What is the additive value of nutritional deficiency to VA-FI in the risk assessment for heart failure patients?

OBJECTIVES: To assess the impact of adding the Prognostic Nutritional Index (PNI) to the U.S. Veterans Health Administration frailty index (VA-FI) for the prediction of time-to-death and other clinical outcomes in Veterans hospitalized with Heart Failure. METHODS: A retrospective cohort study of veterans hospitalized for heart failure (HF) from October 2015 to October 2018. Veterans ≥50 years with albumin and lymphocyte counts, needed to calculate the PNI, in the year prior to hospitalization were included. We defined malnutrition as PNI ≤43.6, based on the Youden index. VA-FI was calculated from the year prior to the hospitalization and identified three groups: robust (≤0.1), prefrail (0.1-0.2), and frail (>0.2). Malnutrition was added to the VA-FI (VA-FI-Nutrition) as a 32nd deficit with the total number of deficits divided by 32. Frailty levels used the same cut-offs as the VA-FI. We compared categories based on VA-FI to those based on VA-FI-Nutrition and estimated the hazard ratio (HR) for post-discharge all-cause mortality over the study period as the primary outcome and other adverse events as secondary outcomes among patients with reduced or preserved ejection fraction in each VA-FI and VA-FI-Nutrition frailty groups. RESULTS: We identified 37,601 Veterans hospitalized for HF (mean age: 73.4 ± 10.3 years, BMI: 31.3 ± 7.4 kg/m2). In general, VA-FI-Nutrition reclassified 1959 (18.6%) Veterans to a higher frailty level. The VA-FI identified 1,880 (5%) as robust, 8,644 (23%) as prefrail, and 27,077 (72%) as frail. The VA-FI-Nutrition reclassified 382 (20.3%) from robust to prefrail and 1577 (18.2%) from prefrail to frail creating the modified-prefrail and modified-frail categories based on the VA-FI-Nutrition. We observed shorter time-to-death among Veterans reclassified to a higher frailty status vs. those who remained in their original group (Median of 2.8 years (IQR:0.5,6.8) in modified-prefrail vs. 6.3 (IQR:1.8,6.8) years in robust, and 2.2 (IQR:0.7,5.7) years in modified-frail vs. 3.9 (IQR:1.4,6.8) years in prefrail). The adjusted HR in the reclassified groups was also significantly higher in the VA-FI-Nutrition frailty categories with a 38% increase in overall all-cause mortality among modified-prefrail and a 50% increase among modified-frails. Similar trends of increasing adverse events were also observed among reclassified groups for other clinical outcomes. CONCLUSION: Adding PNI to VA-FI provides a more accurate and comprehensive assessment among Veterans hospitalized for HF. Clinicians should consider adding a specific nutrition algorithm to automated frailty tools to improve the validity of risk prediction in patients hospitalized with HF.

Improving the Discharge Process at the VA Palo Alto Through Change Management and Implementation of Project Re-Engineered Discharge.

ABSTRACT: This quality improvement project demonstrates that nursing leadership with Project Re-Engineered Discharge can effect change in the discharge process and improve patient outcomes.

Profile of Caregiving Activities and Association With Physical Health Among Dementia Spousal Caregivers.

Background and Objectives: This study aims to identify patterns of caregiving intensity and assess associations between caregiving intensity and multidimensional physical health indicators and health behaviors among spousal caregivers of persons with Alzheimer's disease and related dementia. Research Design and Methods: Using data from 152 spousal caregivers aged 65 and older, the intensity of their caregiving experience was measured as the number and frequency of health- and medical-related helping activities for their care recipient. Multidimensional health indicators included self-reported fatigue, sleep disturbance, physical functioning, pain interference, general health, and the number of chronic conditions from the electronic health records. Self-reported health promotion behaviors were assessed as health responsibility, physical activity, nutrition, interpersonal relations, and stress management. Results: Two distinct caregiving intensity patterns, high-intensity (37.5%) and low-intensity (62.5%) caregiving, were identified with cluster analysis. Caregivers in the high-intensity caregiving cluster reported feeling more tired (t = 2.25, p < .05), experiencing more sleep disturbance (t = 3.06, p < .01), and performing less physical activity (t = 2.05, p < .05) compared with caregivers in the low-intensity group. Discussion and Implications: Future studies are needed to develop effective interventions to address caregiving intensity and its consequences on the health of spousal caregivers of persons with dementia.

Development of Health Professions Education Competencies for a National Fellowship Program: A Group Consensus Process.

ABSTRACT: Health professions educators need knowledge, skills, and attitudes to provide high-quality education within dynamic clinical learning environments. Although postgraduate training opportunities in health professions education (HPE) have increased significantly, no shared competencies exist across the field. This article describes the systematic development of postgraduate HPE competencies for the Health Professions Education, Evaluation, and Research (HPEER) Advanced Fellowship, a 2-year, interprofessional, post-master's degree and postdoctoral HPE training program funded through the Department of Veterans Affairs' Office of Academic Affiliations. Using a modified RAND/University of California at Los Angeles Appropriateness Method, the authors developed competencies from March 2021 to August 2021 that were informed by current practices and standards in HPE. Literature reviews were conducted of published literature from November 2020 to February 2021 and gray literature from February to March 2021, identifying 78 and 274 HPE training competencies, respectively. These competencies were combined with 71 competencies submitted by program faculty from 6 HPEER fellowship sites, resulting in 423 initial competencies. Competencies were organized into 6 primary domains and condensed by deleting redundant items and combining overlapping concepts. Eight subject matter experts completed 3 Delphi surveys and met during 2 nominal group technique meetings. The final 25 competencies spanned 6 domains: teaching methods and learning theories; educational assessment and program evaluation; educational research methods; diversity, equity, and inclusion; interprofessional practice and team science; and leadership and management. In addition to informing the national HPEER curriculum, program evaluation, and learner assessment, these advanced competencies describe the knowledge, skills, and attitudes health professions educators need to provide high-quality education with an emphasis on the global and societal impact of HPE. These competencies represent a step toward leveraging HPE expertise to establish competencies to drive HPE program changes. Other programs should report their competencies and competency development processes to spur further dialog and progress.

State of research in adult Hospital Medicine: Updated results of a national survey and longitudinal analysis of national data.

We sought to understand the current state of research in adult Hospital Medicine by repeating a 2018 survey of leaders in Hospital Medicine with changes to improve the response rate of surveyed programs. We also analyzed the public sources of federal research funding and MEDLINE-indexed publications from 2010 through 2019 among members of the Society of Hospital Medicine (SHM). Of the 102 contacted leaders of Hospital Medicine groups across the country, 49 responded, for a total response rate of 48%. Among the 3397 faculty members represented in responding programs, 72 (2%) of faculty were identified as conducting research for more than 50% of their time. Respondents noted difficulties at every stage of the research development pipeline, from a lack of mentors to running a fellowship program to a lack of applicants seeking further research training. Improvements to our research training pipeline will be essential to the long-term improvement of our profession.

Developing a Parsimonious Frailty Index for Older, Multimorbid Adults With Heart Failure Using Machine Learning.

Frailty is associated with adverse outcomes in heart failure (HF). A parsimonious frailty index (FI) that predicts outcomes of older, multimorbid patients with HF could be a useful resource for clinicians. A retrospective study of veterans hospitalized from October 2015 to October 2018 with HF, aged ≥50 years, and discharged home developed a 10-item parsimonious FI using machine learning from diagnostic codes, laboratory results, vital signs, and ejection fraction (EF) from outpatient encounters. An unsupervised clustering technique identified 5 FI strata: severely frail, moderately frail, mildly frail, prefrail, and robust. We report hazard ratios (HRs) of mortality, adjusting for age, gender, race, and EF and odds ratios (ORs) for 30-day and 1-year emergency department visits and all-cause hospitalizations after discharge. We identified 37,431 veterans (age, 73 ± 10 years; co-morbidity index, 5 ± 3; 43.5% with EF ≤40%). All frailty groups had a higher mortality than the robust group: severely frail (HR 2.63, 95% confidence interval [CI] 2.42 to 2.86), moderately frail (HR 2.04, 95% CI 1.87 to 2.22), mildly frail (HR 1.60, 95% CI 1.47 to 1.74), and prefrail (HR 1.18, 95% CI: 1.07 to 1.29). The associations between frailty and mortality remained unchanged in the stratified analysis by age or EF. The combined (severely, moderately, and mildly) frail group had higher odds of 30-day emergency visits (OR 1.62, 95% CI 1.43 to 1.83), all-cause readmission (OR, 1.75, 95% CI 1.52 to 2.02), 1-year emergency visits (OR 1.70, 95% CI 1.53 to 1.89), rehospitalization (OR 2.18, 95% CI 1.97 to 2.41) than the robust group. In conclusion, a 10-item FI is associated with postdischarge outcomes among patients discharged home after a hospitalization for HF. A parsimonious FI may aid clinical prediction at the point of care.

Developing an Interprofessional Health Care Improvement Portfolio: Results From a Consensus Panel Process.

The increased focus on professional-led, continuous health care improvement has not produced formalized processes for identifying, recognizing, and rewarding excellence in quality improvement. Moreover, the team-based nature of improvement requires a mechanism to document interprofessional contributions. In 2018, the authors created a health care improvement portfolio to document and demonstrate individual impact for the purpose of promotion. A draft portfolio was developed from a review of the literature and publicly available quality improvement and educational portfolios. The portfolio was further refined through a 2-round, modified Delphi consensus process with a panel of interprofessional experts across North America. In the first round, 35 panelists gave feedback through open-ended comments on the design and content of the portfolio. In the second round, 34 panelists rated the comprehensiveness and clarity of the portfolio on a scale of 1-9 (1 = lowest, 9 = highest) and provided comments. Consensus was defined as an average score over 8.0. Panelists in the second round achieved consensus, with average scores of 8.4 in comprehensiveness and 8.3 in clarity (range, 6-9). The finalized portfolio includes the following sections: personal statement; health care improvement training and certification; leadership and administrative roles; health care improvement project activities; health care improvement coaching, teaching, and curricular activities; health care improvement honors, awards, and recognitions; and supporting documents. The portfolio facilitates the documentation of health care professionals' contributions to and impact in health care improvement and covers the breadth of interprofessional health care improvement (i.e., projects, leadership, education, scholarship). The portfolio can be tailored to an individual's area of specific expertise. While this portfolio was originally developed for interprofessional faculty at academic institutions, the content and structure of the portfolio are easily adapted for health care providers in other health care settings.

Use of a Rubric to Improve the Quality of Internal Medicine Resident Event Reporting.

Introduction: As frontline providers, residents report patient safety events and provide crucial safety feedback. Specific ACGME and AAMC requirements for graduating residents include active participation in event reporting and patient safety investigations. However, formal training on what information a quality event report should include to effect real change in the health care system is lacking. Methods: This practical, interactive, case-based workshop educates residents on the key components of a quality event report in a 1-hour time frame. The scoring rubric offers quantitative feedback on the quality of information provided in residents' own event reports. The materials include a presentation template, sample teaching points, pre- and posttraining patient safety cases for residents to complete their own event reports about, and a standardized rubric to score event reports for feedback. Results: During the fall of 2019, 198 internal medicine residents completed the workshop, and 143 matched pre- and postcourse surveys were reviewed. Residents' ability to correctly identify the key concepts of an event report improved from a median score of 4 to 8 (p < .001). After completion of training, residents reported increased knowledge regarding the content of an effective event report (p < .001) and increased confidence in their ability to write one (p < .001). Discussion: Residents' knowledge of key event-reporting concepts and confidence in reporting improved after completion of the workshop. This brief interactive training and its novel rubric can be used as a standardized tool for patient safety curricula in academic training programs.

Implementation and Feasibility of the Re-Engineered Discharge for Surgery (RED-S) Intervention: A Pilot Study.

INTRODUCTION: Adapting Project Re-Engineered Discharge (Project RED), an intervention for reducing internal medicine hospital readmissions, is a promising option for reducing colorectal surgery readmissions. METHODS: We conducted a pilot study for the adaptation and implementation of Project RED with patients admitted for colectomy at a regional VA tertiary care center between July 2014 and January 2015. Implementation was evaluated using adherence to intervention components and results from the Survey of Healthcare Experiences of Patients. The adapted Project RED for Surgery has five components: surgical wound/ostomy-care education, scheduled follow-up appointments, medication reconciliation, an After Hospital Care Plan, and postdischarge phone calls. RESULTS: All (n = 21) participants received postoperative wound care education, and 77% of ostomy patients received education. Follow-up appointments were scheduled for 76% with surgery clinic and 67% with primary care. Half received pharmacist-led medication reconciliation. Seventy-five percent received a postdischarge phone call. Ninety five percent of participants reported positive or satisfactory care transitions versus less than 60% of a comparison group of surgery patients from the same institution. We summarized lessons learned from this intervention study to facilitate future dissemination efforts. CONCLUSION: The lessons learned from this pilot can guide quality improvement teams seeking to implement the Re-Engineered Discharge for Surgery intervention within their existing workflows.

Developing Leaders and Scholars in Health Care Improvement: The VA Quality Scholars Program Competencies.

Despite the need for leaders in health care improvement across health professions, there are no standards for the knowledge and skills that should be achieved through advanced interprofessional health care improvement training. Existing health care improvement training competencies focus on foundational knowledge expected of all trainees or for specific career pathways. Health care improvement leaders fill multiple roles within organizations and promote interprofessional improvement practice. The diverse skill set required of modern health care improvement leaders necessitates the development of training competencies specifically for fellowships in applied health care improvement. The authors describe the development of the revised national Veterans Affairs Quality Scholars (VAQS) Program competencies. The VAQS Program is an interprofessional, postdoctoral training program whose mission is to develop leaders and scholars to improve health care. An interprofessional committee of VAQS faculty reviewed and revised the competencies over 4 months beginning in fall 2018. The first draft was developed using 111 competencies submitted by 11 VAQS training sites and a review of published competencies. The final version included 22 competencies spanning 5 domains: interprofessional collaboration and teamwork, improvement and implementation science, organization and system leadership, methodological skills and analytic techniques for improvement and research, and teaching and coaching. Once attained, the VAQS competencies will guide the skill development that interprofessional health care improvement leaders need to participate in and lead health care improvement scholarship and implementation. These broad competencies are relevant to advanced training programs that develop health care improvement leaders and scholars and may be used by employers to understand the knowledge and skills expected of individuals who complete advanced fellowships in applied health care improvement.

E-consults: an effective way to decrease clinic wait times in rheumatology.

BACKGROUND: To evaluate the effect of E-consults on wait times and resource utilization for positive antinuclear antibody (ANA) referrals in outpatient rheumatology. METHODS: We conducted a pre-post study of E-consult implementation for positive ANA referrals. We retrospectively reviewed "positive ANA" referrals from 1/2015-3/2017. A statistical process control chart was created to display monthly average wait times for in-person clinic visits and to identify special cause variation. Final diagnoses, wait times and resource utilization were recorded and compared between E-consults and in-person referrals. RESULTS: There were 139 referrals for positive ANA with 126 occurring after E-consult implementation in August 2015. Forty-four percent (55/126) of referrals were E-consults; 76% did not have an in-person visit after initial electronic rheumatology recommendation. A control chart demonstrated special cause variation in the form of a shift from June 2016 - January 2017, suggesting a temporal association between decreased wait times and the implementation of E-consults. Eleven patients were diagnosed with ANA-associated rheumatic disease; the majority of patients (73%, 86/139) did not have a rheumatologic diagnosis. Overall E-consults utilized more labs than in-person visits, but this was not statistically significant. In-person visits utilized more imaging studies, which was statistically significant. CONCLUSION: E-consults are an effective way to address positive ANA consults without significant increase in resource utilization and were temporally associated with decreased wait times for in-person visits.

Toward Using Wearables to Remotely Monitor Cognitive Frailty in Community-Living Older Adults: An Observational Study.

Physical frailty together with cognitive impairment (Cog), known as cognitive frailty, is emerging as a strong and independent predictor of cognitive decline over time. We examined whether remote physical activity (PA) monitoring could be used to identify those with cognitive frailty. A validated algorithm was used to quantify PA behaviors, PA patterns, and nocturnal sleep using accelerometer data collected by a chest-worn sensor for 48-h. Participants (N = 163, 75 ± 10 years, 79% female) were classified into four groups based on presence or absence of physical frailty and Cog: PR-Cog-, PR+Cog-, PR-Cog+, and PR+Cog+. Presence of physical frailty (PR-) was defined as underperformance in any of the five frailty phenotype criteria based on Fried criteria. Presence of Cog (Cog-) was defined as a Mini-Mental State Examination (MMSE) score of less than 27. A decision tree classifier was used to identify the PR-Cog- individuals. In a univariate model, sleep (time-in-bed, total sleep time, percentage of sleeping on prone, supine, or sides), PA behavior (sedentary and light activities), and PA pattern (percentage of walk and step counts) were significant metrics for identifying PR-Cog- (p < 0.050). The decision tree classifier reached an area under the curve of 0.75 to identify PR-Cog-. Results support remote patient monitoring using wearables to determine cognitive frailty.

Impact of a Resident-Centered Interprofessional Quality Improvement Intervention on Acute Care Length of Stay.

Competency in interprofessional quality improvement and performance measurement is required by the Accreditation Council for Graduate Medical Education. We implemented an interprofessional quality improvement project to support trainee involvement in systems-level improvement to reduce hospital length of stay and engage trainees in efforts to improve the validity and reliability of clinical documentation contributing to risk-adjusted performance measures. The intervention had three components: daily interprofessional disposition huddles to discuss discharge needs, medical documentation curriculum to improve clinical data accuracy, and scheduled coding huddles to provide real-time feedback on documentation. Outcome measures included an unadjusted and risk-adjusted measure of hospital length of stay. Case severity index (CSI) served as a process measure. Statistical process control charts were used to measure change over time. The mean unadjusted length of stay decreased from 5.84 to 4.98 days. Both the unadjusted and the risk-adjusted length of stay measures exceeded the lower control limit of the statistical control chart. The CSI increased and exceeded the upper control limit of the statistical control chart. Improvements were sustained in the year following implementation. The intervention offers a model for academic institutions to satisfy new Common Program Requirements by engaging trainees in performance measurement and interprofessional improvement efforts.

Wearable Sensors and the Assessment of Frailty among Vulnerable Older Adults: An Observational Cohort Study.

Background: The geriatric syndrome of frailty is one of the greatest challenges facing the U.S. aging population. Frailty in older adults is associated with higher adverse outcomes, such as mortality and hospitalization. Identifying precise early indicators of pre-frailty and measures of specific frailty components are of key importance to enable targeted interventions and remediation. We hypothesize that sensor-derived parameters, measured by a pendant accelerometer device in the home setting, are sensitive to identifying pre-frailty. Methods: Using the Fried frailty phenotype criteria, 153 community-dwelling, ambulatory older adults were classified as pre-frail (51%), frail (22%), or non-frail (27%). A pendant sensor was used to monitor the at home physical activity, using a chest acceleration over 48 h. An algorithm was developed to quantify physical activity pattern (PAP), physical activity behavior (PAB), and sleep quality parameters. Statistically significant parameters were selected to discriminate the pre-frail from frail and non-frail adults. Results: The stepping parameters, walking parameters, PAB parameters (sedentary and moderate-to-vigorous activity), and the combined parameters reached and area under the curve of 0.87, 0.85, 0.85, and 0.88, respectively, for identifying pre-frail adults. No sleep parameters discriminated the pre-frail from the rest of the adults. Conclusions: This study demonstrates that a pendant sensor can identify pre-frailty via daily home monitoring. These findings may open new opportunities in order to remotely measure and track frailty via telehealth technologies.