Improving Use of a Hospital Transitional Care Clinic.

BACKGROUND: In response to Medicare readmission penalties, some hospitals have introduced transitional care clinics (TCCs) to meet the care needs of patients recently discharged from the emergency room or inpatient setting. This study was undertaken to increase the proportion of low-income, medically complex patients using a TCC at a large academic medical center, Northwestern Medical Group Transitional Care Clinic (NMG-TC). METHODS: This quality improvement study combined interviews and quantitative data analysis to determine how to increase use of NMG-TC. Physicians and patients were interviewed and surveyed to identify opportunities to expand clinic use. Logistic regression analysis of electronic health record (EHR) data was used to identify sociodemographic and clinical conditions influencing the TCC appointment show rate. RESULTS: Provider surveys and interviews suggested that referrals would likely increase via automation of referral guidelines and enhanced transitional care education. Patient interviews indicated that better communication of NMG-TC purpose, emphasizing nonmedical offerings, and warm handoffs could increase engagement. EHR analyses revealed that patients least likely to attend appointments were male, uninsured, non-Hispanic black, or homeless; had documented substance use; or lived > 50 miles from the clinic. Conversely, patients with heart failure, anxiety, or malignancy were more likely to attend appointments. CONCLUSION: TCC show rates could be improved with better communication of NMG-TC benefits to both patients and referring providers, as well as warm appointment handoffs, particularly for patients least likely to attend scheduled visits.

Effects of a Transitional Care Practice for a Vulnerable Population: a Pragmatic, Randomized Comparative Effectiveness Trial.

BACKGROUND: There is limited experimental evidence on transitional care interventions beyond 30 days post-discharge and in vulnerable populations. OBJECTIVE: Evaluate effects of a transitional care practice (TC) that comprehensively addresses patients' medical and psychosocial needs following hospital discharge. DESIGN: Pragmatic, randomized comparative effectiveness trial. PATIENTS: Adults discharged from an initial emergency, observation, or inpatient hospital encounter with no trusted usual source of care. INTERVENTIONS: TC intervention included a scheduled post-discharge appointment at the TC practice, where a multidisciplinary team comprehensively assessed patients' medical and psychosocial needs, addressed modifiable barriers, and subsequent linkage to a new primary care source. Routine Care involved assistance scheduling a post-discharge appointment with a primary care provider that often partnered with the hospital where the initial encounter occurred. MAIN MEASURES: The primary outcome was a binary indicator of death or additional hospital encounters within 90 days of initial discharge. Secondary outcomes included any additional hospital encounters, and counts of hospital encounters, over 180 days. KEY RESULTS: Four hundred ninety patients were randomized to TC intervention and 164 to Routine Care; 34.6% were uninsured, 49.7% had Medicaid, and 57.4% were homeless or lived in a high-poverty area. There was no significant difference between arms in the 90-day probability of death or additional hospital encounters (relative risk [RR] 0.89; 0.91; 95% confidence interval [CI] 0.74-1.13). However, TC patients had 37% and 35% lower probability of any inpatient admission over 90 days (RR 0.63; 95% CI 0.43-0.91) and 180 days (RR 0.65; 95% CI 0.47-0.89), respectively. Over 180 days, TC patients had 42% fewer inpatient admissions (incidence rate ratio 0.58; 95% CI 0.37-0.90). CONCLUSIONS: Among patients randomized to a patient-centered transitional care intervention, there was no significant reduction in 90-day probability of death or additional hospital encounters. However, there were significant decreases in measures of inpatient admissions over 180 days. TRIAL REGISTRATION: clinicaltrials.gov identifier NCT03066492.

A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: Design, rationale and baseline characteristics.

Transitional care programs have been widely used to reduce readmissions and improve the quality and safety of the handoff process between hospital and outpatient providers. Very little is known about effective transitional care interventions among patients who are uninsured or with Medicaid. This paper describes the design and baseline characteristics of a pragmatic randomized comparative effectiveness trial of transitional care. Northwestern Medical Group- Transitional Care (NMG-TC) care model was developed to address the needs of patients with multiple medical problems that required lifestyle changes and were amenable to office-based management. We present the design, evaluation methods and baseline characteristics of NMG-TC trial patients. Baseline demographic characteristics indicate that our patient population is predominantly male, Medicaid insured and non-white. This study will evaluate two methods for implementing an effective transitional care model in a medically complex and socioeconomically diverse population.

Using hospital use trends to improve transitional care.

BACKGROUND: This study evaluates the Northwestern Medicine Group Transitional Care clinic (NMG-TC), which transitions patients from an urban hospital to primary care at partner community clinics. We evaluate change over the 55 month study period in emergency department, observation or inpatient use within 90 days of an initial NMG-TC visit. METHODS: Electronic health records were used to determine patient demographic, insurance and clinical characteristics, including inflation-adjusted total hospital charges in the 90 days prior and the 90 days after an initial NMG-TC visit. Multiple logistic regression was used to estimate the likelihood of any 90-day post-NMG-TC visit hospital use, controlled for the simultaneous effects of patient characteristics and pre-visit hospital use level. RESULTS: There were 3318 patients with 90-day follow-up of whom 28.5% had 90 day post-visit hospital encounters. Patients with cancer, infectious disease or pain diagnoses at the time of a NMG-TC visit had the highest 90-day post-visit hospital use. The level of pre-NMG-TC visit hospital charges, the number of NMG-TC visit diagnostic categories and the number of NMG-TC visits all showed a sharply graded effect on subsequent hospital use. Patients with a first NMG-TC visit in the last nine months of the study (2015-2016) had a 38% lower likelihood of any 90-day hospital use (OR = 0.62, 95% CI = 0.45-0.84) as compared to patients seen in 2011-2012. CONCLUSION AND IMPLICATIONS: Reduced post-visit hospital use is likely related to increased clinic resources, Affordable Care Act insurance expansions, and improved clinical and community social service expertise. LEVEL OF EVIDENCE: Cohort study, Level 2.

Prevalence, drug-induced hepatotoxicity, and mortality among patients multi-infected with HIV, tuberculosis, and hepatitis virus.

OBJECTIVES: To investigate the prevalence, incidence of abnormal liver function tests (LFTs), and mortality during anti-TB treatment in patients multi-infected with HIV, tuberculosis (TB), and hepatitis virus (hepatitis B virus (HBV) and hepatitis C virus (HCV)). METHODS: Three hundred and sixty-one HIV-positive TB patients were enrolled and divided into an HIV/TB group, HIV/TB/HBV group, and HIV/TB/HCV group; 1013 HIV-negative TB patients were selected randomly as controls. RESULTS: One hundred and seventeen (32.4%) HIV-positive TB patients were infected with HBV and/or HCV, compared with 90 (8.9%) HIV-negative TB patients (p=0.000). HIV-positive TB patients had a higher incidence of anti-TB drug-induced hepatotoxicity than HIV-negative TB patients (4.2% vs. 1.0%, odds ratio (OR) 4.348, 95% confidence interval (CI) 1.935-9.769, p=0.000). The incidence of abnormal LFTs in the HIV/TB/HBV group and HIV/TB/HCV group were significantly higher than in the HIV/TB group (40.7% vs. 11.1%, OR 5.525, 95% CI 2.325-13.131, p=0.000; 20.0% vs. 11.1%, OR 2.009, 95% CI 1.057-3.820, p=0.031). A total of 68.4% of patients with HBV-DNA >1.0×10(5) copies/ml and 42.9% of patients with HCV-RNA >1.0×10(5) copies/ml had abnormal LFTs. Twenty-three (19.7%) patients multi-infected with HIV, TB, and hepatitis virus died during anti-TB treatment. CONCLUSIONS: HIV, HBV, and HCV are risk factors for the development of abnormal LFTs and mortality during anti-TB treatment. TB patients co-infected with HIV and hepatitis virus need close follow-up.

Effects of hepatitis B immunization on prevention of mother-to-infant transmission of hepatitis B virus and on the immune response of infants towards hepatitis B vaccine.

BACKGROUND: Combined immunization with hepatitis B immunoglobulin (HBIG) plus hepatitis B vaccine (HB vaccine) can effectively prevent perinatal transmission of hepatitis B virus (HBV). With the universal administration of HB vaccine, anti-HBs conferred by HB vaccine can be found increasingly in pregnant women, and maternal anti-HBs can be passed through the placenta. This study was designed to evaluate the effect of hepatitis B immunization on preventing mother-to-infant transmission of HBV and on the immune response of infants towards HB vaccine. METHOD: From 2008 to 2013, a prospective study was conducted in 15 centers in China. HBsAg-positive pregnant women and their infants aged 8-12 months who completed immunoprophylaxis were enrolled in the study and tested for HBV markers (HBsAg, anti-HBs, HBeAg, anti-HBe and anti-HBc). Antepartum administration of HBIG to HBsAg-positive women was based on individual preference. HBsAg-negative pregnant women and their infants of 7-24 months old who received HB vaccines series were enrolled and tests of their HBV markers were performed. RESULTS: 1202 HBsAg-positive mothers and their infants aged 8-12 months were studied and 40 infants were found to be HBsAg positive with the immunoprophylaxis failure rate of 3.3%. Infants with immunoprophylaxis failure were all born to HBeAg-positive mothers of HBV-DNA ≥6 log10copies/ml. Among infants of HBeAg-positive mothers, immunoprophylaxis failure rate in vaccine plus HBIG group, 7.9% (29/367), was significantly lower than the vaccine-only group, 16.9% (11/65), p=0.021; there was no significant difference in the immunoprophylaxis failure rate whether or not antepartum HBIG was given to the pregnant woman, 10.3% (10/97) vs 9.0% (30/335), p=0.685. Anti-HBs positive rate was 56.3% (3883/6899) among HBsAg-negative pregnant women and anti-HBs positive rate was 94.2% in cord blood of anti-HBs-positive mothers. After completing the HB vaccine series, anti-HBs positive rate among infants with maternal anti-HBs titers of <10 IU/L, 10-500 IU/L and ≥500 IU/L was 90.3% (168/186), 90.5% (219/242) and 80.2% (89/111) respectively, p=0.011. Median titers of anti-HBs (IU/L) among infants in the three groups was 344.2, 231.9 and 161.1 respectively, p=0.020. CONCLUSIONS: HBIG plus HB vaccine can effectively prevent mother-to-infant transmission of HBV, but no HBV breakthrough infection was observed in infants born to HBeAg-negative mothers who received HB vaccine with or without HBIG after birth. Antepartum injection of HBIG has no effect on preventing HBV mother-to-infant transmission. High maternal titer of anti-HBs can transplacentally impair immune response of infants towards HB vaccine.

Rapid antiretroviral therapy scale-up in Hubei Province, China.

In 2003, physicians in China were unprepared to care for people with AIDS. Project HOPE partnered with Hubei Province health authorities to train and mentor doctors and build capacity for HIV care. From 2004 to 2006, seventy-eight Chinese "master trainers" were trained, who then trained and mentored 8,759 health workers. During this period, as the free antiretroviral therapy period began, measures of physician competence in HIV care improved significantly, and annual mortality from AIDS fell from 49 percent to 8.8 percent. This international partnership created a sustainable capacity for effective HIV prevention and care that could be replicable in other settings.

Microeconomic loans and health education to families in impoverished communities: implications for the HIV pandemic.

Poverty is among the root causes of death and poor health worldwide. Project HOPE's Village Health Bank (VHB) program is a public health intervention that combines integrated microcredit lending and health education. Groups of 18 to 25 women receive small loans, and biweekly, one-hour health education sessions. Since 1993, about 50,000 women in 949 VHBs have participated in seven countries in the Americas, Africa, and Southeast Asia, receiving more than US$25 million in loans and 8,445 hours of health education. Members of VHBs are charged modest interest rates that enable them to become self-sufficient (eg, able to cover all operating charges, including the costs of the health education staff, and the necessary loan capital to continue without infusion of outside resources). The VHB program produces substantial economic improvements for individuals and groups, and benefits in health knowledge and behaviors, including increased utilization of healthcare services. Data from Guatemala, Malawi, and Thailand demonstrate that VHBs in countries with high HIV prevalence have been comparably successful in spite of the enormous added burdens of chronic illness, deaths, and orphans in need of support. For example, in 2004, 48 percent of 266 VHB members in Malawi experienced at least one death in their household in the preceding year, and 67 percent housed one or more orphans with an average of two orphans per household. Because of the unique combination of increased household economic stability and improved health knowledge, the VHB program is now being adapted to families of people affected by HIV/AIDS, including orphans.