Interpretation of immediately released health information: Informing patient medical education in breast oncology.

BACKGROUND: The Cures Act mandated immediately released health information. In this study, we investigated patient comprehension of mammography reports and the utility of online resources to aid report interpretation. METHODS: Patients who received a normal mammogram from February to April 2022 were invited to complete semi-structured interviews paired with health literacy questionnaires to assess patient's report comprehension before and after internet search. RESULTS: Thirteen selected patients via purposeful sampling completed interviews. Most patients described their initial understanding of the mammography report as "good" and improved to between "good" and "very good" after an internet search. Patients suggested "a little column on the side" for medical terminology, "an extra prompt" for making an appointment, or a recommendation for "good sites" to improve mammography reports. CONCLUSION: Patients varied in their ability to independently interpret medical reports and seek additional resources. While online resources marginally improved patient understanding, actionable and clear resources are needed.

Longitudinal Trends in Patient-Reported Outcomes in the First Year After Lumpectomy Versus Mastectomy.

BACKGROUND: It is unclear how patient-reported outcomes (PROs) change longitudinally after breast cancer surgery. We sought to compare trends in PROs among patients who underwent lumpectomy versus mastectomy over the first year after surgery. PATIENTS AND METHODS: Newly diagnosed stage 0-III female patients with breast cancer who underwent lumpectomy or mastectomy at an academic breast center between June 2019 and March 2023 were invited to participate in a longitudinal PRO study. Enrolled patients received the BREAST-Q™ module, a validated tool measuring domains, such as satisfaction with breasts, psychosocial well-being, physical well-being, and sexual well-being. Scores for each domain were compared between the lumpectomy and mastectomy groups over the first year after surgery. Linear mixed models were used to estimate the change in PRO scores over time. RESULTS: The cohort included 203 who underwent lumpectomy and 144 who underwent mastectomy. Patients who underwent lumpectomy were older, more likely to receive adjuvant radiation and endocrine therapy, and less likely to receive adjuvant chemotherapy. Patients who underwent lumpectomy demonstrated greater increases in scores over time for satisfaction with breasts, psychosocial well-being, and sexual well-being compared with patients who underwent mastectomy, after adjusting for the abovementioned covariates and receipt of reconstruction. The lumpectomy group had a larger decline in physical well-being over time compared with the mastectomy group. CONCLUSIONS: Patients who underwent lumpectomy demonstrated greater satisfaction with their breasts, psychosocial well-being, and sexual well-being but worse physical well-being over the first year after surgery compared with patients who underwent mastectomy. These results may help inform early-stage breast cancer patients making decisions about their surgical care.

Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Health Care System.

OBJECTIVE: We sought to evaluate how implementing a thoracic enhanced recovery after surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection. BACKGROUND: The effect of implementing the ERAS Society/European Society of Thoracic Surgery thoracic ERAS protocol on postoperative outcomes throughout an entire health care system has not yet been reported. METHODS: This was a prospective cohort study within one health care system (January 2019-March, 2023). A thoracic ERAS protocol was implemented on May 1, 2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay, opioid use, chest tube duration, and total cost. Patients were grouped into pre-ERAS and post-ERAS cohorts. Bivariable comparisons were performed using independent t -test, χ 2 , or Fisher exact tests, and multivariable logistic regression was performed to control for confounders. RESULTS: There were 1007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a body mass index between 18.5 and 29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the postimplementation group had lower risk-adjusted rates of any morbidity, respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative length of stay (all P <0.05). CONCLUSIONS: Postoperative outcomes were improved after the implementation of an evidence-based thoracic ERAS protocol throughout the health care system. This study validates the ERAS Society/European Society of Thoracic Surgery guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.

Barriers and facilitators to measuring patient reported outcomes in an academic breast cancer clinic: An application of the RE-AIM framework.

BACKGROUND: Patient reported outcome measures (PROMs) are important for patient-centered, value-based care; however, implementation into surgical practice remains limited. We aimed to demonstrate feasibility of measuring PROMs in an academic breast cancer clinic. METHODS: We conducted a pilot study implementing the patient-reported outcome measure BREAST-Q among patients with Stage 0-III breast cancer at a single institution from 06/2019-03/2023 using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Barriers and facilitators were characterized. Survey completion was assessed pre-operatively and up to 12 months post-operatively. RESULTS: Barriers included limited time and lack of incorporation into the electronic medical record. Facilitators included utilizing trained team members and an automated workflow. Among eligible patients, 74% completed BREAST-Q at 2-weeks post-operatively and 55% at 12 months post-operatively. CONCLUSIONS: We describe the implementation of a PROM using the RE-AIM framework, highlighting facilitators and barriers that may assist others in collecting patient-reported outcome data.

Information transparency with immediate release: Oncology clinician and patient perceptions.

INTRODUCTION: As part of the 21st Century Cures Act (April 2021), electronic health information (EHI) must be immediately released to patients. In this study, we sought to evaluate clinician and patient perceptions regarding this immediate release. METHODS: After surveying 33 clinicians and 30 patients, semi-structured interviews were conducted with a subset of the initial sample, comprising 8 clinicians and 12 patients. Open-ended questions explored clinicians' and patients' perceptions of immediate release of EHI and how they adjusted to this change. RESULTS: Ten themes were identified: Interpreting Results, Strategies for Patient Interaction, Patient Experiences, Communication Strategies, Provider Limitations, Provider Experiences, Health Information Interfaces, Barriers to Patient Understanding, Types of Results, and Changes due to Immediate Release. Interviews demonstrated differences in perceived patient distress and comprehension, emphasizing the impersonal nature of electronic release and necessity for therapeutic clinician-patient communication. CONCLUSIONS: Clinicians and patients have unique insights on the role of immediate release. Understanding these perspectives will help improve communication and develop patient-centered tools (glossaries, summary pages, additional resources) to aid patient understanding of complex medical information.

Novel Electronic Health Records-Based Consultation Workflow Improves Time to Operating Room for Vascular Surgery Patients in an Acute Setting.

BACKGROUND: Inefficient clinical workflows can have downstream effects of increased costs, poor resource utilization, and worse patient outcomes. The surgical consultation process can be complex with unclear communication, potentially delaying care for patients requiring time-sensitive intervention in an acute setting. A novel electronic health records (EHR)-based workflow was implemented to improve the consultation process. After implementation, we assessed the impact of this initiative in patients requiring vascular surgery consultation. METHODS: An EHR-driven consultation workflow was implemented at a single institution, standardizing the process across all consulting services. This order-initiated workflow automated notification to clinicians of consult requests, communication of patient data, patient addition to consultants' lists, and tracking consult completion. Preimplementation (1/1/2020-1/31/2022) and postimplementation (2/1/2022-12/4/2022) vascular surgery consultation cohorts were compared to evaluate the impact of this initiative on timeliness of care. RESULTS: There were 554 inpatient vascular surgery consultations (255 preimplementation and 299 postimplementation); 45 and 76 consults required surgery before and after implementation, respectively. The novel workflow resulted in placement of a consult note 32 min faster than preimplementation (preimplementation: 462 min, postimplementation: 430 min, P = 0.001) for all vascular surgery consults. Furthermore, vascular surgery patients with ASA class III or IV status requiring an urgent or emergent operation were transported to the operating room 63.3% faster after implementation of the workflow (preimplementation: 284 min, postimplementation: 180 min, P = 0.02). There were no differences in procedure duration, postoperative disposition, or intraoperative complication rates. CONCLUSIONS: We implemented a novel workflow utilizing the EHR to standardize and automate the consultation process in the acute inpatient setting. This institutional initiative significantly improved timeliness of care for vascular surgery patients, including decreased time to operation. Innovations such as this can be further disseminated across shared EHR platforms across institutions, representing a powerful tool to increase the value of care in vascular surgery and healthcare overall.

Addressing an epidemic: Improving guideline-concordant opioid prescribing in surgical patients.

BACKGROUND: Excess postoperative opioid prescribing increases the risk of opioid abuse, diversion, and addiction. Clinicians receive variable training for opioid prescribing, and despite the availability of guidelines, wide variations in prescribing practices persist. This quality improvement initiative aimed to assess and improve institutional adherence to published guidelines. METHODS: This study represented a quality improvement initiative at an academic medical center implemented over a 6-month period with data captured 1 year before and after implementation. The quality improvement initiative focused on prescribing education and monthly feedback reports for clinicians. All opioid-naïve, adult patients undergoing a reviewed procedure were included. Demographics, surgical details, hospital course, and opioid prescriptions were reviewed. Opioids prescribed on discharge were evaluated for concordance with recommendations based on published guidelines. Pre- and postimplementation cohorts were compared. RESULTS: There were 4,905 patients included: 2,343 preimplementation and 2,562 postimplementation. There were similar distributions in patient demographics between the 2 cohorts. Guideline-concordant discharge prescriptions improved from 50.3% to 72.2% after the quality improvement initiative was implemented (P < .001). Adjusted analysis controlling for sex, age, discharge clinician, length of stay, outpatient surgery, and procedure demonstrated a 190% increase in odds of receiving a guideline-concordant opioid prescription on discharge in the postimplementation cohort (adjusted odds ratio 2.90; 95% confidence interval = 2.55-3.30). CONCLUSION: This study represented a successful quality improvement initiative improving guideline-concordant opioid discharges and decreasing overprescribing. This study suggested published guidelines are insufficient without close attention to elements of effective change management including the critical importance of locally targeting educational efforts and suggested that real-time, data-driven feedback amplifies impact on prescribing behavior.

Surgeon Perceptions of the Integration of Patient-Reported Outcome Measures into Clinical Practice.

INTRODUCTION: Patient-reported outcome measures (PROMs/PROM) are standardized, validated instruments used to measure the patient's perception of their own health status including their symptoms, functional wellbeing, and mental health. Although PROMs were initially developed as research tools, their use in clinical practice for shared decision-making and to assess the impact of disease and treatment on quality of life of individual patients has been increasing. There is a paucity of research exploring providers' perspectives on the clinical integration of PROMs. We sought to use a qualitative methodology to understand surgeons' perceptions of integrating PROMs into their clinical practices. METHODS: Semistructured interviews were performed from November 2019 until August 2020. All interviews were recorded and transcribed verbatim. Thematic saturation was achieved after interviewing nine surgeons representing eight surgical specialties. Qualitative interview data were thematically analyzed using an inductive approach facilitated by Atlas.ti qualitative software. RESULTS: Forty seven unique codes were identified that fit into 21 themes that revealed five novel insights. Key insights included: (1) PROM data can modify surgical practice on an individual and institutional level, (2) Surgeon's view PROM clinical integration as a potential method of advancing patient-centered care, (3) There are various institutional processes that must be in place, including strong leadership and an integrative platform, to enable successful clinical PROM integration, (4) Surgeons appreciate challenges of integrating PROMs into surgical practice including risks of incorrect use or interpretation, and (5) A PROM platform must be adaptable to the diversity within surgery and to unique physician workflows. CONCLUSIONS: Surgeons perceived value from integrating PROMs into routine care to better inform patients during preoperative discussions and to help identify at-risk patients in the postoperative period. However, they also identified numerous barriers to the implementation of an integrated system for the routine use of PROMs in clinical practice and expressed concern about using PROMs to compare operative outcomes between surgeons. Based on this work, institutions that want to incorporate PROMs into surgical practice need a leadership team capable of supporting the change management necessary for effective integration and use a PROM platform that gives individual surgeons and surgical teams the ability to customize platforms for their unique practices.

Development of a universal thoracic enhanced recover after surgery protocol for implementation across a diverse multi-hospital health system.

Background: Implementation of enhanced recovery after surgery (ERAS) pathways for patients undergoing anatomic lung resection have been reported at individual institutions. We hypothesized that an ERAS pathway can be successfully implemented across a large healthcare system including different types of hospital settings (academic, academic-affiliated, community). Methods: An expert panel with representation from each hospital within a healthcare system was convened to establish a thoracic ERAS pathway for patients undergoing anatomic lung resection and to develop tools and analytics to ensure consistent application. The protocol was translated into an order set and pathway within the electronic health record (EHR). Iterative implementation was performed with recording of the processes involved. Barriers and facilitators to implementation were recorded. Results: Development and implementation of the protocol took 13 months from conception to rollout. Considerable change management was needed for consensus and incorporation into practice. Facilitators of change included peer accountability, incorporating ERAS care elements into the EHR, and conducting case reviews with timely feedback on protocol deviations. Barriers included institutional cultural differences, agreement in defining mindful deviation from the ERAS protocol, lack of access to specific coded data, and resource scarcity caused by the COVID-19 pandemic. Support from the hospital system's executive leadership and institutional commitment to quality improvement helped overcome barriers and maintain momentum. Conclusions: Development and implementation of a health-system wide thoracic ERAS protocol for anatomic lung resections across a six-hospital health system requires a multidisciplinary team approach. Barriers can be overcome though multidisciplinary team engagement and executive leadership support.

Patient comprehension of breast pathology report terminology: The need for patient-centered resources.

BACKGROUND: As health care continues to evolve toward information transparency, an increasing number of patients have access to their medical records, including result reports that were not originally designed to be patient-facing. Previous studies have demonstrated that patients have poor understanding of medical terminology. However, patient comprehension of terminology specific to breast pathology reports has not been well studied. We assessed patient understanding of common medical terms found in breast pathology reports. METHODS: A survey was administered electronically to patients scheduled for a screening mammogram within a multisite health care system. Participants were asked to objectively define and interpret 8 medical terms common to breast biopsy pathology reports. Patient perception of the utility of various educational tools was also assessed. Demographic information including health literacy, education level, previous cancer diagnosis, and primary language was collected. RESULTS: In total, 527 patients completed the survey. Terms including "malignant" and "benign" were the most correctly defined at 80% and 73%, respectively, whereas only 1% correctly defined "high grade." Factors including race/ethnicity and education level were correlated with more correct scores. Patients preferred educational tools that were specific to their diagnosis and available at the time they were reviewing their results. CONCLUSION: Patient comprehension of common medical terminology is poor. Potential assumptions of understanding based on patient factors including education, past medical history, and occupation are misinformed. With the newly mandated immediate release of information to patients, there is a pressing need to develop and integrate educational tools to support patients through all aspects of their care.

Patient and clinician perceptions of the immediate release of electronic health information.

OBJECTIVES: The 21st Century Cures Act requires that institutions release all electronic health information (EHI) to patients immediately. We aimed to understand patient and clinician attitudes toward the immediate release of EHI to patients. METHODS: Patients and clinicians representing distinct specialties at a single academic medical center completed a survey to assess attitudes toward the immediate release of results. Differences between patient and clinician responses were compared using chi-square and student's t-test for categorical and continuous variables, respectively. A two-sided significance level of 0.05 was used for all statistical tests. RESULTS: 69 clinicians and 57 patients completed the survey. Both patients (89.7%) and clinicians (80.6%) agreed or strongly agreed-here after referred to as agreed, that providing patients with access to their health information is necessary in delivering high-quality care. However, 62.7% of clinicians agreed that results released immediately would be more confusing than helpful, whereas the minority of patients agreed with this statement (15.8%) (p < 0.05). Providers were also more likely to disagree that patients are comfortable independently interpreting blood work results (p < 0.05), radiology results (p < 0.05) and pathology reports (p < 0.05). With regard to timing, the majority of patients (75.1%) felt their provider should contact them within 24 h of the release of an abnormal result, whereas only 9.0% of clinicians agreed with this timeframe (p < 0.05). DISCUSSIONS: Patients and clinicians value information transparency. However, the immediate release of results is controversial, especially among clinicians. The discrepancy between patient and clinician perceptions underlines the importance of setting expectations about the communication of results. Additionally, our results emphasize the need to implement strategies to help improve patient comprehension, decrease patient distress and improve clinician workflows.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

INTRODUCTION: Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians' perceptions of the impact of a multi-disciplinary debrief on OR culture. METHODS: A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. RESULTS: Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. CONCLUSIONS: Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

Utilization of lean project management principles and health informatics to reduce operating room delays in a vascular surgery practice.

OBJECTIVES: Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service. METHODS: First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation. RESULTS: 57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders. CONCLUSIONS: Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.

Evaluation of opioid prescribing preferences among surgical residents and faculty.

BACKGROUND: Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. METHODS: Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. RESULTS: Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P = .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. CONCLUSION: There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability.

Resident Opioid Prescribing Habits Do Not Reflect Best Practices in Post-Operative Pain Management: An Assessment of the Knowledge and Education Gap.

OBJECTIVE: To evaluate deficiencies in knowledge and education in opioid prescribing and to compare surgical resident opioid-prescribing practices to Opioid Prescribing Engagement Network (OPEN) procedure-specific guidelines. DESIGN: Anonymous web-based survey distributed to all general surgery residents to evaluate prior education received and confidence in knowledge in opioid prescribing. The number of 5 milligram oxycodone tablets prescribed for common procedures was assessed and compared with OPEN for significance using Wilcoxon signed rank tests. SETTING: General surgery residency program within large university-based tertiary medical center. PARTICIPANTS: Categorical general surgery residents of all postgraduate years. RESULTS: Fifty-six of 72 (78%) categorical residents completed the survey. Few reported receiving formal education in opioid prescribing in medical school (32%) or residency (16%). While 82% of residents felt confident in opioid side effects, fewer felt the same with regards to opioid pharmacokinetics (36%) or proper opioid disposal (29%). Opioids prescribed varied widely with residents prescribing significantly more than recommended by OPEN in 9 of 14 procedures. CONCLUSIONS: Tackling the evolving opioid epidemic requires a multidisciplinary approach that addresses prescribing at all steps of the process, starting with trainee education.

Transforming surgical morbidity and mortality into a systematic case review.

BACKGROUND/PURPOSE: The surgical morbidity and mortality (M&M) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical M&M was migrated to this structured case review format to provide a platform for surgical performance improvement. METHODS: An online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 M&M data was performed using the archived paper system used prior to 2019. RESULTS: For the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content. CONCLUSION: Creation of an online database with interactive dashboard has allowed surgical M&M to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review. TYPE OF STUDY: Retrospective Historical control; Quality improvement. LEVEL OF EVIDENCE: Level III.

Reassessing Opioid Use in Breast Surgery.

BACKGROUND: This study aims to assess multimodal pain management and opioid prescribing practices in patients undergoing breast surgery. METHODS: A retrospective review of patients undergoing breast surgery at an academic medical center between April 1, 2018 and September 30, 2019, was performed. Patients with a history of recent opioid use or conditions precluding use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (APAP) were excluded. Opioid-sparing pain regimens were assessed. Opioids prescribed on discharge were recorded as oral morphine equivalents (OMEs) and concordance with the Opioid Prescribing Engagement Network (OPEN) determined. RESULTS: The total study population consisted of 518 patients. 358 patients underwent minor outpatient procedures (sentinel lymph node biopsy, lumpectomy, and excisional biopsy), 10-40% of whom were appropriately prescribed as per the OPEN. Perioperatively, 53.9% of patients received APAP, 24.6% NSAIDs, 20.4% gabapentin, and 0.3% blocks; intraoperatively, 95.8% received local anesthetic and 25.7% ketorolac. For mastectomy without reconstruction, 63-88% of prescriptions were concordant with the OPEN. For mastectomy with reconstruction, discharge opioids ranged from 25 to 400 OMEs with a mean of 134.4 OMEs; 25% of patients received a refill. Of all patients undergoing mastectomy ± reconstruction, 62.5% received APAP, 18.8% NSAIDs, 38.8% pregabalin, and 20.6% locoregional block perioperatively; 37.5% received local anesthetic and 15.6% ketorolac intraoperatively. Of 143 inpatient stays, 89% received APAP, 38% NSAID, and 29% benzodiazepines; 29 patients received no opioids inpatient but were still prescribed 25-200 OMEs on discharge. CONCLUSIONS: There is need for a multidisciplinary approach to pain management with the use of enhanced recovery after surgery protocols as potential means to standardize perioperative regimens and mitigate opioid overprescription.

Variability in skilled nursing facility screening and admission processes: Implications for value-based purchasing.

BACKGROUND: Hospitalized older adults are increasingly admitted to skilled nursing facilities (SNFs) for posthospital care. However, little is known about how SNFs screen and evaluate potential new admissions. In an era of increasing emphasis on postacute care outcomes, these processes may represent an important target for interventions to improve the value of SNF care. PURPOSE: The aim of this study was to understand (a) how SNF clinicians evaluate hospitalized older adults and make decisions to admit patients to an SNF and (b) the limitations and benefits of current practices in the context of value-based payment reforms. METHODS: We used semistructured interviews to understand the perspective of 18 clinicians at three unique SNFs-including physicians, nurses, therapists, and liaisons. All transcripts were analyzed using a general inductive theme-based approach. RESULTS: We found that the screening and admission processes varied by SNF and that variability was influenced by three key external pressures: (a) inconsistent and inadequate transfer of medical documentation, (b) lack of understanding among hospital staff of SNF processes and capabilities, and (c) hospital payment models that encouraged hospitals to discharge patients rapidly. Responses to these pressures varied across SNFs. For example, screening and evaluation processes to respond to these pressures included gaining access to electronic medical records, providing inpatient physician consultations prior to SNF acceptance, and turning away more complex patients for those perceived to be more straightforward rehabilitation patients. CONCLUSIONS: We found facility behavior was driven by internal and external factors with implications for equitable access to care in the era of value-based purchasing. PRACTICE IMPLICATIONS: SNFs can most effectively respond to these pressures by increasing their agency within hospital-SNF relationships and prioritizing more careful patient screening to match patient needs and facility capabilities.