Telemedicine Adoption in an NCI-Designated Cancer Center During the COVID-19 Pandemic: A Report on Patient Experience of Care.

BACKGROUND: Patients with cancer require timely access to care so that healthcare providers can prepare an optimal treatment plan with significant implications for quality of life and mortality. The COVID-19 pandemic spurred rapid adoption of telemedicine in oncology, but study of patient experience of care with telemedicine in this population has been limited. We assessed overall patient experience of care with telemedicine at an NCI-designated Comprehensive Cancer Center during the COVID-19 pandemic and examined changes in patient experience over time. PATIENTS AND METHODS: This was a retrospective study of outpatient oncology patients who received treatment at Moffitt Cancer Center. Press Ganey surveys were used to assess patient experience. Data from patients with appointments between April 1, 2020, and June 30, 2021, were analyzed. Patient experience was compared between telemedicine and in-person visits, and patient experience with telemedicine over time was described. RESULTS: A total of 33,318 patients reported Press Ganey data for in-person visits, and 5,950 reported Press Ganey data for telemedicine visits. Relative to patients with in-person visits, more patients with telemedicine visits gave higher satisfaction ratings for access (62.5% vs 75.8%, respectively) and care provider concern (84.2% vs 90.7%, respectively) (P<.001). When adjusted for age, race/ethnicity, sex, insurance, and clinic type, telemedicine visits consistently outperformed in-person visits over time regarding access and care provider concern (P<.001). There were no significant changes over time in satisfaction with telemedicine visits regarding access, care provider concern, telemedicine technology, or overall assessment (P>.05). CONCLUSIONS: In this study, a large oncology dataset showed that telemedicine resulted in better patient experience of care in terms of access and care provider concern compared with in-person visits. Patient experience of care with telemedicine visits did not change over time, suggesting that implementing telemedicine was effective.

Advancing Digital Health Innovation in Oncology: Priorities for High-Value Digital Transformation in Cancer Care.

Although health care delivery is becoming increasingly digitized, driven by the pursuit of improved access, equity, efficiency, and effectiveness, progress does not appear to be equally distributed across therapeutic areas. Oncology is renowned for leading innovation in research and in care; digital pathology, digital radiology, real-world data, next-generation sequencing, patient-reported outcomes, and precision approaches driven by complex data and biomarkers are hallmarks of the field. However, remote patient monitoring, decentralized approaches to care and research, "hospital at home," and machine learning techniques have yet to be broadly deployed to improve cancer care. In response, the Digital Medicine Society and Moffitt Cancer Center convened a multistakeholder roundtable discussion to bring together leading experts in cancer care and digital innovation. This viewpoint highlights the findings from these discussions, in which experts agreed that digital innovation is lagging in oncology relative to other therapeutic areas. It reports that this lag is most likely attributed to poor articulation of the challenges in cancer care and research best suited to digital solutions, lack of incentives and support, and missing standardized infrastructure to implement digital innovations. It concludes with suggestions for actions needed to bring the promise of digitization to cancer care to improve lives.

Development of a Patient Activation Toolkit for Hepatitis C Virus Testing.

We evaluated the acceptability of a patient activation toolkit for hepatitis C virus (HCV) testing amidst universal adult guidelines. We developed a patient-facing toolkit that included a letter to the patient from their healthcare provider, HCV factsheet, and question prompt list, which contained questions for their provider about HCV infection and testing. We conducted qualitative interviews with patients ages 18-78 (n = 17), using a semi-structured interview guide based on learner verification. We assessed attraction, comprehension, cultural-linguistic acceptability, self-efficacy, and persuasiveness of toolkit materials using direct content analysis. Participants reported materials were attractive, offering suggestions to improve readability. They reported some understanding of materials but requested use of less medical jargon, particularly for the factsheet. Participants discussed cultural acceptability and suggested ways to improve language inclusiveness and comfort with content, given stigma surrounding HCV risk factors. Participants reported that including a letter, factsheet, and QPL improved the persuasiveness of materials, and they conveyed their motivation to be tested for HCV. Results indicate preliminary acceptability for use of the patient activation toolkit, which will be refined based on participants' recommendations. Overall, this patient activation toolkit holds promise for increasing HCV testing rates.

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.

The HOSPITAL Score Predicts Potentially Preventable 30-Day Readmissions in Conditions Targeted by the Hospital Readmissions Reduction Program.

BACKGROUND/OBJECTIVES: New tools to accurately identify potentially preventable 30-day readmissions are needed. The HOSPITAL score has been internationally validated for medical inpatients, but its performance in select conditions targeted by the Hospital Readmission Reduction Program (HRRP) is unknown. DESIGN: Retrospective cohort study. SETTING: Six geographically diverse medical centers. PARTICIPANTS/EXPOSURES: All consecutive adult medical patients discharged alive in 2011 with 1 of the 4 medical conditions targeted by the HRRP (acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and heart failure) were included. Potentially preventable 30-day readmissions were identified using the SQLape algorithm. The HOSPITAL score was calculated for all patients. MEASUREMENTS: A multivariable logistic regression model accounting for hospital effects was used to evaluate the accuracy (Brier score), discrimination (c-statistic), and calibration (Pearson goodness-of-fit) of the HOSPITAL score for each 4 medical conditions. RESULTS: Among the 9181 patients included, the overall 30-day potentially preventable readmission rate was 13.6%. Across all 4 diagnoses, the HOSPITAL score had very good accuracy (Brier score of 0.11), good discrimination (c-statistic of 0.68), and excellent calibration (Hosmer-Lemeshow goodness-of-fit test, P=0.77). Within each diagnosis, performance was similar. In sensitivity analyses, performance was similar for all readmissions (not just potentially preventable) and when restricted to patients age 65 and above. CONCLUSIONS: The HOSPITAL score identifies a high-risk cohort for potentially preventable readmissions in a variety of practice settings, including conditions targeted by the HRRP. It may be a valuable tool when included in interventions to reduce readmissions within or across these conditions.

The Impact of an Electronic Medication Administration Record (eMAR) and Computerized Physician Order Entry (CPOE) on Nurse Extender and Unit Clerk Staffing.

OBJECTIVE: The aim of this study is to describe the impact of the introduction of health information technology (HIT) on the utilization and payroll costs of nurse extenders and unit clerks in medicine and surgery units in a large regional health system. BACKGROUND: Long-term policy goals of HIT implementation are reported to include system-level reductions in labor costs, achieved through improved efficiency. METHODS: Using a retrospective cohort model, we analyzed how hours worked per patient day and staffing costs per patient day varied with the implementation of HIT over time at 2 different hospitals within a health system. RESULTS: Implementation of electronic medication administration records was not associated with significant changes in staffing or labor costs. Both labor hours and costs associated with nurse extenders and unit clerks were significantly reduced after the subsequent addition of computerized provider order entry. Simultaneously, units that did not implement any HIT experienced a significant increase in both labor hours and costs. CONCLUSION: Health information technology implementation in the inpatient setting is associated with significant savings in labor hours and costs in non-registered nursing roles.

Physician Perspectives on Factors Contributing to Readmissions and Potential Prevention Strategies: A Multicenter Survey.

BACKGROUND: The transition out of the hospital is a vulnerable time for patients, relying heavily on communication and coordination of resources across care settings. Understanding the perspectives of inpatient and outpatient physicians regarding factors contributing to readmission and potential preventive strategies is crucial in designing appropriately targeted readmission prevention efforts. OBJECTIVE: To examine and compare inpatient and outpatient physician opinions regarding reasons for readmission and interventions that might have prevented readmission. DESIGN: Cross-sectional multicenter study. PARTICIPANTS: We identified patients readmitted to general medicine services within 30 days of discharge at 12 US academic medical centers, and surveyed the primary care physician (PCP), discharging physician from the index admission, and admitting physician from the readmission regarding their endorsement of pre-specified factors contributing to the readmission and potential preventive strategies. MAIN MEASURES: We calculated kappa statistics to gauge agreement between physician dyads (PCP-discharging physician, PCP-admitting physician, and admitting-discharging physician). KEY RESULTS: We evaluated 993 readmission events, which generated responses from 356 PCPs (36 % of readmissions), 675 discharging physicians (68 % of readmissions), and 737 admitting physicians (74 % of readmissions). The most commonly endorsed contributing factors by both PCPs and inpatient physicians related to patient understanding and ability to self-manage. The most commonly endorsed preventive strategies involved providing patients with enhanced post-discharge instructions and/or support. Although PCPs and inpatient physicians endorsed contributing factors and potential preventive strategies with similar frequencies, agreement among the three physicians on the specific factors and/or strategies that applied to individual readmission events was poor (maximum kappa 0.30). CONCLUSIONS: Differing opinions among physicians on factors contributing to individual readmissions highlights the importance of communication between inpatient and outpatient providers at discharge to share their different perspectives, and suggests that multi-faceted, broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors.

The impact of health information technology on staffing.

Hospitals nationwide must demonstrate meaningful use by 2015 or face fines. For over 20 years, researchers have attempted to assess the impact of electronic record keeping technologies on the quality, safety, and efficiency of care, but results are inconclusive and hospital managers have little evidence on which to base staffing decisions as we hurtle toward the era of the paperless hospital.

Novel Virtual Reality App for Training Patients on MRI-guided Radiation Therapy.

Purpose: Patients receiving respiratory gated magnetic resonance imaging-guided radiation therapy (MRIgRT) for abdominal targets must hold their breath for ≥25 seconds at a time. Virtual reality (VR) has shown promise for improving patient education and experience for diagnostic MRI scan acquisition. We aimed to develop and pilot-test the first VR app to educate, train, and reduce anxiety and discomfort in patients preparing to receive MRIgRT. Methods and Materials: A multidisciplinary team iteratively developed a new VR app with patient input. The app begins with minigames to help orient patients to using the VR device and to train patients on breath-holding. Next, app users are introduced to the MRI linear accelerator vault and practice breath-holding during MRIgRT. In this quality improvement project, clinic personnel and MRIgRT-eligible patients with pancreatic cancer tested the VR app for feasibility, acceptability, and potential efficacy for training patients on using breath-holding during MRIgRT. Results: The new VR app experience was tested by 19 patients and 67 clinic personnel. The experience was completed on average in 18.6 minutes (SD = 5.4) by patients and in 14.9 (SD = 3.5) minutes by clinic personnel. Patients reported the app was "extremely helpful" (58%) or "very helpful" (32%) for learning breath-holding used in MRIgRT and "extremely helpful" (28%) or "very helpful (50%) for reducing anxiety. Patients and clinic personnel also provided qualitative feedback on improving future versions of the VR app. Conclusion: The VR app was feasible and acceptable for training patients on breath-holding for MRIgRT. Patients eligible for MRIgRT for pancreatic cancer and clinic personnel reported on future improvements to the app to enhance its usability and efficacy.

Examining disparities in large-scale patient-reported data capture using digital tools among cancer patients at clinical intake.

BACKGROUND: Patient-reported data can improve quality of healthcare delivery and patient outcomes. Moffitt Cancer Center ("Moffitt") administers the Electronic Patient Questionnaire (EPQ) to collect data on demographics, including sexual orientation and gender identity (SOGI), medical history, cancer risk factors, and quality of life. Here we investigated differences in EPQ completion by demographic and cancer characteristics. METHODS: An analysis including 146,142 new adult patients at Moffitt in 2009-2020 was conducted using scheduling, EPQ and cancer registry data. EPQ completion was described by calendar year and demographics. Logistic regression was used to estimate associations between demographic/cancer characteristics and EPQ completion. More recently collected information on SOGI were described. RESULTS: Patient portal usage (81%) and EPQ completion rates (79%) were consistently high since 2014. Among patients in the cancer registry, females were more likely to complete the EPQ than males (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.14-1.20). Patients ages 18-64 years were more likely to complete the EPQ than patients aged ≥65. Lower EPQ completion rates were observed among Black or African American patients (OR = 0.59, 95% CI = 0.56-0.63) as compared to Whites and among patients whose preferred language was Spanish (OR = 0.40, 95% CI = 0.36-0.44) or another language as compared to English. Furthermore, patients with localized (OR = 1.16, 95% CI = 1.12-1.19) or regional (OR = 1.16, 95% CI = 1.12-1.20) cancer were more likely to complete the EPQ compared to those with metastatic disease. Less than 3% of patients self-identified as being lesbian, gay, or bisexual and <0.1% self-identified as transgender, genderqueer, or other. CONCLUSIONS: EPQ completion rates differed across demographics highlighting opportunities for targeted process improvement. Healthcare organizations should evaluate data acquisition methods to identify potential disparities in data completeness that can impact quality of clinical care and generalizability of self-reported data.

Longitudinal Collection of Patient-Reported Outcomes and Activity Data during CAR-T Therapy: Feasibility, Acceptability, and Data Visualization.

Background: Clinicians must closely monitor patients for toxicities after chimeric antigen receptor T-cell therapy (CAR-T). Patient-reported outcomes (PROs) (e.g., toxicities, quality of life) and activity data (e.g., steps, sleep) may complement clinicians' observations. This study tested the feasibility and acceptability of collecting PROs and activity data from patients with hematologic malignancies during CAR-T and explored preliminary data patterns. Methods: Participants wore a Fitbit tracker and completed PROs at several timepoints through 90-days post-infusion. Feasibility was assessed with a priori benchmarks for recruitment (≥50%), retention (≥70%), PRO completion (≥70%), and days wearing the Fitbit (≥50%). Acceptability was assessed with participant satisfaction (a priori benchmark > 2 on a 0−4 scale). Results: Participants (N = 12) were M = 66 years old (SD = 7). Rates of recruitment (68%), retention (83%), PRO completion (85%), and days wearing the Fitbit (85%) indicated feasibility. Satisfaction with completing the PROs (M = 3.2, SD = 0.5) and wearing the Fitbit (M = 2.9, SD = 0.5) indicated acceptability. Preliminary data patterns suggested that participants with better treatment response (vs. progressive disease) had a higher toxicity burden. Conclusions: Longitudinal PRO and activity data collection was feasible and acceptable. Data collected on a larger scale may be used to specify risk prediction models to identify predictors of severe CAR-T-related toxicities and inform early interventions.

Predictors and Outcomes of Patient Knowledge of Plan of Care in Hospital Medicine: A Quality Improvement Study.

BACKGROUND: Patient understanding of plan of care is associated with positive outcomes in ambulatory settings. In hospital medicine settings, patient-physician agreement on plan of care (concordance) has been limited and difficult to improve. This study examined the impact of adding a hospitalist to interdisciplinary rounds (IDR) on physician-patient-nurse concordance and the relationship between concordance and outcomes. METHODS: IDR were conducted by core teams made up of unit-based nurses, a case manager, and a pharmacist. Over time, with cohorting, hospitalists were included in IDR (hospitalist IDR) for some patients assigned to unit-based hospitalists. In developing hospitalist IDR, the researchers emphasized using an IDR checklist, including a patient communication plan. Patient-nurse-physician interviews were used to assess concordance in the domains of diagnosis, tests and procedures, and expected discharge date. Using two-hospitalist review, agreement was rated as none, partial, or complete, and a total concordance score was calculated for each patient in both IDR groups. Multivariate analysis was used to examine the relationship between concordance, IDR type, patient factors, and utilization outcomes. RESULTS: For 658 patients, the mean concordance score was 11.71 out of a possible 18. There was no difference in concordance between hospitalist and core IDR groups (11.68 vs. 11.84, p = 0.7). Higher total concordance score was associated with lower lengths of stay (p < 0.001) and readmission rates (p = 0.001). Total concordance had a negative association with patient age (p = 0.04). CONCLUSION: Concordance did not change with IDR type. Higher concordance appears to be related to positive utilization outcomes. Future studies are needed to evaluate potential interventions to improve concordance.

Invisible work and changing roles: Health information technology implementation and reorganization of work practices for the inpatient nursing team.

Hospitals have invested heavily in health information technology (HIT) which has been promoted as an integral component of quality, safe, and efficient health-care delivery. Research on the expanding use of such technology, however, has shown that user/technology interactions are shaped through practices of use that can yield far from normative, even unexpected outcomes. Drawing upon focus group and interview data from an inpatient, two-hospital health system in the United States, this paper considers the perceived impact of HIT implementation on work practices and roles for nurse managers and unit clerks. We find that HIT implementation generated significant reconfigurations of work practices at the expense of nurse/patient interaction. Following such changes, nursing leadership described re-prioritizing patient care and interaction - perceived to them as essential to the patient experience and unit functioning - through realignments in staffing that prioritized more versatile staff and task delegation of largely invisible, articulation work to unit clerks. Despite maintaining an integral role as "gatekeeper" and the "face on the floor," unit clerks experienced significant reconfigurations of their work and some concomitant uncertainty about their role. We consider the implications of our findings for literature on the socio-materiality of HIT, with particular attention to literature on work practices, roles, and the visibility of work within organizational power hierarchies.

Simplification of the HOSPITAL score for predicting 30-day readmissions.

OBJECTIVE: The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted. DESIGN AND SETTING: Retrospective study in 9 large hospitals across 4 countries, from January through December 2011. PARTICIPANTS: We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility. MEASUREMENTS: The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) 'discharge from an oncology division' was replaced by 'cancer diagnosis or discharge from an oncology division'; (2) 'any procedure' was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration. RESULTS: Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2-5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories. CONCLUSIONS: The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: A systematic review and suggested taxonomy.

BACKGROUND: Interdisciplinary rounds (IDR) have been described to improve outcomes. However, there is limited understanding of optimal IDR design. PURPOSE: To systematically review published reports of IDR to catalog types of IDR and outcomes, and assess the influence of IDR design on outcomes. DATA SOURCES: Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Journals Ovid, Cumulative Index to Nursing and Allied Health Literature (EBSCOhost), and PubMed from 1990 through December 2014, and hand searching of article bibliographies. STUDY SELECTION: Experimental, quasiexperimental, and observation studies in English-language literature where physicians rounded with another healthcare professional in inpatient medicine units. DATA EXTRACTION: Studies were abstracted for study setting and characteristics, and design and outcomes of IDR. DATA SYNTHESIS: Twenty-two studies were included in the qualitative analysis. Many were of low to medium quality with few high-quality studies. There is no clear definition of IDR in the literature. There was wide variation in IDR design and team composition across studies. We found three different models of IDR: pharmacist focused, bedside rounding, and interdisciplinary team rounding. There are reasonable data to support an association with length of stay and staff satisfaction but little data on patient safety or satisfaction. Positive outcomes may be related to particular components of IDR design, but the relationship between design and outcomes remains unclear. CONCLUSIONS: Future studies should be more deliberately designed and fully reported with careful attention to team composition and features of IDR and their impact on selected outcomes. We present a proposed IDR definition and taxonomy for future studies. Journal of Hospital Medicine 2016;11:513-523. © 2016 Society of Hospital Medicine.

Embedding a trauma hospitalist in the trauma service reduces mortality and 30-day trauma-related readmissions.

BACKGROUND: Recognizing the increasing age and comorbid conditions of patients admitted to our trauma service, we embedded a hospitalist on the trauma service at our Level I trauma center.This program was initiated in January 2013. This study was designed to investigate differences in outcomes between trauma patients who received care from the trauma hospitalist (THOSP) program and similarly medically complex trauma patients who did not receive THOSP care. METHODS: There were 566 patients comanaged with THOSP between December 2013 and November 2014. These patients were matched (1:2) with propensity scores to a contemporaneous control group based on age, Injury Severity Score (ISS), and comorbid conditions. Outcomes examined included mortality, trauma-related readmissions, upgrades to the intensive care unit, hospital length of stay, the development of in-hospital complications, and the frequency of obtaining medical subspecialist consultation. Differences in outcomes were compared with Mann-Whitney U-test or χ test as appropriate. RESULTS: High-quality matching resulted in the loss of 97 THOSP patients for the final analysis. Table 1 shows the balance between the two groups after matching. While there was a 1-day increase in hospital length of stay and an increase in upgrades to the intensive care unit, there was a reduction in mortality, trauma-related readmissions, and the development of renal failure after implementation of the THOSP program (Table 2). Implementation of this program made no significant difference in the frequency of cardiology, nephrology, neurology, or endocrinology consultations. There was also no difference in the development of the complications of venous thromboembolism, pneumonia, stroke, urinary tract infection, bacteremia, or alcohol withdrawal. CONCLUSION: Our study provides evidence that embedding a hospitalist on the trauma service reduces mortality and trauma-related readmissions. A reason for these improved outcomes may be related to THOSP "vigilance." LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

International Validity of the HOSPITAL Score to Predict 30-Day Potentially Avoidable Hospital Readmissions.

IMPORTANCE: Identification of patients at a high risk of potentially avoidable readmission allows hospitals to efficiently direct additional care transitions services to the patients most likely to benefit. OBJECTIVE: To externally validate the HOSPITAL score in an international multicenter study to assess its generalizability. DESIGN, SETTING, AND PARTICIPANTS: International retrospective cohort study of 117 065 adult patients consecutively discharged alive from the medical department of 9 large hospitals across 4 different countries between January 2011 and December 2011. Patients transferred to another acute care facility were excluded. EXPOSURES: The HOSPITAL score includes the following predictors at discharge: hemoglobin, discharge from an oncology service, sodium level, procedure during the index admission, index type of admission (urgent), number of admissions during the last 12 months, and length of stay. MAIN OUTCOMES AND MEASURES: 30-day potentially avoidable readmission to the index hospital using the SQLape algorithm. RESULTS: Overall, 117 065 adults consecutively discharged alive from a medical department between January 2011 and December 2011 were studied. Of all medical discharges, 16 992 of 117 065 (14.5%) were followed by a 30-day readmission, and 11 307 (9.7%) were followed by a 30-day potentially avoidable readmission. The discriminatory power of the HOSPITAL score to predict potentially avoidable readmission was good, with a C statistic of 0.72 (95% CI, 0.72-0.72). As in the derivation study, patients were classified into 3 risk categories: low (n = 73 031 [62.4%]), intermediate (n = 27 612 [23.6%]), and high risk (n = 16 422 [14.0%]). The estimated proportions of potentially avoidable readmission for each risk category matched the observed proportion, resulting in an excellent calibration (Pearson χ2 test P = .89). CONCLUSIONS AND RELEVANCE: The HOSPITAL score identified patients at high risk of 30-day potentially avoidable readmission with moderately high discrimination and excellent calibration when applied to a large international multicenter cohort of medical patients. This score has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions.

Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients.

IMPORTANCE: Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement. OBJECTIVES: To determine preventability of readmissions and to use these estimates to prioritize areas for improvement. DESIGN, SETTING, AND PARTICIPANTS: An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors. MAIN OUTCOME AND MEASURE: Likelihood that a readmission could have been prevented. RESULTS: The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%). CONCLUSIONS AND RELEVANCE: Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management.

The Hospital Medicine Reengineering Network (HOMERuN): a learning organization focused on improving hospital care.

Converting the health care delivery system into a learning organization is a key strategy for improving health outcomes. Although the collaborative learning organization approach has been successful in neonatal intensive care units and disease-specific collaboratives, there are few examples in general medicine and none in adult medicine that have leveraged the role of hospitalists nationally across multiple institutions to implement improvements. The authors describe the rationale for and early work of the Hospital Medicine Reengineering Network (HOMERuN), a collaborative of hospitals, hospitalists, and multidisciplinary care teams founded in 2011 that seeks to measure, benchmark, and improve the efficiency, quality, and outcomes of care in the hospital and afterwards. Robust and timely evaluation, with learning and refinement of approaches across institutions, should accelerate improvement efforts. The authors review HOMERuN's collaborative model, which focuses on a community-based participatory approach modified to include hospital-based staff as well as the larger community. HOMERuN's initial project is described, focusing on care transition measurement using perspectives from the patient, caregiver, and providers. Next steps and sustainability of the organization are discussed, including benchmarking, collaboration, and effective dissemination of best practices to stakeholders.

Patient-centered outcomes of a value-based insurance design program for patients with diabetes.

Value-based insurance design (VBID) initiatives have been associated with modest improvements in adherence based on evaluations of administrative claims data. The objective of this prospective cohort study was to report the patient-centered outcomes of a VBID program that eliminated co-payments for diabetes-related medications and supplies for employees and dependents with diabetes at a large health system. The authors compared self-reported values of medication adherence, cost-related nonadherence, health status, and out-of-pocket health care costs for patients before and 1 year after program implementation. Clinical metrics and satisfaction with the program also are reported. In all, 188 patients completed the follow-up evaluation. Overall, patients reported a significant reduction in monthly out-of-pocket costs (P<0.001), which corresponded to a significant reduction in cost-related nonadherence from 41% to 17.5% (P<0.001). Self-reported medication adherence increased for hyperglycemic medications (P=0.011), but there were no apparent changes in glycemic control. Overall, 89% of participants agreed that the program helped them take better care of their diabetes. The authors found that a VBID program for employees and dependents with diabetes was associated with self-reported reductions in cost-related nonadherence and improvements in medication adherence. Importantly, the program was associated with high levels of satisfaction among participants and strongly perceived by participants to facilitate medication utilization and self-management for diabetes. These findings suggest that VBID programs can accomplish the anticipated goals for medication utilization and are highly regarded by participants. Patient-centered outcomes should be included in VBID evaluations to allow decision makers to determine the true impact of VBID programs on participants.