Systematic review of service improvements for home enteral tube feeding in adults.

BACKGROUND: Patients receiving home enteral tube feeding (HETF) have a high risk of complications and readmission to hospital. This study aims to evaluate effectiveness of staff- and/or patient-focused service-improvement strategies on clinical, patient-reported, and economic outcomes for patients receiving HETF across adult settings. METHODS: The search was conducted using MEDLINE, EMBASE, and CINAHL databases. Quality of studies were appraised using the Cochrane Collaboration Risk of Bias tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment. RESULTS: Eleven studies met the inclusion criteria. Pooled data found targeted HETF education with patients, carers, and staff significantly improved knowledge immediately after education and was sustained at 3-6 months. Multimodal interventions, including the formation of specialist HETF teams, significantly reduced complications such as infection, gastrostomy blockage, tube displacement, and feed intolerance but do not significantly reduce unplanned hospital encounters (outpatient clinic visits, hospitalizations, and emergency presentations). Owing to the high risk of bias in the included studies, there is low-quality evidence to support staff training, patient education, and dedicated HETF teams. CONCLUSION: This review highlights the need for further quality research to allow higher-level evidence for determining the usefulness of interventions aimed at improving outcomes for patients receiving HETF. Future research needs to include greater assessment of quality of life, quantification of the value of interventions in economic terms, and use of translational research frameworks. However, effective staff and patient education programs, along with comprehensive multidisciplinary care, should be considered standard care until a larger research base is developed.

Barriers to Care and Root Cause Analysis of LGBTQ+ Patients' Experiences: A Qualitative Study.

BACKGROUND: LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning, and others) people face a unique set of barriers to receiving quality healthcare. Very little exists in nursing literature that addresses these barriers. OBJECTIVE: This study aimed to analyze patient experience data to better understand the context of barriers to care that LGBTQ+ patients experience, in addition to institutional responses. METHODS: Documentary analysis was employed to review four LGBTQ+ patient experiences that resulted in formal feedback provided to the Office of Patient Relations. Each case was analyzed for content, process, and outcomes. RESULTS: Through the outlined analysis, the study team found three primary themes and five secondary themes across the four cases. The overarching themes identified through the study's case review include (a) lack of provider knowledge, (b) lack of patient-centered care, and (c) lack of institutional infrastructures associated with the provision of affirming care to LGBTQ+ individuals. DISCUSSION: Findings suggest the need for a multipronged approach when addressing the care of LGBTQ+ communities. A combination of provider-level education and institutional capacity building to treat diverse patient populations is necessary for addressing the issues demonstrated within the data. Moreover, further research is needed to identify unique needs of transgender and nonbinary patients and determine efficacy of institutional efforts to build capacity for caring and studying the health needs of LGBTQ+ communities.

Using Patient-Reported Outcomes toAssess Healthcare Quality: Toward Better Measurement of Patient-Centered Care in Cardiovascular Disease.

Patient-reported outcomes (PROs) are elicited directly from patients so they can describe their overall health status, including their symptoms, function, and quality of life. While commonly used as end points in clinical trials, PROs can play an important role in routine clinical care, population health management, and as a means for quantifying the quality of patient care. In this review, we propose that PROs be used to improve patient-centered care in the treatment of cardiovascular diseases given their importance to patients and society and their ability to improve doctor- provider communication. Furthermore, given the current variability in patients' health status across different clinics and the fact that PROs can be improved by titrating therapy, we contend that PROs have a key opportunity to serve as measures of healthcare quality.

Associations of patient-centered medical home with quality of care, patient experience, and health expenditures: A STROBE-compliant cross-sectional study.

ABSTRACT: In efforts to improve the delivery of quality primary care, patient-centered medical home (PCMH) model has been promoted. However, evidence on its association with health outcomes has been mixed. The aim of this study was to assess the performance of PCMH model on quality of care, patient experience, health expenditures.This was a cross-sectional study of the 2015-2016 Medical Expenditure Panel Survey-Medical Organization Survey linked data, including 5748 patient-provider pairs. We examined twenty-four quality of care measures (18 high-value and 6 low-value care services), health service utilization, patient experience (patient-provider communication, satisfaction), and health expenditure.Of 5748 patients, representing a weighted population of 56.2 million American adults aged 18 years and older, 44.2% were cared for by PCMH certified providers. 9.3% of those with PCMHs had at least one inpatient stay in the past year, which was comparable to the 11.4% among those with non-PCMHs. Similarly, 17.4% of respondents cared for by PCMH and 18.5% cared for by non-PCMH had at least one ED visit. Overall, we found no significant differences in quality of care measures (neither high-nor low-value of care) between the two groups. The overall satisfaction, the experience of access to care, and communication with providers were also comparable. Patients who were cared for by PCMHs had less total health expenditure (difference $217) and out-of-pocket spending (difference $91) than those cared for by non-PCMHs; however, none of these differences reached the statistical significance (adjusted P > 0.05 for all).This study found no meaningful difference in quality of care, patient experience, health care utilization, or health care expenditures between respondents cared for by PCMH and non-PCMH. Our findings suggest that the PCMH model is not superior in the quality of care delivered to non-PCMH providers.

Communication as a High-Stakes Clinical Skill: "Just-in-Time" Simulation and Vicarious Observational Learning to Promote Patient- and Family-Centered Care and to Improve Trainee Skill.

Patient-provider communication is a hallmark of high-quality care and patient safety; however, the pace and increasingly complex challenges that face overextended teams strain even the most dedicated clinicians. The COVID-19 pandemic has further disrupted communication between clinicians and their patients and families. The dependence on phone communication and the physical barriers of protective gear limit nonverbal communication and diminish clinicians' ability to recognize and respond to emotion. Developing new approaches to teach communication skills to trainees who are often responsible for communicating with patients and their families is challenging, especially during a pandemic or other crisis. "Just-in-time" simulation-simulation-based training immediately before an intervention-provides the scaffolding and support trainees need for conducting difficult conversations, and it enhances patients' and families' experiences. Using a realistic scenario, the author illustrates key steps for effectively using just-in-time simulation-based communication training: assessing the learner's understanding of the situation; determining what aspects of the encounter may prove most challenging; providing a script as a cognitive aid; refreshing or teaching a specific skill; preparing learners emotionally through reflection and mental rehearsal; coaching on the approach, pace, and tone for a delivery that conveys empathy and meaning; and providing specific, honest, and curious feedback to close a performance gap. Additionally, the author acknowledges that clinical conditions sometimes require learning by observing rather than doing and has thus provided guidance for making the most of vicarious observational learning: identify potential challenges in the encounter and explicitly connect them to trainee learning goals, explain why a more advanced member of the team is conducting the conversation, ask the trainee to observe and prepare feedback, choose the location carefully, identify everyone's role at the beginning of the conversation, debrief, share reactions, and thank the trainee for their feedback and observations.

Standard tools for non-standard care: The values and scripts of a person-centred assessment protocol.

This article uses a material semiotic perspective to study a highly influential model of healthcare policy and practice today: person-centred care. While person-centred care is often regarded as implying a turn away from technology and standardization towards more humanistic values in care, this article shows that mundane standardization technologies, such as an assessment protocol, are integral components of person-centred care. Building on interviews and observational studies at a Swedish hospital introducing person-centred care, the article analyses the person-centred protocol in situ. The article teases out three core concerns inscribed in the protocol: a concern for the patient experience and perspective, a valuing of evidence-based knowledge and a managerial imperative. The article illustrates how these contrasting values were rendered compatible through the continuous tinkering of healthcare professionals. Finally, it shows how users modified the script of the protocol under analysis and how relations between the three core concerns were adjusted in the process. The article concludes that tinkering and user-technology relations are of significance for the fate of person-centred care at large.

The impact of patient-centered medical home certification on quality of care for patients with diabetes.

OBJECTIVE: To identify the impact of changes surrounding certification as a patient-centered medical home (PCMH) on outcomes for patients with diabetes. STUDY SETTING: Minnesota legislation established mandatory quality reporting for patients with diabetes and statewide standards for certification as a PCMH. Patient-level quality reporting data (2008-2018) were used to study the impact of transition to a PCMH. STUDY DESIGN: Achievement of Minnesota's optimal diabetes care standard-in aggregate and by component-was modeled for adult patients with Type 1 or Type 2 diabetes as a function of time relative to the year the patient's primary care practice achieved PCMH certification. Patients from uncertified practices were used to control for general trend. Practice-level random effects captured time-invariant characteristics of practices and the practices' average patient. DATA COLLECTION: Electronic health record data were submitted by 695 Minnesota practices capturing components of the quality standard: blood sugar control, cholesterol control, blood pressure control, nonsmoking status, and use of aspirin. PRINCIPAL FINDINGS: The first cohort of practices achieving PCMH certification (July 2010-June 2014) showed statistically insignificant changes in optimal care. The next cohort of practices (July 2014-June 2018) achieved larger, clinically meaningful increases in quality of care during the time prior to and following certification. Specifically, this second cohort of practices was estimated to achieve a 12.8 percentage-point improvement (P < .001) in the predicted probability of providing optimal diabetes care over the period spanning 3 years before to 3 years after certification. CONCLUSIONS: Our results suggest that the initial cohort of certified practices was already performing at a high level before certification, perhaps requiring little change in their operations to achieve PCMH certification. The second cohort, on the other hand, made meaningful, quality-improving changes in the years surrounding certification. Differences by cohort may partially explain the inconsistent PCMH impacts found in the literature.

Disparities in patient-centered communication for Black and Latino men in the U.S.: Cross-sectional results from the 2010 health and retirement study.

BACKGROUND: A lack of patient-centered communication (PCC) with health providers plays an important role in perpetuating disparities in health care outcomes and experiences for minority men. This study aimed to identify factors associated with any racial differences in the experience of PCC among Black and Latino men in a nationally representative sample. METHODS: We employed a cross-sectional analysis of four indicators of PCC representative of interactions with doctors and nurses from (N = 3082) non-Latino White, Latino, and Black males from the 2010 Health and Retirement Study (HRS) Core and the linked HRS Health Care Mail in Survey (HCMS). Men's mean age was 66.76 years. The primary independent variable was Race/Ethnicity (i.e. Black and Hispanic/Latino compared to white males) and covariates included age, education, marital status, insurance status, place of care, and self-rated health. RESULTS: Bivariate manova analyses revealed racial differences across each of the four facets of PCC experience such that non-Hispanic white men reported PC experiences most frequently followed by black then Hispanic/Latino men. Multivariate linear regressions predictive of PCC by race/ethnicity revealed that for Black men, fewer PCC experiences were predicted by discriminatory experiences, reporting fewer chronic conditions and a lack of insurance coverage. For Hispanic/Latino men, access to a provider proved key where not having a place of usual care solely predicted lower PCC frequency. IMPLICATIONS: Researchers and health practitioners should continue to explore the impact of inadequate health care coverage, time-limited medical visits and implicit racial bias on medical encounters for underrepresented patients, and to advocate for accessible, inclusive and responsive communication between minority male patients and their health providers.

Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System.

Importance: Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care. Objective: To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors. Design, Setting, and Participants: In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019. Interventions: Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months. Main Outcomes and Measures: Contextual error rates, patient outcomes, and hospitalization rates and costs were measured. Results: The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention. Conclusions and Relevance: These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.

Practicality Assessment of the Improved ICT-Based Dementia Care Mapping Support System.

OBJECTIVES: Authors have developed an ICT (Information-Communication Technology)-based Dementia Care Mapping (DCM™) support system and assessed its usefulness previously using videos. The aim of this study is to evaluate practicality of the improved support system by actual mapping. METHODS: We obtained highly reliable mapping data by a team of 3 mappers (M1, M2, and M3), who mapped 5 elderly people with dementia continuously over 4 hours in 2 sites. M1 mapped by conventional paper-based DCM™, while M2 and M3 mapped using the support system. Collected mapping data (n = 8, total of 232.5 hours = 2790 time frames) were compared. RESULTS: The concordance rates between M1 and M2/M3 were over 70%; the required level for DCM™ evaluation purposes, with 1 exception. We also obtained users' positive ratings regarding the system usability. CONCLUSION: Practicality of the ICT-based DCM™ support system was confirmed for evaluation purposes, demonstrating the system is ready for practical use.

Assessment of patient-centered outcomes (PROs) in inflammatory bowel disease (IBD): a multicenter survey preceding a cross-disciplinary (functional) consensus.

BACKGROUND: With a shift in the healthcare paradigm towards a more patient-centered approach, data on inflammatory bowel disease (IBD) needs to be further explored. This study aimed to determine patient perspectives on the effect of IBD and features of patients with lower satisfaction level and compare patient and physician perception of IBD-related Quality of Care (QoC). METHODS: A previously developed pre-standardised set of questions regarding patient-centered outcome (PRO) measures for IBD, comprising 36 items, was administered in five centers, and a concomitant questionnaire for specialised physicians was adapted and administered. RESULTS: Overall, 1005 patients with IBD met the inclusion criteria. Sixty-five questionnaires were administered to specialised physicians. Both patients and physicians perceived the IBD-related QoC as being satisfactory. Furthermore, this study revealed areas of shortcomings where it comes to patient perceptions. Female sex and the presence of negatively impacting disease characteristics (presence of significant pain or discomfort, lack of energy, feeling fatigued most of the time, experiencing anxiety or depression in the last 2 weeks) were associated with lower satisfaction levels. CONCLUSIONS: Our findings can be used in establishing strategies aimed at improving patient QoC and defining strategic priorities. These data can aid in improving the communication of the pressing needs of IBD patients, to both the public payers and health authorities.

Impact of health information technology optimization on clinical quality performance in health centers: A national cross-sectional study.

BACKGROUND: Delivery of preventive care and chronic disease management are key components of a high functioning primary care practice. Health Centers (HCs) funded by the Health Resources and Services Administration (HRSA) have been delivering affordable and accessible primary health care to patients in underserved communities for over fifty years. This study examines the association between health center organization's health information technology (IT) optimization and clinical quality performance. METHODS AND FINDINGS: Using 2016 Uniform Data System (UDS) data, we performed bivariate and multivariate analyses to study the association of Meaningful Use (MU) attestation as a proxy for health IT optimization, patient centered medical home (PCMH) recognition status, and practice size on performance of twelve electronically specified clinical quality measures (eCQMs). Bivariate analysis demonstrated performance of eleven out of the twelve preventive and chronic care eCQMs was higher among HCs attesting to MU Stage 2 or above. Multivariate analysis demonstrated that Stage 2 MU or above, PCMH status, and larger practice size were positively associated with performance on cancer screening, smoking cessation counseling and pediatric weight assessment and counseling eCQMs. CONCLUSIONS: Organizational advancement in MU stages has led to improved quality of care that augments HCs patient care capacity for disease prevention, health promotion, and chronic care management. However, rapid technological advancement in health care acts as a potential source of disparity, as considerable resources needed to optimize the electronic health record (EHR) and to undertake PCMH transformation are found more commonly among larger HCs practices. Smaller practices may lack the financial, human and educational assets to implement and to maintain EHR technology. Accordingly, targeted approaches to support small HCs practices in leveraging economies of scale for health IT optimization, clinical decision support, and clinical workflow enhancements are critical for practices to thrive in the dynamic value-based payment environment.

Listening to Women: Recommendations from Women of Color to Improve Experiences in Pregnancy and Birth Care.

INTRODUCTION: Women of color are at increased risk for poor birth outcomes, often driven by upstream social determinants and socially structured systems. Given the increasing rate of maternal mortality in the United States, particularly for women of color, there is a pressing need to find solutions to improving care quality and access for racially marginalized communities. This study aims to describe and thematically analyze the recommendations to improve pregnancy and birth care made by women of color with lived experience of perinatal health care. METHODS: Twenty-two women of color living in the San Francisco Bay Area and receiving support services from a community-based nonprofit organization participated in semistructured interviews about their experiences receiving health care during pregnancy and birth. Interviews were audio-recorded and transcribed, and transcripts were analyzed using thematic analysis to highlight recommendations for improving perinatal care experiences. RESULTS: Participants shared experiences and provided recommendations for improving care at the individual health care provider level, including spending quality time, relationship building and making meaningful connections, individualized person-centered care, and partnership in decision making. At the health systems level, recommendations included continuity of care, racial concordance with providers, supportive health care system structures to meet the needs of women of color, and implicit bias trainings and education to reduce judgment, stereotyping, and discrimination. DISCUSSION: Participants in this study shared practical ways that health care providers and systems can improve pregnancy and birth care experiences for women of color. In addition to the actions needed to address the recommendations, health care providers and systems need to listen more closely to women of color as experts on their experiences in order to create effective change. Community-centered research, driven by and for women of color, is essential to improve health disparities during pregnancy and birth.

Benefits and Risks of Visitor Restrictions for Hospitalized Children During the COVID Pandemic.

To control the spread of severe acute respiratory syndrome coronavirus 2, the virus responsible for coronavirus disease 2019, many hospitals have strict visitor restriction policies. These policies often prohibit both parents from visiting at the same time or having grandparents or other family members visit at all. We discuss cases in which such policies created ethical dilemmas and possibly called for compassionate exceptions from the general rules.

Best Evidence to Best Practice: Implementing an Innovative Model of Nutrition Care for Patients with Head and Neck Cancer Improves Outcomes.

Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting outcomes. Despite publication of nutrition care evidence-based guidelines (EBGs), evidence-practice gaps exist. This study aimed to implement and evaluate the integration of a patient-centred, best-practice dietetic model of care into an HNC multidisciplinary team (MDT) to minimise the detrimental sequelae of malnutrition. A mixed-methods, pre-post study design was used to deliver key interventions underpinned by evidence-based implementation strategies to address identified barriers and facilitators to change at individual, team and system levels. A data audit of medical records established baseline adherence to EBGs and clinical parameters prior to implementation in a prospective cohort. Key interventions included a weekly Supportive Care-Led Pre-Treatment Clinic and a Nutrition Care Dashboard highlighting nutrition outcome data integrated into MDT meetings. Focus groups provided team-level evaluation of the new model of care. Economic analysis determined system-level impact. The baseline clinical audit (n = 98) revealed barriers including reactive nutrition care, lack of familiarity with EBGs or awareness of intensive nutrition care needs as well as infrastructure and dietetic resource limitations. Post-implementation data (n = 34) demonstrated improved process and clinical outcomes: pre-treatment dietitian assessment; use of a validated nutrition assessment tool before, during and after treatment. Patients receiving the new model of care were significantly more likely to complete prescribed radiotherapy and systemic therapy. Differences in mean percentage weight change were clinically relevant. At the system level, the new model of care avoided 3.92 unplanned admissions and related costs of $AUD121K per annum. Focus groups confirmed clear support at the multidisciplinary team level for continuing the new model of care. Implementing an evidence-based nutrition model of care in patients with HNC is feasible and can improve outcomes. Benefits of this model of care may be transferrable to other patient groups within cancer settings.

Reframing Financial Incentives Around Reducing Readmission After Radical Cystectomy.

OBJECTIVE: To better understand the financial implications of readmission after radical cystectomy, an expensive surgery coupled with a high readmission rate. Currently, whether hospitals benefit financially from readmissions after radical cystectomy remains unclear, and potentially obscures incentives to invest in readmission reduction efforts. MATERIALS AND METHODS: Using a 20% sample of national Medicare beneficiaries, we identified 3544 patients undergoing radical cystectomy from January 2010 to November 2014. We compared price-standardized Medicare payments for index admissions and readmissions after surgery. We also examined the variable financial impact of length of stay and the proportion of Medicare payments coming from readmissions based on overall readmission rate. RESULTS: Medicare patients readmitted after cystectomy had higher index hospitalization payments ($19,164 readmitted vs $18,146 non-readmitted, P = .03) and an average readmission payment of $7356. Adjusted average Medicare readmission payments and length of stay varied significantly across hospitals, ranging from $2854 to $15,605, and 2.0 to 17.1 days, respectively (both P <.01), with longer length of stay associated with increased payments. After hospitals were divided into quartiles based on overall readmission rates, the percent of payments coming from readmissions ranged from 5% to 13%. CONCLUSION: Readmissions following radical cystectomy were associated with increased Medicare payments for the index hospitalization, and the readmission payment, potentially limiting incentives for readmission reduction programs. Our findings highlight opportunities to reframe efforts to support patients, caregivers, and providers through improving the discharge and readmission processes to create a patient-centered experience, rather than for fear of financial penalties.