Using Patient Experience Survey Data to Improve In-Center Hemodialysis Care: A Practical Review.

Patient experience is an integral aspect of the care we deliver to our dialysis patients. Standardized evaluation of patient experience with in-center hemodialysis started in the United States in 2012 with the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey. Over time there have been a few changes to this survey, how it is administered, and how it fits within the Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program. Although the importance of this survey has been growing, knowledge of this survey among nephrologists has lagged. We provide a review of the survey development and how its use has evolved since 2012. We discuss in detail research done on this survey to date, including survey psychometric evaluation. We highlight gaps in our knowledge that need further research and end with general recommendations to improve patient experience within hemodialysis facilities, which we believe is a worthy goal for all members of the dialysis team.

Trends in Opioid Prescribing for Adolescents and Young Adults in Ambulatory Care Settings.

BACKGROUND: Adolescents and young adults are at high risk for opioid misuse after exposure from medical treatment. However, the epidemiology of opioid prescribing among outpatient adolescents and young adults remains poorly described. We aimed to characterize opioid prescribing in adolescents and young adults receiving care in emergency departments (EDs) and outpatient clinics. METHODS: We analyzed National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data from 2005 to 2015. We included visits to EDs and outpatient clinics for adolescents (13-17 years old) and young adults (18-22 years old). Rates of opioid prescribing were calculated with 95% confidence intervals (CIs), and linear trends over time were examined with logistic regression models. RESULTS: Nearly 57 million visits (5.7%; 95% CI 5.4% to 6.0%) by adolescents and young adults were associated with an opioid prescription. The rate of opioid prescribing was 14.9% (95% CI 14.4% to 15.6%) for ED visits and 2.8% (95% CI 2.5% to 3.1%) for outpatient clinic visits. There was a small but significant decrease in the rate of opioid prescriptions among ED visits (odds ratio 0.96; 95% CI 0.95 to 0.98); no change was seen for outpatient clinic visits. Among ED visits, opioid-prescribing rates were highest among adolescents and young adults with dental disorders (59.7% and 57.9%, respectively), followed by adolescents with clavicle (47.0%) and ankle fractures (38.1%). CONCLUSIONS: Rates of opioid prescribing in EDs and outpatient clinics remain high for adolescents and young adults, especially for certain emergency conditions. These findings inform targeted educational campaigns aiming to ensure judicious use of opioids in this high-risk population.

Patient Satisfaction with Clinicians and Short-Term Mortality in a US National Sample: the Roles of Morbidity and Gender.

BACKGROUND: In a prior study, we found patient satisfaction was associated with mortality. However, that study included few deaths, yielding wide confidence intervals, was criticized for possible morbidity under-adjustment, and lacked power to explore sociodemographic moderation. OBJECTIVE: To revisit the satisfaction-mortality association in a larger national sample, allowing more precise risk estimates, sequential morbidity adjustment, and exploration of sociodemographic moderation. DESIGN: Prospective cohort study. PARTICIPANTS: 2000-2015 Adult Medical Expenditures Panel Surveys (MEPS) respondents (N = 92,952), each enrolled for 2 consecutive years. MAIN MEASURES: We used five Consumer Assessment of Health Plans Survey (CAHPS) items to assess patients' year 1 satisfaction with their clinicians. Death during the 2 years of MEPS participation was determined by proxy report. We modeled the satisfaction-mortality association in sequential regressions: model 1 included sociodemographics, model 2 added health status (approximating recommended CAHPS adjustment), and model 3 added smoking status, disease burden, and healthcare utilization. KEY RESULTS: Satisfaction was not associated with mortality in model 1. In model 2, higher satisfaction was associated with higher mortality (hazard ratios [95% CIs] for 2nd, 3rd, and 4th (top) quartiles vs. 1st quartile: 1.28 (1.01, 1.62), P = 0.04; 1.43 (1.12, 1.82), P = 0.004; and 1.57 (1.25, 1.98), P < 0.001, respectively). The associations were not attenuated in model 3. There was a significant interaction between gender and satisfaction (F[3, 443] = 3.62, P = 0.01). The association between satisfaction and mortality was significant in women only, such that their mortality advantage over men was eliminated in the highest satisfaction quartile. CONCLUSIONS: The association of higher patient satisfaction with clinicians with higher short-term mortality was evident only after CAHPS-recommended adjustment, was not attenuated by further morbidity adjustment, and was evident in women but not men. The findings suggest that characteristics among women who are more satisfied with their clinicians may be associated with increased mortality risk.

Mapping the UK renal psychosocial workforce: the first comprehensive workforce survey.

BACKGROUND: Emerging evidence of psychosocial problems in CKD patients has led to an acceptance that a focus on the emotional wellbeing of the patient should be included in the provision of comprehensive CKD care. It is unclear if an increased attention for psychosocial needs in guidelines and policy documents has led to a rise in psychosocial staffing levels or change in composition of staff since the last workforce mapping in 2002. This paper offers a critical analysis and in-depth discussion of findings and their implications, in addition to providing an international perspective and exposing gaps in current knowledge. METHODS: Data on psychosocial staffing levels was taken from a survey based on the Scottish Renal Association's (SRA) staffing survey that was sent to all units in England, Wales and Northern-Ireland in 2016. In addition, data from a psychosocial staffing survey designed by and distributed via psychosocial professional groups was used. This data was then completed with Freedom of Information (FOI) requests and collated to describe the current renal psychosocial workforce in all 84 UK renal units. This was compared to results from the last renal workforce mapping in 2002. RESULTS: The results from this mapping show great variability in models of service provision, significant exceeding of benchmarks for staffing levels, and a change in staffing patterns over the past 15 years. Adult psychology services have increased in number, but provision remains low due to increased patient numbers, whereas adult social work and paediatric services have decreased. CONCLUSION: A lack in the provision of renal psychosocial services has been identified, together with the absence of a general service provision model. These findings provide a valuable benchmark for units, a context from which to review and monitor provision alongside patient need. Along with recommendations, this paper forms a foundation for future research and workforce planning. Research into best practice models of service provision and the psychosocial needs of CKD patients lies at the heart of the answers to many identified questions.

Use of CT for Head Trauma: 2007-2015.

BACKGROUND AND OBJECTIVES: International efforts have been focused on identifying children at low risk of clinically important traumatic brain injury in whom computed tomography (CT) neuroimaging can be avoided. We sought to determine if CT use for pediatric head trauma has decreased among US emergency departments (EDs). METHODS: This was a cross-sectional analysis of the National Hospital Ambulatory Care Medical Survey database of nationally representative ED visits from 2007 to 2015. We included children <18 years of age evaluated in the ED for head injury. Survey weighting procedures were used to estimate the annual proportion of children who underwent CT neuroimaging and to perform multivariable logistic regression. RESULTS: There were an estimated 14.3 million pediatric head trauma visits during the 9-year study period. Overall, 32% (95% confidence interval [CI]: 29%-35%) of children underwent CT neuroimaging with no significant annual linear trend (P trend = .50). Multivariate analysis similarly revealed no difference by year (adjusted odds ratio [aOR]: 1.02; 95% CI: 0.97-1.07) after adjustment for patient- and ED-level covariates. CT use was associated with age ≥2 years (aOR: 1.51; 95% CI: 1.13-2.01), white race (aOR: 1.43; 95% CI: 1.10-1.86), highest triage acuity (aOR: 8.24 [95% CI: 4.00-16.95]; P < .001), and presentation to a nonteaching (aOR: 1.47; 95% CI: 1.05-2.06) or nonpediatric (aOR: 1.53; 95% CI: 1.05-2.23) hospital. CONCLUSIONS: CT neuroimaging did not decrease from 2007 to 2015. Findings suggest an important need for quality improvement initiatives to decrease CT use among children with head injuries.

Transition Planning Among US Youth With and Without Special Health Care Needs.

BACKGROUND: Researchers have shown that most youth with special health care needs (YSHCN) are not receiving guidance on planning for health care transition. This study examines current transition planning among US youth with and without special health care needs (SHCN). METHODS: The 2016 National Survey of Children's Health is nationally representative and includes 20 708 youth (12-17 years old). Parents and/or caregivers were asked if transition planning occurred, based on the following elements: (1) doctor or other health care provider (HCP) discussed the eventual shift to an HCP who cares for adults, (2) an HCP actively worked with youth to gain self-care skills or understand changes in health care at age 18, and (3) youth had time alone with an HCP during the last preventive visit. Sociodemographic and health system characteristics were assessed for associations with transition planning. RESULTS: Nationally, 17% of YSHCN and 14% of youth without SHCN met the overall transition measure. Older age (15-17 years) was the only sociodemographic factor associated with meeting the overall transition measure and individual elements for YSHCN and youth without SHCN. Other sociodemographic characteristics associated with transition planning differed among the 2 populations. Receipt of care coordination and a written plan was associated with transition planning for YSHCN. CONCLUSIONS: This study reveals that few youth with and without SHCN receive transition planning support. It underscores the need for HCPs to work with youth independently and in collaboration with parents and/or caregivers throughout adolescence to gain self-care skills and prepare for adult-focused care.

The Medical Home and Health Care Transition for Youth With Autism.

BACKGROUND: Our objective in this study was to describe the association between the receipt of health care transition services (HCTS) and having a medical home in youth with autism spectrum disorder (ASD). Youth with ASD receive HCTS less often than other youth with special health care needs but are in particular need of continuous, comprehensive health care. METHODS: We used the National Survey of Children with Special Health Care Needs to describe the receipt of HCTS in youth with ASD and its association with presence of a medical home. Descriptive statistics are presented, and logistic regression is used to assess the association between medical home and HCTS. RESULTS: Twenty-one percent of youth with ASD met the criteria for receiving HCTS. Youth with ASD and a medical home were almost 3 times as likely to receive HCTS as youth without a medical home, and youth who received family-centered care and have adequate care coordination within the medical home were more than twice as likely to receive HCTS as those who did not. CONCLUSIONS: Youth with ASD are not receiving HCTS at the same rate as their peers. Increasing provider awareness of autism, the components of a medical home, and of the importance of HCTS could greatly help increase the percentage of youth who receive effective HCTS.

Retrospective Analysis of Physician-based Surveys Published in OPRS.

PURPOSE: To review physician-based clinical surveys published in Ophthalmic Plastic and Reconstructive Surgery. METHODS: Complementary Ovid and PubMed searches of Ophthalmic Plastic and Reconstructive Surgery journal content were performed for the term "survey." Results were narrowed to studies that specifically addressed physicians' clinical practices. This search resulted in 162 articles, and after dual-investigator independent screening, 13 surveys met inclusion criteria. RESULTS: Of the 13 surveys published from 2007 to January 2017, 6 were published since 2015, showing an increased trend in survey-based publications. Topics included assessing practice patterns regarding eyelid disorders, thyroid eye disease, optic nerve sheath fenestration, anophthalmic socket, and diagnosing lacrimal disorders. Average response rate was 38.7% (range 17.5-60%), with 201 average number of replies (range 72-310). Nine out of 13 surveys included some form of statistical analysis with the remainder presenting data in percentages. CONCLUSIONS: There has been an increased rate of survey-type publications in Ophthalmic Plastic and Reconstructive Surgery over the past 10 years. The low response rate and frequent lack of statistical analysis raise concerns regarding the validity and usefulness of such studies. The authors believe that survey studies can be improved through better standardization and the use of author guidelines. They have made specific recommendations to improve the impact of survey papers in the future.

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois.

INTRODUCTION: This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012-2013) pre-ACA period and a 24-month post-ACA (2014-2015) period across 88 socioeconomically diverse areas of Illinois. METHODS: We used annual American Community Survey estimates for 2012-2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18-64 residents. Over 12 million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents of each PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. We then estimated n=88 correlations between population insurance-status changes and changes in ED visit rates per 1,000 residents comparing the two years before and after ACA implementation. RESULTS: The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductions in uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment. Compared to 2012-2013, 2014-2015 average monthly ED visits by the uninsured dropped 42%, but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increases in Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollment was the only significant correlate of area change in total ED visits and explained a third of variation across the 88 PUMAs. CONCLUSION: ACA implementation in Illinois accelerated existing trends towards greater use of hospital ED care. It remains to be seen whether providing better access to primary and preventive care to the formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a part of continued, long-term growth. Monitoring ED use at the local level is critical to the success of new home- and community-based care coordination initiatives.

Alcohol-Related Visits to US Emergency Departments, 2001-2011.

AIMS: Alcohol intoxication is a source of significant illness and injury commonly resulting in emergency department (ED) visits. We characterize recent trends in alcohol-related visits to US EDs using nationally representative data. METHODS: We conducted a retrospective review of data on national ED visits among patients aged 18 years or older with alcohol intoxication between 2001 and 2011 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Demographic and resource utilization trends in alcohol-related visits were examined. We also assessed ED length of stay (LOS) across the study period, as well as the total hours spent on ED care for alcohol-related complaints. RESULTS: Between 2001-2002 and 2010-2011, alcohol-related visits increased from 2,459,748 to 3,856,346 (P = 0.049). Utilization of resources such as laboratory tests, medications and radiography increased, with the use of advanced imaging (i.e. computed tomography and magnetic resonance imaging) increasing 232.2% (P < 0.001) from 2001-2002 to 2010-2011. Overall LOS increased 16.1% (P = 0.028), while LOS among patients admitted to the hospital increased 24.9% (P = 0.076). Total alcohol-related hours spent in EDs nationwide increased from 5.6 million in 2001 to 11.6 million in 2011, an increase of 108.5% (P < 0.001) compared with an increase in overall ED hours of 54.0% (P < 0.001). CONCLUSION: Alcohol-related ED visits are increasing at a greater rate than overall ED visits and represent a growing burden on hospital resources.

National Trends in Outpatient Antihypertensive Prescribing in People with Dementia in the United States.

OBJECTIVE: The objectives were to investigate national trends in outpatient antihypertensive prescribing in people with dementia in the United States between 2006 and 2012, and to investigate clinical and demographic factors associated with different antihypertensive prescribing patterns. METHODS: This was an analysis of the National Ambulatory Medical Care Survey (NAMCS) and the outpatient department component of the National Hospital Ambulatory Medical Care Survey (NHAMCS). Outpatient visits by people aged ≥65 years with documented dementia were analyzed. Complex samples multivariate logistic regression was conducted to estimate temporal trends and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) for factors associated with prescribing of antihypertensives, multiple antihypertensives and different antihypertensive classes. RESULTS: There was a statistically significant increase in the proportion of physician visits by older people with dementia with a documented diagnosis of hypertension from 49.3% (95% CI: 41.3% -57.4%) in 2006 to 55.7% (95% CI: 50.2% -61.2%) in 2012. There were non-significant increases in overall antihypertensive use and the use of multiple antihypertensive classes. Male sex was associated with any antihypertensive use (AOR 1.37, 95% CI 1.02-1.84) and multiple antihypertensive class use (AOR 1.52, 95% CI 1.14-2.04). Black race (AOR 2.04, 95% CI 1.12-3.71) and Midwest residence (AOR 2.03, 95% CI 1.46-2.82) were associated with multiple antihypertensive use. CONCLUSION: There was an increase in documented hypertension in physician visits by older people with dementia from 2006 to 2012, but minimal increases in overall antihypertensive use. Various demographic and clinical factors were associated with the prescribing of antihypertensives in people with dementia.

ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education-2015.

PURPOSE: The results of the 2015 ASHP national survey of pharmacy practice in hospital settings are presented. METHODS: A stratified random sample of pharmacy directors at 1432 U.S. general and children's medical-surgical hospitals were surveyed using a mixed-mode method. IMS Health supplied data on hospital characteristics; the survey sample was drawn from IMS's hospital database. RESULTS: The survey response rate was 22.7%. Since the 2000 survey, the proportion of hospitals reporting that pharmacists monitor at least 75% of patients has increased from 20.3% to 57.8%. The use of therapeutic drug monitoring has increased from 63.0% to 70.6% since the 2012 survey. The percentage of hospitals reporting that pharmacists have primary responsibility for discharge counseling has increased from 1.2% to 7.3% since the 2012 survey, with 33.8% of hospitals reporting pharmacist counseling of at-risk patients. Virtually all hospitals (97.5%) have partially or completely implemented electronic health records; most have computerized prescriber-order-entry (84.1%) and barcode-assisted medication administration (93.7%) systems. At an increasing percentage of hospitals (86.2% in the 2015 survey), medication orders are reviewed by a pharmacist before a dose is made available and administered to a patient. CONCLUSION: The role of pharmacists in measuring, monitoring, and managing medication use in health systems continues to be significant, important, and growing. The evolution of electronic health information and technologies that make this information more readily available to patients is transforming healthcare in a positive way and enabling pharmacists to more efficiently contribute to improving medication use.

Altered treatment of chronic lymphocytic leukemia in Germany during the last decade.

Chronic lymphocytic leukemia (CLL) is the most common subtype of adult leukemia in the western world. We here report a nationwide survey monitoring the treatment decisions concerning CLL patients in Germany in 2011 and compare treatment trends to sequential surveys performed previously during the last decade. The rate of patients diagnosed in early stages (Binet A/B) notably increased (2006: 66 %, 2009: 71 %, 2011: 77 %) over the years. From 2006 to 2009, the most frequent applied regime switched from chlorambucil to fludarabine containing regimes (2006 chlorambucil: 32 %, 2009: 14 %, fludarabine 2006: 23 %, 2009: 37 %). In 2011, the combination of rituximab with bendamustine (31 %) was most frequent used followed by the rituximab-fludarabine-cyclophosphamide (22 %) regime. Further, immune-chemotherapies were administered significantly more often over the observation period (2006: 15 %, 2011: 73 %). Taken together, this data reflects the change of treatment strategies over the last decade in clinical reality.

[HBSC Study as an Instrument for Health Reporting among Children and Adolescents - Potential and Limitations]. / HBSC-Studie als Instrument der Gesundheitsberichterstattung im Kindes- und Jugendalter - Potenziale und Grenzen.

Prevention and health promotion have to target children and adolescents. Health reporting significantly contributes to assess the needs in terms of intervention planning in children and adolescents and to plan interventions of the highest priority. In Germany, reporting on children and adolescent's health takes place at federal, federal state and regional levels. Health reporting is based on surveys or monitoring, official statistics or on other data provided by institutions and stakeholders in the health system. The nationally representative Health Behaviour in School-Aged Children (HBSC) survey under the auspices of the WHO - which has been conducted every 4 years since 1982, is a further database in Germany that is representative for the 11-15-year olds girls and boys from general educational schools. In this paper, the HBSC survey will be located within the canon of the German health reporting system. A special emphasis is to describe the potential and limitations of HBSC study for health reporting and to highlight the additional value for health reporting in Germany.

Motivos de derivación a una consulta ambulatoria de Traumatología Infantil / A Paediatric Orthopaedic outpatient clinic referral patterns

INTRODUCCIÓN: El objetivo de este estudio fue conocer los motivos de consulta más frecuentes en una consulta de Traumatología Infantil de un Centro de Especialidades y así poder mejorar el programa de formación de los residentes de Pediatría en el manejo de problemas músculo-esqueléticos. MATERIAL Y MÉTODOS: Se recogieron prospectivamente los motivos de consulta, la edad, el sexo y el diagnostico final de todos los pacientes menores de 15 años derivados a una consulta específica de Traumatología Infantil de un Centro de Especialidades. RESULTADOS: Los motivos de consulta más frecuentes fueron el dolor músculo-esquelético (37%), valorar una posible deformidad de los pies (20%), una posible deformidad de la columna (15%), el patrón de marcha (11%), la alineación de los miembros inferiores (4%) y el desarrollo de la cadera (4%). El 42% de los pacientes presentaron una exploración normal o una variante de la normalidad. El 17% de los pacientes presentaron una patología que únicamente requiere ser valorada por parte de Traumatología Infantil si un tratamiento previo con antiinflamatorios no esteroideos o rehabilitación no resuelve la sintomatología. El 8% presentaba una deformidad que solo requiere tratamiento si es sintomática. CONCLUSIONES: La mayoría de las consultas correspondieron a variantes de la normalidad o a condiciones leves que solo precisan tratamiento sintomático. El programa de formación de la residencia de Pediatría no refleja la prevalencia de los problemas músculo-esqueléticos en la práctica clínica diaria

INTRODUCTION: The aim of this study was to identify the commonest referrals to a paediatric orthopaedic outpatient clinic and, therefore, to be able to improve the paediatric residency program in managing musculoskeletal problems. MATERIAL AND METHODS: Demographic data, referrals and final diagnosis were collected prospectively on all patients that were evaluated in a paediatric orthopaedic outpatient clinic. RESULTS: The majority of referrals were to evaluate musculoskeletal pain (37%), foot deformity (20%), spine deformity (15%), walking pattern (11%), alignment of the lower limbs (4%), and development of the hip (4%). A normal physical examination or a normal variation was observed in 42% of patients. A mild condition was observed in 17% of patients that should have only been referred to a paediatric orthopaedic clinic after failing to resolve pain with anti-inflammatories or physiotherapy. A mild deformity that only needed treatment if it became symptomatic was seen in 8% of patients. CONCLUSIONS: The majority of referrals were due to a normal variation or mild conditions that only required symptomatic treatment. Paediatric residency programs do not reflect the prevalence of musculoskeletal conditions in clinical practice

Risky Drinking, Alcohol Use Disorders, and Health Services Utilization in the U.S. General Population: Data from the 2005 and 2010 National Alcohol Surveys.

BACKGROUND: While alcohol-related problems have been found to be overrepresented in clinical samples of patients, less is known about health services utilization in the general population. METHODS: To explore the association of risky drinking and alcohol use disorders (AUD) with inpatient and outpatient services utilization, data are analyzed from a merged sample of 13,165 respondents in the 2005 and 2010 U.S. National Alcohol Surveys. Propensity score weighting was used to minimize potential bias associated with the heterogeneity in individual-level characteristics across respondents which might influence these relationships. RESULTS: No significant differences were found between risky and nonrisky drinkers on any of the utilization variables in the last year, with 11% reporting an emergency room (ER) visit, a third reporting a primary care visit, and 6.2 to 7.6% reporting hospitalization. Those with an AUD were significantly more likely than those without to report an ER visit in the last year (18.2% vs. 11.6%; p = 0.003) as well as a greater number of such visits (p = 0.007), and to report more primary care visits (p = 0.05) and any hospitalization (11.2% vs. 6.7%; p = 0.019). CONCLUSIONS: The data suggest a significant and potentially costly increase in health services utilization due to AUD. ERs and primary care settings would benefit from devoting increased resources to addressing AUD, which could result in clinical benefits of improvement in overall health status as well as economic benefits in lowering healthcare costs for both patients and society as a whole.