ABSTRACT
After discharge of premature infants with complex care needs from the neonatal intensive care unit, a care gap arises due to the transition from inpatient to outpatient care. Consequences can be rehospitalization, revolving door effects, and high costs. Therefore, following hospitalization or inpatient rehabilitation, the patient is intended to transition to sociomedical aftercare. The legal basis for this is formed by § 43 paragraph 2 of the Fifth Book of the German Social Code (SGB V). Over 80 aftercare institutions in Germany work according to the model of the Bunter Kreis. The comprehensive concept describes possibilities for networking which exceed the services provided by sociomedical aftercare. Simultaneously, depending on their stage of development, young adults can receive aftercare according to this model up to their 27th year of life. The interdisciplinary team at the Bunter Kreis comprises nurses, social workers, social education workers, psychologists, and specialist physicians. The largest group of supported persons, with 6000-8000 children per year, is comprised of premature and at-risk babies as well as multiple births, followed by 3000-5000 children with neurologic and syndromic diseases. Other common diseases are metabolic diseases, epilepsy, and diabetes, as well as children after trauma and with rare diseases. Overall, the various diseases sum up to around 20 clinical pictures. The current article presents the Bunter Kreis aftercare process based on case examples.
Subject(s)
Aftercare , Infant, Premature, Diseases , Intensive Care Units, Neonatal , Patient Discharge , Humans , Infant, Newborn , Germany , Aftercare/organization & administration , Infant, Premature, Diseases/therapy , Intersectoral Collaboration , Interdisciplinary Communication , Child, Preschool , Young Adult , Patient Readmission , Adult , Patient Care Team/organization & administration , Infant , Transition to Adult Care/organization & administration , National Health Programs/legislation & jurisprudence , Health Services Needs and Demand/organization & administration , Cooperative BehaviorABSTRACT
BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, hospitals and healthcare systems launched innovative responses to emerging needs. The creation and use of programs to remotely follow patient clinical status and recovery after COVID-19 hospitalization has not been thoroughly described. OBJECTIVE: To characterize deployment of remote post-hospital discharge monitoring programs during the COVID-19 pandemic METHODS: Electronic surveys were administered to leaders of 83 US academic hospitals in the Hospital Medicine Re-engineering Network (HOMERuN). An initial survey was completed in March 2021 with follow-up survey completed in July 2022. RESULTS: There were 35 responses to the initial survey (42%) and 15 responses to the follow-up survey (43%). Twenty-two (63%) sites reported a post-discharge monitoring program, 16 of which were newly developed for COVID-19. Physiologic monitoring devices such as pulse oximeters were often provided. Communication with medical teams was often via telephone, with moderate use of apps or electronic medical record integration. Programs launched most commonly between January and June 2020. Only three programs were still active at the time of follow-up survey. CONCLUSIONS: Our findings demonstrate rapid, ad hoc development of post-hospital discharge monitoring programs during the COVID-19 pandemic but with little standardization or evaluation. Additional study could identify the benefits of these programs, instruct their potential application to other disease processes, and inform further development as part of emergency preparedness for upcoming crises.
Subject(s)
COVID-19 , Humans , COVID-19/epidemiology , Telemedicine/organization & administration , Patient Discharge , Surveys and Questionnaires , United States/epidemiology , Hospital Medicine/methods , Pandemics , SARS-CoV-2 , Monitoring, Physiologic/methods , Hospitalization , Aftercare/methods , Aftercare/organization & administrationABSTRACT
BACKGROUND: Transportation influences attendance at posthospitalization appointments (PHAs). In 2017, our pediatric hospital medicine group found that our patients missed 38% of their scheduled PHAs, with several being due to transportation insecurity. To address this, we implemented a quality improvement project to perform inpatient assessment of transportation insecurity and provide mitigation with the goal of improving attendance at PHAs. METHODS: The process measure was the percentage of patients with completed transportation insecurity screening, and the outcome measure was PHA attendance. An interprofessional team performed plan-do-study-act cycles. These included educating staff about the significance of transportation insecurity, its assessment, and documentation; embedding a list of local transportation resources in discharge instructions and coaching families on using these resources; notifying primary care providers of families with transportation insecurity; and auditing PHA attendance. RESULTS: Between July 2018 and December 2019, electronic health record documentation of transportation insecurity assessment among patients on the pediatric hospital medicine service and discharged from the hospital (n = 1731) increased from 1% to 94%, families identified with transportation insecurity increased from 1.2% to 5%, and attendance at PHAs improved for all patients (62%-81%) and for those with transportation insecurity (0%-57%). Our balance measure, proportion of discharges by 2 pm, remained steady at 53%. Plan-do-study-act cycles revealed that emphasizing PHA importance, educating staff about transportation insecurity, and helping families identify and learn to use transportation resources all contributed to improvement. CONCLUSIONS: Interventions implemented during the inpatient stay to assess for and mitigate transportation insecurity led to improvement in pediatric PHA attendance.
Subject(s)
Aftercare/organization & administration , Aftercare/standards , Appointments and Schedules , Patient Discharge/standards , Quality Improvement , Transportation , Checklist , Hospitals, Pediatric/organization & administration , Hospitals, Pediatric/standards , Humans , MaineABSTRACT
BACKGROUND: Substance use disorders (SUDs), prevalent worldwide, are associated with significant morbidity and health care utilization. OBJECTIVES: To identify interventions addressing hospital and emergency department utilization among people with substance use, to summarize findings for those seeking to implement such interventions, and to articulate gaps that can be addressed by future research. RESEARCH DESIGN: A scoping review of the literature. We searched PubMed, PsycInfo, and Google Scholar for any articles published from January 2010 to June 2020. The main search terms included the target population of adults with substance use or SUDs, the outcomes of hospital and emergency department utilization, and interventions aimed at improving these outcomes in the target population. SUBJECTS: Adults with substance use or SUDs, including alcohol use. MEASURES: Hospital and emergency department utilization. RESULTS: Our initial search identified 1807 titles, from which 44 articles were included in the review. Most interventions were implemented in the United States (n=35). Half focused on people using any substance (n=22) and a quarter on opioids (n=12). The tested approaches varied and included postdischarge services, medications, legislation, and counseling, among others. The majority of study designs were retrospective cohort studies (n=31). CONCLUSIONS: Overall, we found few studies assessing interventions to reduce health care utilization among people with SUDs. The studies that we did identify differed across multiple domains and included few randomized trials. Study heterogeneity limits our ability to compare interventions or to recommend one specific approach to reducing health care utilization among this high-risk population.
Subject(s)
Emergency Service, Hospital/statistics & numerical data , Substance-Related Disorders/therapy , Aftercare/organization & administration , Alcoholism/therapy , Counseling/organization & administration , Hospitalization/economics , Hospitalization/statistics & numerical data , Humans , Substance-Related Disorders/economics , United StatesABSTRACT
Patients undergoing an allogeneic hematopoietic cell transplant (allo-HCT) need to understand and adhere to the transplant process as well as post-transplant follow-up requirements. A working group has met during the eleventh edition of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) Practice Harmonization Workshops. The analysis of a survey that was sent to several transplant centers belonging to the SFGM-TC has been used as a milestone to this article. While, post-transplant medical follow-up was comparable from one center to another, nursing care was found to lack harmonization between centers, although, all patients would receive therapeutic education at one time or another regarding potential transplant-related complications. A few centers in France has established a therapeutic education program that was approved by French health authorities. The aim of this work was to set up guidelines to help centers establishing such a program in well-harmonized way.
Subject(s)
Aftercare , Hematopoietic Stem Cell Transplantation/standards , Patient Compliance , Patient Education as Topic/standards , Aftercare/organization & administration , Aftercare/standards , France , Health Care Surveys , Hematopoietic Stem Cell Transplantation/adverse effects , Humans , Nursing Care/organization & administration , Nursing Care/standards , Postoperative Complications , Societies, Medical , Transplantation, HomologousABSTRACT
Importance: Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up. Objective: To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events. Design, Setting, and Participants: This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018. Main Outcomes and Measures: Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics. Results: This study included 1â¯131â¯722 patients (611â¯821 [54%] female; mean [SD] age, 43 [22] years) with 2â¯178â¯440 total appointments (307â¯888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type. Conclusions and Relevance: In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.
Subject(s)
Aftercare/organization & administration , Ambulatory Care/statistics & numerical data , Primary Health Care/organization & administration , Telemedicine/statistics & numerical data , Appointments and Schedules , Cohort Studies , Female , Humans , Male , Outcome Assessment, Health Care , Patient Acceptance of Health Care/statistics & numerical dataABSTRACT
BACKGROUND: Trauma care is associated with unplanned readmissions, which may occur at facilities other than the index treatment facility. This "fragmentation of care" may be associated with adverse outcomes. We evaluated a statewide database that includes readmissions to analyze the incidence and impact of FC. METHODS: The California Office of Statewide Health Planning and Development patient discharge data set was evaluated for calendar years 2016 to 2018. Patients 15 years or older diagnosed with blunt abdominal solid organ injury during the index admission were identified. Readmissions were evaluated postdischarge at 1, 3, and 6 months. Patients readmitted within 6 months to a facility other than the index admission facility (fragmented care [FC]) were compared with those readmitted to their index admission facility (non-FC). Logistic regression modeling was used to evaluate risk of FC. RESULTS: Of the total 1,580 patients, there were 752 FC (47.6%) and 828 (52.4%) non-FC. Readmissions representing FC at months 1, 3, and 6 were 40.3%, 49.3%, and 53.4%, respectively. At index admission, the groups were demographically and clinically similar, with similar rates of abdominal operations and complications. Non-FC patients had a higher rate of abdominal reoperation at readmission (5.8% non-FC vs. 2.9% FC, p = 0.006). In an adjusted model, multiple readmissions (odds ratio [OR] 1.11, p = 0.014), readmission >30 days after index facility discharge (OR, 1.98; p < 0.001), and discharge to a nonmedical facility (OR, 2.46; p < 0.0001) were associated with increased odds of FC. Operative intervention at index admission was associated with lower odds of FC (OR, 0.77; p = 0.039). However, FC was not independently associated with demographic or insurance characteristics. CONCLUSION: The rate of FC among patients with blunt abdominal injury is high. The risk of FC is mitigated when patients are managed operatively during the index admission. Trauma systems should implement measures to ensure that these patients are followed postdischarge. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III; Care management, level IV.
Subject(s)
Abdominal Injuries/surgery , Aftercare/organization & administration , Patient Readmission/statistics & numerical data , Trauma Centers/organization & administration , Wounds, Nonpenetrating/surgery , Adult , Aftercare/standards , Aftercare/statistics & numerical data , Aged , Female , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Patient Discharge/standards , Patient Discharge/statistics & numerical data , Quality Improvement/organization & administration , Quality Improvement/standards , Retrospective Studies , Risk Factors , Time Factors , Trauma Centers/standards , Trauma Centers/statistics & numerical data , United StatesABSTRACT
OBJECTIVE: To determine factors associated with completion of recommended outpatient follow-up visits in children with complex chronic conditions (CCCs) following hospital discharge. METHODS: We retrospectively identified children aged 1 to 17 years diagnosed with a CCC who were discharged from our rural tertiary care children's hospital between 2017 and 2018 with a diagnosis meeting published CCC criteria. Patients discharged from the neonatal intensive care unit and patients enrolled in a care coordination program for technology-dependent children were excluded. RESULTS: Of 113 eligible patients, 77 (68%) had outpatient follow-up consistent with discharge instructions. Intensive care unit (ICU) admission (P = .020) and prolonged length of stay (P = .004) were associated with decreased likelihood of completing recommended follow-up. CONCLUSIONS: Among children with CCCs who were not already enrolled in a care coordination program, ICU admission was associated with increased risk of not completing recommended outpatient follow-up. This population could be targeted for expanded care coordination efforts.
Subject(s)
Aftercare/organization & administration , Chronic Disease/epidemiology , Chronic Disease/therapy , Patient Discharge/statistics & numerical data , Child , Humans , Quality of Health Care , Risk Factors , Tertiary Care Centers/organization & administration , United StatesSubject(s)
Aftercare/organization & administration , Myocardial Infarction , Residence Characteristics , Social Determinants of Health/ethnology , Ethnicity , Health Equity/standards , Healthcare Disparities/ethnology , Humans , Myocardial Infarction/mortality , Myocardial Infarction/therapy , Survival AnalysisABSTRACT
ABSTRACT: Recently, activities of daily living (ADL) were identified as a prognostic factor among elderly patients with heart disease; however, a specific association between ADL and prognosis after cardiac and aortic surgery is not well established. We aimed to clarify the impact of ADL capacity at discharge on prognosis in elderly patients after cardiac and aortic surgery.This retrospective cohort study included 171 elderly patients who underwent open operation for cardiovascular disease in a single center (median age: 74âyears; men: 70%). We used the Barthel Index (BI) as an indicator for ADL. Patients were classified into 2 groups according to the BI at discharge, indicating a high (BI ≥ 85) or low (BIâ<â85) ADL status. All-cause mortality and unplanned readmission events were observed after discharge.Thirteen all-cause mortality and 44 all-cause unplanned readmission events occurred during the median follow-up of 365âdays. Using Kaplan-Meier analysis, a low ADL status was determined to be significantly associated with all-cause mortality and unplanned readmission. In the multivariable Cox proportional hazard models, a low ADL status was an independent predictor of all-cause mortality and unplanned readmission after adjusting for age, sex, length of hospital stay, and other variables (including preoperative status, surgical parameter, and postoperative course).A low ADL status at discharge predicted all-cause mortality and unplanned readmission in elderly patients after cardiac and aortic surgery. A comprehensive approach from the time of admission to postdischarge to improve ADL capacity in elderly patients undergoing cardiac and aortic surgery may improve patient outcomes.
Subject(s)
Activities of Daily Living , Cardiovascular Surgical Procedures , Patient Discharge , Patient Readmission/statistics & numerical data , Aftercare/methods , Aftercare/organization & administration , Aged , Cardiovascular Diseases/surgery , Cardiovascular Surgical Procedures/adverse effects , Cardiovascular Surgical Procedures/methods , Cardiovascular Surgical Procedures/mortality , Female , Humans , Japan/epidemiology , Kaplan-Meier Estimate , Length of Stay/statistics & numerical data , Male , Physical Functional Performance , Prognosis , Retrospective Studies , Risk Assessment/methods , Risk FactorsABSTRACT
BACKGROUND: Nearly 1-in-10 trauma patients in the United States are readmitted within 30 days of discharge, with a median hospital cost of more than $8,000 per readmission. There are national efforts to reduce readmissions in trauma care, but we do not yet understand which are potentially preventable. Our study aims to quantify the potentially preventable readmissions (PPRs) in trauma care to serve as the anchor point for ongoing efforts to curb hospital readmissions and ultimately, bring preventable readmissions to zero. METHODS: We identified inpatient hospitalizations after trauma and readmissions within 90 days in the 2017 National Readmissions Database (NRD). Potentially preventable readmissions were defined as the Agency for Healthcare Research and Quality-defined Ambulatory Care Sensitive Conditions, in addition to superficial surgical site infection, acute kidney injury/acute renal failure, and aspiration pneumonitis. Mean costs for these admissions were calculated using the NRD. A multivariable logistic regression model was used to characterize the relationship between patient characteristics and PPR. RESULTS: A total of 1,320,083 patients were admitted for trauma care in the 2017 NRD, and 137,854 (10.4%) were readmitted within 90 days of discharge. Of these readmissions, 22.7% were potentially preventable. The mean cost was $10,001/PPR, resulting in $313,802,278 in cost to the US health care system. Of readmitted trauma patients younger than 65 years, Medicaid or Medicare patients had 2.7-fold increased odds of PPRs compared with privately insured patients. Patients of any age with congestive heart failure had 2.9 times increased odds of PPR, those with chronic obstructive pulmonary disease or complicated diabetes mellitus had 1.8 times increased odds, and those with chronic kidney disease had 1.7 times increased odds. Furthermore, as the days from discharge increased, the proportion of readmissions due to PPRs increased. CONCLUSION: One-in-five trauma readmissions are potentially preventable, which account for more than $300 million annually in health care costs. Improved access to postdischarge ambulatory care may be key to minimizing PPRs, especially for those with certain comorbidities. LEVEL OF EVIDENCE: Economic and value-based evaluations, level II.
Subject(s)
Aftercare/organization & administration , Ambulatory Care/organization & administration , Hospital Costs/statistics & numerical data , Patient Readmission/economics , Wounds and Injuries/therapy , Aged , Comorbidity , Cost Savings , Databases, Factual/statistics & numerical data , Humans , Medicaid/economics , Medicaid/statistics & numerical data , Medicare/economics , Medicare/statistics & numerical data , Patient Readmission/statistics & numerical data , Retrospective Studies , Risk Factors , United States , Wounds and Injuries/economics , Wounds and Injuries/epidemiologySubject(s)
COVID-19/psychology , Mental Disorders/therapy , Mental Health , Primary Health Care/organization & administration , Aftercare/organization & administration , COVID-19/epidemiology , Counseling/organization & administration , Humans , Mental Disorders/epidemiology , Mental Disorders/psychology , Prevalence , United Kingdom/epidemiologyABSTRACT
BACKGROUND: Post-hospitalization transition interventions remain a priority in preventing rehospitalization. However, not all patients referred for readmission prevention interventions receive them. We sought to 1) define patient characteristics associated with non-receipt of readmission prevention interventions (among those eligible for them), and 2) determine whether these same patient characteristics are associated with hospital readmission at the state level. METHODS: We used state-wide data from the Maryland Health Services Cost Review Commission to determine patient-level factors associated with state-wide readmissions. Concurrently, we conducted a retrospective analysis of discharged patients referred to receive 1 of 3 post-discharge interventions between January 2013 and July 2019-a nurse transition guide, post-discharge phone call, or follow-up appointment in our post-discharge clinic-to determine patient-level factors associated with not receiving the intervention. Multivariable generalized estimating equation logistic regression models were used to calculate the odds of not accepting or not receiving the interventions. RESULTS: Older age, male gender, black race, higher expected readmission rate, and lower socioeconomic status were significantly associated with 30-day readmission in hospitalized Maryland patients. Most of these variables (age, sex, race, payer type [Medicaid or non-Medicaid], and socioeconomic status) were also associated with non-receipt of intervention. CONCLUSIONS: We found that many of the same patient-level characteristics associated with the highest readmission risk are also associated with non-receipt of readmission reduction interventions. This highlights the paradox that patients at high risk of readmission are least likely to accept or receive interventions for preventing readmission. Identifying strategies to engage hard-to-reach high-risk patients continues to be an unmet challenge in readmission prevention.
Subject(s)
Aftercare , Patient Acceptance of Health Care/statistics & numerical data , Patient Readmission/statistics & numerical data , Patient Transfer , Preventive Health Services/methods , Aftercare/methods , Aftercare/organization & administration , Aftercare/statistics & numerical data , Aged , Continuity of Patient Care , Female , Humans , Male , Maryland/epidemiology , Patient Discharge , Patient Transfer/methods , Patient Transfer/statistics & numerical data , Risk Assessment , Sex Factors , Socioeconomic FactorsSubject(s)
Aftercare/organization & administration , COVID-19 , Nervous System Diseases/therapy , Neurology/organization & administration , Patient Satisfaction , Telemedicine/organization & administration , Adult , Aftercare/standards , Aged , Female , Hospitals, Teaching , Humans , Male , Mexico , Middle Aged , Neurology/standards , Program Development , Telemedicine/instrumentation , Telemedicine/standardsABSTRACT
OBJECTIVES: Transitional care program refers to the health care continuity during transferring from one health care setting to another or to home. This is an essential program for cancer patients and reduces the risk of unnecessary hospital admissions as well as the complications of the disease. The aim of this study was to develop a transitional cancer care program from hospital to home in the health care system of Iran. METHODS: This study is a health policy and system research. It was conducted in four stages from October 2019 to January 2020. The first stage was a qualitative study. The qualitative data were collected through semi-structured interviews with 24 participants and a focus group with eight experts. In the second stage, a literature review of transitional care models was carried out. The initial version of the transitional cancer care program was developed based on the qualitative results and the literature review in the third stage. The validity and feasibility of the program were assessed using the Delphi study in the fourth stage. RESULTS: Six major categories were extracted from the qualitative results, consisting of "integrated services for the continuity of care", "holistic care", "care standardization", "the use of telemedicine", "the transparency of rules" and "the care process provision". Using these results and extracted the three common models of transitional care, the initial program was developed in three phases of pre-discharge, post-discharge, and transitional care with six protocols. The content validity of the program (98.7%) and its feasibility (95.8%) were approved by experts in the Delphi rounds. CONCLUSIONS: It is necessary to revise hospitals' discharge program, and home health care center's plan for admission and delivering health care services for cancer patients. Also, a pilot program is necessary to find the system advantages and disadvantages.
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Subject(s)
Aftercare/organization & administration , Delivery of Health Care/organization & administration , Home Care Services/organization & administration , Transitional Care/organization & administration , Adult , Female , Focus Groups , Health Policy , Humans , Iran , Male , Middle Aged , Patient Discharge , Qualitative ResearchABSTRACT
BACKGROUND: Childhood cancer survivors (CCSs) face increased risks during the period when they leave pediatric care and transition into adult-focused aftercare. We examined the experiences of CCSs entering adult-focused aftercare to gain a better understanding of current transition practices and barriers to transition, and to identify opportunities for improving care. METHODS: We conducted a qualitative study using in-person and telephone semi-structured interviews. Childhood cancer survivors who recently transitioned out of pediatric care and health care providers (HCPs) who provide care for CCSs in Newfoundland and Labrador were identified using purposive sampling. Participants were interviewed between July 2017 and March 2019. Data were analyzed using both qualitative descriptive and thematic analysis. RESULTS: We conducted interviews with 5 CCSs and 9 HCPs. All CCSs interviewed reported receiving aftercare through their pediatric oncology program; only 2 reported receiving any form of aftercare in the adult setting. The lack of a structured transition process for CCSs in the province emerged as a theme in this study. Interview participants identified several barriers to transition: the added challenges for survivors in rural areas, changes in the availability of services after the transition to adult-focused aftercare, challenges associated with navigating the adult system, and a lack of education on transitioning into adult aftercare. INTERPRETATION: We found that there was little preparation for the transition of CCSs into adult care, and their aftercare was disrupted. Programs serving CCSs have opportunities to improve care by standardizing and better supporting these transitions, for example through the development of context-appropriate educational resources.
Subject(s)
Aftercare , Child Health Services/standards , Health Services Accessibility/standards , Neoplasms , Psychosocial Support Systems , Adolescent , Aftercare/methods , Aftercare/organization & administration , Aftercare/psychology , Cancer Survivors/psychology , Cancer Survivors/statistics & numerical data , Child , Female , Health Services Needs and Demand , Humans , Male , Neoplasms/epidemiology , Neoplasms/psychology , Neoplasms/therapy , Newfoundland and Labrador/epidemiology , Qualitative Research , Quality Improvement , Reference Standards , Rural Health/standards , Transition to Adult Care/organization & administration , Transitional Care/standardsABSTRACT
BACKGROUND: The symptoms, radiography, biochemistry and healthcare utilisation of patients with COVID-19 following discharge from hospital have not been well described. METHODS: Retrospective analysis of 401 adult patients attending a clinic following an index hospital admission or emergency department attendance with COVID-19. Regression models were used to assess the association between characteristics and persistent abnormal chest radiographs or breathlessness. RESULTS: 75.1% of patients were symptomatic at a median of 53 days post discharge and 72 days after symptom onset and chest radiographs were abnormal in 47.4%. Symptoms and radiographic abnormalities were similar in PCR-positive and PCR-negative patients. Severity of COVID-19 was significantly associated with persistent radiographic abnormalities and breathlessness. 18.5% of patients had unscheduled healthcare visits in the 30 days post discharge. CONCLUSIONS: Patients with COVID-19 experience persistent symptoms and abnormal blood biomarkers with a gradual resolution of radiological abnormalities over time. These findings can inform patients and clinicians about expected recovery times and plan services for follow-up of patients with COVID-19.
Subject(s)
Aftercare , Biomarkers/analysis , COVID-19 , Patient Discharge/standards , Radiography, Thoracic , Symptom Assessment , Aftercare/methods , Aftercare/organization & administration , COVID-19/blood , COVID-19/diagnostic imaging , COVID-19/epidemiology , COVID-19/physiopathology , Female , Humans , Male , Middle Aged , Patient Acceptance of Health Care/statistics & numerical data , Radiography, Thoracic/methods , Radiography, Thoracic/statistics & numerical data , Recovery of Function , Retrospective Studies , SARS-CoV-2 , Severity of Illness Index , Symptom Assessment/methods , Symptom Assessment/statistics & numerical data , Time Factors , United Kingdom/epidemiologyABSTRACT
Survivors of COVID-19 are a vulnerable population, with complex needs because of lingering symptoms and complications across multiple organ systems. Those who required hospitalization or intensive care are also at risk for post-hospital syndrome and post-ICU syndromes, with attendant cognitive, psychological, and physical impairments, and high levels of health care utilization. Effective ambulatory care for COVID-19 survivors requires coordination across multiple subspecialties, which can be burdensome if not well coordinated. With growing recognition of these needs, post-COVID-19 clinics are being created across the country. We describe the design and implementation of multidisciplinary post-COVID-19 clinics at two academic health systems, Johns Hopkins and the University of California-San Francisco. We highlight components of the model which should be replicated across sites, while acknowledging opportunities to tailor offerings to the local institutional context. Our goal is to provide a replicable framework for others to create these much-needed care delivery models for survivors of COVID-19.
Subject(s)
Aftercare/organization & administration , COVID-19 , Outpatient Clinics, Hospital/organization & administration , Survivors , COVID-19/therapy , Hospital Design and Construction , Humans , Time FactorsABSTRACT
INTRODUCTION: In 2016, under its new National Adherence Guidelines (AGL), South Africa formalized an existing model of fast-track HIV treatment initiation counselling (FTIC). Rollout of the AGL included an evaluation study at 24 clinics, with staggered AGL implementation. Using routinely collected data extracted as part of the evaluation study, we estimated and compared the costs of HIV care and treatment from the provider's perspective at the 12 clinics implementing the new, formalized model (AGL-FTIC) to costs at the 12 clinics continuing to implement some earlier, less formalized, model that likely varied across clinics (denoted here as early-FTIC). METHODS: This was a cost-outcome analysis using standard methods and a composite outcome defined as initiated antiretroviral therapy (ART) within 30 days of treatment eligibility and retained in care at 9 months. Using patient-level, bottom-up resource-utilization data and local unit costs, we estimated patient-level costs of care and treatment in 2017 U.S. dollars over the 9-month evaluation follow-up period for the two models of care. Resource use and costs, disaggregated by antiretroviral medications, laboratory tests, and clinic visits, are reported by model of care and stratified by the composite outcome. RESULTS: A total of 350/343 patients in the early-FTIC/AGL-FTIC models of care are included in this analysis. Mean/median costs were similar for both models of care ($135/$153 for early-FTIC, $130/$151 for AGL-FTIC). For the subset achieving the composite outcome, resource use and therefore mean/median costs were similar but slightly higher, reflecting care consistent with treatment guidelines ($163/$166 for early-FTIC, $168/$170 for AGL-FTIC). Not surprisingly, costs for patients not achieving the composite outcome were substantially less, mainly because they only had two or fewer follow-up visits and, therefore, received substantially less ART than patients who achieved the composite outcome. CONCLUSION: The 2016 adherence guidelines clarified expectations for the content and timing of adherence counseling sessions in relation to ART initiation. Because clinics were already initiating patients on ART quickly by 2016, little room existed for the new model of fast-track initiation counseling to reduce the number of pre-ART clinic visits at the study sites and therefore to reduce costs of care and treatment. TRIAL REGISTRATION: Clinical Trial Number: NCT02536768.