Reducing low-value interhospital transfers for mild traumatic brain injury.

BACKGROUND: The modified Brain Injury Guidelines (mBIG) were developed to stratify traumatic brain injuries (TBIs) and improve health care utilization by selectively requiring repeat imaging, intensive care unit admission, and neurosurgical (NSG) consultation. The goal of this study is to assess safety and potential resource savings associated with the application of mBIG on interhospital patient transfers for TBI. METHODS: Adult patients with TBI transferred to our Level I trauma center from January 2017 to December 2022 meeting mBIG inclusion criteria were retrospectively stratified into mBIG1, mBIG2, and mBIG3 based on initial clinicoradiological factors. At the time, our institution routinely admitted patients with TBI and intracranial hemorrhage (ICH) to the intensive care unit and obtained a repeat head computed tomography with NSG consultation, independent of TBI severity or changes in neurological examination. The primary outcome was progression of ICH on repeat imaging and/or NSG intervention. Secondary outcomes included length of stay and financial charges. Subgroup analysis on isolated TBI without significant extracranial injury was performed. RESULTS: Over the 6-year study period, 289 patients were classified into mBIG1 (61; 21.1%), mBIG2 (69; 23.9%), and mBIG3 (159; 55.0%). Of mBIG1 patients, 2 (2.9%) had radiological progression to mBIG2 without clinical decline, and none required NSG intervention. Of mBIG2, 2 patients (3.3%) progressed to mBIG3, and both required NSG intervention. More than 35% of transferred patients had minor isolated TBI. For mBIG1 and mBIG2, the median hospitalization charges per patient were $152,296 and $149,550, respectively, and the median length of stay was 4 and 5 days, respectively, with the majority downgraded from the intensive care unit within 48 hours. CONCLUSION: Clinically significant progression of ICH occurred infrequently in 1.5% of patients with mBIG1 and mBIG2 injuries. More than 35% of interfacility transfers for minor isolated TBI meeting mBIG1 and 2 criteria are low value and may potentially be safely deferred in an urban health care setting. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Clinical outcomes and health care costs of transferring rural Western Australians for invasive coronary angiography, and a cost-effective alternative care model: a retrospective cross-sectional study.

OBJECTIVES: To examine the severity of coronary artery disease (CAD) in people from rural or remote Western Australia referred for invasive coronary angiography (ICA) in Perth and their subsequent management; to estimate the cost savings were computed tomography coronary angiography (CTCA) offered in rural centres as a first line investigation for people with suspected CAD. DESIGN: Retrospective cohort study. SETTING, PARTICIPANTS: Adults with stable symptoms in rural and remote WA referred to Perth public tertiary hospitals for ICA evaluation during the 2019 calendar year. MAIN OUTCOME MEASURES: Severity and management of CAD (medical management or revascularisation); health care costs by care model (standard care or a proposed alternative model with local CTCA assessment). RESULTS: The mean age of the 1017 people from rural and remote WA who underwent ICA in Perth was 62 years (standard deviation, 13 years); 680 were men (66.9%), 245 were Indigenous people (24.1%). Indications for referral were non-ST elevation myocardial infarction (438, 43.1%), chest pain with normal troponin level (394, 38.7%), and other (185, 18.2%). After ICA assessment, 619 people were medically managed (60.9%) and 398 underwent revascularisation (39.1%). None of the 365 patients (35.9%) without obstructed coronaries (< 50% stenosis) underwent revascularisation; nine patients with moderate CAD (50-69% stenosis; 7%) and 389 with severe CAD (≥ 70% stenosis or occluded vessel; 75.5%) underwent revascularisation. Were CTCA used locally to determine the need for referral, 527 referrals could have been averted (53%), the ICA:revascularisation ratio would have improved from 2.6 to 1.6, and 1757 metropolitan hospital bed-days (43% reduction) and $7.3 million in health care costs (36% reduction) would have been saved. CONCLUSION: Many rural and remote Western Australians transferred for ICA in Perth have non-obstructive CAD and are medically managed. Providing CTCA as a first line investigation in rural centres could avert half of these transfers and be a cost-effective strategy for risk stratification of people with suspected CAD.

Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature.

BACKGROUND: Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed. METHODS: A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020. RESULTS: Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs. CONCLUSIONS: An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.

Futile trauma transfers: An infrequent but costly component of regionalized trauma care.

BACKGROUND: Appropriate interfacility transfers are a key component of highly functioning trauma systems but transfer of unsalvageable patients can overburden the resources of higher-level centers. We sought to identify the occurrence and associated reasons for futile transfers within our trauma system. METHODS: Using prospectively collected data from our system database, a retrospective cohort study was conducted to identify patients who underwent interfacility transfer to our American College of Surgeons level I center. Adult patients from June 2017 to June 2019 who died, had comfort measures implemented, were discharged, or went to hospice care within 48 hours of admission without significant operation, procedure, or radiologic intervention were examined. Futility was defined as resulting in death or hospice discharge within 48 hours of transfer without major operative, endoscopic, or radiologic intervention. RESULTS: A total of 1,241 patients transferred to our facility during the study period. Four hundred seven patients had a length of stay less than or equal to 48 hours. Eighteen (1.5%) met the criteria for futility. The most common reason for transfer in the futile population was traumatic brain injury (56%) and need for neurosurgical capabilities (62%). Futile patients had a median age and Injury Severity Score of 75 and 21. The main transportation method was ground 9 (50%) with 8 (44.4%) being transported by helicopter and 1 (5.6%) being transported by both. Combining transport costs with hospital charges, each futile transfer was estimated to cost US $56,396 (interquartile range, 41,889-106,393) with a total cost exceeding US $1.7 million. With an estimated 33,000 interfacility transfers annually for trauma in the United States, the cost of futile transfers to the American trauma system would exceed 27 million dollars each year. CONCLUSION: Futile transfers represent a small but costly portion transfer volume. Identification of patients whose conditions preclude the benefit of transfer due to futility and development of appropriate support for referral will significantly improve appropriate allocation of health care resources. LEVEL OF EVIDENCE: Economic; Care management, level IV.

Secondary overtriage of isolated facial trauma.

DESIGN: Retrospective chart review. SETTING: Academic, tertiary care, level I trauma center in a rural state. BACKGROUND: Unnecessary transfer of certain facial trauma patients results in a burden of time, money, and other resources on both the patient and healthcare system; identification and development of outpatient treatment pathways for these patients is a significant opportunity for cost savings. OBJECTIVES: To investigate the treatment and disposition of un-complicated, stable, isolated facial trauma injuries transferred from outside hospitals and determine the significance of secondary overtriage. METHODS: Retrospective chart review utilizing our institutional trauma database, including patients transferred to our emergency department between January 2012 and December 2017. Patients were identified by ICD9 or ICD10 codes and only those with isolated facial trauma were included. RESULTS: We identified 538 isolated facial trauma patients who were transferred to our institution during the study period. The majority of those patients were transferred via ground ambulance for an average of 76 miles. Overall, 82% of patients (N = 440) were discharged directly from our institution's emergency department. Almost 30% of patients did not require any formal treatment for their injuries; the potential savings associated with elimination of these unnecessary transfers was estimated to be between $388,605 and $771,372. CONCLUSIONS: We identified a high rate of patients with stable, isolated facial trauma that could potentially be evaluated and treated without emergent transfer. The minimization of these unnecessary transfers represents a significant opportunity for cost and resource utilization savings. LEVEL OF EVIDENCE: 2b- Economic and Cost Analysis.

The impact of transfers from neonatal intensive care to paediatric intensive care.

OBJECTIVES: Infants receiving care from neonatal intensive care unit (NICU) can develop chronic problems and be transferred to a paediatric intensive care unit (PICU) for on-going care. There is concern that such infants may take up a large amount of PICU resource, but this is not evidence based. We determined the impact of such transfers. METHODS: We reviewed 10 years of NICU admissions to two tertiary PICUs, which had approximately 12,000 admissions during that period. RESULTS: Sixty-seven infants, gestational age at birth 34.7 (IQR 27.1-38.8) weeks and postnatal age on transfer 81 (IQR 9-144) days were admitted from NICUs. The median (IQR) length of stay was 12 (4-41) days. The 19 infants born <28 weeks of gestation had a greater median length of stay (32, range IQR 10-93 days) than more mature born infants (7.5, IQR 4-26 days) (p=0.003). The median cost of PICU stay for NICU transfers was £23,800 (range 1,205-1,034,000) per baby. The total cost of care for infants transferred from NICUs was £6,457,955. CONCLUSIONS: Infants transferred from NICUs were a small proportion of PICU admissions but, particularly those born <28 weeks of gestation, had prolonged stays which needs to be considered when determining bed capacity.

Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission.

BACKGROUND: Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments. METHODS: We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests. RESULTS: Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use. CONCLUSION: Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: economic evaluation and considerations.

BACKGROUND: Mechanical thrombectomy (MT) is a time-sensitive emergency procedure for patients who had ischaemic stroke leading to improved health outcomes. Health systems need to ensure that MT is delivered to as many patients as quickly as possible. Using decision modelling, we aimed to evaluate the cost-effectiveness of secondary transfer by helicopter emergency medical services (HEMS) compared with ground emergency medical services (GEMS) of rural patients eligible for MT in England. METHODS: The model consisted of (1) a short-run decision tree with two branches, representing secondary transfer transportation strategies and (2) a long-run Markov model for a theoretical population of rural patients with a confirmed ischaemic stroke. Strategies were compared by lifetime costs: quality-adjusted life years (QALYs), incremental cost per QALY gained and net monetary benefit. Sensitivity and scenario analyses explored uncertainty around parameter values. RESULTS: We used the base case of early-presenting (<6 hours to arterial puncture) patient aged 75 years who had stroke to compare HEMS and GEMS. This produced an incremental cost-effectiveness ratio (ICER) of £28 027 when a 60 min reduction in travel time was assumed. Scenario analyses showed the importance of the reduction in travel time and futile transfers in lowering ICERs. For late presenting (>6 hours to arterial puncture), ground transportation is the dominant strategy. CONCLUSION: Our model indicates that using HEMS to transfer patients who had stroke eligible for MT from remote hospitals in England may be cost-effective when: travel time is reduced by at least 60 min compared with GEMS, and a £30 000/QALY threshold is used for decision-making. However, several other logistic considerations may impact on the use of air transportation.

Trends in Hospital-to-Hospital Transfers for Aneurysmal Subarachnoid Hemorrhage: A Single-Institution Experience from 2006 to 2017.

BACKGROUND: Despite evidence to support that aneurysmal subarachnoid hemorrhage (aSAH) is best treated at high-volume centers, it is unknown whether clinical practice reflects these findings. METHODS: We analyzed patients transferred to our high-volume center for aSAH between 2006 and 2017. Data collection included number of transfers, demographic data, Hunt and Hess score, Fisher score, comorbid conditions, length of stay (LOS), discharge disposition, in-hospital mortality rates, insurance status, and hospital charges. Comparisons were made across 3 time periods (2006-2009, 2010-2013, and 2014-2017) and included subgroup analyses by treatment modality (endovascular vs. microsurgical). RESULTS: aSAH transfers declined from 213 in 2006-2009 to 160 in 2014-2017. While there was no change in presenting Hunt and Hess scores, the percentage of modified Fisher scores of 4 increased from 2006-2009 to 2014-2017. Transferred patients had a greater comorbidity index and decreased predicted 10-year survival. Despite this, the average LOS decreased. In-hospital mortality decreased from 2006-2009 to 2014-2017, especially in the endovascular cohort. The proportions of patients who were either self-pay or Medicaid did not change. Overall inflation-adjusted hospital charges decreased from $76,975 in 2006-2009 to $59,870 in 2014-2017. CONCLUSIONS: Between 2006 and 2017, transfers to our center for aSAH declined. However, transferred patients had greater levels of complexity, more comorbidities, and were at greater risk for vasospasm based on their presenting Fisher score. Nonetheless, average LOS, in-hospital mortality, and cost declined. These changing referral patterns have implications for outcome data, quality reporting, resident education, and developing systems of care to optimize outcomes.

Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting.

INTRODUCTION: Interfacility transfers may reflect a time delay of definitive surgical care, but few studies have examined the prevalence of interfacility transfers in the urban low- and middle-income (LMIC) setting. The aim of this study was to determine the number of interfacility transfers required for surgical and obstetric conditions in an urban MIC setting to better understand access to definitive surgical care among LMIC patients. METHODS: A retrospective analysis of public interfacility transfer records was conducted from April 2015 to April 2016 in Cali, Colombia. Data were obtained from the single municipal ambulance agency providing publicly funded ambulance transfers in the city. Interfacility transfers were defined as any patient transfer between two healthcare facilities. We identified the number of transfers for patients with surgical conditions and categorized transfers based on patient ICD-9-CM codes. We compared surgical transfers from public vs. private healthcare facilities by condition type (surgical, obstetric, nonsurgical), transferring physician specialty, and transfer acuity (code blue, emergent, urgent and nonurgent) using logistic regression. RESULTS: 31,659 patient transports occurred over the 13-month study period. 22250 (70.2%) of all transfers were interfacility transfers and 7777 (35%) of transfers were for patients with surgical conditions with an additional 2,244 (10.3%) for obstetric conditions. 49% (8660/17675) of interfacility transfers from public hospitals were for surgical and obstetric conditions vs 32% (1466/4580) for private facilities (P<0.001). The most common surgical conditions requiring interfacility transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%). CONCLUSION: Surgical and obstetric conditions account for nearly half of all urban interfacility ambulance transfers. The most common reasons for transfer are basic surgical conditions with public healthcare facilities transferring a greater proportion of patient with surgical conditions than private facilities. Timely access to an initial healthcare facility may not be a reliable surrogate of definitive surgical care given the substantial need for interfacility transfers.

Transit Care Hub pharmacist: improving patient flow within the hospital.

Background The Transit Care Hub (TCH) is an inpatient ward traditionally used as a waiting area for patients who require transport to return home. In July 2018, a six-month pilot of a TCH pharmacist was funded to improve the flow of patients through the hospital. Setting Major Australian teaching hospital. Objective(s) To determine the effect that the TCH pharmacist had on patient flow within the hospital and on the time saved for other clinical pharmacists, as well as estimating cost savings. Methods A service delivery framework for the TCH pharmacist was developed and tested. This involved a proactive approach to patient discharge with ward-based staff. Data were collected from July to November 2018, 20 weeks prior to and 20 weeks after the commencement of the pilot. Main outcome measure Measurements included the number of best possible medication histories (BPMHs) completed during admission, improvements in arrival time to TCH from inpatient wards and cost savings. Results During the pilot study period (20 weeks), 791 patients were discharged by the TCH pharmacist, arriving an average of 70 minutes earlier than other patients discharging through TCH. There was a 16% increase in patients discharging through TCH which released ward beds. The TCH pharmacist increased the number of BPMHs on day of admission by 14%. There was an estimated annual saving of AU$252,008 for the hospital. Conclusions The TCH pharmacist service enhanced patient flow by coordinating earlier discharges, increasing the timely completion of BPMHs, and saving ward pharmacist time. Significant cost savings supported a permanently funded position.

Stop Flying the Patients! Evaluation of the Overutilization of Helicopter Transport of Trauma Patients.

INTRODUCTION: Helicopter transport is a resource intensive and expensive method for transportation of patients by helicopter. The primary objective of this study was to evaluate the appropriateness of helicopter transport determined by procedural care within 1-h of transfer at an urban level I trauma center. METHODS: All trauma patients transported by helicopter from January 2015-December 2017 to an urban level I trauma center from referring hospitals or the scene were retrospectively analyzed. A subgroup analysis was performed evaluating patients that required a procedure or operation within 1-h of transport compared with the remainder of the patient cohort who were transported via helicopter. RESULTS: A total of 1590 patients were transported by helicopter. Thirty-nine percent of patients (n = 612) were admitted directly to the floor from the trauma bay and 16% (n = 249) of patients required only observation or were discharged home after helicopter transfer. Approximately one-third of the entire study cohort (36%, n = 572) required any procedure, with a median time to procedure of 31.5 h (interquartile range 54.4). Only 13% (n = 74) required a procedure within 1-h of helicopter transport. The average distance (in miles) if the patient had been driven by ground transport rather than helicopter was 67.0 miles (SD ± 27.9) and would take an estimated 71.5 min (±28.4) for patients who required a procedure within 1-h compared with 61.6 miles (SD ± 30.9) with an estimated 66.1 min (SD ± 30.8) for the remainder of the cohort (P value 0.899 and 0.680, respectively). CONCLUSIONS: This analysis demonstrates that helicopter transport was not necessary for the vast majority of trauma patients transported via helicopter.

Are cost advantages from a modern Indian hospital transferable to the United States?

BACKGROUND: Multiple modern Indian hospitals operate at very low cost while meeting US-equivalent quality accreditation standards. Though US hospitals face intensifying pressure to lower their cost, including proposals to extend Medicare payment rates to all admissions, the transferability of Indian hospitals' cost advantages to US peers remains unclear. METHODS: Using time-driven activity-based costing methods, we estimate the average cost of personnel and space for an elective coronary artery bypass graft (CABG) surgery at two American hospitals and one Indian hospital (NH). All three hospitals are Joint Commission accredited and have reputations for use of modern performance management methods. Our case study applies several analytic steps to distinguish transferable from non-transferable sources of NH's cost savings. RESULTS: After removing non-transferable sources of efficiency, NH's residual cost advantage primarily rests on shifting tasks to less-credentialed and/or less-experienced personnel who are supervised by highly-skilled personnel when perceived risk of complications is low. NH's high annual CABG volume facilitates such supervised work "downshifting." The study is subject to limitations inherent in case studies, does not account for the younger age of NH's patients, or capture savings attributable to NH's negligible frequency of re-admission or post-acute care facility placement. CONCLUSIONS: Most transferable bases for a modern Indian hospital's cost advantage would require more flexible American states' hospital and health professional licensing regulations, greater family participation in inpatient care, and stronger support by hospital executives and clinicians for substantially lowering the cost of care via regionalization of complex surgeries and weekend use of costly operating rooms.

Are all trauma centers created equal? Level 1 to level 1 trauma center patient transfers in the setting of rapid trauma center proliferation.

BACKGROUND: Level 1 trauma centers should provide definitive care for every aspect of injury. However, in environments that have experienced trauma center proliferation, not all level 1 centers may have the resources or expertise needed for every patient, necessitating transfer to another trauma center. The purpose of this study was to assess the incidence of such transfers and associated impact on patient outcome and burden on the receiving level 1 center. METHODS: In a metropolitan area experiencing trauma center proliferation, we performed a 5.5-year review of patient transfers to an established level 1 (index center) from other state designated level 1 centers. American College of Surgeons verification level was identified for each facility. Comparisons were performed between the cohort of transferred patients and patients with similar demographics, injury patterns, and severity managed at the index center using propensity score matching. RESULTS: A total of 104 patients were received from other state level 1 centers (39% American College of Surgeons level 2, 61% American College of Surgeons level 1). Nearly 70% of patients were transferred for definitive evaluation and/or management of brain, spine, or cerebrovascular injury. For 76% of this subgroup, specialty consultation was available, but the injury was deemed beyond their capability. Comparison of the transfer cohort propensity score matched to the control cohort (93 vs. 558 patients) demonstrated increased length of stay (6.5 days vs. 4.6 days, p = 0.001) and cost (US $36,027 vs. US $30,654, p = 0.033) associated with the transfer cohort, with similar mortality (12.1% vs. 9.7%, p = 0.492). CONCLUSION: The number of level 1 to level 1 transfers observed imply a disparity in resources and capability among level 1 trauma centers in the region. The majority of transfers were for neurosurgical care, suggestive of a deficit of adequate neurosurgical coverage in the setting of trauma center proliferation. Both patients and established trauma centers bear the burden for these transfers with respect to increased cost and length of stay. LEVEL OF EVIDENCE: Care management, level IV.

Peer support for discharge from inpatient to community mental health services: Study protocol clinical trial (SPIRIT Compliant).

INTRODUCTION: In the period shortly after discharge from inpatient to community mental health care, people are at increased risk of self-harm, suicide, and readmission to hospital. Discharge interventions including peer support have shown potential, and there is some evidence that community-based peer support reduces readmissions. However, systematic reviews of peer support in mental health services indicate poor trial quality and a lack of reporting of how peer support is distinctive from other mental health support. This study is designed to establish the clinical and cost effectiveness of a peer worker intervention to support discharge from inpatient to community mental health care, and to address issues of trial quality and clarity of reporting of peer support interventions. METHODS: This protocol describes an individually randomized controlled superiority trial, hypothesizing that people offered a peer worker discharge intervention in addition to usual follow-up care in the community are less likely to be readmitted in the 12 months post discharge than people receiving usual care alone. A total of 590 people will be recruited shortly before discharge from hospital and randomly allocated to care as usual plus the peer worker intervention or care as usual alone. Manualized peer support provided by trained peer workers begins in hospital and continues for 4 months in the community post discharge. Secondary psychosocial outcomes are assessed at 4 months post discharge, and service use and cost outcomes at 12 months post discharge, alongside a mixed methods process evaluation. DISCUSSION: Clearly specified procedures for sequencing participant allocation and for blinding assessors to allocation, plus full reporting of outcomes, should reduce risk of bias in trial findings and contribute to improved quality in the peer support evidence base. The involvement of members of the study team with direct experience of peer support, mental distress, and using mental health services, in coproducing the intervention and designing the trial, ensures that we theorize and clearly describe the peer worker intervention, and evaluate how peer support is related to any change in outcome. This is an important methodological contribution to the evidence base. TRIAL REGISTRATION: This study was prospectively registered as ISRCTN 10043328 on November 28, 2016.

My Bridge (Mi Puente), a care transitions intervention for Hispanics/Latinos with multimorbidity and behavioral health concerns: protocol for a randomized controlled trial.

BACKGROUND: Multimorbidity affects four of ten US adults and eight of ten adults ages 65 years and older, and frequently includes both cardiometabolic conditions and behavioral health concerns. Hispanics/Latinos (hereafter, Latinos) and other ethnic minorities are more vulnerable to these conditions, and face structural, social, and cultural barriers to obtaining quality physical and behavioral healthcare. We report the protocol for a randomized controlled trial that will compare Mi Puente (My Bridge), a cost-efficient care transitions intervention conducted by a specially trained Behavioral Health Nurse and Volunteer Community Mentor team, to usual care or best-practice discharge approaches, in reducing hospital utilization and improving patient reported outcomes in Latino adults with multiple cardiometabolic conditions and behavioral health concerns. The study will examine the degree to which Mi Puente produces superior reductions in hospital utilization at 30 and 180 days (primary aim) and better patient-reported outcomes (quality of life/physical health; barriers to healthcare; engagement with outpatient care; patient activation; resources for chronic disease management), and will examine the cost effectiveness of the Mi Puente intervention relative to usual care. METHODS: Participants are enrolled as inpatients at a South San Diego safety net hospital, using information from electronic medical records and in-person screenings. After providing written informed consent and completing self-report assessments, participants randomized to usual care receive best-practice discharge processes, which include educational materials, assistance with outpatient appointments, referrals to community-based providers, and other assistance (e.g., with billing, insurance) as required. Those randomized to Mi Puente receive usual-care materials and processes, along with inpatient visits and up to 4 weeks of follow-up phone calls from the intervention team to address their integrated physical-behavioral health needs and support the transition to outpatient care. DISCUSSION: The Mi Puente Behavioral Health Nurse and Volunteer Community Mentor team intervention is proposed as a cost-effective and culturally appropriate care transitions intervention for Latinos with multimorbidity and behavioral health concerns. If shown to be effective, close linkages with outpatient healthcare and community organizations will help maximize uptake, dissemination, and scaling of the Mi Puente intervention. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02723019. Registered on 30 March 2016.