RESUMEN
OBJECTIVES: Hospital at home (HAH) is a health care delivery model that substitutes hospital-level services in the home for inpatient hospitalizations. HAH has been shown to be safe and effective for medical patients but has not been investigated in surgical readmissions. We estimated the potential impact of an HAH program for patients readmitted within 60 days postoperatively and described the characteristics of eligible patients to aid in the design of future programs. STUDY DESIGN: This was a cross-sectional study of 60-day postoperative readmissions at a tertiary care center in 2018. METHODS: We identified the number of readmissions that may have been eligible for HAH, collected descriptive information, and estimated the financial margin that could have been generated had eligible readmissions been diverted to HAH. RESULTS: There were 2366 readmissions within 60 days of surgery in 2018. A total of 731 readmissions met inclusion criteria for HAH (30.1%), accounting for 4152 bed days. Of these readmissions, the most common diagnoses were infection, gastrointestinal complications, and cardiac complications. Patients' home addresses were within 16 miles of the hospital in 447 cases (61.1%). Avoidance of these readmissions and use of the beds for new admissions represented a potential backfill margin of $8.8 million, not incorporating the cost of HAH. CONCLUSIONS: Many 60-day postoperative readmissions may be amenable to HAH enrollment, representing a significant opportunity to improve patient experience and generate hospital revenue. This is of particular interest in the post-COVID-19 era. To maximize their impact, HAH programs should tailor clinical and operational services to this population.
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COVID-19 , Readmisión del Paciente , Estudios Transversales , Hospitales , Humanos , SARS-CoV-2RESUMEN
For hospital-affiliated accountable care organizations (ACOs), emergency care represents a unique challenge for coordination of care and a major source of ACO leakage. The authors analyzed emergency department (ED) visits among ACO members to assess the potential impact of ambulance transport on the use of in-network versus out-of-network EDs. To better understand factors influencing the use of in-network versus out-of-network EDs, 2018 claims data from members of a regional subset of a large ACO in the greater Boston area were analyzed. Within this population, multivariable logistic regression was used to assess the relationship between ambulance transport as well as demographic factors, insurance type, and hospital distance on the use of in-network versus out-of-network EDs. Arrival to an ED via ambulance was found to be significantly associated with reduced odds of presenting to an in-network ED compared to arriving by private transportation (odds ratio 0.70, 95% confidence interval: 0.58-0.85). Age older than 65 years, commercial insurance (relative to Medicare), proximity to an in-network ED, and distance from an out-of-network ED also were significantly associated with use of in-network EDs relative to out-of-network EDs. Given the central role of the ED as a primary source of hospital admissions in the United States, emergency care represents a key potential target for interventions aimed at reducing patient leakage. Future efforts should aim to identify and evaluate new ways that emergency medical services can be leveraged to promote effective care coordination.
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Organizaciones Responsables por la Atención , Servicios Médicos de Urgencia , Anciano , Ambulancias , Servicio de Urgencia en Hospital , Humanos , Medicare , Estados UnidosRESUMEN
BACKGROUND: Unnecessary hospitalizations may pose the risk of iatrogenic complications, suboptimal patient experience, and increased cost. Administrative data lack granularity to understand the proportion and causes of hospitalizations preventable through optimizing care continuum (HPOCC). We aim to identify the incidence and causes of HPOCC through clinician-adjudicated chart review. METHODS: A retrospective review was performed for inpatient admissions from the emergency department (ED) over 1 week. Each admission was reviewed by a clinician to determine whether it is an HPOCC defined as not requiring inpatient care with the assumption of idealized outpatient care and social support. RESULTS: Of the 515 patients admitted from the ED, 31 (6.0%) patients were judged to have had an HPOCC. Causes of HPOCC include urgent diagnostics (9, 29.0%), unnecessary transfer from a long-term facility (7, 23.0%), needing IV therapy (5, 16.0%), benign incidental finding (5, 16.0%), diagnostic uncertainty in complex chronic illness (3, 10.0%), and lack of access to care for disposition (2, 6.0%). CONCLUSION: Hospitalizations preventable through optimizing care continuum account for about 1 in every 15 hospitalizations in an urban academic medical center. The need for urgent diagnostics accounts for a plurality of HPOCC and could be an important target for quality improvement.
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Atención Ambulatoria , Hospitalización , Continuidad de la Atención al Paciente , Servicio de Urgencia en Hospital , Humanos , Estudios RetrospectivosRESUMEN
High rates of asymptomatic coronavirus disease 2019 infection suggest benefits to routine testing in congregate care settings. Screening was undertaken in a single nursing facility without a known case of coronavirus disease 2019, demonstrating an 85% prevalence among residents and 37% among staff. Serology was not helpful in identifying infections.
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COVID-19 , SARS-CoV-2 , Infecciones Asintomáticas , Humanos , Reacción en Cadena en Tiempo Real de la Polimerasa , Instituciones de Cuidados Especializados de EnfermeríaRESUMEN
BACKGROUND: The passage of the Hospital Readmissions Reduction Program (HRRP) has been associated with been associated with decreased risk-standardized readmission rates for heart failure (HF) patients. However, some quantitative analyses have shown association between HRRP and increased mortality for hospitalized HF patients. Qualitative information on what hospital programs were actually implemented can help us understand if this trend is a causal effect of the law or an unrelated trend. PURPOSE: To perform a systematic literature review to synthesize evidence on what clinical programs American hospitals implemented in response to HRRP. METHODS: Following PRISMA guidelines, we conducted a systematic review in April 2020 that included a search of PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Literature (CINAHL) for studies related to hospital strategies to reduce HF readmissions. RESULTS: Of 20 included articles, 8 were qualitative (survey and interviews), 3 were systematic reviews, 5 were single site quality improvement (QI) initiatives, 2 were plans for ongoing randomized control trials (RCTs), one was a plan for a future RCT and one was an observational analysis. We found that interventions hospitals undertook in response to HRRP to reduce HF readmissions fell into four categories: inpatient care, discharge, transitional care and data collection/administration. The majority of interventions were related to transitional care, most commonly scheduling follow up appointments within 7-14 days of discharge, performing post-discharge phone calls and partnering with community physicians. CONCLUSIONS: We did not find any published evidence of practices that could mechanistically be linked to harm to HF patients enacted by hospitals in response to HRRP. For example, no programs encouraged emergency department providers to discharge patients from emergency departments. We found QI initiatives, improved discharge planning and increased post-discharge follow up.
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Insuficiencia Cardíaca , Readmisión del Paciente , Benchmarking , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/terapia , Hospitales , Humanos , Alta del Paciente , Estados UnidosRESUMEN
During the surge of Coronavirus Disease 2019 (COVID-19) infections in March and April 2020, many skilled-nursing facilities in the Boston area closed to COVID-19 post-acute admissions because of infection control concerns and staffing shortages. Local government and health care leaders collaborated to establish a 1000-bed field hospital for patients with COVID-19, with 500 respite beds for the undomiciled and 500 post-acute care (PAC) beds within 9 days. The PAC hospital provided care for 394 patients over 7 weeks, from April 10 to June 2, 2020. In this report, we describe our implementation strategy, including organization structure, admissions criteria, and clinical services. Partnership with government, military, and local health care organizations was essential for logistical and medical support. In addition, dynamic workflows necessitated clear communication pathways, clinical operations expertise, and highly adaptable staff.
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Conducta Cooperativa , Infecciones por Coronavirus/epidemiología , Unidades Móviles de Salud/organización & administración , Pandemias , Neumonía Viral/epidemiología , Anciano , Betacoronavirus , Boston/epidemiología , COVID-19 , Femenino , Humanos , Masculino , Persona de Mediana Edad , Admisión y Programación de Personal/organización & administración , SARS-CoV-2 , Instituciones de Cuidados Especializados de Enfermería , Atención SubagudaAsunto(s)
Enfermedades Asintomáticas/epidemiología , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/transmisión , Neumonía Viral/diagnóstico , Neumonía Viral/transmisión , Instituciones de Cuidados Especializados de Enfermería/organización & administración , Anciano , Anciano de 80 o más Años , Betacoronavirus , COVID-19 , Infecciones por Coronavirus/epidemiología , Brotes de Enfermedades , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/epidemiología , SARS-CoV-2 , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated. METHODS AND RESULTS: We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119). CONCLUSIONS: An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.
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Prestación Integrada de Atención de Salud/tendencias , Infarto del Miocardio/terapia , Paquetes de Atención al Paciente/tendencias , Readmisión del Paciente/tendencias , Mejoramiento de la Calidad/tendencias , Indicadores de Calidad de la Atención de Salud/tendencias , Anciano , Anciano de 80 o más Años , Atención Ambulatoria/tendencias , Boston , Servicio de Cardiología en Hospital/tendencias , Servicio de Urgencia en Hospital/tendencias , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Evaluación de Programas y Proyectos de Salud , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background Medicare's Hospital Readmissions Reduction Program assesses financial penalties to hospitals based on risk-standardized readmission rates after specific episodes of care, including acute myocardial infarction. Detailed information about the type of patients included in the penalty is unknown. Methods and Results Starting with administrative data from Medicare, we conducted physician-adjudicated chart reviews of all patients considered 30-day readmissions after acute myocardial infarction from July 2012 to June 2015. Of 197 readmissions, 68 (34.5%) received percutaneous coronary intervention and 18 (9.1%) underwent coronary artery bypass grafting on index hospitalization. The remaining 111 patients did not receive any intervention. Of the 197 patients, 56 patients (28.4%) were considered too high risk for invasive management, 23 (11.7%) had nonobstructive coronary artery disease on diagnostic catheterization and therefore no indication for revascularization, 19 patients had a type II myocardial infarction (9.6%) for which noninvasive, outpatient workup was recommended, and 13 (6.6%) declined further care. The most common readmission diagnoses were cardiac causes and noncardiac chest discomfort, infection, and gastrointestinal bleeding. Conclusions Our results demonstrate that more than a quarter of the patients included in the penalty do not receive revascularization either because of provider assessment of risk or patient preference, and nearly one tenth have type II myocardial infarction. As such, administrative codes for prohibitive procedural risk, patient-initiated "do not resuscitate" status, or type II myocardial infarction may improve the risk-adjustment of the metric. Furthermore, provider organizations seeking to reduce readmission rates should focus resources on the needs of these patients, such as care coordination, hospice services when requested by patients, and treatment of noncardiac conditions.
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Infarto del Miocardio/terapia , Readmisión del Paciente/estadística & datos numéricos , Ajuste de Riesgo/métodos , Anciano , Anciano de 80 o más Años , Codificación Clínica , Puente de Arteria Coronaria , Femenino , Hospitales , Humanos , Masculino , Medicare , Infarto del Miocardio/fisiopatología , Prioridad del Paciente , Intervención Coronaria Percutánea , Medición de Riesgo , Índice de Severidad de la Enfermedad , Estados UnidosAsunto(s)
Epididimitis/diagnóstico , Mycobacterium tuberculosis/aislamiento & purificación , Orquitis/diagnóstico , Testículo/patología , Tuberculosis de los Genitales Masculinos/diagnóstico , Anciano de 80 o más Años , Diagnóstico Diferencial , Edema/etiología , Epididimitis/microbiología , Epididimitis/patología , Humanos , Masculino , Orquiectomía , Orquitis/microbiología , Orquitis/patología , Enfermedades Testiculares/diagnóstico , Testículo/diagnóstico por imagen , Tuberculosis de los Genitales Masculinos/complicaciones , Tuberculosis de los Genitales Masculinos/patología , UltrasonografíaRESUMEN
The highest cost patients account for a disproportionately large share of American healthcare costs and are increasingly the focus of research and policy efforts to stem the rapid growth of these costs. These patients tend to be medically complex and frail, but we know little about how such characteristics influence healthcare spending from the perspectives of the patients and their caregivers. Therefore, we examined five of the highest cost patients at an academic medical center in a case series. We interviewed the patients, their family members, and their clinicians and analyzed their claims data and medical charts to explore how patient and health system characteristics influenced their health costs. We found that their complex medical issues, physical disability/frailty, and mental illness/substance use seemed to be linked with increased costs, while their socioeconomic status, social network, activation, and trust in clinicians and the health system appeared to increase or decrease costs depending on context. In these patients' narratives, trust seemed to modify the interaction between patient activation and cost. Our observations raise questions about whether factors mediating costs in high-cost patients may be more heterogenous than previously described and if patient trust and activation may be important, potentially modifiable drivers of these costs. Our case series illustrates the challenges of unilateral policies to address high cost patients and the need for targeted approaches.
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Enfermedad Crónica/economía , Enfermedad Crónica/psicología , Costos de la Atención en Salud/normas , Centros Médicos Académicos/organización & administración , Adulto , Anciano , Femenino , Humanos , Masculino , Asistencia Médica/economía , Persona de Mediana Edad , Clase Social , Estados UnidosRESUMEN
BACKGROUND: Patients with multiple chronic conditions have garnered particular attention from policymakers and health service researchers because these patients utilize more services and contribute disproportionally to rising health care expenses. The growing prevalence of patients with multiple chronic conditions has increased the importance of achieving better health care integration for this patient population. Patients may be well positioned to assess integration of their care, but the relationship between patients' perceptions of care integration and use of health services has not been studied. We sought to understand how patient-perceived integrated care relates to utilization of health services. METHODS: We fielded the Patient Perceptions of Integrated Care survey among a random sample of 3000 (<65 years) patients with multiple chronic conditions belonging to the Massachusetts General Hospital Physician Organization; 1503 responses were collected (50% response rate). We assessed relationships between provider performance on 11 domains of patient-reported integrated care and rates of emergency department (ED) visits, hospital admissions, and outpatient visits. RESULTS: Better performance on two of the surveyed dimensions of integrated care (information flow to other providers in your doctor's office and responsiveness independent of visits, p<0.05) was significantly associated with lower ED visit rates. Better performance on three dimensions of integrated care (information flow to your specialist, p<0.05, post-visit information flow to the patient, p<0.001, and continuous familiarity with patient over time, p<0.05) was associated with lower outpatient visit rates. No dimensions of integration were associated with hospital admission rates. CONCLUSIONS: In a single health system, patient perceptions of integrated care were associated with ED and outpatient utilization but not inpatient utilization. With further development, patient reports of integration could be useful guides to improving health system efficiency.
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Prestación Integrada de Atención de Salud/normas , Atención a la Salud/estadística & datos numéricos , Pacientes/psicología , Percepción , Anciano , Anciano de 80 o más Años , Atención Ambulatoria/estadística & datos numéricos , Enfermedad Crónica/epidemiología , Enfermedad Crónica/tendencias , Atención a la Salud/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Hospitales/estadística & datos numéricos , Humanos , Masculino , Massachusetts , Estados Unidos/epidemiologíaRESUMEN
Hospital readmissions are common and costly and, in some cases, may be related to problems with care processes. We sought to reduce readmissions after percutaneous coronary intervention (PCI) in a large tertiary care facility through programs to target vulnerabilities predischarge, after discharge, and during re-presentation to the emergency department. During initial hospitalization, we assessed patients' readmission risk with a validated risk score and used a discharge checklist to ensure access to appropriate medications and close follow-up for high-risk patients. We also developed patient education videos about chest discomfort and heart failure. After discharge, we established a new follow-up clinic with cardiology fellows. A computerized system was developed to automatically notify cardiologists when patients presented to the emergency department within 30 days of PCI to enhance patient access to cardiology care in the emergency department. Early cardiologist assessment and assistance with triage was encouraged, and the emergency department used a risk stratification algorithm derived from a local database of patients to triage patients presenting with chest discomfort after PCI. We tracked the number of patients readmitted after PCI to our hospital. With our interventions, from 2011 to 2015, the index hospital readmission rate has declined from 9.6% to 5.3%. This program could provide tangible structural changes that can be implemented in other healthcare centers, both reducing the cost of care and improving the quality of care for patients with PCI.