Access to routine care and risks for 30-day readmission in patients with cardiovascular disease.

BACKGROUND: Studies have shown that access to routine medical care is associated with the prevention, diagnosis, and treatment of chronic diseases. However, studies have not examined whether patient-reported difficulties in access to care are associated with rehospitalization in patients with cardiovascular disease. METHODS: Electronic medical records and a standardized survey were used to examine cardiovascular patients admitted to a large medical center from January 1, 2015 through January 10, 2017 (n=520). All-cause readmission within 30 days of discharge was the primary outcome for analysis. Logistic regression models were used to examine the association between access to care and 30-day readmission while adjusting for patient demographics, socioeconomic status, healthcare utilization, and health status. RESULTS: Nearly 1-in-6 patients (15.7%) reported difficulty in accessing routine medical care; and those who were younger, male, non-white, uninsured, with heart failure, and had low social support were significantly more likely to report difficulty. Patients who reported difficulty in accessing care had significantly higher rates of 30-day readmission than patients who did not report difficulty (33.3% vs. 17.9%; P=.001); and the risks remained largely unchanged after accounting for nearly two dozen covariates (unadjusted odds ratio [OR]=2.29; 95% CI, 1.46-3.60 vs. adjusted OR=2.17; 95% CI, 1.29-3.66). Risks for readmission were especially high for patients who reported issues with transportation (OR=3.24; 95% CI, 1.28-8.16) and scheduling appointments (OR=3.56; 95% CI, 1.43-8.84), but not for other reasons (OR=1.47; 95% CI, 0.61-3.54). CONCLUSIONS: Cardiovascular patients who reported difficulty in accessing routine care had substantial risks of readmission within 30 days after discharge. These findings have important implications for identifying high-risk patients and developing interventions to improve access to routine medical care.

Socioeconomic, Psychosocial and Behavioral Characteristics of Patients Hospitalized With Cardiovascular Disease.

BACKGROUND: Recent studies have drawn attention to nonclinical factors to better understand disparities in the development, treatment and prognosis of patients with cardiovascular disease. However, there has been limited research describing the nonclinical characteristics of patients hospitalized for cardiovascular care. METHODS: Data for this study come from 520 patients admitted to the Duke Heart Center from January 1, 2015 through January 10, 2017. Electronic medical records and a standardized survey administered before discharge were used to ascertain detailed information on patients' demographic (age, sex, race, marital status and living arrangement), socioeconomic (education, employment and health insurance), psychosocial (health literacy, health self-efficacy, social support, stress and depressive symptoms) and behavioral (smoking, drinking and medication adherence) attributes. RESULTS: Study participants were of a median age of 65 years, predominantly male (61.4%), non-Hispanic white (67.1%), hospitalized for 5.11 days and comparable to all patients admitted during this period. Results from the survey showed significant heterogeneity among patients in their demographic, socioeconomic and behavioral characteristics. We also found that the patients' levels of psychosocial risks and resources were significantly associated with many of these nonclinical characteristics. Patients who were older, women, nonwhite and unmarried had generally lower levels of health literacy, self-efficacy and social support, and higher levels of stress and depressive symptoms than their counterparts. CONCLUSIONS: Patients hospitalized with cardiovascular disease have diverse nonclinical profiles that have important implications for targeting interventions. A better understanding of these characteristics will enhance the personalized delivery of care and improve outcomes in vulnerable patient groups.

Identifying Nonclinical Factors Associated With 30-Day Readmission in Patients with Cardiovascular Disease: Protocol for an Observational Study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of hospitalization in older adults and high readmission rates have attracted considerable attention as actionable targets to promote efficiency in care and to reduce costs. Despite a plethora of research over the past decade, current strategies to predict readmissions have been largely ineffective and efforts to identify novel clinical predictors have been largely unsuccessful. OBJECTIVE: The objective of this study is to examine a wide array of socioeconomic, psychosocial, behavioral, and clinical factors to predict risks of 30-day hospital readmission in cardiovascular patients. METHODS: The study includes patients (aged 18 years and older) admitted for the treatment of cardiovascular-related illnesses at the Duke Heart Center, which is among the nation's largest and top-ranked cardiovascular care hospitals. The study uses a novel standardized survey to ascertain data on a comprehensive array of patient characteristics that will be linked to their electronic medical records. A series of univariate and multivariate models will be used to estimate the associations between the patient-level factors and 30-day readmissions. The performance of the risk models will be examined based on 2 components of accuracy-model calibration and discrimination-to determine how closely the predicted outcome agrees with the observed (actual) outcome and how well the model distinguishes patients who were readmitted and those who were not. The purpose of this paper is to present the protocol for the implementation of this study. RESULTS: The study was launched in February 2014 and is actively recruiting patients from the Heart Center. Approximately 550 patients have been enrolled to date and the study is expected to continue recruitment until February 2018. Preliminary results show that participants in the study were aged 63.6 years on average (SD 14.0), predominately male (61.2%), and primarily non-Hispanic white (64.6%) or non-Hispanic black (31.7%). The demographic characteristics of study participants were not significantly different from all patients admitted to the Heart Center during this period with an average age of 65.0 years (SD 15.3) and predominately male (58.6%), non-Hispanic white (62.9%) or non-Hispanic black (31.8%) The integration of the interview data with clinical data from the patient electronic medical records is currently underway. The study has received funding and ethical approval. CONCLUSIONS: Many US hospitals continue to struggle with high readmission rates in patients with cardiovascular disease. The primary objective of this study is to collect and integrate a comprehensive array of patient attributes to develop a powerful yet parsimonious model to stratify risks of rehospitalization in cardiovascular patients. The results of this research also have the potential to identify actionable targets for tailored interventions to improve patient outcomes.

Randomized Trial of Population-Based Clinical Decision Support to Facilitate Care Transitions.

Medicaid beneficiaries in 6 North Carolina counties were randomly assigned to 1 of 3 clinical decision support (CDS) care transition strategies: (1) usual care (Control), (2) CDS messaging to patients and their medical homes (Reports), or (3) CDS messaging to patients, their medical homes, and their care managers (Reports+). We included 7146 Medicaid patients and evaluated transitions from specialist visit, ER and hospital encounters back to the patient's medical home. Patients enrolled in Medicare and Medicaid were not eligible. The number of care manager contacts was greater for patients in the Reports+ Group than in the Control Group. However, there were no treatment-related differences in emergency department (ED) encounter rates, or in the secondary outcomes of outpatient and hospital encounter rates and medical costs. Study monitors found study intervention documentation in approximately 60% of patient charts. These results highlight the importance of effectively integrating information interventions into healthcare delivery workflow systems.

Place-Based Initiatives to Improve Health in Disadvantaged Communities: Cross-Sector Characteristics and Networks of Local Actors in North Carolina.

OBJECTIVES: To examine the leadership attributes and collaborative connections of local actors from the health sector and those outside the health sector in a major place-based health initiative. METHODS: We used survey data from 340 individuals in 4 Healthy Places North Carolina counties from 2014 to assess the leadership attributes (awareness, attitudes, and capacity) and network connections of local actors by their organizational sector. RESULTS: Respondents' leadership attributes-scored on 5-point Likert scales-were similar across Healthy Places North Carolina counties. Although local actors reported high levels of awareness and collaboration around community health improvement, we found lower levels of capacity for connecting diversity, identifying barriers, and using resources in new ways to improve community health. Actors outside the health sector had generally lower levels of capacity than actors in the health sector. Those in the health sector exhibited the majority of network ties in their community; however, they were also the most segregated from actors in other sectors. CONCLUSIONS: More capacity building around strategic action-particularly in nonhealth sectors-is needed to support efforts in making widespread changes to community health.

Education, glucose control, and mortality risks among U.S. older adults with diabetes.

AIMS: Studies have shown that diabetes mellitus disproportionately afflicts persons of low socioeconomic status and that the burden of disease is greatest among the disadvantaged. However, our understanding of educational differences in the control of diabetes and its impact on survival is limited. This study investigated the associations among education, hemoglobin A1c (HbA1c), and subsequent mortality in adults with diabetes. METHODS: Prospective cohort data from the 2006, 2008, and 2010 Health and Retirement Study were linked with biomarker data for U.S. older adults with diabetes (n=3312). Weighted distributions were estimated for all subjects at baseline and by the American Diabetes Association's general guidelines for HbA1c control (<7.0% [53 mmol/mol] vs. ≥7.0% [53 mmol/mol]). Proportional hazard models were used to estimate educational differences in all-cause mortality by HbA1c level with sequential adjustments for contributing risk factors. RESULTS: Mortality risks associated with HbA1c≥7.0% [53 mmol/mol] were significantly greater in lower-educated adults than higher-educated adults (P<0.001). We found that the hazard ratios (HR) associated with HbA1c ≥7.0% [53 mmol/mol] were highest among low-educated adults (HR=2.18, 95% CI: 1.62, 2.94) and that a combination of socioeconomic, psychosocial, and behavioral factors accounted for most, but not all, of the associations. CONCLUSIONS: Educational differences in HbA1c control have significant implications for mortality and efforts to reduce these disparities should involve more vigilant screening and monitoring of lower-educated adults with diabetes.

Barriers to care for patients with diabetes in Durham, North Carolina, why are we withholding life-sustaining medications from the patients who need them the most?

The diabetes epidemic and its complications disproportionately affect minorities and the poor. Medical treatments that can prevent or delay diabetes complications are widely available but poverty underlies much of why there are disparities in diabetes care and outcomes. Lack of access to care, food insecurity and inability to pay for medications prevents adherence to a medication and lifestyle regimen that can be life-sustaining. At the very least, US policies should be changed to provide life-sustaining medications that prevent costly complications to patients who cannot afford them. Adopting value-based insurance design would benefit patients with diabetes who cannot afford to pay for medications but would also reduce healthcare costs in the long run.

Decision support for evidence-based pharmacotherapy detects adherence problems but does not impact medication use.

Although evidence-based pharmacotherapies are a principal component of patient care, 30-50% of patients do not take their medications as prescribed. We conducted a randomized trial of two clinical decision support (CDS) interventions in 2219 patients: patient adherence reports to providers (n=744), patient adherence reports to providers + email notices to care managers (n=736), and controls (739). At 18-month follow-up, there were no treatment-related differences in patient medication adherence (overall, by medication class, and by medical condition). There also were no treatment-related differences in patient clinical and economic outcomes. Thus, while this study's CDS information interventions were successfully delivered to providers and care managers, and were effective in identifying medication adherence deficits and in increasing care manager responses to medication adherences issues, these interventions were not able to alter patient medication behavior.

A randomized trial of population-based clinical decision support to manage health and resource use for Medicaid beneficiaries.

To determine whether a clinical decision support system can favorably impact the delivery of emergency department and hospital services. Randomized clinical trial of three clinical decision support delivery modalities: email messages to care managers (email), printed reports to clinic administrators (report) and letters to patients (letter) conducted among 20,180 Medicaid beneficiaries in Durham County, North Carolina with follow-up through 9 months. Patients in the email group had fewer low-severity emergency department encounters vs. controls (8.1 vs. 10.6/100 enrollees, p < 0.001) with no increase in outpatient encounters or medical costs. Patients in the letter group had more outpatient encounters and greater outpatient and total medical costs. There were no treatment-related differences for patients in the reports group. Among patients <18 years, those in the email group had fewer low severity (7.6 vs. 10.6/100 enrollees, p < 0.001) and total emergency department encounters (18.3 vs. 23.5/100 enrollees, p < 0.001), and lower emergency department ($63 vs. $89, p = 0.002) and total medical costs ($1,736 vs. $2,207, p = 0.009). Patients who were ≥18 years in the letter group had greater outpatient medical costs. There were no intervention-related differences in patient-reported assessments of quality of life and medical care received. The effectiveness of clinical decision support messaging depended upon the delivery modality and patient age. Health IT interventions must be carefully evaluated to ensure that the resultant outcomes are aligned with expectations as interventions can have differing effects on clinical and economic outcomes.

Population-based clinical decision support: a clinical and economic evaluation.

Governments are investing in health information technologies (HIT) to improve care quality and reduce medical costs. However, evidence of these benefits is limited. We conducted a randomized trial of three clinical decision support (CDS) interventions in 20,180 patients: email to care managers (n=3329), reports to primary care administrators (n=3368), letters to patients (n=3401), and controls (10,082). At 7-month follow-up, the letters to patients group had greater use of outpatient services and higher outpatient and total medical costs; whereas, the other groups had no change in clinical events or medical costs. As our CDS interventions were associated with no change or an increase in medical costs, it appears that investments in HIT without consideration for organizational context may not be sufficient to achieve improvements in clinical and economic outcomes.

Clinical and economic results from a randomized trial of clinical decision support in a rural health network.

BACKGROUND: Replication studies evaluate technologies in usual use settings. METHODS: We conducted a clinical trial to determine whether reductions in clinical and economic results observed in a previous study could be replicated in a larger setting. Subjects were randomized to receive intervention (email notifications for sentinel health events sent to their care managers) or control. MAIN OUTCOME MEASURES: The primary outcome was the rate of emergency department visits for low severity conditions. Secondary outcomes included: medical costs and other clinical event rates. RESULTS: We randomized 13,454 individuals (intervention, 6740; control, 6714). Subjects in both groups had similar rates of clinical events and medical costs. CONCLUSION: The use of email notifications to care managers was associated with no reductions in clinical events or medical costs.

A randomized clinical trial of clinical decision support in a rural community health network serving lower income individuals: study design and baseline characteristics.

Lower income individuals in the US frequently experience difficulties in obtaining access to needed health care services. We describe a randomized clinical trial that seeks to improve the quality of, and access to healthcare services for medically underserved populations in five rural counties of North Carolina. We propose to achieve these improvements by implementing system-to-system integration via a telehealth network with an asynchronous clinical decision support system for health care providers.

Deployment of health information kiosks in diverse community settings: experience and lessons learned.

The use of kiosks in healthcare by patients to collect and deliver health information is growing rapidly. When planning kiosk deployment many factors such as proper location, presentation, access, and support need to be considered to foster usage. This poster describes how these factors were addressed, presents actual experiences with kiosk deployment, and provides lessons learned from the field.

Coupling direct collection of health risk information from patients through kiosks with decision support for proactive care management.

Data collection from patients for use in clinical decision making is foundational for medical practice. Increasingly, kiosks are being used to facilitate direct data collection from patients. However, kiosk-collected data are generally not integrated into the care process. In this project, 4,014 people initiated a kiosk-administered health risk assessment questionnaire using a free-standing public-access kiosk. For 201 of these initiated sessions, kiosk users supplied a Medicaid identification number which allowed their data to be integrated into a regional health information exchange and reviewed by a standards-based clinical decision support system. This system identified 479 survey responses which had been predetermined to warrant follow-up. Notices about these sentinel responses were emailed to care managers and sent to clinical sites. While this study demonstrates the feasibility of collecting and acting on patient-entered health data, it also identifies key challenges to providing proactive care management in this manner.

Providing contextually relevant health literature for at-risk patients using free-standing touchscreen computer kiosks in community settings.

In this project we describe the successful implementation of a computer kiosk system that collects health risk information directly from patients and provides both contextually relevant and patient-tailored health information. We include usage statistics for kiosks located in community settings and demonstrate that patients will readily utilize these kiosks to access health information.

Proactive population health management in the context of a regional health information exchange using standards-based decision support.

The clinic-based healthcare model does not deliver high quality, cost-effective care to populations of patients. Despite public perception that aggressive investment in information technology will lead to improvements in the safety and quality of healthcare delivery, there is little evidence that health information technology can be used to promote population-based health management. This paper describes the use of a standards-based clinical decision support system to facilitate proactive population health management using data from a regional health information exchange (HIE) network. The initial release of this system was designed to detect ten sentinel health events related to hospitalization, emergency department (ED) utilization, and care coordination in a population of 36,000 individuals. In an analysis of 11,899 continuously enrolled patients from a single county over a six-month period, 2,285 unique patients experienced 7,226 sentinel health events. The most common events were ED utilization for low severity conditions (2,546), two or more missed appointments within a 60-day period (1,728), ED encounters for patients with asthma (1,220), and three or more ED encounters within 90 days (731). Logistic regression analysis identified patients aged 19-64 as the population most likely to have sentinel health events. In addition to presenting data demonstrating the feasibility of population health management in the context of an HIE, this paper also includes lessons learned from the development, implementation, and operational support of the population health management system.

Perceptions about use of a patient Internet portal among Medicaid beneficiaries.

Patient Internet portals that allow patients to access their personal health information are an emerging form of enabling technology. The purported benefits from increasing use of information technology in healthcare, however, may not be universal because of a widening digital divide along racial and socioeconomic lines. In this pilot study, we surveyed 31 Medicaid beneficiaries to ascertain their interest in and projected use of a healthcare patient Internet portal. We found that most Medicaid beneficiaries were very interested in accessing personal health information about themselves or their dependents online. Moreover, ninety percent of respondents reported that they have access to the Internet, and sixty-eight percent of those with Internet access use the Internet once a week or more.

Perceptions of Medicaid beneficiaries regarding the usefulness of accessing personal health information and services through a patient Internet portal.

Increasing emphasis is being placed on the importance of information technology to improve the safety and quality of healthcare. However, concern is growing that these potential benefits will not be equally distributed across the population because of a widening digital divide along racial and socioeconomic lines. In this pilot study, we surveyed 31 Medicaid beneficiaries to ascertain their interest in and projected use of a healthcare patient Internet portal. We found that most Medicaid beneficiaries (or their parents/guardians) were very interested in accessing personal health information about themselves (or their dependents) online. Additionally, they were interested in accessing healthcare services online. We also found that many Medicaid beneficiaries have Internet access, including a slight majority with access to high-speed Internet connections. Our study revealed significant concern about the privacy of online health information.