Longitudinal Monitoring of Clinician-Patient Video Visits During the Peak of the COVID-19 Pandemic: Adoption and Sustained Challenges in an Integrated Health Care Delivery System.

BACKGROUND: Numerous prior opinion papers, administrative electronic health record data studies, and cross-sectional surveys of telehealth during the pandemic have been published, but none have combined assessments of video visit success monitoring with longitudinal assessments of perceived challenges to the rapid adoption of video visits during the pandemic. OBJECTIVE: This study aims to quantify (1) the use of video visits (compared with in-person and telephone visits) over time during the pandemic, (2) video visit successful connection rates, and (3) changes in perceived video visit challenges. METHODS: A web-based survey was developed for the dual purpose of monitoring and improving video visit implementation in our health care system during the COVID-19 pandemic. The survey included questions regarding rates of in-person, telephone, and video visits for clinician-patient encounters; the rate of successful connection for video visits; and perceived challenges to video visits (eg, software, hardware, bandwidth, and technology literacy). The survey was distributed via email to physicians, advanced practice professionals, and clinicians in May 2020. The survey was repeated in March 2021. Differences between the 2020 and 2021 responses were adjusted for within-respondent correlation across surveys and tested using generalized estimating equations. RESULTS: A total of 1126 surveys were completed (511 surveys in 2020 and 615 surveys in 2021). In 2020, only 21.7% (73/336) of clinicians reported no difficulty connecting with patients during video visits and 28.6% (93/325) of clinicians reported no difficulty in 2021. The distribution of the percentage of successfully connected video visits ("Over the past two weeks of scheduled visits, what percentage did you successfully connect with patients by video?") was not significantly different between 2020 and 2021 (P=.74). Challenges in conducting video visits persisted over time. Poor connectivity was the most common challenge reported by clinicians. This response increased over time, with 30.5% (156/511) selecting it as a challenge in 2020 and 37.1% (228/615) in 2021 (P=.01). Patients not having access to their electronic health record portals was also a commonly reported challenge (109/511, 21.3% in 2020 and 137/615, 22.3% in 2021, P=.73). CONCLUSIONS: During the pandemic, our health care delivery system rapidly adopted synchronous patient-clinician communication using video visits. As experience with video visits increased, the reported failure rate did not significantly decline, and clinicians continued to report challenges related to general network connectivity and patient access to technology.

The Academic Learning Health System: A Framework for Integrating the Multiple Missions of Academic Medical Centers.

The learning health system (LHS) has emerged over the past 15 years as a concept for improving health care delivery. Core aspects of the LHS concept include: promoting improved patient care through organizational learning, innovation, and continuous quality improvement; identifying, critically assessing, and translating knowledge and evidence into improved practices; building new knowledge and evidence around how to improve health care and health outcomes; analyzing clinical data to support learning, knowledge generation, and improved patient care; and engaging clinicians, patients, and other stakeholders in processes of learning, knowledge generation, and translation. However, the literature has paid less attention to how these LHS aspects may integrate with the multiple missions of academic medical centers (AMCs). The authors define an academic learning health system (aLHS) as an LHS built around a robust academic community and central academic mission, and they propose 6 features that emphasize how an aLHS differs from an LHS. An aLHS capitalizes on embedded academic expertise in health system sciences; engages the full spectrum of translational investigation from mechanistic basic sciences to population health; builds pipelines of experts in LHS sciences and clinicians with fluency in practicing in an LHS; applies core LHS principles to the development of curricula and clinical rotations for medical students, housestaff, and other learners; disseminates knowledge more broadly to advance the evidence for clinical practice and health systems science methods; and addresses social determinants of health, creating community partnerships to mitigate disparities and improve health equity. As AMCs evolve, the authors expect that additional differentiating features and ways to operationalize the aLHS will be identified and hope this article stimulates further discussion around the intersection of the LHS concept and AMCs.

Characteristics of Adult Primary Care Patients Who Use the Patient Portal: A Cross-Sectional Analysis.

BACKGROUND: The patient portal allows patients to engage with their health care team beyond the clinical encounter. While portals can improve patient outcomes, there may be disparities in which patients access the portal by sociodemographic factors. Understanding the characteristics of patients who use the portal could help design future interventions to expand portal adoption. OBJECTIVES: This study aimed to (1) examine the socioeconomic factors, comorbid conditions, and health care utilization among patients of a large academic primary care network who are users and non-users of the patient portal; and (2) describe the portal functions most frequently utilized. METHODS: We included all adult patients at Atrium Health Wake Forest Baptist who had at least two primary care visits between 2018 and 2019. Patients' demographics, comorbidities, health care utilization, and portal function usage were extracted from the electronic health record and merged with census data (income, education, and unemployment) from the American Community Survey. A myWakeHealth portal user was defined as a patient who used a bidirectional portal function at least once during the study period. We used multivariable logistic regression to determine which patient characteristics were independently associated with being a portal user. RESULTS: Of the 178,720 patients who met inclusion criteria, 32% (N = 57,122) were users of myWakeHealth. Compared to non-users, users were more likely to be 18 to 64 years of age, female, non-Hispanic White, married, commercially insured, have higher disease burden, and have lower health care utilization. Patients residing in areas with the highest educational attainment had 51% higher odds of being a portal user than the lowest (p <0.001). Among portal users, the most commonly used function was messaging clinic providers. CONCLUSION: We found that patient demographics and area socioeconomic factors were associated with patient portal adoption. These findings suggest that efforts to improve portal adoption should be targeted at vulnerable patients.

Feasibility of Mobile Technology to Identify and Address Patients' Unmet Social Needs in a Primary Care Clinic.

Mobile health tools may overcome barriers to social needs screening; however, there are limited data on the feasibility of using these tools in clinical settings. The objective was to determine the feasibility of using a mobile health system to screen for patients' social needs. In one large primary care clinic, the authors tested a tablet-based system that screens patients for social needs, transmits results to the electronic health record, and alerts providers. All adult patients presenting for a nonurgent visit were eligible. The authors evaluated the feasibility of the system and conducted follow-up surveys to determine acceptability and if patients accessed resources through the process. All providers were surveyed. Of the 252 patients approached, 219 (86.9%) completed the screen. Forty-three (19.6%) required assistance with the tablet, and 150 (68.5%) screened positive for at least 1 unmet need (food, housing, or transportation). Of the 150, 103 (68.7%) completed a follow-up survey. The majority agreed that people would learn to use the tablet quickly. Forty-eight patients (46.6%) reported contacting at least 1 community organization through the process. Of the 27 providers, 23 (85.2%) completed a survey and >70% agreed the system would result in patients having better access to resources. It was feasible to use a tablet-based system to screen for social needs. Clinics considering using mobile tools will need to determine how to screen patients who may need assistance with the tool and how to connect patients to resources through the system based on the burden of unmet needs.

Advancing the learning health system by incorporating social determinants.

The learning health system (LHS) has gained traction as a powerful framework for improving the cost and quality of healthcare. The goal of an LHS is to systematically integrate internal data and experience with external evidence so patients receive higher-quality, safer, and more efficient care. However, if the goal of an LHS is to improve health, as well as healthcare, it must account for and mitigate the negative impact of social and economic factors on health, known as the social determinants of health. In this paper, we discuss the critical role the LHS can play in addressing patients' social risk factors. We also discuss how integrating data on the social determinants and activities to reduce patients' social risk factors could advance the mission of the LHS to enhance patient engagement, improve the delivery of personalized care, and more accurately evaluate the effectiveness of care. Without the collection and integration of data on the social determinants of health, the LHS may fail to reach its full potential to improve health and healthcare.

Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans.

OBJECTIVE: Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. METHODS: The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. RESULTS: Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. CONCLUSIONS: VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.

Pragmatic clinical trials embedded in healthcare systems: generalizable lessons from the NIH Collaboratory.

BACKGROUND: The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. METHODS: To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. RESULTS: In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. CONCLUSION: A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.

Elderly veterans with dual eligibility for VA and Medicare services: where do they obtain a colonoscopy?

OBJECTIVES: To examine the receipt of colonoscopy through the Veterans Health Administration (VA) or through Medicare by older veterans who are dually enrolled. STUDY DESIGN: Retrospective cohort study. METHODS: The VA Outpatient Care Files and Medicare Enrollment Files were used to identify 1,060,523 patients 65 years and older in 15 of the 22 Veterans Integrated Service Networks nationally, who had 2 or more VA primary care visits in 2009 and who were simultaneously enrolled in Medicare. VA and Medicare files were used to identify the receipt of an outpatient colonoscopy. Patients were categorized as receiving care in community-based outpatient clinics (CBOCs) (n=601,337; 57%) or VA medical centers (n=459,186; 43%) based on where most patient-centered encounters occurred. Analyses used multinomial logistic regression to identify patient characteristics related to the odds of receiving a colonoscopy at the VA or through Medicare. RESULTS: Patients had a mean age of 76.9 (SD=7.0) years; 98% were male, 89% were white, and 21% resided in a rural location. Overall, 100,060 (9.4%) patients underwent outpatient colonoscopy either through the VA (n=33,600; 35.5%) or Medicare providers (n=65,716; 65.5%). The adjusted odds of receiving a colonoscopy from Medicare providers were higher (P<.001) for patients who were male, white, receiving primary care at CBOCs, and for residents of an urban location. The receipt of colonoscopy through the VA decreased dramatically by age; for example, the odds of colonoscopy by the VA in patients aged >85 years and 80 to 84 years, relative to patients aged 65 to 69 years, were 0.26 and 0.13, respectively. In contrast, the receipt of colonoscopy through Medicare did not decline as markedly with age. CONCLUSIONS: In a national analysis of the receipt of an outpatient colonoscopy by older veterans, more veterans received their colonoscopies through CMS than through the VA. The use of colonoscopy within the VA was found to be more concordant with age-related practice guidelines.

Racial disparities in outcomes after cardiac surgery: the role of hospital quality.

Patients from racial and ethnic minorities experience higher mortality after cardiac surgery compared to white patients, both during the early postoperative phase as well as long term. A number of factors likely explain poor outcomes in black and minority patients, which include differences in biology, comorbid health conditions, socioeconomic background, and quality of hospital care. Recent evidence suggests that a major factor underlying excess mortality in these groups is due to their over-representation in low-quality hospitals, where all patients regardless of race have worse outcomes. In this review, we examine the factors underlying racial disparities in outcomes after cardiac surgery, with a primary focus on the role of hospital quality.

Structuring payment to medical homes after the affordable care act.

The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.

Insurance status and the transfer of hospitalized patients: an observational study.

BACKGROUND: There is little objective evidence to support concerns that patients are transferred between hospitals based on insurance status. OBJECTIVE: To examine the relationship between patients' insurance coverage and interhospital transfer. DESIGN: Data analyzed from the 2010 Nationwide Inpatient Sample. PATIENTS: All patients aged 18 to 64 years discharged alive from U.S. acute care hospitals with 1 of 5 common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, and skin or subcutaneous infection). MEASUREMENTS: For each diagnosis, the proportion of hospitalized patients who were transferred to another acute care hospital based on insurance coverage (private, Medicare, Medicaid, or uninsured) was compared. Logistic regression was used to estimate the odds of transfer for uninsured patients (reference category, privately insured) while patient- and hospital-level factors were adjusted for. All analyses incorporated sampling and poststratification weights. RESULTS: Among 315 748 patients discharged from 1051 hospitals with any of the 5 diagnoses, the percentage of patients transferred to another acute care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses, uninsured patients were significantly less likely to be transferred for 3 diagnoses (P 0.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for 4 diagnoses: biliary tract disease (odds ratio, 0.73 [95% CI, 0.55 to 0.96]), chest pain (odds ratio, 0.63 [CI, 0.44 to 0.89]), septicemia (odds ratio, 0.76 [CI, 0.64 to 0.91]), and skin infections (odds ratio, 0.64 [CI, 0.46 to 0.89]). Women were significantly less likely to be transferred than men for all diagnoses. LIMITATION: This analysis relied on administrative data and lacked clinical detail. CONCLUSION: Uninsured patients (and women) were significantly less likely to undergo interhospital transfer. Differences in transfer rates may contribute to health care disparities. PRIMARY FUNDING SOURCE: National Institutes of Health.

Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data.

OBJECTIVE: To examine whether racial disparities in usage and outcomes of total knee and total hip arthroplasty (TKA and THA) have declined over time. METHODS: We used data from the US Medicare Program (MedPAR data) for years 1991-2008 to identify four separate cohorts of patients (primary TKA, revision TKA, primary THA, revision THA). For each cohort, we calculated standardised arthroplasty usage rates for Caucasian and African-American Medicare beneficiaries for each calendar year, and examined changes in disparities over time. We examined unadjusted and adjusted outcomes (30-day readmission rate, discharge disposition etc.) for Caucasians and African-Americans, and whether disparities decreased over time. RESULTS: In 1991, the use of primary TKA was 36% lower for African-Americans compared with Caucasians (20.6 per 10,000 for African-Americans; 32.1 per 10,000 for Caucasians; p<0.0001); in 2008, usage of primary TKA was 40% lower for African-Americans (41.5 per 10,000 for African-Americans; 68.8 per 10,000 for Caucasians; p<0.0001) with similar findings for the other cohorts. Black-White disparities in 30-day hospital readmission increased significantly from 1991-2008 among three patient cohorts. For example in 1991 30-day readmission rates for African-Americans receiving primary TKA were 6% higher than for Caucasians; by 2008 readmission rates for African-Americans were 24% higher (p<0.05 for change in disparity). Similarly, black-white disparities in the proportion of patients discharged to home after surgery increased across the study period for all cohorts (p<0.05). CONCLUSIONS: In an 18-year analysis of US Medicare data, we found little evidence of declines in racial disparities for joint arthroplasty usage or outcomes.

Smoking bans linked to lower hospitalizations for heart attacks and lung disease among medicare beneficiaries.

Policies limiting exposure to cigarette smoke have been associated with reduced hospitalizations for heart attacks, but little is known about the impact of smoking bans on other health conditions and whether findings from individual communities generalize to other areas. We investigated the association between smoking bans targeting workplaces, restaurants, and bars passed throughout the United States during 1991-2008 and hospital admissions for smoking-related illnesses-acute myocardial infarction and chronic obstructive pulmonary disease-among Medicare beneficiaries age sixty-five or older. Risk-adjusted hospital admission rates for acute myocardial infarction fell 20-21 percent thirty-six months following implementation of new restaurant, bar, and workplace smoking bans. Admission rates for chronic obstructive pulmonary disease fell 11 percent where workplace smoking bans were in place and 15 percent where bar smoking bans were present. By contrast, very little effect was found for hospitalization for gastrointestinal hemorrhage and hip fracture-two conditions largely unrelated to smoking and examined as points of comparison. These findings provide further support for the public health benefits of laws that limit exposure to tobacco smoke.

Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiaries.

BACKGROUND: Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization. METHODS: We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents >or=70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity. RESULTS: Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001). CONCLUSIONS: We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.

Identifying medication misadventures: poor agreement among medical record, physician, nurse, and patient reports.

STUDY OBJECTIVE: To analyze and compare four different methods of detecting medication misadventures in order to determine the optimal system for reporting clinically observed medication misadventures. DESIGN: Prospective cohort study. SETTING: Forty-eight-bed general internal medicine inpatient ward at a large academic teaching hospital with a decentralized pharmacy system. PATIENTS: One hundred twenty-six patients (54% male, mean age 54 yrs) with 133 consecutive admissions to the ward (mean length of stay 7.8 days) over an 8-week period from December 2001-February 2002. INTERVENTION: Medication misadventures were detected by four methods: house staff (resident physicians) report during their morning conference, nursing report during shift change, patient report at the discharge interview, and standardized medical record review. All methods of reporting medication misadventures were compared with the hospital's existing electronic medication misadventure reporting system. MEASUREMENTS AND MAIN RESULTS: Overall, 63 patients (47% of 133 admissions) experienced at least one medication misadventure. Thirty-seven adverse drug events (ADEs) and 69 medication errors were observed over 1035 patient bed-days. Little overlap was noted among the four intervention methods, with nearly 80% of all 106 events detected by only a single method (medical record review 51% [54 events], patient interview 11% [12], house-staff report 9% [10], nurse report 8% [9]). Of the 37 ADEs, 6 (16%) were due to medication errors and 10 (27%) were preventable. Of five life-threatening ADEs, all were preventable, and all were reported in the medical record and the electronic reporting system; however, only two were reported by a nurse, two by a resident physician, and one by a patient. CONCLUSION: Little overlap was noted among the individual medication misadventure reporting methods, suggesting the need to use multiple complementary methods to identify medication misadventures in hospitalized patients. These findings have important implications for development of surveillance systems, design of prevention initiatives, and future medication safety research.

Uncompensated care provided by for-profit, not-for-profit, and government owned hospitals.

BACKGROUND: There is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals. METHODS: We used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served. RESULTS: Our cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth. CONCLUSIONS: For the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.

Prior hospitalization and the risk of heart attack in older adults: a 12-year prospective study of Medicare beneficiaries.

BACKGROUND: We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old. METHODS: Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect. RESULTS: The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.

The Department of Veterans Affairs National Quality Scholars Fellowship Program: experience from 10 years of training quality scholars.

The Department of Veterans Affairs (VA) National Quality Scholars Fellowship Program (VAQS) was established in 1998 as a postgraduate medical education fellowship to train physicians in new methods of improving the quality and safety of health care for veterans and the nation. The VAQS curriculum is based on adult learning theory, with a national core curriculum of face-to-face components, technologically mediated distance learning components, and a unique local curriculum that draws from the strengths of regional resources. VAQS has established strong ties with other VA programs. Fellows' research and quality improvement projects are integrated with local and regional VA leaders' priorities, enhancing the relevance and visibility of the fellows' efforts and promoting recruitment of fellows to VA positions. VAQS has enrolled 98 fellows since 1999; 75 have completed the program and 24 are currently enrolled. Fellowship graduates have pursued a variety of career paths: 17% are continuing training (most in VA), 31% hold a VA faculty/staff position, 66% are academic faculty, and 80% conduct clinical or research work related to health care improvement. Graduates have held leadership positions in VA, Department of Defense, academic medicine, and public health agencies. Combining knowledge about the improvement of health care with adult learning strategies, distance learning technologies, face-to-face meetings, local mentorship, and experiential projects has been successful in improving care in VA and preparing physicians to participate in, study, and lead the improvement of health care quality and safety.

The aftermath of hip fracture: discharge placement, functional status change, and mortality.

The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.

Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System.

BACKGROUND: Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining. METHODS: We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. RESULTS: Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). CONCLUSION: Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.