An Observational Study of Disparities in Telemedicine Utilization in Primary Care Patients Before and During the COVID-19 Pandemic.

Background: The rapid scale up of telemedicine due to the COVID-19 pandemic may have disadvantaged patients less able to use technology. Objectives: We tested the hypothesis that certain patient groups may have been disadvantaged in accessing primary care using telemedicine. Design: We compared visit type and patient characteristics for April-May 2019 with April-May 2020 at a large urban academic medical center. Variables of interest included age, gender, race, ethnicity, language, visit type, visit status, insurance type, and zip code to approximate average income. Results: There was a 5% increase in patient visits in the observation period from 2019 to 2020. Care shifted from 100% in person to 83% telemedicine, 60% of which occurred through video and 23% by telephone. In 2020, there was a significant increase in the percentage of older patients, patients of lower income, patients whose preferred language was not English, and patients without commercial insurance who accessed care. For patients who completed a telemedicine visit, racial minority status, Hispanic/Latino ethnicity, older age, and non-English language preference significantly increased the likelihood of a telephone visit compared with younger adult, white, non-Hispanic/Latino and English-preference patients. Conclusions: The increase in visits in 2020 and particularly visits by older, non-English preference and lower income patients, demonstrates that the telemedicine scale-up increased access and reached patients regardless of age, language, and income. However, varied usage of televideo and telephone visits for certain groups suggests the need to explore the differences between these modalities to ensure quality telemedicine care for all patients.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS: Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Reasons for readmission after hospital discharge in patients with chronic diseases-Information from an international dataset.

BACKGROUND: Chronic diseases are increasingly prevalent in Western countries. Once hospitalised, the chance for another hospitalisation increases sharply with large impact on well-being of patients and costs. The pattern of readmissions is very complex, but poorly understood for multiple chronic diseases. METHODS: This cohort study of administrative discharge data between 2009-2014 from 21 tertiary hospitals (eight USA, five UK, four Australia, four continental Europe) investigated rates and reasons of readmissions to the same hospital within 30 days after unplanned admission with one of the following chronic conditions; heart failure; atrial fibrillation; myocardial infarction; hypertension; stroke; chronic obstructive pulmonary disease (COPD); bacterial pneumonia; diabetes mellitus; chronic renal disease; anaemia; arthritis and other cardiovascular disease. Proportions of readmissions with similar versus different diseases were analysed. RESULTS: Of 4,901,584 admissions, 866,502 (17.7%) were due to the 12 chronic conditions. In-hospital, 43,573 (5.0%) patients died, leaving 822,929 for readmission analysis. Of those, 87,452 (10.6%) had an emergency 30-day readmission, rates ranged from 2.8% for arthritis to 18.4% for COPD. One third were readmitted with the same condition, ranging from 53% for anaemia to 11% for arthritis. Reasons for readmission were due to another chronic condition in 10% to 35% of the cases, leaving 30% to 70% due to reasons other than the original 12 conditions (most commonly, treatment related complications and infections). The chance of being readmitted with the same cause was lower in the USA, for female patients, with increasing age, more co-morbidities, during study period and with longer initial length of stay. CONCLUSION: Readmission in chronic conditions is very common and often caused by diseases other than the index hospitalisation. Interventions to reduce readmissions should therefore focus not only on the primary condition but on a holistic consideration of all the patient's comorbidities.

From harm to hope and purposeful action: what could we do after Francis?

Responses to the reports on the inquiry into Mid Staffordshire have resulted in calls from politicians, NHS leaders and the public to improve care across the NHS in England. However, the substance of what needs to be done remains unclear. In this paper, we offer seven key 'ingredients' required to sustain improvement of care, supported by evidence drawn from published literature. We believe that empowering and upskilling the front-line workforce in understanding and implementing improvement techniques, supported by changes at system and policy level and reinforced by what leaders say and do, will result in sustainable benefit for patients and families, as well as greater satisfaction for staff.

Health care-associated infection reporting: the need for ongoing reliability and validity assessment.

Government-mandated reporting of health care-associated infections (HAIs) and new reimbursement regulations place a premium on accurate and reliable detection of HAIs. This commentary addresses the challenges and opportunities of having consistent, well-defined, and continuous methods in place to ensure the reliability and validity of HAI detection and reporting. In addition, such procedures could support the development and expertise of infection preventionists. A Web-based clinical vignette model is suggested for improving HAI reporting for hospitals participating in the Centers for Disease Control and Prevention's National Healthcare Safety Network.