CPC) score and patient satisfaction score. METHODS: Observational analysis that used data from three sources: Medicare Hospital Compare Database, American Hospital Association 2010 Annual Survey and Medicare Impact File. The final study sample included 2,491 U.S. acute care hospitals eligible for the VBP program. The association of hospital characteristics with the mean VBP score and specific VBP score percentiles were assessed by ordinary least square (OLS) regression and quantile regression (QR), respectively. RESULTS: VBP score had substantial variations, with mean score of 30 and 60 in the first and fourth quartiles of the VBP score distribution. For-profit status (vs. non-profit), smaller bed size (vs. 100-199 beds), East South Central region (vs. New England region) and the report of specific CPC measures (discharge instructions, timely provision of antibiotics and beta blockers, and serum glucose controls in cardiac surgery patients) were positively associated with mean VBP scores (p<0.01 in all). Total number of CPC measures reported, bed size of 400-499 (vs. 100-199 beds), a few geographic regions (Mid-Atlantic, West North Central, Mountain and Pacific) compared to the New England region were negatively associated with mean VBP score (p<0.01 in all). Disproportionate share index, proportion of Medicare and Medicaid days to total inpatient days had significant (p<0.01) but small effects. QR results indicate evidence of differential effects of some of the hospital characteristics across low-, medium- and high-quality providers. CONCLUSIONS: Although hospitals serving the poor and the elderly are more likely to score lower under the VBP program, the correlation appears small. Profit status, geographic regions, number and type of CPC measures reported explain the most variation among scores.

Measure health, not care.

Effective and meaningful measurement of health is vitally important if we are to improve the health and experience of patients and reduce costs. We need to take an entirely different approach to measurement than we have in the past. Patient-reported outcomes measures provide more meaningful information than process and patient satisfaction measures and are easier for researchers and clinicians to implement.

Salience of Medical Concepts of Inside Clinical Texts and Outside Medical Records for Referred Cardiovascular Patients.

Outside medical records (OMRs) accompanying referred patients are frequently sent as faxes from external healthcare providers. Accessing useful and relevant information from these OMRs in a timely manner is a challenging task due to a combination of the presence of machine-illegible information and the limited system interoperability inherent in healthcare. Little research has been done on investigating information in OMRs. This paper evaluated overlapping and non-overlapping medical concepts captured from digitally faxed OMRs for patients transferring to the Department of Cardiovascular Medicine and from clinical consultant notes generated at the Mayo Clinic. We used optical character recognition (OCR) techniques to make faxed OMRs machine-readable and used natural language processing (NLP) techniques to capture clinical concepts from both machine-readable OMRs and Mayo clinical notes. We measured the level of overlap in medical concepts between OMRs and Mayo clinical narratives in the quantitative approaches and assessed the salience of concepts specific to Cardiovascular Medicine by calculating the ratio of those mentioned concepts relative to an independent clinical corpus. Among the concepts collected from the OMRs, 11.19% of those were also present in the Mayo clinical narratives that were generated within the 3 months after their initial encounter at the Mayo Clinic. For those common concepts, 73.97% were identified in initial consultant notes (ICNs) and 26.03% were captured over subsequent follow-up consultant notes (FCNs). These findings implied that information collected from the OMRs is potentially informative for patient care, but some valuable information (additionally identified in FCNs) collected from the OMRs is not fully used in an earlier stage of the care process. The concepts collected from the ICNs have the highest salience to Cardiovascular Medicine (0.112) compared to concepts in OMRs and concepts in FCNs. Additionally, unique concepts captured in ICNs (unseen in OMRs or FCNs) carried the most salient information (0.094), which demonstrated that ICNs provided the most informative concepts for the care of transferred patients.

A longitudinal analysis of outcomes associated with abciximab and eptifibatide in a consecutive series of 3074 percutaneous coronary interventions.

BACKGROUND: Although the efficacy of platelet glycoprotein IIb/IIIa inhibitors (GPIIb/IIIa) in reducing complication rates during percutaneous coronary intervention (PCI) is well established, comparative studies assessing currently approved agents as administered in current practice are limited. We studied the clinical and length of stay (LOS) outcomes of patients undergoing PCI who received either abciximab or eptifibatide. METHODS: All patients undergoing elective, urgent, or emergency PCI at Mayo Clinic Rochester between November 17, 2000 and August 31, 2004 who received either abciximab or eptifibatide were included. Clinical, angiographic, and follow-up data were prospectively recorded in the Mayo Clinic PCI Registry; administrative data recorded LOS. We used logistic and Cox proportional hazard models to estimate the risk of adverse events and generalized linear modeling to predict LOS. Propensity score and standard risk adjustments were used to account for baseline differences. RESULTS: A total of 2123 PCI patients received eptifibatide and 951 received abciximab. The adjusted odds ratio for in-hospital death and myocardial infarction (MI) with eptifibatide was 0.80 (95% CI 0.56-1.14, P = 0.21) versus abciximab. Adjusted hazard ratios for death and MI and for death, MI, or target vessel revascularization during a median follow-up of 24.6 months were 0.84 (95% CI 0.68-1.02, P = 0.08) and 0.95 (95% CI 0.81-1.11, P = 0.53), respectively. Adjusted postprocedural LOS was similar at 3.4 days. CONCLUSION: This large observational study found no evidence of a clinical or LOS advantage to physician choice of either abciximab or eptifibatide during PCI in contemporary practice.

Standardized care processes to improve quality and safety of patient care in a large academic practice: the Plummer Project of the Department of Medicine, Mayo Clinic.

There are opportunities to improve quality and safety of care provided to adult patients. The Plummer Project of the Department of Medicine at the Mayo Clinic (Rochester, MN, USA) is an initiative to redesign outpatient practice. We used multidisciplinary teams to standardize the tasks essential to improve patient care. With the initiative to standardize the rooming process, patient care and safety improved with greater accuracy of the medication list. The standardization also improved physician efficiency because trained clinical assistants helped address the needs of the patient. Physicians were satisfied by the new process and the technology enhancements. Clinical assistants were also highly satisfied by the training process. The quality and safety of patient care can be significantly improved by practice redesign. This practice redesign was satisfying for all, especially the patients, physicians and support team in our practice.

Perioperative Cardiovascular Risk of Prior Coronary Stent Implantation Among Patients Undergoing Noncardiac Surgery.

BACKGROUND: Previous studies have observed high rates of perioperative cardiovascular events in patients with coronary stents undergoing noncardiac surgery (NCS). It is uncertain whether this finding reflects an independent association. OBJECTIVES: The goal of this study was to assess the independent relationship between prior coronary stent implantation and the occurrence of perioperative major adverse cardiac and cerebrovascular events (MACCE) and bleeding and its relation with time from stenting to NCS. METHODS: A total of 24,313 NCS cases at the Mayo Clinic (Rochester, Minnesota) from 2006 through 2011 were included in the study; 1,120 (4.6%) cases involved patients with coronary stents. MACCE was defined as death, myocardial infarction, cardiac arrest, or stroke. Age-adjusted odds ratios (aORs) were calculated after propensity adjustment for Revised Cardiac Risk Index factors and other conventional risk factors. RESULTS: The 30-day MACCE rates were 3.7% and 1.5% in stented and unstented patients, respectively (p < 0.001). The risk of MACCE was largely related to the time from stent implantation to NCS, indicating substantially elevated risk in the first year after stenting (aOR: 2.59; 95% confidence interval [CI]: 1.36 to 4.94) but not thereafter (aOR: 0.89; 95% CI: 0.59 to 1.36). Bleeding displayed a similar pattern, indicating elevated risk in the first year after stenting (aOR: 2.23; 95% CI: 1.55 to 3.21) but not thereafter (aOR: 1.07; 95% CI: 0.89 to 1.28). Subgroup analysis in patients with known stent type found that the increased risk of both MACCE and bleeding >1 month after stent implantation was not limited to only those with drug-eluting stents. CONCLUSIONS: This study found that prior coronary stent implantation is an independent risk factor for MACCE and bleeding when time from stenting to NCS is <1 year, both in patients with bare-metal and drug-eluting stents.

Paradigm shifts in cardiovascular medicine.

Cardiovascular medicine is changing rapidly with the development, testing, and introduction of new diagnostic and therapeutic methods. New interventional techniques such as the use of drug-eluting stents have important implications for the care of individual patients and the delivery and economics of health care in general. Drug-eluting stents have been shown to improve outcomes among patients undergoing percutaneous coronary intervention by significantly reducing restenosis rates. Two randomized trials have documented that per 100 patients treated with the sirolimus drug-eluting stent, 12.5 to 13.6 patients avoided the need for subsequent target lesion revascularization, when compared with patients treated with conventional stents. The economic effect of the introduction of these stents, which are projected to be two to three times as expensive as conventional stents, is complex and depends on which segment of health care is considered. These stents will be favorably received by patients, physicians, employers, and society as well as payers. However, hospitals may be adversely affected by having increased procedural costs for the stents, along with fewer procedures for evaluation and treatment of restenosis and probably decreased surgical volumes. Drug-eluting stents are only the first of many new technologic advances that will affect cardiovascular care. These procedures have many features in common, including: 1). replacement of major surgical procedures with less invasive approaches; and 2). redistribution of costs, with a decrease in hospital profits but potentially lower costs of health care delivery for society as a whole.

Optimizing weekend availability for sophisticated tests and procedures in a large hospital.

The reduced availability of sophisticated tests and procedures in hospitals on weekends (the so-called "weekend effect") delays care. Addressing this problem requires hospital managers to balance the desire for timeliness with the need for efficient operations. We illustrate how a hospital can profile timeliness, demand, and capacity utilization across the week for multiple testing areas. This simple, practical method; using data extracted from the hospital's accounting system, makes visible the pattern and magnitude of delays caused by reduced availability on weekends, while also showing how capacity is deployed. We combined the analytical tool with a process of transparent feedback and local problem solving that engages multiple stakeholders in the hospital. The goal is to optimally configure capacity so as to balance the imperatives of timely availability and efficient resource utilization.

Low-risk percutaneous coronary interventions without on-site cardiac surgery: two years' observational experience and follow-up.

BACKGROUND: We studied the safety and efficacy of performing low-risk elective and acute infarct percutaneous coronary interventions at a community hospital without cardiac surgical capability. METHODS: Immanuel St Joseph's Hospital is located 85 miles from St Mary's Hospital, which is the nearest center with on-site cardiac surgery. All components of the Mayo Clinic percutaneous coronary intervention program were replicated at Immanuel St Joseph's Hospital, including a telemedicine system to enable real-time consultation with interventional and cardiac surgical colleagues during procedures. RESULTS: From March 1999 to June 2001, 196 patients underwent elective percutaneous coronary intervention at Immanuel St Joseph's Hospital. Procedural success was achieved in 195 (99.5%) patients, with 1 (0.5%) inhospital death. At mean follow-up of 8.2 months, 2 (1.0%) additional patients died of noncardiac causes and 15 (7.7%) patients required target vessel revascularization. From March 2000 to June 2001, 89 patients underwent primary percutaneous coronary intervention for acute myocardial infarction. Procedural success was achieved in 83 (93.3%) patients, with 3 (3.4%) inhospital deaths. At 30-day follow up, no additional patients died, had recurrent myocardial infarction, or required target vessel revascularization. No patients required transfer to another facility for emergent cardiac surgery for a procedure-related complication. CONCLUSIONS: Low-risk elective and acute infarct percutaneous coronary interventions can be performed with safety and efficacy at a community hospital without cardiac surgical capability by following rigorous standards.

Optimization of a research web environment for academic internal medicine faculty.

Usability evaluations are a powerful tool that can assist developers in their efforts to optimize the quality of their web environment. This underutilized, experimental method can serve to move applications toward true user-centered design. This article describes the usability methodology and illustrates its importance and application by describing a usability study undertaken at the Mayo Clinic for the purpose of improving an academic research web environment. Academic institutions struggling in an era of declining reimbursements are finding it difficult to maintain academic enterprises on the back of clinical revenues. This may result in declining amounts of time that clinical investigators have to spend in non-patient-related activities. For this reason, we have undertaken to design a web environment, which can minimize the time that a clinician-investigator needs to spend to accomplish academic instrumental activities of daily living. Usability evaluation is a powerful application of human factors engineering, which can improve the utility of web-based Informatics applications.

The physician workforce: a medical school dilemma.

Richard Cooper has advanced a projection of a sizable deficit in physicians in the United States, requiring the training of as many as 10,000 additional physicians annually by the year 2025. He questions the ability of U.S. medical schools to "fill the gap." This challenge presents another important dilemma for medical education. Could the applicant pool be enlarged sufficiently to increase qualified applicants? Would medical schools be able to accommodate this increase in students? The impact of these increases could be an ultimate decrease in the quality of health care and the production of physicians who are not current with research findings, particularly in the area of genetics.

Lessons learned-UME-21 project.

The Undergraduate Medical Education for the 21st Century (UME-21) project evolved from two prior projects that were aimed at studying the interface between managed care and undergraduate medical education. The project provided funding for 18 US medical schools to demonstrate how they would produce graduates who eventually could practice in a rapidly changing health care environment. Medical schools were required to provide educational opportunities in nine content areas or outline why such educational opportunities could not be provided in their individual projects. Participating schools were chosen via an involved process after careful evaluation by a panel of experienced medical educators. In a project of this type, many lessons are learned. In the UME-21 project, lessons learned were gleaned from progress reports, participant annual reports, proceedings from annual project meetings and a National Symposium, findings of a National Education Group, and published papers. A lesson must have been reported by a least two involved schools to be included. The lessons learned were divided into six categories as follows: content areas, implementation, collaboration, evaluation, governance, implications- summary. Many lessons emanated from each of these categories; however, only the 10 most important lessons in each category are presented. The implications of the lessons learned are outlined and provide direction for the future of medical education innovation and research.

Harmonizing and consolidating the measurement of patient-reported information at health care institutions: a position statement of the Mayo Clinic.

Patient-reported outcomes (PROs) capture how patients perceive their health and their health care; their use in clinical research is longstanding. Today, however, PROs increasingly are being used to inform the care of individual patients, and document the performance of health care entities. We recently wrote and internally distributed an institutional position statement titled "Harmonizing and Consolidating the Measurement of Patient-Reported Outcomes at Mayo Clinic: A Position Statement for the Center for the Science of Health Care Delivery". The statement is meant to educate clinicians, clinical teams, and institutional administrators about the merits of using PROs in a systematic manner for clinical care and quality measurement throughout the institution. The present article summarizes the most important messages from the statement, describing PROs and their use, identifying practical considerations for implementing them in routine practice, elucidating potential barriers to their use, and formulating strategies to overcome these barriers. The lessons learned from our experience - including pitfalls, challenges, and successes - may inform other health care institutions that are interested in systematically using PROs in health care delivery science and practice.

Direct costs of bipolar disorder versus other chronic conditions: an employer-based health plan analysis.

OBJECTIVE: This study was a retrospective data-based analysis of health care utilization and costs for patients diagnosed as having bipolar disorder compared with patients with diagnoses of depression, diabetes, coronary artery disease, or asthma. METHODS: Data were from an employer-based health plan. Consistent diagnosis and continuous enrollment from 2004 to 2007 were used to identify the study population (total N = 7,511), including those with bipolar disorder (N = 122), depression (N = 1,290), asthma (N = 2,770), coronary artery disease (N = 1,759), diabetes (N = 1,418), and diabetes with coronary artery disease (N = 455). Resource utilization quantified as cost (total, specialty care, psychiatric outpatient) and number of visits (specialty care and outpatient psychiatric care) was compared across groups. RESULTS: Patients with bipolar disorder had higher adjusted mean per member per month (PMPM) costs than any other comparison group except for those with both diabetes and coronary artery disease. The cost was predominantly related to pharmacy costs and both inpatient and outpatient psychiatric care. A subset of 20% of patients with bipolar disorder accounted for 64% of the total costs. This subgroup of patients was more likely to be female, to have frequent hospital stays, and to have a higher number of comorbidities. Depressed patients, in contrast to bipolar disorder patients, had higher adjusted mean PMPM costs in primary care and nonpsychiatric inpatient costs. CONCLUSIONS: Health care costs for bipolar disorder exceeded those for several common chronic illnesses. These data provide further evidence for employers, insurers, and providers to seek innovative models to deliver effective and efficient care to individuals with bipolar illness.

Mayo Clinic employees responded to new requirements for cost sharing by reducing possibly unneeded health services use.

Some health plans have experimented with increasing consumer cost sharing, on the theory that consumers will use less unnecessary health care if they are expected to bear some of the financial responsibility for it. However, it is unclear whether the resulting decrease in use is sustained beyond one or two years. In 2004 Mayo Clinic's self-funded health plan increased cost sharing for its employees and their dependents for specialty care visits (adding a $25 copayment to the high-premium option) and other services such as imaging, testing, and outpatient procedures (adding 10 or 20 percent coinsurance, depending on the option). The plan also removed all cost sharing for visits to primary care providers and for preventive services such as colorectal screening and mammography. The result was large decreases in the use of diagnostic testing and outpatient procedures that were sustained for four years, and an immediate decrease in the use of imaging that later rebounded (possibly to levels below the expected trend). Beneficiaries decreased visits to specialists but did not make greater use of primary care services. These results suggest that implementing relatively low levels of cost sharing can lead to a long-term decrease in utilization.

Effect of multiple chronic conditions among working-age adults.

OBJECTIVE: To determine the longitudinal effect on healthcare costs of multiple chronic conditions among adults aged 18 to 64 years. STUDY DESIGN: Retrospective cohort assessment of working-age employees and their dependents with continuous coverage in a self-funded health plan from January 1, 2004, to December 31, 2007. Data were obtained from health benefit enrollment files and from medical and pharmacy claims. METHODS: Individuals were defined as having chronic conditions based on modification of a published method. The mean annual healthcare costs were estimated for individuals with 0, 1, 2, 3, 4, or 5 or more chronic conditions. The probability of persistence in high-cost categories across years was estimated for individuals in each group. RESULTS: Overall, 75.3% of working-age adult enrollees had at least 1 chronic condition, 54.3% had multiple chronic conditions, and 16.5% had 5 or more chronic conditions. The cost of healthcare was higher among individuals with more chronic conditions for all ages. The mean medical cost per year for an individual with no chronic conditions was $2137, while that for an individual with 5 or more chronic conditions was $21,183. Enrollees with more chronic conditions had higher persistence in high-cost categories between years and persisted at these high costs for more years. CONCLUSIONS: While multiple chronic conditions are common in the population 65 years and older, they are also of great concern for the working-age population. Understanding how to effectively manage individuals with multiple chronic conditions is an important challenge. Effective care management focused on managing the patient as opposed to a condition has the potential to significantly affect healthcare costs.