'Physician advocates': a novel strategy for improving the value of hospital care by employing hospitalists part time to support non-hospitalist physicians.

BACKGROUND AND OBJECTIVE: At many hospitals, private-practice physicians still admit their own patients and are accustomed to autonomy in clinical practice. This creates challenges for hospital's efforts to improve the efficiency, quality, and value of care. Experienced inpatient-focused physicians - 'Physician Advocates' - could act as liaisons between private practitioners and the fast-paced inpatient microsystem. METHODS: We conducted a controlled pre-post ('differences-in-differences') analysis at an academic medical center where private-practice physicians care for about 40% of medical inpatients and hospitalist groups care for 60%. In the intervention, 'Physician Advocates' participated in daily multidisciplinary 'Progression of Care Rounds,' offering suggestions to increase care quality for private-practice physicians' patients. Controls were cared for by a large, well-established hospitalist group, which convened separate, unchanged multidisciplinary rounds. Outcomes were length of stay (LOS; primary outcome), 30-day readmissions, and inpatient mortality. RESULTS: In a risk-adjusted analysis of 31,632 medical inpatients, LOS declined by 4 hours more from the baseline period to the post-intervention period in the intervention group relative to the control group (ratio: 0.96, 95% CI: 0.93-0.99, p = 0.004). Readmissions declined 22% more in the intervention group (OR: 0.78, 95% CI: 0.63-0.97, p = 0.023). Mortality was unchanged (OR: 1.23, 95% CI: 0.78-1.93 p-value = 0.378). CONCLUSION: Among inpatients cared for by private practitioners, adding Physician Advocates to multidisciplinary rounds was associated with improved LOS and reduced readmissions - measures of efficiency and value. The Physician Advocates approach should be tested in diverse health systems because it allows hospitals to leverage the expertise of on-site clinicians while respecting the traditional private-practice care model, in which primary care physicians manage their hospitalized patients.

Association between operational positive depression symptom screen scores on hospital admission and 30-day readmissions.

BACKGROUND: Positive scores on inpatient depression symptom screens have been found to be associated with readmissions, yet most studies have used depression screens collected as part of research studies. OBJECTIVE: We evaluated whether the relationship between depression severity and readmission persisted when depression screening data was obtained for operational purposes. DESIGN: Retrospective analysis studying prospective use of PHQ data. SETTING: Large academic medical center. INTERVENTION: Ward nurses obtained depression screens from patients soon after admission. Patients who answered 'yes' to at least one Patient Health Questionnaire (PHQ)-2 question were screened using the PHQ-9. MAIN OUTCOMES AND MEASURES: We examined the association between depression severity and 30-day readmissions using logistic regression, adjusting for known predictors of hospital readmission. RESULTS: From July 2014-June 2016, 18,792 discharged adult medicine inpatients received an initial depression screen (PHQ-2) and 1105 patients (5.90%) had at least one positive response. Of this group, 3163 patients (6.32%) were readmitted within 30 days. 1128 patients received the PHQ-9. Compared to patients with no depression, patients with moderately-severe depression had 3.03 higher odds (95%CI, 1.44-6.38) and patients with severe depression had 1.63 higher odds (95%CI, 0.70-3.78) of being readmitted, after adjusting for known predictors of hospital admission. Adding PHQ-9 results did not significantly improve the predictive power of a readmissions model. CONCLUSIONS: Our mixed results call into question whether PHQ data obtained for operational purposes may differ compared to data obtained for research purposes. Differences in training of screening staff or patient discomfort with discussing depression in the hospital could explain our findings.

Vaginal birth after cesarean: do California hospital policies follow national guidelines?

OBJECTIVE: To review whether California hospitals are adhering to national practice guidelines with regard to vaginal birth after cesarean (VBAC). STUDY DESIGN: We performed a content analysis of the American College of Obstetricians and Gynecologists (ACOG) and American Association of Family Physicians published guidelines and identified 39 specific recommendations, which were categorized into the following 5 content areas: patient criteria, procedure, staff and resources, uterine rupture or other complications, and miscellaneous clinical issues. We evaluated individual hospital policies with regard to adherence to 34 recommendations made specifically by ACOG. RESULTS: Of the 225 surveyed hospitals, 167 (74%) allow VBAC, and 22% of these (36 of 167) provided VBAC protocols for review. Approximately 80% of protocols included < 50% of the ACOG items (median, 13.5; range, 3-27 items). The highest percent adherence was observed in the procedure and staff and resources categories, where over two thirds of study hospitals exhibited 75-100% adherence. One third of participating hospitals were less adherent (0-25%) in the categories of patient criteria, uterine rupture or other complications, and miscellaneous clinical issues. CONCLUSION: In a sample of written VBAC protocols, we found a wide range of adherence to ACOG recommendations, as evidenced by the number and type of items explicitly documented in the protocols.

Medication adherence as a predictor of 30-day hospital readmissions.

PURPOSE: The aim of this study was to test whether patient medication adherence, a modifiable risk factor obtainable at hospital admission, predicts readmission within 30 days. PATIENTS AND METHODS: We used a retrospective cohort study design to test whether patient medication adherence to all chronic medications, as determined by the 4-item Morisky Medication Adherence Scale (MMAS-4) administered by a pharmacist at the time of hospital admission, predicts 30-day readmissions. We compared readmission rates among 385 inpatients who had their adherence assessed from February 1, 2013, to January 31, 2014. Multiple logistic regression was used to examine the benefit of adding medication adherence to previously published variables that have been shown to predict 30-day readmissions. RESULTS: Patients with low and intermediate adherence (combined) had readmission rates of 20.0% compared to a readmission rate of 9.3% for patients with high adherence (P=0.005). By adding MMAS-4 data to previously published variables that have been shown to predict 30-day readmissions, we found that patients with low and intermediate medication adherence had an adjusted 2.54-fold higher odds of readmission compared to those in patients with high adherence (95% confidence interval [CI]: 1.32-4.90, P=0.005). The model's predictive power, as measured by the c-statistic, improved from 0.65 to 0.70 after adding adherence. CONCLUSION: Because medication adherence assessed at hospital admission was independently associated with 30-day readmission risk, it offers potential for targeting interventions to improve adherence.

Engaging nurse leaders in health services research.

OBJECTIVE: To describe effective methods to engage nurse leaders in structured interview research. BACKGROUND: The American Organization of Nurse Executives has identified the support of nurse leader participation in research as a key strategy to achieving its education and research objectives, particularly with regard to identifying and documenting nursing sensitive outcomes. Previous studies have delineated several methods to increase participation. METHODS: Nurse leaders of California labor and delivery units reporting more than 50 deliveries during 2002 were asked to participate in a structured interview about staffing and clinical policies on their unit. Recruitment methodology involved 3 levels of intervention, including introductory letters, follow-up contacts, and personal encouragement from senior regional leaders and nurse executives. RESULTS: Of the 268 eligible hospitals, 225 (84%) participated in the study. Fifty-four percent (n = 114) of the structured interviews were scheduled upon initial and second contacts by the research coordinator, and 73% (n = 161) were completed at the first scheduled appointment. Unit managers or directors personally completed 91% (n = 205) of the interviews, with only 20 (8.9%) designated to a staff nurse. CONCLUSIONS: Nurse leader participation is essential to the success of research dependent on collecting information regarding nurse practices and clinical processes. Using a multilevel approach to engage nurse leaders in research, such as endorsements and "detailing" by opinion leaders, phone calls, electronic mail, and incentives, is an effective strategy.