Factors Associated With Disparities in Hospital Readmission Rates Among US Adults Dually Eligible for Medicare and Medicaid.

Importance: Low-income older adults who are dually eligible (DE) for Medicare and Medicaid often experience worse outcomes following hospitalization. Among other federal policies aimed at improving health for DE patients, Medicare has recently begun reporting disparities in within-hospital readmissions. The degree to which disparities for DE patients are owing to differences in community-level factors or, conversely, are amenable to hospital quality improvement, remains heavily debated. Objective: To examine the extent to which within-hospital disparities in 30-day readmission rates for DE patients are ameliorated by state- and community-level factors. Design Setting and Participants: In this retrospective cohort study, Centers for Medicare & Medicaid Services (CMS) Disparity Methods were used to calculate within-hospital disparities in 30-day risk-adjusted readmission rates for DE vs non-DE patients in US hospitals participating in Medicare. All analyses were performed in February and March 2019. The study included Medicare patients (aged ≥65 years) hospitalized for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2014 to 2017. Main Outcomes and Measures: Within-hospital disparities, as measured by the rate difference (RD) in 30-day readmission between DE vs non-DE patients following admission for AMI, HF, or pneumonia; variance across hospitals; and correlation of hospital RDs with and without adjustment for state Medicaid eligibility policies and community-level factors. Results: The final sample included 475 444 patients admitted for AMI, 898 395 for HF, and 1 214 282 for pneumonia, of whom 13.2%, 17.4%, and 23.0% were DE patients, respectively. Dually eligible patients had higher 30-day readmission rates relative to non-DE patients (RD >0) in 99.0% (AMI), 99.4% (HF), and 97.5% (pneumonia) of US hospitals. Across hospitals, the mean (IQR) RD between DE vs non-DE was 1.00% (0.87%-1.10%) for AMI, 0.82% (0.73%-0.96%) for HF, and 0.53% (0.37%-0.71%) for pneumonia. The mean (IQR) RD after adjustment for community-level factors was 0.87% (0.73%-0.97%) for AMI, 0.67% (0.57%-0.80%) for HF, and 0.42% (0.29%-0.57%) for pneumonia. Relative hospital rankings of corresponding within-hospital disparities before and after community-level adjustment were highly correlated (Pearson coefficient, 0.98). Conclusions and Relevance: In this cohort study, within-hospital disparities in 30-day readmission for DE patients were modestly associated with differences in state Medicaid policies and community-level factors. This suggests that remaining variation in these disparities should be the focus of hospital efforts to improve the quality of care transitions at discharge for DE patients in efforts to advance equity.

The impact and efficiency of medical screening exams in forward treatment areas at New York City public hospitals during the initial COVID-19 surge.

BACKGROUND: New York City (NYC) emergency departments (EDs) experienced a surge of patients because of coronavirus disease 2019 (COVID-19) in March 2020. NYC Health and Hospitals established rapid medical screening exams (MSE) and each hospital designated areas to perform their MSE. Five of the 11 hospitals created a forward treatment area (FTA) external to the ED to disposition patients before entering who presented with COVID-like symptoms. Three hospitals used paper-based, and 2 used an electronic medical record (EMR)-based MSE. This study evaluated the effectiveness of safely discharging patients home from the FTA while also evaluating the efficiency of using paper-based versus EMR-based MSEs. METHODS: Charts were reviewed using standardized data extraction templates. Patients discharged from the FTA were contacted by phone, and a structured interview captured additional data regarding subsequent clinical courses. Chi-square tests were used to compare proportions of patients hospitalized, as well as proportions of patients with vital signs recorded. Mortality rates were compared with Fisher exact test. A logistic regression model with fixed effects to account for clustering at hospitals was used to compare the odds of being sent to the ED for further evaluation based on vital signs and adjusted for age and sex. RESULTS: Across 5 EDs, 3335 patients were evaluated in their FTAs from March 17, 2020, to April 27, 2020. A total of 970 (29.1%) patients were referred for further evaluation into the ED, of which 203 (20.9%) were hospitalized and 19 (2.0%) died. Of 2302 patients discharged from the FTA, 182 (7.9%) returned to the ED within 7 days, resulting in 42 (1.8%) hospitalizations and 7 (0.3%) deaths. Facilities using EMR-MSE discharged more patients from their FTA (81.9% vs 65.3%, P < 0.001) and had similar 7-day return (9.3% vs 7.1%, P = 0.055) and mortality rates (0.49% vs 0.20%, P = 0.251). CONCLUSION: MSEs in an FTA are an effective process to disposition patients safely in a high-volume situation. Differences exist in paper- versus EMR-based approaches, suggesting EMR-MSEs provide better data, efficiency, and effectiveness. This suggests prioritizing an EMR-based MSE should be considered in future circumstances.

Pediatric Emergency Imaging Studies in Academic Radiology Departments: A Nationwide Survey of Staffing Practices.

OBJECTIVE: Particularly for pediatric patients presenting with acute conditions or challenging diagnoses, identifying variation in emergency radiology staffing models is essential in establishing a standard of care. We conducted a cross-sectional survey among radiology departments at academic pediatric hospitals to evaluate staffing models for providing imaging interpretation for emergency department imaging requests. METHODS: We conducted an anonymous telephone survey of academic pediatric hospitals affiliated with an accredited radiology residency program across the United States. We queried the timing, location, and experience of reporting radiologists for initial and final interpretations of emergency department imaging studies, during weekday, overnight, and weekend hours. We compared weekday with overnight, and weekday with weekend, using Fisher's exact test and an α of 0.05. RESULTS: Surveying 42 of 47 freestanding academic pediatric hospitals (89%), we found statistically significant differences for initial reporting radiologist, final reporting radiologist, and final report timing between weekday and overnight. We found statistically significant differences for initial reporting radiologist and final report timing between weekday and weekend. Attending radiologist involvement in initial reports was 100% during daytime, but only 33.3% and 69.0% during overnight and weekends. For initial interpretation during overnight and weekend, 38.1% and 28.6% use resident radiologists without attending radiologists, and 28.6% and 2.4% use teleradiology. All finalized reports as soon as possible during weekdays, but only 52.4% and 78.6% during overnight and weekend. DISCUSSION: A minority of hospitals use 24-hour in-house radiology attending radiologist coverage. During overnight periods, the majority of academic pediatric emergency departments rely on resident radiologists without attending radiologist supervision or outside teleradiology services to provide initial reports. During weekend periods, over a quarter rely on resident radiologists without attending radiologist supervision for initial reporting. This demonstrates significant variation in staffing practices at academic pediatric hospitals. Future studies should look to determine whether this variation has any impact on standard of care.

Using Information Technology To Improve COVID-19 Care At New York City Health + Hospitals.

As the coronavirus disease 2019 (COVID-19) pandemic surged in New York City, the city's public hospital system, New York City Health + Hospitals, recognized that innovative technological solutions were needed to respond to the crisis. Our health system recently transitioned to a unified enterprisewide electronic medical record across all of our hospitals. This accelerated our ability to implement a series of technological solutions to the crisis. We engaged in focused efforts to improve staff efficiency, including rapid medical screening exams for low-acuity patients, use of "SmartNotes," and improved vital sign monitoring. We standardized patient workup using specialty-specific order sets, created dashboards to give insight into enterprisewide bed availability and facilitate transfers from the hardest-hit hospitals, and improved the patient experience by using tablets to connect patients with loved ones. The technology bridged divides between different hospital systems across New York City to encourage the sharing of data and improve patient care. By rapidly expanding its use of information technology, NYC Health + Hospitals was able to respond to the COVID-19 surge and is now better positioned to work in a more integrated fashion in the future.

Staying Connected In The COVID-19 Pandemic: Telehealth At The Largest Safety-Net System In The United States.

New York City Health + Hospitals is the largest safety-net health care delivery system in the United States. Before the coronavirus disease 2019 (COVID-19) pandemic, NYC Health + Hospitals served more than one million patients annually, including the most vulnerable New Yorkers, while billing fewer than five hundred telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve our existing patients while treating the surge of new patients. Starting in March 2020, we were able to transform the system using virtual care platforms through which we conducted almost eighty-three thousand billable televisits in one month, as well as more than thirty thousand behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, postdischarge follow-up, and palliative care for patients with COVID-19. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients.

Critical Care And Emergency Department Response At The Epicenter Of The COVID-19 Pandemic.

New York City has emerged as the global epicenter for the coronavirus disease 2019 (COVID-19) pandemic. The city's public health system, New York City Health + Hospitals, has been key to the city's response because its vulnerable patient population is disproportionately affected by the disease. As the number of cases rose in the city, NYC Health + Hospitals carried out plans to greatly expand critical care capacity. Primary intensive care unit (ICU) spaces were identified and upgraded as needed, and new ICU spaces were created in emergency departments, procedural areas, and other inpatient units. Patients were transferred between hospitals to reduce strain. Critical care staffing was supplemented by temporary recruits, volunteers, and Department of Defense medical personnel. Supplies needed to deliver critical care were monitored closely and replenished to prevent interruptions. An emergency department action team was formed to ensure that the experience of front-line providers was informing network-level decisions. The steps taken by NYC Health + Hospitals greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases in NYC. These steps, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases.

Ambulance use is not associated with patient acuity after road traffic collisions: a cross-sectional study from Addis Ababa, Ethiopia.

BACKGROUND: Africa accounts for one sixth of global road traffic deaths-most in the pre-hospital setting. Ambulance transport is expensive relative to other modes of pre-hospital transport, but has advantages in time-sensitive, high-acuity scenarios. Many countries, including Ethiopia, are expanding ambulance fleets, but clinical characteristics of patients using ambulances remain ill-defined. METHODS: This is a cross-sectional study of 662 road traffic collisions (RTC) patients arriving to a single trauma referral center in Addis Ababa, Ethiopia, over 7 months. Emergency Department triage records were used to abstract clinical and arrival characteristics, including acuity. The outcome of interest was ambulance arrival. Secondary outcomes of interest were inter-facility referral and referral communication. Descriptive and multivariable statistics were computed to identify factors independently associated with outcomes. RESULTS: Over half of patients arrived with either high (13.1%) or moderate (42.2%) acuity. Over half (59.0%) arrived by ambulance, and nearly two thirds (65.9%) were referred. Among referred patients, inter-facility communication was poor (57.7%). Patients with high acuity were most likely to be referred (aOR 2.20, 95%CI 1.16-4.17), but were not more likely to receive ambulance transport (aOR 1.56, 95%CI 0.86-2.84) or inter-facility referral communication (aOR 0.98, 95%CI 0.49-1.94) than those with low acuity. Nearly half (40.2%) of all patients were referred by ambulance despite having low acuity. CONCLUSIONS: Despite ambulance expansion in Addis Ababa, ambulance use among RTC patients remains heavily concentrated among those with low-acuity. Inter-facility referral appears a primary contributor to low-acuity ambulance use. In other contexts, similar routine ambulance monitoring may help identify low-value utilization. Regional guidelines may help direct ambulance use where most valuable, and warrant further evaluation.

Impact of nutrition interventions on pediatric mortality and nutrition outcomes in humanitarian emergencies: A systematic review.

OBJECTIVES: Malnutrition contributes to paediatric morbidity and mortality in disasters and complex emergencies, but summary data describing specific nutritional interventions in these settings are lacking. This systematic review aimed to characterise such interventions and their effects on paediatric mortality, anthropometric measures and serum markers of nutrition. METHODS: A systematic search of OVID MEDLINE, Cochrane Library and relevant grey literature was conducted. We included all randomised controlled trials and observational controlled studies evaluating effectiveness of nutritional intervention(s) on defined health outcomes in children and adolescents (0-18 years) within a disaster or complex emergency. We extracted study characteristics, interventions and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: A total of 31 studies met inclusion criteria. Most were conducted in Africa (17), during periods of conflict or hunger gaps (14), and evaluated micronutrient supplementation (14) or selective feeding (10). Overall study quality was low, with only two high and four moderate quality studies. High- and medium-quality studies demonstrated positive impact of fortified spreads, ready-to-use therapeutic foods, micronutrient supplementation, and food and cash transfers. CONCLUSION: In disasters and complex emergencies, high variability and low quality of controlled studies on paediatric malnutrition limit meaningful data aggregation. If existing research gaps are to be addressed, the inherent unpredictability of humanitarian emergencies and ethical considerations regarding controls may warrant a paradigm shift in what constitutes adequate methods. Periodic hunger gaps may offer a generalisable opportunity for robust trials, but consensus on meaningful nutritional endpoints is needed.

Nonacademic Attributes Predict Medical and Nursing Student Intentions to Emigrate or to Work Rurally: An Eight-Country Survey in Asia and Africa.

AbstractWe sought to identify independent, nonacademic predictors of medical and nursing student intent to migrate abroad or from rural to urban areas after graduation in low- and middle-income countries (LMIC). This was a cross-sectional survey of 3,199 first- and final-year medical and nursing students at 16 training institutions in eight LMIC. Questionnaires assessed demographics, career intentions, and preferences regarding selected career, location, and work-related attributes. Using principal component analysis, student preferences were reduced into four discrete categories of priorities: 1) work environment resources, 2) location livability, 3) altruistic job values, and 4) individualistic job values. Students' preferences were scored in each category. Using students' characteristics and priority scores, multivariable proportional odds models were used to derive independent predictors of intentions to emigrate for work outside the country, or to work in a rural area in their native country. Students prioritizing individualistic values more often planned international careers (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.16-1.78), whereas those prioritizing altruistic values preferred rural careers (aOR = 1.82, 95% CI = 1.50-2.21). Trainees prioritizing high-resource environments preferentially planned careers abroad (aOR = 1.38, 95% CI = 1.12-1.69) and were unlikely to seek rural work (aOR = 0.60, 95% CI = 0.49-0.73). Independent of their priorities, students with prolonged prior rural residence were unlikely to plan emigration (aOR = 0.67, 95% CI = 0.50-0.90) and were more likely to plan a rural career (aOR = 1.53, 95% CI = 1.16-2.03). We conclude that use of nonacademic attributes in medical and nursing admissions processes would likely increase retention in high-need rural areas and reduce emigration "brain drain" in LMIC.

Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings.

INTRODUCTION: Although dehydration from diarrhea is a leading cause of morbidity and mortality in children under five, existing methods of assessing dehydration status in children have limited accuracy. OBJECTIVE: To assess the accuracy of point-of-care ultrasound measurement of the aorta-to-IVC ratio as a predictor of dehydration in children. METHODS: A prospective cohort study of children under five years with acute diarrhea was conducted in the rehydration unit of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Ultrasound measurements of aorta-to-IVC ratio and dehydrated weight were obtained on patient arrival. Percent weight change was monitored during rehydration to classify children as having "some dehydration" with weight change 3-9% or "severe dehydration" with weight change > 9%. Logistic regression analysis and Receiver-Operator Characteristic (ROC) curves were used to evaluate the accuracy of aorta-to-IVC ratio as a predictor of dehydration severity. RESULTS: 850 children were enrolled, of which 771 were included in the final analysis. Aorta to IVC ratio was a significant predictor of the percent dehydration in children with acute diarrhea, with each 1-point increase in the aorta to IVC ratio predicting a 1.1% increase in the percent dehydration of the child. However, the area under the ROC curve (0.60), sensitivity (67%), and specificity (49%), for predicting severe dehydration were all poor. CONCLUSIONS: Point-of-care ultrasound of the aorta-to-IVC ratio was statistically associated with volume status, but was not accurate enough to be used as an independent screening tool for dehydration in children under five years presenting with acute diarrhea in a resource-limited setting.