Trends in telehealth and in-person transitional care management visits during the COVID-19 pandemic.

BACKGROUND/OBJECTIVES: Transitional care management (TCM) visits delivered following hospitalization have been associated with reductions in mortality, readmissions, and total costs; however, uptake remains low. We sought to describe trends in TCM visit delivery during the COVID-19 pandemic. DESIGN: Cross-sectional study of ambulatory electronic health records from December 30, 2019 and January 3, 2021. SETTING: United States. PARTICIPANTS: Forty four thousand six hundred and eighty-one patients receiving transitional care management services. MEASUREMENTS: Weekly rates of in-person and telehealth TCM visits before COVID-19 was declared a national emergency (December 30, 2019 to March 15, 2020), during the initial pandemic period (March 16, 2020 to April 12, 2020) and later period (April 12, 2020 to January 3, 2021). Characteristics of patients receiving in-person and telehealth TCM visits were compared. RESULTS: A total of 44,681 TCM visits occurred during the study period with the majority of patients receiving TCM visits age 65 years and older (68.0%) and female (55.0%) Prior to the COVID-19 pandemic, nearly all TCM visits were conducted in-person. In the initial pandemic, there was an immediate decline in overall TCM visits and a rise in telehealth TCM visits, accounting for 15.4% of TCM visits during this period. In the later pandemic, the average weekly number of TCM visits was 841 and 14.0% were telehealth. During the initial and later pandemic periods, 73.3% and 33.6% of COVID-19-related TCM visits were conducted by telehealth, respectively. Across periods, patterns of telehealth use for TCM visits were similar for younger and older adults. CONCLUSION: The study findings highlight a novel and sustained shift to providing TCM services via telehealth during the COVID-19 pandemic, which may reduce barriers to accessing a high-value service for older adults during a vulnerable transition period. Further investigations comparing outcomes of in-person and telehealth TCM visits are needed to inform innovation in ambulatory post-discharge care.

Greasing the wheels: The impact of COVID-19 on US physician attitudes and practices regarding medication abortion.

OBJECTIVE: To explore US provider perspectives about self-sourced medication abortion and how their attitudes and clinic practices changed in the context of the COVID-19 pandemic. STUDY DESIGN: We conducted a multi-method study of survey and interview data. We performed 40 baseline interviews and surveys in spring 2019 and 36 follow-up surveys and ten interviews one year later. We compared pre- and post-Likert scale responses of provider views on the importance of different aspects of standard medication abortion assessment and evaluation (e.g., related to ultrasounds and blood-typing). We performed content analysis of the follow-up interviews using deductive-inductive analysis. RESULTS: Survey results revealed that clinics substantially changed their medication abortion protocols in response to COVID-19, with more than half increasing their gestational age limits and introducing telemedicine for follow-up of a medication abortion. Interview analysis suggested that physicians were more supportive of self-sourced medication abortion in response to changing clinic protocols that decreased in-clinic assessment and evaluation for medication abortion, and as a result of physicians' altered assessments of risk in the context of COVID-19. Having evidence already in place that supported these practice changes made the implementation of new protocols more efficient, while working in a state with restrictive abortion policies thwarted the flexibility of clinics to adapt to changes in standards of care. CONCLUSION: This exploratory study reveals that the COVID-19 pandemic has altered clinical assessment of risk and has shifted practice towards a less medicalized model. Further work to facilitate person-centered abortion information and care can build on initial modifications in response to the pandemic. IMPLICATIONS: COVID-19 has shifted clinician perception of risk and has catalyzed a change in clinical protocols for medication abortion. However, state laws and policies that regulate medication abortion limit physician ability to respond to changes in risk assessment.

Telemedicine use in neonatal follow-up programs - What can we do and what we can't - Lessons learned from COVID-19.

Little empirical data support the use of telemedicine to provide medical and developmental follow-up care to preterm and high-risk infants after hospital discharge. Nevertheless, the COVID-19 pandemic temporarily rendered telemedicine the only means by which to provide essential follow-up care to this population. In this article we discuss our institution's experience with rapid implementation of telemedicine in a multi-site neonatal follow-up program as well as benefits and limitations of the use of telemedicine in this context. Finally, we discuss the current problems that must be solved in order to optimize telemedicine as a tool for providing comprehensive, multidisciplinary medical and developmental care to high risk infants and their families.

Drivers of variation in 90-day episode payments after mechanical thrombectomy for acute ischemic stroke.

BACKGROUND: Although mechanical thrombectomy for acute ischemic stroke from a large vessel occlusion is now the standard of care, little is known about cost variations in stroke patients following thrombectomy and factors that influence these variations. METHODS: We evaluated claims data for 2016 to 2018 for thrombectomy-performing hospitals within Michigan through a registry that includes detailed episode payment information for both Medicare and privately insured patients. We aimed to analyze price-standardized and risk-adjusted 90-day episode payments in patients who underwent thrombectomy. Hospitals were grouped into three payment terciles for comparison. Statistical analysis was carried out using unpaired t-test, Chi-square, and ANOVA tests. RESULTS: 1076 thrombectomy cases treated at 16 centers were analyzed. The average 90-day episode payment by hospital ranged from $53 046 to $81,767, with a mean of $65 357. A $20 467 difference (35.1%) existed between the high and low payment hospital terciles (P<0.0001), highlighting a significant payment variation across hospital terciles. The primary drivers of payment variation were related to post-discharge care which accounted for 38% of the payment variation (P=0.0058, inter-tercile range $11,977-$19,703) and readmissions accounting for 26% (P=0.016, inter-tercile range $3,315-$7,992). This was followed by professional payments representing 20% of the variation (P<0.0001, inter-tercile range $7525-$9,922), while index hospitalization payment was responsible for only 16% of the 90-day episode payment variation (P=0.10, inter-tercile range $35,432-$41,099). CONCLUSIONS: There is a wide variation in 90-day episode payments for patients undergoing mechanical thrombectomy across centers. The main drivers of payment variation are related to differences in post-discharge care and readmissions.

Teleoncology or telemedicine for oncology patients during the COVID-19 pandemic: the new normal for breast cancer survivors?

Background: Telemedicine is seen as a savior during the COVID-19 pandemic. Materials & methods: This study is a descriptive cross-sectional study conducted with cancer patients who were interviewed via telemedicine from a tertiary care comprehensive oncology center. Results: A total of 421 patients were included in the study and 118 of them (28.0%) were >65 years old. Communication was provided most frequently by voice call (n = 213; 50.5%). The majority of the patients contacted by telemedicine had breast cancer (n = 270; 64.1%). For 135 patients (32.1%) no further examination or intervention was required and the previously planned follow-up visit was postponed by the clinician. Conclusion: This study showed that telemedicine could open a new era for medical oncology specialists.

Simulating Episode-Based Bundled Payments for Cranial Neurosurgical Procedures.

BACKGROUND: Episode-based bundled payments were introduced by Medicare in 2013 as the Bundled Payments for Care Improvement (BPCI) in order to improve care coordination and cost efficiency. BPCI has not yet been applied to cranial neurosurgical procedures. OBJECTIVE: To determine projected values of episode-based bundled payments when applied to common cranial neurosurgical procedures using retrospective data from a large database. METHODS: We performed a large retrospective observational study using the MarketScan administrative database to project bundled payment payments for 4 groups of common cranial neurosurgical procedures. RESULTS: We identified 15 276 procedures that met our inclusion criteria. We observed significant variability between groups, with 90-d bundle projected payments ranging from $ 58,200 for craniotomy for meningioma to $ 102,073 for craniotomy for malignant glioma. We also found significant variability in projected bundled payments within each class of operation. On average, payment for the index hospitalization accounted for 85% of projected payments for a 30-d bundle and 70.5% of projected payments for a 90-d bundle. Multivariable analysis showed that hospital readmission, discharge to postacute care facilities, venous-thrombo-embolism, medical comorbidities, adjuvant therapies, and payer status significantly contributed to projected cranial bundle payments. CONCLUSION: For the first time, to our knowledge, we project the values of episode-based bundled payments for common vascular and tumor cranial operations. As previously identified in orthopedic procedures, there is significant variability in total bundle payments within each cranial procedure. Compared to spine and orthopedic procedures, postdischarge care significantly impacts total bundle payments in cranial neurosurgery.

Cost-Effectiveness of Transcatheter Aortic Valve Implantation Using a Balloon-Expandable Valve in Japan: Experience From the Japanese Pilot Health Technology Assessment.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an innovative and effective treatment in high-surgical-risk (HR) and inoperable patients with symptomatic severe aortic stenosis. OBJECTIVES: This cost-effectiveness analysis of transfemoral TAVI (TF-TAVI) compared with surgical aortic valve replacement (SAVR) conforms with the methodological guidelines for cost-effectiveness evaluation by the Ministry of Health, Labor, and Welfare in Japan. METHODS: The cost-effectiveness of TF-TAVI using SAPIEN XT was evaluated using a lifetime Markov simulation from the national payer perspective. Comparators were SAVR for HR patients and standard of care (SOC) for inoperable patients. A systematic literature review for clinical evidence of TF-TAVI and comparators was conducted. The evidence for TF-TAVI was derived from the SOURCE XT registry and Japanese post marketing surveillance. Because there was no literature directly or indirectly comparing TF-TAVI using SAPIEN XT with comparators, the comparator data were selected from relevant published studies, considering the similarity of study eligibility criteria and patient backgrounds (eg, age and surgical risk scores). Sensitivity analyses were used to validate the robustness of results. RESULTS: The incremental cost-effectiveness ratio of TF-TAVI versus SAVR for HR patients was ¥1.3 million/quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio of TF-TAVI versus SOC for inoperable patients was ¥3.5 million/QALY. CONCLUSIONS: TF-TAVI was cost-effective when compared with SAVR for HR patients and when compared with SOC for inoperable patients, using a threshold of ¥5 million/QALY.

Care trajectories of chronically ill older adult patients discharged from hospital: a quantitative cross-sectional study using health insurance claims data.

BACKGROUND: For older adults, a good transition from hospital to the primary or long-term care setting can decrease readmissions. This paper presents the 6-month post-discharge healthcare utilization of older adults and describes the numbers of readmissions and deaths for the most frequently occurring aftercare arrangements as a starting point in optimizing the post-discharge healthcare organization. METHODS: This cross-sectional study included older adults insured with the largest Dutch insurance company. We described the utilization of healthcare within 180 days after discharge from their first hospital admission of 2015 and the most frequently occurring combinations of aftercare in the form of geriatric rehabilitation, community nursing, long-term care, and short stay during the first 90 days after discharge. We calculated the proportion of older adults that was readmitted or had died in the 90-180 days after discharge for the six most frequent combinations. We performed all analyses in the total group of older adults and in a sub-group of older adults who had been hospitalized due to a hip fracture. RESULTS: A total of 31.7% of all older adults and 11.4% of the older adults with a hip fracture did not receive aftercare. Almost half of all older adults received care of a community nurse, whereas less than 5% received long-term home care. Up to 18% received care in a nursing home during the 6 months after discharge. Readmissions were lowest for older adults with a short stay and highest in the group geriatric rehabilitation + community nursing. Mortality was lowest in the total group of older aldults and subgroup with hip fracture without aftercare. CONCLUSIONS: The organization of post-discharge healthcare for older adults may not be organized sufficiently to guarantee appropriate care to restore functional activity. Although receiving aftercare is not a clear predictor of readmissions in our study, the results do seem to indicate that older adults receiving community nursing in the first 90 days less often die compared to older adults with other types of aftercare or no aftercare. Future research is necessary to examine predictors of readmissions and mortality in both older adult patients discharged from hospital.

Updates in heart failure 30-day readmission prevention.

Heart failure (HF) and HF 30-day readmission rates have been a major focus of efforts to reduce health care cost in the recent era. Since the implementation of the Affordable Care Act (ACA) in 2012 and the Hospital Readmission Reduction Program (HRRP), concerted efforts have focused on reduction of 30-day HF readmissions and other admission diagnoses targeted by the HRRP. Hospitals and organizations have instituted wide-ranging programs to reduce short-term readmissions, but the data supporting these programs is often mixed. In this review, we will discuss the challenges associated with reducing HF readmissions and summarize the rationale and effect of specific programs on HF 30-day readmission rates, ranging from medical therapy and adherence to remote hemodynamic monitoring. Finally, we will review the effect that the focus on reducing 30-day HF readmissions has had on the care of the HF patient.

National Trends in Active Surveillance for Prostate Cancer: Validation of Medicare Claims-based Algorithms.

OBJECTIVE: To better describe the real-world use of active surveillance. Active surveillance is a preferred management option for low-risk prostate cancer, yet its use outside of high-volume institutions is poorly understood. We created multiple claims-based algorithms, validated them using a robust clinical registry, and applied them to Medicare claims to describe national utilization. MATERIALS AND METHODS: We identified men with prostate cancer from 2012-2014 in a 100% sample of Michigan Medicare data and linked them with the Michigan Urologic Surgery Improvement Collaborative (MUSIC) registry. Using MUSIC treatment assignment as the standard, we determined the performance of 8 claims-based algorithms to identify men on active surveillance. We selected 3 algorithms (the most sensitive, the most specific, and a balanced algorithm incorporating age and comorbidity) and applied them to a 20% national Medicare sample to describe national trends. RESULTS: We identified 1186 men with incident prostate cancer and completely linked data. Eight algorithms were tested with sensitivity ranging from 23.5% to 88.2% and specificity ranging from 93.5% to 99.1%. We found that the use of surveillance for men with incident prostate cancer increased from 2007 to 2014, nationally. However, among all men in the population, there was a large decrease in the rate of prostate cancer diagnosis and an increased or stable rate in the use of active surveillance, depending on the algorithm used. Less than 25% of men on active surveillance underwent a confirmatory prostate biopsy. CONCLUSION: We describe the performance of claims-based algorithms to identify active surveillance.

Assessment of melanoma follow-up trends in Medicare patients: a large scale, multi-regional analysis.

BACKGROUND: Research on patient follow-up compliance after a diagnosis of melanoma has been limited. OBJECTIVE: To assess the timelines for follow-up among patients who are diagnosed with melanoma and to assess the socioeconomic and provider factors which influence follow-up adherence. METHODS: A retrospective, population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was conducted to evaluate 10,813 patients who were diagnosed with melanoma from 2005-2013. RESULTS: We found that 97% of the individuals with melanoma had at least one follow-up visit, with 80.5% having their first follow-up visit within the first 6 months and 88.6% having their first follow-up visit within 12 months. Patients who had a dermatologist as the diagnosing provider were significantly more likely to follow up. Additionally, patients who returned were more likely to live in a community with a higher socioeconomic status. LIMITATIONS: Applicability of the data to a non-Medicare population and confounding variables such as co-morbid conditions are limitations. CONCLUSIONS: The majority of patients diagnosed with melanoma follow up with a provider within one year. However, socioeconomic and provider factors play important roles in influencing patient return visits.

Trends in Aging-Related Services During Nephrectomy: Implications for Surgery in an Aging Population.

OBJECTIVES: To characterize the extent to which geriatric and related healthcare services are provided to older adults undergoing surgery for kidney cancer, a potential growth area in geriatrics and oncology. DESIGN: Population-based observational study. SETTING: Surveillance, Epidemiology, and End Results cancer data linked with Medicare claims. PARTICIPANTS: Adults aged 65 and older with kidney cancer treated surgically from 2000 to 2009 (N = 19,129). MEASUREMENTS: Receipt of geriatric consultation, medical comanagement during the surgical hospitalization, inpatient physical or occupational therapy (PT/OT), and postacute PT/OT during the surgical care episode. Multivariable, mixed-effects models were used to identify associated participant and hospital characteristics, examine trends over time, and characterize hospital-level variation. RESULTS: Geriatric consultation occurred rarely in the perioperative period (2.6%). Medical comanagement (15.8%), inpatient PT/OT (34.2%), and postacute PT/OT (15.6%) occurred more frequently. In our mixed-effects models, participant age and comorbidity burden appeared to be consistent determinants of use of services, although hospital-level variation was also noted (P < .001). Use of geriatric consultation increased modestly in the latter years of the study period (P < .05). In contrast, medical comanagement (183%), inpatient PT/OT (73%), and postacute PT/OT (71%) increased substantially over the study period (P < .001). CONCLUSION: Although geriatric consultation remained sparse, use of medical comanagement and rehabilitation services has grown considerably for older adults undergoing surgery for kidney cancer. Efforts to reorganize cancer and surgery care should explore reasons for variation and the potential for these service elements to meet the health needs of an aging population.

[Internet based cognitive behavioral interventions: state of the art and implementation possibilities in rehabilitation]. / Internetbasierte kognitiv-behaviorale Behandlungs-ansätze: State of the Art und Einsatzmöglichkeiten in der Rehabilitation.

Internet-based health interventions (IHIs) provide a way to treat people via the Internet. The spectrum is wide, comprising interventions for mental disorders and somatic diseases as well as health and risk behavior change interventions. Numerous international studies have demonstrated the efficacy of IHIs for the aforementioned areas. Through the resource-saving applications IHIs are cost-efficient, not least suggesting their usefulness for medical rehabilitation. The present overview starts with a description of IHIs with a differentiation of technical-formal and thematic aspects. In doing so, the focus lies primarily on cognitive-behavioral treatment approaches, as the best scientifically investigated IHIs to date. An overview of the empirical evidence of IHIs is given, followed by a discussion of the implementation possibilities in medical rehabilitation.

Socioeconomic status and care after stroke: results from the Registry of the Canadian Stroke Network.

BACKGROUND AND PURPOSE: Socioeconomic status is inversely associated with mortality after stroke; however, the reasons behind this finding are not well-understood. We undertook a study to determine whether posthospitalization care and medication adherence vary with neighborhood income. METHODS: We conducted a cohort study of 11 050 patients with ischemic stroke or transient ischemic attack admitted to any of 11 specialized stroke centers in Ontario, Canada, between July 1, 2003 and March 31, 2008. Socioeconomic status measured as neighborhood income quintiles was imputed from the 2006 Canadian Census. We used linkages to administrative databases to evaluate processes of stroke care and medication adherence within 1 year of discharge. We used multivariable analyses to assess whether differences in stroke care and medication adherence existed across income groups after adjustment for age, sex, stroke severity, and comorbid conditions. RESULTS: Higher income was associated with higher rates of stroke unit admission, neurology consultations, referrals to secondary prevention clinics, and physician visits after hospital discharge; however, the absolute differences in rates were small. There was no difference across income quintiles in the use of postdischarge homecare services or in adherence to antihypertensive, antithrombotic, or lipid-lowering medications. CONCLUSIONS: Higher income is associated with improvements in some aspects of stroke care delivery. However, the magnitude of the care gap across income quintiles is small and is unlikely to account for the previously observed association between socioeconomic status and survival after stroke.

Follow-up of patients with new cardiovascular implantable electronic devices: are experts' recommendations implemented in routine clinical practice?

BACKGROUND: A 2008 expert consensus statement outlined the minimum frequency of follow-up of patients with cardiovascular implantable electronic devices (CIEDs). METHODS AND RESULTS: We studied 38 055 Medicare beneficiaries who received a new CIED between January 1, 2005, and June 30, 2009. The main outcome measure was variation of follow-up by patient factors and year of device implantation. We determined the number of patients who were eligible for and attended an in-person CIED follow-up visit within 2 to 12 weeks, 0 to 16 weeks, and 1 year after implantation. Among eligible patients, 42.4% had an initial in-person visit within 2 to 12 weeks. This visit was significantly more common among white patients than black patients and patients of other races (43.0% versus 36.8% versus 40.5%; P<0.001). Follow-up within 2 to 12 weeks improved from 40.3% in 2005 to 55.1% in 2009 (P<0.001 for trend). The rate of follow-up within 0 to 16 weeks was 65.1% and improved considerably from 2005 to 2009 (62.3%-79.6%; P<0.001 for trend). Within 1 year, 78.0% of the overall population had at least 1 in-person CIED follow-up visit. CONCLUSIONS: Although most Medicare beneficiaries who received a new CIED between 2005 and 2009 did not have an initial in-person CIED follow-up visit within 2 to 12 weeks after device implantation, the rate of initial follow-up improved appreciably over time. This CIED follow-up visit was significantly more common in white patients than in patients of other races.

Quality of life in cancer survivorship: 20 years later.

OBJECTIVES: To discuss the unique quality-of-life (QOL) issues for cancer survivors and provide guidance for the selection of measures to assess them. DATA SOURCES: Literature review, PubMed search, electronic data, websites. CONCLUSION: QOL is a vital outcome for cancer survivors. QOL measurement of the unique needs of cancer survivors has increased over the past 20 years. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses can move QOL science in cancer survivorship forward by using research findings to implement evidence-based practice.

[Medical rehabilitation: "change we need"]. / Medizinische Rehabilitation: "Change we need".

Medical Rehabilitation in Germany needs change. Weaknesses of the present care system are pointed out, and the potential for change is explored. The latter implies a more active search for rehabilitation need and the implementation of problem-focussed, flexible programmes. Above all, better evidence for the effectiveness of the German rehabilitation system is crucial.