Virtual Access to Subspecialty Care.

Telehealth programs existed in many subspecialities before the COVID-19 pandemic, and the public health event motivated many subspecialties to reflect on how current technologies could be leveraged to benefit patient outcomes and increase health-care access. This article reviews the history and current state of telehealth access in many areas of subspecialty care. Primary care physicians (PCPs) may be unaware of the telehealth services and options local subspecialists offer. To best serve patients, PCPs could partner with subspecialists to develop processes to link patients to the right subspecialist at the right time and in the right visit type.

Practice Transformation to Improve Cancer Screening Outcomes at an Academic Medical Center.

In 2011, Texas received federal approval of the 1115 Healthcare Transformation waiver, which went to support the Texas Delivery System Reform Incentive Payment Program (DSRIP) incentivizing the transformation of service delivery practices which included expanded coverage of preventive cancer screenings. There is limited evidence that quality improvement initiatives stemming from DSRIP improve cancer screening outcomes for the Medicaid, low-income, and uninsured (MLIU) patient population. The present the results of a quality initiative to improve breast, cervical, and colorectal cancer screening rates for MLIU patients receiving primary care at an academic medical center. The initiative included engaging multidisciplinary primary care teams, health information technology (IT), and quality departments to standardize workflows. We found significantly improved rates of cervical and colorectal cancer screening among patients eligible to receive one or more screenings. Aligning primary care, IT, and quality processes resulted in significant improvement in cancer screening.

Longitudinal, multidisciplinary, resident-driven intervention to increase immunisation rates for Medicaid, low-income and uninsured patients.

INTRODUCTION: More payers are closely linking reimbursement to high-value care outcomes such as immunisation rates. Despite this, there remain high rates of pneumonia and influenza-related hospitalisations generating hospital expenditures as high as $11 000 per hospitalisation. Vaccinating the public is an integral part of preventing poor health and utilisation outcomes and is particularly relevant to high-risk patients. As part of a multidisciplinary effort between family and internal medicine residency programmes, our goal was to improve vaccination rates to an average of 76% of eligible Medicaid, low-income and uninsured (MLIU) patients at an academic primary care practice. METHODS: The quality improvement project was completed over 3 months by three primary care resident groups. The setting was a suburban academic primary care practice and eligible patients were 18 years of age or older. Our aim was to increase immunisation rates of pneumococcal, influenza, varicella, herpes zoster virus and tetanus and diphtheria vaccination. There were 1690 patients eligible for the vaccination composite metric. Data were derived from the electronic health record and administrative data. INTERVENTIONS: Cohort 1 developed an initial intervention that consisted of a vaccine questionnaire for patients to complete while in the waiting room. Cohort 2 modified questionnaire after reviewing results from initial intervention. Cohort 3 recommended elimination of questionnaire and implementation of a bundled intervention approach. RESULTS: There were minimal improvements in patient immunisation rates after using a patient-directed paper questionnaire. After implementation of multiple interventions via an improvement bundle, there were improvements in immunisation rates which were sustained and the result of special cause variation. CONCLUSION: A key to improving immunisation rates for MLIU patients in this clinic was developing relationships with faculty and staff stakeholders. We received feedback from all the medical staff and then applied it to the interventions and made an impact in the average of vaccinations.

The Impact of COVID-19 on Cancer Screening: Challenges and Opportunities.

Cancer is a leading cause of death in the United States and across the globe. Cancer screening is an effective preventive measure that can reduce cancer incidence and mortality. While cancer screening is integral to cancer control and prevention, due to the COVID-19 outbreak many screenings have either been canceled or postponed, leaving a vast number of patients without access to recommended health care services. This disruption to cancer screening services may have a significant impact on patients, health care practitioners, and health systems. In this paper, we aim to offer a comprehensive view of the impact of COVID-19 on cancer screening. We present the challenges COVID-19 has exerted on patients, health care practitioners, and health systems as well as potential opportunities that could help address these challenges.

The impact of continuity of care on antibiotic prescribing in acute otitis media.

BACKGROUND: The rate of antibiotic prescribing for acute otitis media (AOM) remains high despite efforts to decrease inappropriate use. Studies have aimed to understand the prescribing patterns of providers to increase antibiotic stewardship. Watch and wait (WAW) prescriptions are effective at decreasing the number of antibiotic prescriptions being filled by patients. Additionally, poor continuity of care has been associated with higher cost and lower quality health care. OBJECTIVE: To understand the antibiotic prescribing habits for AOM in a largely Hispanic population. METHODS: A retrospective review was performed from 2016 to 2018 of all patients under 25 years old with a diagnosis of AOM seen at multiple outpatient primary care clinics of a single institution. Charts were reviewed for factors including race, ethnicity, gender, insurance status, presence of fever, primary care physician visit, and treatment choice. Data were collected and analyzed using STATA software with t-tests, ANOVA, and Pearson chi squared analysis. RESULTS: Antibiotics were prescribed 95.6% of the time with 3.8% being WAW prescriptions. There was no significant difference in antibiotic prescribing by race (p = 0.66), ethnicity (p = 0.38), gender (p = 0.34) or insurance status (p = 0.24). There was a difference between physicians, nurse practitioners, and physician's assistants and antibiotic prescribing rate (p < 0.01). Additionally, seen by their primary care provider were less likely to be prescribed antibiotics (85.8% vs 94.4%, p = 0.01). CONCLUSION: While a patient's race, ethnicity, gender, and insurance status did not influence the prescribing rate of physicians, continuity of care may play an important role in decreasing inappropriate antibiotic prescribing.

Project RED Impacts Patient Experience.

BACKGROUND: Hospitalized patients are frequently unprepared to care for themselves after discharge often leading to unplanned hospital readmission. One strategy to reduce readmission rates is improving the quality of patient education and preparation before hospital discharge. The ReEngineered Discharge (RED) is a standardized hospital-based program designed to provide patients and caregivers the information they need to continue care at home. OBJECTIVES: We sought to study the impact of the RED intervention on posthospitalization adult patient experience scores in an urban academic safety-net hospital. METHODS: We conducted a descriptive study of a pilot program that compared posthospitalization survey responses to the Press Ganey survey item "Instructions were given about how to care for yourself at home." We compared the survey results for 3 groups of adult patients: those receiving the RED program, those receiving a standard discharge on the same hospital unit, and those receiving a standard discharge on other hospital units. RESULTS: A greater percentage of adult patients who received the RED discharge program rated the quality of their discharge as "very good" as compared to those receiving a standard discharge on the same hospital unit and those receiving a standard discharge on other hospital units (61%, 35%, and 41%, respectively, P = .0001). CONCLUSION: Delivery of a standardized hospital discharge program resulted in a larger proportion of top-box "very good" responses on a Press Ganey posthospitalization survey. Future research should examine whether hospital-based transition programs can sustain improvement in patient experience measures and whether these improvements can be observed in other patient populations.

Health Services Utilization Among Fee-for-Service Medicare and Medicaid Patients Under Age 65 with Behavioral Health Illness at an Urban Safety Net Hospital.

BACKGROUND: In 2011, fee-for-service patients with both Medicare and Medicaid (dual eligible) sustained $319.5 billion in health care costs. OBJECTIVE: To describe the emergency department (ED) use and hospital admissions of adult dual eligible patients aged under 65 years who used an urban safety net hospital. METHODS: This was a retrospective database analysis of patients aged between 18 and 65 years with Medicare and Medicaid, who used an urban safety net academic health center between January 1, 2011, and December 31, 2011. We compared patients with and without behavioral health illness. The main outcome measures were hospital admission and ED use. Chi-square and Wilcoxon rank-sum tests were used for descriptive statistics on categorical and continuous variables, respectively. Greedy propensity score matching was used to control for confounding factors. Rate ratios (RR) and 95% confidence intervals (CI) were determined after matching and after adjusting for those variables that remained significantly different after matching. RESULTS: In 2011, 10% of all fee-for-service dual eligible patients aged less than 65 years in Massachusetts were seen at Boston Medical Center. Data before propensity score matching showed significant differences in age, sex, race/ethnicity, marital status, education, employment, physical comorbidities, and Charlson Comorbidity Index score between patients with and without behavioral health illness. Analysis after propensity score matching found significant differences in sex, Hispanic race, and other education and employment status. Compared with patients without behavioral health illness, patients with behavioral health illness had a higher RR for hospital admissions (RR = 2.07; 95% CI = 1.81-2.38; P < 0.001) and ED use (RR = 1.61; 95% CI = 1.46-1.77; P < 0.001). Results were robust after adjusting for characteristics that remained statistically significantly different after propensity score matching. CONCLUSIONS: Adult dual eligible patients aged less than 65 years with behavioral health illness in the Medicaid fee-for-service plan had significantly higher rates of hospital admission and ED use compared with dual eligible patients without behavioral health illness at the largest urban safety net medical center in New England. Safety net hospitals care for a large proportion of dual eligible patients with behavioral health illness. Further research is needed to elucidate the systems-related and patient-centered factors contributing to the utilization behaviors of this patient population. DISCLOSURES: This research was funded in part by a National Research Service Award (T3HP10028-14-01). The authors have no conflicts of interests to disclose. Cancino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Cancino, Jack, and Burgess, with assistance from Cremieux. Cancino and Cremieux took the lead in data collection, along with Jack and Burgess, and data interpretation was performed by Jarvis, Cummings, and Cooper, along with the other authors. The manuscript was written primarily by Cancino, along with Jack and Burgess, and revised primarily by Cancino, along with the other authors.

Dose-response relationship between depressive symptoms and hospital readmission.

BACKGROUND: Evidence suggests depression increases hospital readmission risk. OBJECTIVE: Determine whether depressive symptoms are associated with unplanned readmission within 30 days of discharge of general medical patients. DESIGN: Secondary analysis of the Project Re-Engineered Discharge (RED) randomized controlled trials. SETTING: Urban academic safety-net hospital. PATIENTS: A total of 1418 hospitalized adult English-speaking patients. INTERVENTION: The 9-Item Patient Health Questionnaire (PHQ-9) was used to screen patients for depressive symptoms. MEASUREMENTS: Hospital readmission within 30 days of discharge. Poisson regression was used to control for confounding variables. RESULTS: There were 225 (16%) patients who screened positive for mild depressive symptoms (5 ≤PHQ-9 ≤ 9) and 336 (24%) for moderate or severe depressive symptoms (PHQ-9 ≥ 10). After controlling for confounders, a higher rate of readmission was observed in subjects with mild depressive symptoms compared to subjects with PHQ-9 <5, incidence rate ratio (IRR) 1.49 (95% confidence interval [CI]: 1.11-2.00). The adjusted IRR of readmission for those with moderate-to-severe symptoms was 1.96 (95% CI: 1.51-2.49) compared to those with no depression. CONCLUSIONS: Screening positive for mild and moderate-to-severe depressive symptoms during a hospitalization on a general medical service is associated with an increased dose-dependent readmission rate within 30 days of discharge in an urban, academic, safety-net hospital. Further research is needed to determine whether treatments targeting the reduction of depressive symptoms reduce the risk of readmission.

Comparing patient-level and site-level anticoagulation control as predictors of adverse events.

INTRODUCTION: Percent time in therapeutic range (TTR) is increasingly used to summarize anticoagulation control over time among patients receiving warfarin. Higher TTR improves outcomes of care, but studies have varied regarding whether TTR is best summarized as center-based percent time in therapeutic range (cTTR) or as individual percent time in therapeutic range (iTTR). Our aim was to compare cTTR to iTTR in predicting ischemic stroke, major hemorrhage, and all-cause mortality. MATERIALS AND METHODS: Veterans Health Administration data of 57,281 patients receiving warfarin therapy were included. iTTR was calculated using linear interpolation. Each site's mean TTR was calculated, and the cTTR was assigned to all patients at that site. We used Cox proportional hazards to examine cTTR and iTTR as predictors of major hemorrhage, ischemic stroke, and all-cause mortality. RESULTS: Comparing worst to best quartiles of INR control, cTTR was not a statistically significant predictor of major hemorrhage or ischemic stroke, hazard ratios (HR) were 1.02 (95% confidence interval [CI] 0.93-1.11) and 1.00 (95% CI: 0.88-1.13), respectively. cTTR was a weak predictor of all-cause mortality (HR: 1.14, 95% CI: 1.07-1.22). iTTR predicted major hemorrhage (HR: 1.79, 95% CI: 1.63-1.96), ischemic stroke (HR: 1.91, 95% CI: 1.67-2.19), and all-cause mortality (HR: 2.20, 95% CI: 2.05-2.35). CONCLUSION: iTTR significantly predicted risk of major hemorrhage, ischemic stroke, and all-cause mortality. cTTR was a weak predictor of all-cause mortality. Though cTTR may be a better target for site-level quality improvement efforts, iTTR may be a more suitable measure for use in comparative effectiveness research.