Efficacy of a Primary Care-Based Mobile Application to Increase Hepatitis C Screening Among Asian Americans: A Secondary Analysis of a Randomized Clinical Trial.

Background: Hepatitis C virus (HCV) screening remains suboptimal. We assessed the efficacy of a mobile application and provider alert in enhancing HCV screening among Asian Americans. Methods: A secondary analysis of a cluster-randomized clinical trial was performed during the birth cohort screening era to assess the efficacy of a Hepatitis App (intervention), a multilingual mobile application delivering interactive video education on viral hepatitis and creating a Provider Alert printout, at primary care clinics within 2 healthcare systems in San Francisco from 2015 to 2017. A comparison group received usual care and a similar intervention on nutrition and physical activity. The outcome was electronic health record (EHR) documentation of HCV screening along with patient-provider communication about testing and test ordering. Results: Four hundred fifty-two participants (mean age 57 years, 36% male, 80% foreign-born) were randomized by provider clusters to the intervention (n = 270) or comparison groups (n = 182). At 3-month follow up, the intervention group was more likely than the comparison group to be aware of HCV (75% vs 59%, P = .006), to discuss HCV testing with their providers (63% vs 13%, P < .001), to have HCV testing ordered (39% vs 10%, P < .001), and to have EHR-verified HCV testing (30% vs 6%, P < .001). Within the intervention group, being born between 1945 and 1965 (odds ratio, 3.15; 95% confidence interval, 1.35-7.32) was associated with increased HCV testing. Conclusions: The Hepatitis App delivered in primary care settings was effective in increasing HCV screening in a socioeconomically diverse Asian American cohort. This highlights the importance of mobile technology as a patient-centered strategy to address gaps in HCV care.

Lessons Learned From a New Reverse-Integration Model to Improve Primary Care Screening in Community Mental Health Settings.

The authors sought to describe a reverse-integration intervention aimed at improving preventive health screening in a community mental health clinic. The intervention, CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness), integrated primary care services into a large urban community mental health setting. It was implemented in 2015 and included a patient-centered team, population-based care, emphasis on screening, and evidence-based treatment. CRANIUM's strengths included provider acceptability, a patient-centered approach, sustained patient engagement, and economic feasibility. Challenges included underutilized staff, registry maintenance, and unanticipated screening barriers. The CRANIUM reverse-integration model can be feasibly implemented and was acceptable to providers.

Health Within Reach-a Patient-Centered Intervention to Increase Hepatitis B Screening Among Asian Americans: a Randomized Clinical Trial.

BACKGROUND: There are few studies to date of interventions to increase viral hepatitis screening among Asian Americans, who have high rates of chronic hepatitis B (HBV) infection. OBJECTIVE: To develop, implement, and test the efficacy of a mobile application (Hepatitis App) delivered in four languages to increase HBV screening among Asian Americans. DESIGN: Cluster-randomized clinical trial. PARTICIPANTS: Four hundred fifty-two Asian American patients ≥ 18 years of age, who had no prior HBV testing, and received primary care within two healthcare systems in San Francisco, CA. INTERVENTIONS: The intervention group received the Hepatitis App, delivering interactive video education on viral hepatitis in English, Cantonese, Mandarin, or Vietnamese and a provider printout (Provider Alert) and Provider Panel Notification. The comparison group received a mobile application delivering nutrition and physical activity education and Provider Panel Notification. MAIN MEASURES: Primary outcomes were patient-provider discussion about HBV and documentation of a HBV screening test within 3 months post-intervention. Secondary outcome was documentation of an order for a HBV screening test. KEY RESULTS: Participants had a mean age of 57 years and were 64% female, 80% foreign-born, and 44% with limited English fluency. At post-visit, over 80% of intervention participants reported they liked using the Hepatitis App. At 3-month follow-up, the intervention group was more likely than the comparison group (all P < 0.001) to have discussed HBV with their provider (70% vs.16%), have a HBV test ordered (44% vs.10%), and receive a HBV test (38% vs.8%). In multivariable analyses, the intervention odds ratio for HBV test ordering was 7.6 (95% CI: 3.9, 14.8) and test receipt was 7.5 (95% CI: 3.6, 15.5). CONCLUSIONS: A multi-lingual educational intervention using a mobile application in primary care clinics was well received by Asian American patients, enhanced patient-provider communication about HBV, and increased HBV screening. Technology can improve healthcare quality among Asian Americans. TRIAL REGISTRATION: ClinicalTrials.gov NCT02139722 ( https://clinicaltrials.gov/ct2/show/NCT02139722 ).

Informatics response to address the COVID-19 pandemic in a safety net healthcare system.

In service of particularly vulnerable populations, safety net healthcare systems must nimbly leverage health information technology (IT), including electronic health records (EHRs), to coordinate the medical and public health response to the novel coronavirus (COVID-19). Six months after the San Francisco Department of Public Health implemented a new EHR across its hospitals and citywide clinics, California declared a state of emergency in response to COVID-19. This paper describes how the IT and informatics teams supported San Francisco Department of Public Health's goals of expanding the safety net healthcare system capacity, meeting the needs of specific vulnerable populations, increasing equity in COVID-19 testing access, and expanding public health analytics and research capacity. Key enabling factors included critical partnerships with operational leaders, early identification of priorities, a clear governance structure, agility in the face of rapidly changing circumstances, and a commitment to vulnerable populations.

High perceived social support and hospital readmissions in an older multi-ethnic, limited English proficiency, safety-net population.

BACKGROUND: Early readmission amongst older safety-net hospitalized adults is costly. Interventions to prevent early readmission have had mixed success. The role of perceived social support is unclear. We examined the association of perceived social support in 30-day readmission or death in older adults admitted to a safety-net hospital. METHODS: This is an observational cohort study derived from the Support From Hospital to Home for Elders (SHHE) trial. Participants were community-dwelling English, Spanish and Chinese speaking older adults admitted to medicine wards at an urban safety-net hospital in San Francisco. We assessed perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). We defined high social support as the highest quartile of MSPSS. We ascertained 30-day readmission and mortality based on a combination of participant self-report, hospital and death records. We used multiple/multivariable logistic regression to adjust for patient demographics, health status, and health behaviors. We tested for whether race/ethnicity modified the effect high social support had on 30-day readmission or death by including a race-social support interaction term. RESULTS: Participants (n = 674) had mean age of 66.2 (SD 9.0), with 18.8% White, 24.8% Black, 31.9% Asian, and 19.3% Latino. The 30-day readmission or death rate was 15.0%. Those with high social support had half the odds of readmission or death than those with low social support (OR = 0.47, 95% CI 0.26-0.88). Interaction analyses revealed race modified this association; higher social support was protective against readmission or death among minorities (AOR = 0.35, 95% CI 0.16-0.76) but increased likelihood of readmission or death among Whites (AOR = 3.7, 95% CI 1.07-12.9). CONCLUSION: In older safety-net patients nearing discharge, high perceived social support may protect against 30-day readmission or death among minorities. Assessing patients' social support may aid targeting of transitional care resources and intervention design. How perceived social support functions across racial/ethnic groups in health outcomes warrants further study. TRIAL REGISTRATION: NIH trials registry number ClinicalTrials.gov: NCT01221532 .

Association of Rapid Molecular Testing With Duration of Respiratory Isolation for Patients With Possible Tuberculosis in a US Hospital.

Importance: New guidelines recommend that molecular testing replace sputum-smear microscopy to guide discontinuation of respiratory isolation in patients undergoing evaluation for active tuberculosis (TB) in health care settings. Objective: To evaluate the implementation and impact of a molecular testing strategy to guide discontinuation of isolation. Design, Setting, and Participants: Prospective cohort study with a pragmatic, before-and-after-implementation design of 621 consecutive patients hospitalized at Zuckerberg San Francisco General Hospital and Trauma Center who were undergoing sputum examination for evaluation for active pulmonary TB from January 2014 to January 2016. Interventions: Implementation of a sputum molecular testing algorithm using GeneXpert MTB/RIF (Xpert; Cepheid) to guide discontinuation of isolation. Main Outcomes and Measures: We measured the proportion of patients with molecular testing ordered and completed; the accuracy of the molecular testing algorithm in reference to mycobacterial culture; the duration of each component of the testing and isolation processes; length of stay; mean days in isolation and in hospital; and mean cost. We extracted data from hospital records and compared measures before and after implementation. Results: Clinicians ordered sputum testing for TB for 621 patients at ZSFG during the 2-year study period. Of 301 patients in the preimplementation period with at least 1 sputum microscopy and culture ordered, clinicians completed the rapid TB testing evaluation process for 233 (77%).Among 320 patients evaluated in the postimplementation period, clinicians ordered molecular testing for 234 (73%) patients and received results for 295 of 302 (98%) tests ordered. Median age was 54 years (interquartile range, 44-63 years), and 161 (26%) were women. The molecular testing algorithm accurately diagnosed all 7 patients with culture-confirmed TB and excluded TB in all 251 patients with Mycobacterium tuberculosis (MTB) culture-negative results. Compared with the preimplementation period, there were significant decreases in median times to final rapid test result (39.1 vs 22.4 hours, P < .001), discontinuation of isolation (2.9 vs 2.5 days, P = .001), and hospital discharge (6.0 vs 4.9 days, P = .003), on average saving $13 347 per isolated TB-negative patient. Conclusions and Relevance: A sputum molecular testing algorithm to guide discontinuation of respiratory isolation for patients undergoing evaluation for active TB was safe, feasible, widely and sustainably adopted, and provided substantial clinical and economic benefits. Molecular testing may facilitate more efficient, patient-centered evaluation for possible TB in US hospitals.

Clinician Perspectives on the Management of Abnormal Subcritical Tests in an Urban Academic Safety-Net Health Care System.

BACKGROUND: Missed or delayed follow-up of abnormal subcritical tests (tests that do not require immediate medical attention) can lead to poor patient outcomes. Safety-net health systems with limited resources and socially complex patients are vulnerable to safety gaps resulting from delayed management. Clinician perspectives to identify system challenges, vulnerable situations, and potential solutions were sought in focus groups. METHODS: Five semistructured focus groups were conducted in 2015 with purposefully sampled clinicians from radiology, hospital medicine, emergency medicine, risk management, and ambulatory care from an urban, academic, integrated, safety-net health system. Thematic analysis identified challenges of current management of abnormal subcritical tests, vulnerable situations, and solution characteristics. A total of 43 clinicians participated. RESULTS: Clinicians cited challenges in assigning responsibility for follow-up and identified tests pending at discharge and tests requiring delayed follow-up as vulnerable situations. The lack of tracking systems and missing contact information for patients and providers exacerbated these challenges. Proposed solution characteristics involved protocols to aid in assigning responsibility, reliable paths of communication, and systems to track the status of tests. Clinicians noted a strong desire for integration of the work flow and technology solutions into existing structures. CONCLUSION: In an urban safety-net setting, clinicians recommended outlining clear chains of responsibility and communication in the management of subcritical test results, and employing simple, integrated technological solutions that allow for tracking and management of tests. Existing test management solutions should be adapted to work within safety-net systems, which often have fewer resources and more complex patients and may function in the absence of integrated technology systems.

A novel flexible cuff-like microelectrode for dual purpose, acute and chronic electrical interfacing with the mouse cervical vagus nerve.

OBJECTIVE: Neural reflexes regulate immune responses and homeostasis. Advances in bioelectronic medicine indicate that electrical stimulation of the vagus nerve can be used to treat inflammatory disease, yet the understanding of neural signals that regulate inflammation is incomplete. Current interfaces with the vagus nerve do not permit effective chronic stimulation or recording in mouse models, which is vital to studying the molecular and neurophysiological mechanisms that control inflammation homeostasis in health and disease. We developed an implantable, dual purpose, multi-channel, flexible 'microelectrode' array, for recording and stimulation of the mouse vagus nerve. APPROACH: The array was microfabricated on an 8 µm layer of highly biocompatible parylene configured with 16 sites. The microelectrode was evaluated by studying the recording and stimulation performance. Mice were chronically implanted with devices for up to 12 weeks. MAIN RESULTS: Using the microelectrode in vivo, high fidelity signals were recorded during physiological challenges (e.g potassium chloride and interleukin-1ß), and electrical stimulation of the vagus nerve produced the expected significant reduction of blood levels of tumor necrosis factor (TNF) in endotoxemia. Inflammatory cell infiltration at the microelectrode 12 weeks of implantation was limited according to radial distribution analysis of inflammatory cells. SIGNIFICANCE: This novel device provides an important step towards a viable chronic interface for cervical vagus nerve stimulation and recording in mice.

Drinking water system treatment and contamination in Shatila Refugee Camp in Beirut, Lebanon.

Drinking water at Shatila Palestinian Refugee Camp in Beirut, Lebanon is of poor quality and unpredictably intermittent quantity. We aimed to characterize drinking water sources and contamination at Shatila and determine how drinking water can be managed to reduce community health burdens. We interviewed the Popular Committee, well owners, water vendors, water shopkeepers and preschool administrators about drinking water sources, treatment methods and the population served. Water samples from the sources and intermediaries were analysed for thermotolerant faecal coliforms (FCs), Giardia lamblia, Cryptosporidium parvum and microsporidia, using immunofluorescent antibody detection for G. lamblia and C. parvum, and chromotrope-2 stain for microsporidia. All drinking water sources were contaminated with FCs and parasites. FC counts (cfu/mL) were as follows: wells (35-300), water vendors (2-178), shops (30-300) and preschools (230-300). Responsible factors identified included: unskilled operators; improper maintenance of wells and equipment; lack of proper water storage and handling; and misperception of water quality. These factors must be addressed to improve water quality at Shatila and other refugee camps.

Drinking water system treatment and contamination in Shatila refugee camp in Beirut, Lebanon

Drinking water at Shatila Palestinian Refugee Camp in Beirut, Lebanon is of poor quality and unpredictably intermittent quantity. We aimed to characterize drinking water sources and contamination at Shatila and determine how drinking water can be managed to reduce community health burdens. We interviewed the Popular Committee, well owners, water vendors, water shopkeepers and preschool administrators about drinking water sources, treatment methods and the population served. Water samples from the sources and intermediaries were analysed for thermotolerant faecal coliforms [FCs], Giardia lamblia, Cryptosporidium parvum and microsporidia, using immunofluorescent antibody detection for G. lamblia and C. parvum, and chromotrope-2 stain for microsporidia. All drinking water sources were contaminated with FCs and parasites. FC counts [cfu/mL] were as follows: wells [35-300], water vendors [2-178], shops [30-300] and preschools [230-300]. Responsible factors identified included: unskilled operators; improper maintenance of wells and equipment; lack of proper water storage and handling; and misperception of water quality. These factors must be addressed to improve water quality at Shatila and other refugee camps

L'eau potable dans le camp de réfugiés palestiniens de Chatila, au Liban, est de mauvaise qualité et n'est disponible qu'en quantités imprévisibles et irrégulières. La présente étude avait pour objectif d'identifier les sources d'eau potable et de contamination à Chatila, et de déterminer la façon dont l'eau potable peut être gérée pour réduire la charge des problèmes de santé communautaires. Nous avons interrogé le Comité populaire, les propriétaires de puits, les vendeurs d'eau ambulants, les marchands d'eau, les responsables de structures préscolaires sur les sources d'eau potable, les méthodes de traitement et la population desservie. Des échantillons d'eau à la source et au niveau des intermédiaires ont été analysés afin de détecter la présence de coliformes thermotolérants, de Giardia lamblia, de Cryptosporidium parvum et de microsporidies, à l'aide de la recherche des anticorps par immunofluorescence pour G. lamblia and C. parvum, et de la coloration au chromotrope 2R pour les microsporidies. Toutes les sources d'eau potable étaient contaminées par des coliformes thermotolérants et des parasites. Les taux [ufc/ml] de coliformes thermotolérants étaient les suivants : puits [35-300], vendeurs d'eau ambulants [2-178], commerces [30-300] et structures préscolaires [230-300]. Les facteurs responsables identifiés incluaient les points suivants : des opérateurs non formés, une mauvaise maintenance des puits et des équipements, un stockage et une manutention de l'eau inappropriés, et une perception erronée de la qualité de l'eau. Il est nécessaire d'agir sur ces facteurs afin d'améliorer la qualité de l'eau à Chatila et dans les autres camps de réfugiés

Role of thigh muscle cross-sectional area and strength in progression of knee cartilage degeneration over 48 months - data from the Osteoarthritis Initiative.

OBJECTIVE: To determine in a 48-month longitudinal study the association of thigh muscle cross-sectional area (CSA) and strength on progression of morphologic knee cartilage degeneration using 3T magnetic resonance imaging (MRI). DESIGN: Seventy Osteoarthritis Initiative (OAI) subjects aged 50-60 years, with no radiographic evidence of osteoarthritis (OA) and constant muscle strength over 48 months as measured by isometric knee extension testing were included. Baseline right thigh muscle CSAs were assessed on axial T1-weighted magnetic resonance (MR) images, and extensor to flexor CSA ratios were calculated. Degenerative knee abnormalities at baseline and 48-months were graded on right knee 3T MRIs using a modified whole organ MRI score (WORMS). Statistical analysis employed Student's t-tests and multivariable regression models adjusted for age, body mass index and gender. RESULTS: Extension strength was significantly and positively correlated with baseline thigh muscle CSA (r = 0.65, P < 0.001). Greater baseline total thigh muscle CSA was significantly associated with increase of cartilage WORMS scores over 48 months in patellar (P = 0.027) and trochlear (P = 0.038) compartments, but not in other knee compartments. Among specific muscle groups, CSA of extensors (P = 0.021) and vastus medialis (VM) (P = 0.047) were associated with patellar cartilage increase in WORMS. Baseline E/F ratio had a significant positive association with patellar WORMS cartilage score increase over 48 months, P = 0.0015. There were no other significant associations between muscle CSA/ratios and increase in WORMS scores. CONCLUSION: Maintenance of proper extensor to flexor muscle balance about the knee through decreased E/F ratios may slow patellofemoral cartilage deterioration, while higher extensor and VM CSA may increase patellofemoral cartilage loss.

Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering.

BACKGROUND: Displaying radiation exposure and cost information at electronic order entry may encourage clinicians to consider the value of diagnostic imaging. METHODS: An urban safety-net health system displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. We assessed whether there were differences in numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians' responses to the intervention. RESULTS: There were 23 171 outpatient CTs, 15 052 MRIs and 43 266 ultrasounds from 2011 to 2014. The ratio of CTs to ultrasounds decreased by 15% (95% CI 9% to 21%), from 58.2 to 49.6 CTs per 100 ultrasounds; the ratio of MRIs to ultrasounds declined by 13% (95% CI 7% to 19%), from 37.5 to 32.5 per 100. Of 300 invited, 190 (63%) completed the web-based survey in 17 clinics. 154 (81%) noticed the radiation exposure information and 158 (83.2%) noticed the cost information. Clinicians believed radiation exposure information was more influential than cost information: when unsure clinically about ordering a test (radiation=69.7%; cost=46.4%), when a patient wanted a test not clinically indicated (radiation=77.5%; cost=54.8%), when they had a choice between imaging modalities (radiation=77.9%; cost=66.6%), in patient care discussions (radiation=71.9%; cost=43.2%) and in trainee discussions (radiation=56.5%; cost=53.7%). Resident physicians and nurse practitioners were more likely to report that the cost information influenced them (p<0.05). CONCLUSIONS: Displaying radiation exposure and cost information at order entry may improve clinician awareness about diagnostic imaging safety risks and costs. More clinicians reported the radiation information influenced their clinical practice.

From the closest observers of patient care: a thematic analysis of online narrative reviews of hospitals.

OBJECTIVE: Patient-centred care has become a priority in many countries. It is unknown whether current tools capture aspects of care patients and their surrogates consider important. We investigated whether online narrative reviews from patients and surrogates reflect domains in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and we described additional potential domains. DESIGN: We used thematic analysis to assess online narrative reviews for reference to HCAHPS domains and salient non-HCAHPS domains and compared results by reviewer type (patient vs surrogate). SETTING: We identified hospitals for review from the American Hospital Association database using a stratified random sampling approach. This approach ensured inclusion of reviews of a diverse set of hospitals. We searched online in February 2013 for narrative reviews from any source for each hospital. PARTICIPANTS: We included up to two narrative reviews for each hospital. EXCLUSIONS: Outpatient or emergency department reviews, reviews from self-identified hospital employees, or reviews of <10 words. RESULTS: 50.0% (n=122) of reviews (N=244) were from patients and 38.1% (n=93) from friends or family members. Only 57.0% (n=139) of reviews mentioned any HCAHPS domain. Additional salient domains were: Financing, including unexpected out-of-pocket costs and difficult interactions with billing departments; system-centred care; and perceptions of safety. These domains were mentioned in 51.2% (n=125) of reviews. Friends and family members commented on perceptions of safety more frequently than patients. CONCLUSIONS: A substantial proportion of consumer reviews do not mention HCAHPS domains. Surrogates appear to observe care differently than patients, particularly around safety.

Availability of Advanced Breast Imaging at Screening Facilities Serving Vulnerable Populations.

OBJECTIVE: Among vulnerable women, unequal access to advanced breast imaging modalities beyond screening mammography may lead to delays in cancer diagnosis and unfavourable outcomes. We aimed to compare on-site availability of advanced breast imaging services (ultrasound, magnetic resonance imaging [MRI], and image-guided biopsy) between imaging facilities serving vulnerable patient populations and those serving non-vulnerable populations. SETTING: 73 imaging facilities across five Breast Cancer Surveillance Consortium regional registries in the United States during 2011 and 2012. METHODS: We examined facility and patient characteristics across a large, national sample of imaging facilities and patients served. We characterized facilities as serving vulnerable populations based on the proportion of mammograms performed on women with lower educational attainment, lower median income, racial/ethnic minority status, and rural residence.We performed multivariable logistic regression to determine relative risks of on-site availability of advanced imaging at facilities serving vulnerable women versus facilities serving non-vulnerable women. RESULTS: Facilities serving vulnerable populations were as likely (Relative risk [RR] for MRI = 0.71, 95% Confidence Interval [CI] 0.42, 1.19; RR for MRI-guided biopsy = 1.07 [0.61, 1.90]; RR for stereotactic biopsy = 1.18 [0.75, 1.85]) or more likely (RR for ultrasound = 1.38 [95% CI 1.09, 1.74]; RR for ultrasound-guided biopsy = 1.67 [1.30, 2.14]) to offer advanced breast imaging services as those serving non-vulnerable populations. CONCLUSIONS: Advanced breast imaging services are physically available on-site for vulnerable women in the United States, but it is unknown whether factors such as insurance coverage or out-of-pocket costs might limit their use.

Facility Mammography Volume in Relation to Breast Cancer Screening Outcomes.

OBJECTIVES: To clarify the relationship between facility-level mammography interpretive volume and breast cancer screening outcomes. METHODS: We calculated annual mammography interpretive volumes from 2000-2009 for 116 facilities participating in the U.S. Breast Cancer Surveillance Consortium (BCSC). Radiology, pathology, cancer registry, and women's self-report information were used to determine the indication for each exam, cancer characteristics, and patient characteristics. We examined the effect of annual total volume and percentage of mammograms that were screening on cancer detection rates using multinomial logistic regression adjusting for age, race/ethnicity, time since last mammogram, and BCSC registries. "Good prognosis" tumours were defined as screen-detected invasive cancers that were <15 mm, early stage, and lymph node negative at diagnosis. RESULTS: From 3,098,481 screening mammograms, 9,899 cancers were screen-detected within one year of the exam. Approximately 80% of facilities had annual total interpretive volumes of >2,000 mammograms, and 42% had >5,000. Higher total volume facilities were significantly more likely to diagnose invasive tumours with good prognoses (odds ratio [OR] 1.32; 95% confidence interval [CI] 1.10-1.60, for total volume of 5,000-10,000/year v. 1,000-2,000/year; p-for-trend <0.001). A concomitant decrease in tumours with poor prognosis was seen (OR 0.78; 95%CI 0.63-0.98 for total volume of 5,000-10,000/year v. 1,000-2,000/year). CONCLUSIONS: Mammography facilities with higher total interpretive volumes detected more good prognosis invasive tumours and fewer poor prognosis invasive tumours, suggesting that women attending these facilities may be more likely to benefit from screening.

The Effect of a Care Transition Intervention on the Patient Experience of Older Multi-Lingual Adults in the Safety Net: Results of a Randomized Controlled Trial.

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Care Transitions Measure (CTM-3) scores are patient experience measures used to determine hospital value-based purchasing reimbursement. Interventions to improve 30-day readmissions have met with mixed results, but less is known about their potential to improve the patient experience among older ethnically and linguistically diverse adults receiving care at safety-net hospitals. In this study, we assessed the effect of a nurse-led hospital-based care transition intervention on discharge-related patient experience in an older multilingual population of adults hospitalized at a safety-net hospital. METHODS: We randomized 700 inpatients aged 55 and older at an academic urban safety-net hospital. In addition to usual care, intervention participants received inpatient visits by a language-concordant study nurse and post-discharge phone calls from a language-concordant nurse practitioner to reinforce the care plan and to address acute complaints. We measured HCAHPS nursing, medication, and discharge communication domain scores and CTM-3 scores at 30 days after hospital discharge. RESULTS: Of 685 participants who survived to 30 days, 90 % (n = 616) completed follow-up interviews. The mean age was 66.2 years; over half (54.2 %) of the participants had cognitive impairment, and 33.8 % had moderate to severe depression. The majority (62.1 %) of interviews were conducted in English; 23.3 % were conducted in Chinese and 14.6 % in Spanish. Study nurses spent an average of 157 min with intervention participants. Between intervention and usual care participants, CTM-3 scores (80.5 % vs 78.5 %; p = 0.18) and HCAHPS discharge communication domain scores (74.8 % vs 68.7 %; p = 0.11) did not differ, nor did HCAHPS scores in medication (44.5 % vs 53.1 %; p = 0.13) and nursing domains (67.9 % vs 64.9 %; p = 0.43). When stratified by language, no significant differences were seen. CONCLUSION: An inpatient standalone transition-of-care intervention did not improve patient discharge experience. Older multi-lingual and cognitively impaired populations may require higher-intensity interventions post-hospitalization to improve discharge experience outcomes.

Hospitalization-Associated Disability in Adults Admitted to a Safety-Net Hospital.

BACKGROUND: Little is known about hospitalization-associated disability (HAD) in older adults who receive care in safety-net hospitals. OBJECTIVES: To describe HAD and to examine its association with age in adults aged 55 and older hospitalized in a safety-net hospital. DESIGN: Secondary post hoc analysis of a prospective cohort from a discharge intervention trial, the Support from Hospital to Home for Elders. SETTING: Medicine, cardiology, and neurology inpatient services of San Francisco General Hospital, a safety-net hospital. PARTICIPANTS: A total of 583 participants 55 and older who spoke English, Spanish, or Chinese. We determined the incidence of HAD 30 days post-hospitalization and ORs for HAD by age group. MEASUREMENTS: The outcome measure was death or HAD at 30 days after hospital discharge. HAD is defined as a new or additional disability in one or more activities of daily living (ADL) that is present at hospital discharge compared to baseline. Participants' functional status at baseline (2 weeks prior to admission) and 30 days post-discharge was ascertained by self-report of ADL function. RESULTS: Many participants (75.3 %) were functionally independent at baseline. By age group, HAD occurred as follows: 27.4 % in ages 55-59, 22.2 % in ages 60-64, 17.4 % in ages 65-69, 30.3 % in ages 70-79, and 61.7 % in ages 80 or older. Compared to the youngest group, only the adjusted OR for HAD in adults over 80 was significant, at 2.45 (95 % CI 1.17, 5.15). CONCLUSIONS: In adults at a safety-net hospital, HAD occurred in similar proportions among adults aged 55-59 and those aged 70-79, and was highest in the oldest adults, aged ≥ 80. In safety-net hospitals, interventions to reduce HAD among patients 70 years and older should consider expanding age criteria to adults as young as 55.

Effect of Present-on-Admission (POA) Reporting Accuracy on Hospital Performance Assessments Using Risk-Adjusted Mortality.

OBJECTIVE: To evaluate how the accuracy of present-on-admission (POA) reporting affects hospital 30-day acute myocardial infarction (AMI) mortality assessments. DATA SOURCES: A total of 2005 California patient discharge data (PDD) and vital statistics death files. STUDY DESIGN: We compared hospital performance rankings using an established model assessing hospital performance for AMI with (1) a model incorporating POA indicators of whether a secondary condition was a comorbidity or a complication of care, and (2) a simulation analysis that factored POA indicator accuracy into the hospital performance assessment. For each simulation, we changed POA indicators for six major acute risk factors of AMI mortality. The probability of POA being changed depended on patient and hospital characteristics. PRINCIPAL FINDINGS: Comparing the performance rankings of 268 hospitals using the established model with that using the POA indicator, 67 hospitals' (25 percent) rank differed by ≥10 percent. POA reporting inaccuracy due to overreporting and underreporting had little additional impact; POA overreporting contributed to 4 percent of hospitals' difference in rank compared to the POA model and POA underreporting contributed to <1 percent difference. CONCLUSION: Incorporating POA indicators into risk-adjusted models of AMI care has a substantial impact on hospital rankings of performance that is not primarily attributable to inaccuracy in POA hospital reporting.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital.

OBJECTIVES: To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age. DESIGN: Cross-sectional analysis. SETTING: Safety-net hospital in San Francisco, California. PARTICIPANTS: English-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699). MEASUREMENTS: At hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors. RESULTS: Overall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability. CONCLUSION: Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.

Support from hospital to home for elders: a randomized trial.

BACKGROUND: Hospitals are implementing discharge support programs to reduce readmissions, and these programs have had mixed success. OBJECTIVE: To examine whether a peridischarge, nurse-led intervention decreased emergency department (ED) visits or readmissions among ethnically and linguistically diverse older patients admitted to a safety-net hospital. DESIGN: Randomized, controlled trial using computer-generated randomization with 1:1 allocation, stratified by language. (Clinical Trials.gov: NCT01221532). SETTING: Publicly funded urban hospital in Northern California. PATIENTS: Hospitalized adults aged 55 years or older with anticipated discharge to the community who spoke English, Spanish, or Chinese (Mandarin or Cantonese). INTERVENTION: Usual care versus in-hospital, one-on-one, self-management education given by a dedicated language-concordant registered nurse combined with a telephone follow-up after discharge from a nurse practitioner. MEASUREMENTS: Staff blinded to the study groups determined ED visits or readmissions to any facility at 30, 90, and 180 days after initial hospital discharge using administrative data from several hospitals. RESULTS: There were 700 low-income, ethnically and linguistically diverse patients with a mean age of 66.2 years (SD, 9.0). The primary outcome of ED visits or readmissions did not differ between the intervention and usual care groups (hazard ratio, 1.26 [95% CI, 0.89 to 1.78] at 30 days, 1.21 [CI, 0.91 to 1.62] at 90 days, and 1.11 [CI, 0.86 to 1.43] at 180 days). LIMITATIONS: This study was done at a single acute-care hospital. There were fewer outcomes than expected, which may have caused the study to be underpowered. CONCLUSION: A nurse-led, in-hospital discharge support intervention did not show a reduction in readmissions or ED visits among diverse, low-income older adults at a safety-net hospital. Although wide CIs preclude firm conclusions, the intervention may have increased ED visits. Alternative readmission prevention strategies should be tested in this population. PRIMARY FUNDING SOURCE: Gordon and Betty Moore Foundation.