Interventions to Reduce Hospital Length of Stay in High-risk Populations: A Systematic Review.

Importance: Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction. Objective: To identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS. Evidence Review: Multiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide. Findings: Our searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days). Conclusions and Relevance: This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.

Leveraging insights from behavioral economics to improve mobility for adults with stroke: Design and rationale of the BE Mobile clinical trial.

Physical inactivity post-stroke can negatively impact long-term health outcomes and contribute to cardiovascular deconditioning, muscle loss, and increased risk for recurrent stroke. The limited number of interventions designed to improve daily physical activity post-stroke have lacked precision in step goals, are resource intensive, and difficult to scale. The purpose of the Leveraging Insights from Behavioral Economics to Improve Mobility for Adults with Stroke (BE Mobile) trial is to examine the preliminary effectiveness of a novel gamification with social incentives intervention for improving physical activity post-stroke. This trial includes adults who have experienced an ischemic or hemorrhagic stroke ≥3 months prior to the time of recruitment who are randomized to a control or gamification arm. All participants receive a Fitbit Inspire 2 wearable device to quantify daily steps and complete a 2-week baseline run-in period followed by an 8-week intervention period. All participants select a daily step goal and the gamification arm is enrolled in a game with loss-framed points and levels to help participants achieve their daily step goal. Participants in the gamification arm also select a support partner who receives weekly updates on their progress in the game. The primary outcome is change in daily steps from baseline during the intervention period. The secondary outcome is difference in the proportion of days participants achieved their daily step goal. Results from this trial will inform future, larger studies that leverage insights from behavioral economics to help improve daily physical activity post-stroke. Trial registration: NCT #04607811.

Influence of bedspacing on outcomes of hospitalised medicine service patients: a retrospective cohort study.

BACKGROUND: Specialty wards cohort hospitalised patients to improve outcomes and lower costs. When demand exceeds capacity, patients overflow and are "bedspaced" to alternate wards. Some studies have demonstrated that bedspacing among medicine service patients is associated with adverse patient-centred outcomes, however, results have been inconsistent and have primarily been performed within national health systems. The objective of this study was to assess the association of bedspacing with patient-centred outcomes among United States patients admitted to general medicine services. METHODS: We performed a retrospective cohort study of internal medicine, family medicine and geriatric service patients who were bedspaced vs cohorted for the entirety of their hospital stay within three large, urban United States hospitals (quaternary referral centre, tertiary referral centre and community hospital, with different patient demographics and case-mixes) in 2014 and 2015. We performed quantile regression to determine differences in length of stay (LOS) between bedspaced vs cohorted patients and logistic regression for in-hospital mortality and discharge to home. RESULTS: Among 18 802 patients in 33 wards, 6119 (33%) patients were bedspaced. Bedspaced patients had significantly longer LOS compared with cohorted patients at the 25th (0.1 days, 95% CI: 0.05 to 0.2, p=0.001), 50th (0.2 days, 95% CI: 0.1 to 0.3, p=0.003) and 75th (0.3 days, 95% CI: 0.2 to 0.5, p<0.001) percentiles; and no statistically significant differences in odds of mortality (OR=0.9, 95% CI: 0.6 to 1.3, p=0.5) or discharge to home (OR=0.9, 95% CI: 0.9 to 1.0, p=0.06) in adjusted analyses. CONCLUSION: Bedspacing is associated with adverse patient-centred outcomes. Future work is needed to confirm these findings, understand mechanisms contributing to adverse outcomes and identify factors that mitigate these adverse effects in order to provide high-value, patient-centred care to hospitalised patients.

"I Feel Trapped": The Tension Between Personal and Structural Factors of Social Isolation and the Desire for Social Integration Among Older Residents of a High-Crime Neighborhood.

BACKGROUND AND OBJECTIVES: The aim of this study was to examine the factors contributing to the social isolation of older residents of a high-crime neighborhood through the in-depth examination of their lived experiences. A deeper understanding of factors contributing to social isolation can allow policymakers and health care providers to create policies and programs to alleviate the social isolation of these vulnerable and understudied individuals. RESEARCH DESIGN AND METHODS: Participants were recruited through the support of the Housing Authority and Police and Fire Departments of Richmond, California, a town with a high-crime rate. Fifty-nine ethnographic interviews were conducted with 20 individuals of 58-95 years of age. Transcripts and fieldnotes were analyzed with a focus on the specific factors contributing the social isolation of participants. RESULTS: An overarching theme of tension between personal and structural factors of social isolation and desire for social integration emerged from qualitative content analysis. A tension emerged between a longing to participate in society and the immersion in a reality so dense with obstacles that made participation in society difficult to attain. Four specific themes also emerged. Three themes demonstrated underlying factors of social isolation stemming from the personal sphere and the physical and social environment. The fourth theme illustrated participants' desire for social integration. DISCUSSION AND IMPLICATIONS: Findings demonstrate the salience of interventions and programs to make neighborhoods safe and accessible to older residents. Findings also suggest a need to reframe the conceptual framework for social isolation to better measure and alleviate this public health problem.

Functional Impairment: An Unmeasured Marker of Medicare Costs for Postacute Care of Older Adults.

OBJECTIVES: To assess the effects of preadmission functional impairment on Medicare costs of postacute care up to 365 days after hospital discharge. DESIGN: Longitudinal cohort study. SETTING: Health and Retirement Study (HRS). PARTICIPANTS: Nationally representative sample of 16,673 Medicare hospitalizations of 8,559 community-dwelling older adults from 2000 to 2012. MEASUREMENTS: The main outcome was total Medicare costs in the year after hospital discharge, assessed according to Medicare claims data. The main predictor was functional impairment (level of difficulty or dependence in activities of daily living (ADLs)), determined from HRS interview preceding hospitalization. Multivariable linear regression was performed, adjusted for age, race, sex, income, net worth, and comorbidities, with clustering at the individual level to characterize the association between functional impairment and costs of postacute care. RESULTS: Unadjusted mean Medicare costs for 1 year after discharge increased with severity of impairment in a dose-response fashion (P < .001 for trend); 68% had no functional impairment ($25,931), 17% had difficulty with one ADL ($32,501), 7% had dependency in one ADL ($39,928), and 8% had dependency in two or more ADLs ($45,895). The most severely impaired participants cost 77% more than those with no impairment; adjusted analyses showed attenuated effect size (33% more) but no change in trend. Considering costs attributable to comorbidities, only three conditions were more expensive than severe functional impairment (lymphoma, metastatic cancer, paralysis). CONCLUSION: Functional impairment is associated with greater Medicare costs for postacute care and may be an unmeasured but important marker of long-term costs that cuts across conditions.

Solving the puzzle of posthospital recovery: What is the role of the individual physician?

Improving transitions of care from the acute care setting has been an important focus of health policy in the United States and Canada. Over the past decade, hospital performance metrics related to successful recovery have been used in the United States to implement incentives for reform. This focus has led to a laudable number of interventions to reduce readmissions--a proxy for failed recovery--but most of these have focused on the hospital or system level rather than the individual physician level. Individual physicians in both the inpatient and outpatient setting have important roles to play, but little guidance or structured support is available to them to enable successful engagement in postdischarge management of patient transitions. We describe several tensions of physician engagement in this process from the perspective of front-line providers and highlight several possible approaches to improve physician engagement in transitions.

Hospitalization-Associated Disability in Adults Admitted to a Safety-Net Hospital.

BACKGROUND: Little is known about hospitalization-associated disability (HAD) in older adults who receive care in safety-net hospitals. OBJECTIVES: To describe HAD and to examine its association with age in adults aged 55 and older hospitalized in a safety-net hospital. DESIGN: Secondary post hoc analysis of a prospective cohort from a discharge intervention trial, the Support from Hospital to Home for Elders. SETTING: Medicine, cardiology, and neurology inpatient services of San Francisco General Hospital, a safety-net hospital. PARTICIPANTS: A total of 583 participants 55 and older who spoke English, Spanish, or Chinese. We determined the incidence of HAD 30 days post-hospitalization and ORs for HAD by age group. MEASUREMENTS: The outcome measure was death or HAD at 30 days after hospital discharge. HAD is defined as a new or additional disability in one or more activities of daily living (ADL) that is present at hospital discharge compared to baseline. Participants' functional status at baseline (2 weeks prior to admission) and 30 days post-discharge was ascertained by self-report of ADL function. RESULTS: Many participants (75.3 %) were functionally independent at baseline. By age group, HAD occurred as follows: 27.4 % in ages 55-59, 22.2 % in ages 60-64, 17.4 % in ages 65-69, 30.3 % in ages 70-79, and 61.7 % in ages 80 or older. Compared to the youngest group, only the adjusted OR for HAD in adults over 80 was significant, at 2.45 (95 % CI 1.17, 5.15). CONCLUSIONS: In adults at a safety-net hospital, HAD occurred in similar proportions among adults aged 55-59 and those aged 70-79, and was highest in the oldest adults, aged ≥ 80. In safety-net hospitals, interventions to reduce HAD among patients 70 years and older should consider expanding age criteria to adults as young as 55.

Functional impairment and hospital readmission in Medicare seniors.

IMPORTANCE: Medicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment. OBJECTIVE: To assess the effects of functional impairment on Medicare hospital readmissions given the high prevalence of functional impairments in community-dwelling seniors. DESIGN, SETTING, AND PARTICIPANTS: We created a nationally representative cohort of 7854 community-dwelling seniors in the Health and Retirement Study, with 22,289 Medicare hospitalizations from January 1, 2000, through December 31, 2010. MAIN OUTCOMES AND MEASURES: Outcome was 30-day readmission assessed by Medicare claims. The main predictor was functional impairment determined from the Health and Retirement Study interview preceding hospitalization, stratified into the following 5 levels: no functional impairments, difficulty with 1 or more instrumental activities of daily living, difficulty with 1 or more activities of daily living (ADL), dependency (need for help) in 1 to 2 ADLs, and dependency in 3 or more ADLs. Adjustment variables included age, race/ethnicity, sex, annual income, net worth, comorbid conditions (Elixhauser score from Medicare claims), and prior admission. We performed multivariable logistic regression to adjust for clustering at the patient level to characterize the association of functional impairments and readmission. RESULTS: Patients had a mean (SD) age of 78.5 (7.7) years (range, 65-105 years); 58.4% were female, 84.9% were white, 89.6% reported 3 or more comorbidities, and 86.0% had 1 or more hospitalizations in the previous year. Overall, 48.3% had some level of functional impairment before admission, and 15.5% of hospitalizations were followed by readmission within 30 days. We found a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty with 1 or more instrumental activities of daily living (odds ratio [OR], 1.06; 95% CI, 0.94-1.20), 14.4% with difficulty with 1 or more ADL (OR, 1.08; 95% CI, 0.96-1.21), 16.5% with dependency in 1 to 2 ADLs (OR, 1.26; 95% CI, 1.11-1.44), and 18.2% with dependency in 3 or more ADLs (OR, 1.42; 95% CI, 1.20-1.69). Subanalysis restricted to patients admitted with conditions targeted by Medicare (ie, heart failure, myocardial infarction, and pneumonia) revealed a parallel trend with larger effects for the most impaired (16.9% readmission rate for no impairment vs 25.7% for dependency in 3 or more ADLs [OR, 1.70; 95% CI, 1.04-2.78]). CONCLUSIONS AND RELEVANCE: Functional impairment is associated with increased risk of 30-day all-cause hospital readmission in Medicare seniors, especially those admitted for heart failure, myocardial infarction, or pneumonia. Functional impairment may be an important but underaddressed factor in preventing readmissions for Medicare seniors.

Building community capacity: sustaining the effects of multiple, two-year community-based participatory research projects.

BACKGROUND: The time-limited nature of health and public health research fellowships poses a challenge to trainees' and community partners' efforts to sustain effective, collaborative, community-based participatory research (CBPR) relationships. OBJECTIVES: This paper presents CBPR case studies of partnerships between health services research trainees and community organization leaders in a medium-sized city to describe how participation in the partnership altered community partners' understanding and willingness to conduct research and to engage with research-derived data. METHODS: Trainees and faculty used participatory methods with community leaders to identify research questions, and conduct and disseminate research. Throughout the process, trainees and faculty included research capacity building of community partners as a targeted outcome. Community partners were asked to reflect retrospectively on community research capacity building in the context of CBPR projects. Reflections were discussed and categorized by the authorship team, who grouped observations into topics that may serve as a foundation for development of future prospective analyses. RESULTS: Important ideas shared include that trainee participation in CBPR may have an enduring impact on the community by increasing the capacity of community partners and agencies to engage in research beyond that which they are conducting with the current trainee. CONCLUSION: We posit that CBPR with research trainees may have an additive effect on community research capacity when it is conducted in collaboration with community leaders and focuses on a single region. More research is needed to characterize this potential outcome.

Understanding how to improve collaboration between hospitals and primary care in postdischarge care transitions: a qualitative study of primary care leaders' perspectives.

BACKGROUND: There is limited collaboration between hospitals and primary care despite parallel efforts to improve postdischarge care transitions. OBJECTIVE: To understand what primary care leaders perceived as barriers and facilitators to collaboration with hospitals. METHODS: Qualitative study with in-depth, semistructured interviews of 22 primary care leaders in 2012 from California safety-net clinics. RESULTS: Major barriers to collaboration included lack of institutional financial incentives for collaboration, competing priorities (e.g., regulatory requirements, strained clinic capacity, financial strain) and mismatched expectations about role and capacity of primary care to improve care transitions. Facilitators included relationship building through interpersonal networking and improving communication and information transfer via electronic health record (EHR) implementation. CONCLUSIONS: Efforts to improve care transitions should focus on aligning financial incentives, standardizing regulations around EHR interoperability and data sharing, and enhancing opportunities for interpersonal networking.

Improving the quality of discharge care for the homeless: a patient-centered approach.

Homeless patients are at risk for low-quality discharge care, yet there are limited patient-centered data to guide improvement. We explored relationships between assessment of housing status by hospital staff and quality of discharge care using quantitative and qualitative data from interviews and chart reviews with 98 homeless patients: 80% male, mean homelessness 2.8 years, mean age 44. Patient-reported performance of discharge care varied substantially across seven domains from 16-75% and chart review documented lower performance than patient report. Over half (56%) were not asked about their housing status and multivariable logistic regression showed assessment of housing status was independently associated with higher performance in five domains: discussions about cost of medications, physical activity levels, diet, transportation, and mental health follow-up. Qualitative data revealed patient concerns about stigmatization from disclosure of housing status. Our findings suggest that addressing housing status in acute care settings while avoiding stigmatization may improve discharge care for homeless patients.

Global health experiences of U.S. Physicians: a mixed methods survey of clinician-researchers and health policy leaders.

BACKGROUND: Interest and participation in global health activities among U.S. medical trainees has increased sharply in recent decades, yet the global health activities of physicians who have completed residency training remain understudied. Our objectives were to assess associations between individual characteristics and patterns of post-residency global health activities across the domains of health policy, education, and research. METHODS: Cross-sectional, mixed methods national survey of 521 physicians with formal training in clinical and health services research and policy leadership. Main measures were post-residency global health activity and characteristics of this activity (location, funding, products, and perceived synergy with domestic activities). RESULTS: Most respondents (73%) hold faculty appointments across 84 U.S. medical schools and a strong plurality (46%) are trained in internal medicine. Nearly half of all respondents (44%) reported some global health activity after residency; however, the majority of this group (73%) reported spending ≤10% of professional time on global health in the past year. Among those active in global health, the majority (78%) reported receiving some funding for their global health activities, and most (83%) reported at least one scholarly, educational, or other product resulting from this work. Many respondents perceived synergies between domestic and global health activities, with 85% agreeing with the statement that their global health activities had enhanced the quality of their domestic work and increased their level of involvement with vulnerable populations, health policy advocacy, or research on the social determinants of health. Despite these perceived synergies, qualitative data from in-depth interviews revealed personal and institutional barriers to sustained global health involvement, including work-family balance and a lack of specific avenues for career development in global health. CONCLUSIONS: Post-residency global health activity is common in this diverse, multi-specialty group of physicians. Although those with global health experience describe synergies with their domestic work, the lack of established career development pathways may limit the benefits of this synergy for individuals and their institutions.

Medical education in sub-Saharan Africa: a literature review.

OBJECTIVES: This review synthesises research published in the traditional and 'grey' literature to promote a broader understanding of the history and current status of medical education in sub-Saharan Africa (SSA). METHODS: We performed an extensive review and analysis of existing literature on medical education in SSA. Relevant literature was identified through searches of five traditional medical databases and three non-traditional or grey literature databases featuring many African journals not indexed by the traditional databases. We focused our inquiry upon three themes of importance to educators and policymakers: innovation; capacity building, and workforce retention. RESULTS: Despite the tremendous heterogeneity of languages and institutions in the region, the available literature is published predominantly in English in journals based in South Africa, the UK and the USA. In addition, first authors usually come from those countries. Several topics are thoroughly described in this literature: (i) human resources planning priorities; (ii) curricular innovations such as problem-based and community-based learning, and (iii) the 'brain drain' and internal drain. Other important topics are largely neglected, including: (i) solution implementation; (ii) programme outcomes, and (iii) the development of medical education as a specialised field of inquiry. CONCLUSIONS: Medical education in SSA has undergone dramatic changes over the last 50 years, which are recorded within both the traditionally indexed literature and the non-traditional, grey literature. Greater diversity in perspectives and experiences in medical education, as well as focused inquiry into neglected topics, is needed to advance medical education in the region. Lessons learned from this review may be relevant to other regions afflicted by doctor shortages and inequities in health care resulting from inadequate capacity in medical education; the findings from this study might be used to inform specific efforts to address these issues.

A history of medical student debt: observations and implications for the future of medical education.

Over the last 50 years, medical student debt has become a problem of national importance, and obtaining medical education in the United States has become a loan-dependent, individual investment. Although this phenomenon must be understood in the general context of U.S. higher education as well as economic and social trends in late-20th-century America, the historical problem of medical student debt requires specific attention for several reasons. First, current mechanisms for students' educational financing may not withstand debt levels above a certain ceiling which is rapidly approaching. Second, there are no standards for costs of medical school attendance, and these can vary dramatically between different schools even within a single city. Third, there is no consensus on the true cost of educating a medical student, which limits accountability to students and society for these costs. Fourth, policy efforts to improve physician workforce diversity and mitigate shortages in the primary care workforce are inhibited by rising levels of medical student indebtedness. Fortunately, the current effort to expand the U.S. physician workforce presents a unique opportunity to confront the unsustainable growth of medical student debt and explore new approaches to the financing of medical students' education.

Medical schools in sub-Saharan Africa.

Small numbers of graduates from few medical schools, and emigration of graduates to other countries, contribute to low physician presence in sub-Saharan Africa. The Sub-Saharan African Medical School Study examined the challenges, innovations, and emerging trends in medical education in the region. We identified 168 medical schools; of the 146 surveyed, 105 (72%) responded. Findings from the study showed that countries are prioritising medical education scale-up as part of health-system strengthening, and we identified many innovations in premedical preparation, team-based education, and creative use of scarce research support. The study also drew attention to ubiquitous faculty shortages in basic and clinical sciences, weak physical infrastructure, and little use of external accreditation. Patterns recorded include the growth of private medical schools, community-based education, and international partnerships, and the benefit of research for faculty development. Ten recommendations provide guidance for efforts to strengthen medical education in sub-Saharan Africa.

Online posting of unprofessional content by medical students.

CONTEXT: Web 2.0 applications, such as social networking sites, are creating new challenges for medical professionalism. The scope of this problem in undergraduate medical education is not well-defined. OBJECTIVE: To assess the experience of US medical schools with online posting of unprofessional content by students and existing medical school policies to address online posting. DESIGN, SETTING, AND PARTICIPANTS: An anonymous electronic survey was sent to deans of student affairs, their representatives, or counterparts from each institution in the Association of American Medical Colleges. Data were collected in March and April 2009. MAIN OUTCOME MEASURES: Percentage of schools reporting incidents of students posting unprofessional content online, type of professionalism infraction, disciplinary actions taken, existence of institution policies, and plans for policy development. RESULTS: Sixty percent of US medical schools responded (78/130). Of these schools, 60% (47/78) reported incidents of students posting unprofessional online content. Violations of patient confidentiality were reported by 13% (6/46). Student use of profanity (52%; 22/42), frankly discriminatory language (48%; 19/40), depiction of intoxication (39%; 17/44), and sexually suggestive material (38%; 16/42) were commonly reported. Of 45 schools that reported an incident and responded to the question about disciplinary actions, 30 gave informal warning (67%) and 3 reported student dismissal (7%). Policies that cover student-posted online content were reported by 38% (28/73) of deans. Of schools without such policies, 11% (5/46) were actively developing new policies to cover online content. Deans reporting incidents were significantly more likely to report having such a policy (51% vs 18%; P = .006), believing these issues could be effectively addressed (91% vs 63%; P = .003), and having higher levels of concern (P = .02). CONCLUSION: Many responding schools had incidents of unprofessional student online postings, but they may not have adequate policy in place.