RESUMO
OBJECTIVE: The objective of this work was to establish sustainable systems for quality improvement in an Academic Medical Center and Safety Net Hospital. METHOD: High reliability principles of leadership engagement, a culture of safety, and sustainable performance improvement were used. Target areas for improvement were clinical outcomes for patients, public reputation scores, and lower cost of care. The system was based on annual focused goals with specific targets, improvement teams, transparent scorecards, and data driven work. Program visibility was championed by leaders. Consistent education on quality, safety, efficiency, and effectiveness for all employees created buy-in. Data review and accountability tracked progress, helped resource allocation, and defined next steps. RESULTS: In the first 5 years, all patient quality and safety metrics improved between 10% and 60%. This improvement resulted in higher CMS Star Ranking and Leapfrog patient safety grade. The next phase included maximizing value by expanding into hospital operations and finance with a focus on improved clinical documentation and reduced length of stay and cost of care. Clinical documentation improvement led to a 15% increase in comorbidity capture. This positively impacted reported outcomes and hospital payment by appropriate risk adjustment. Length of stay was addressed with a new care coordination program and physician-driven utilization review. CONCLUSIONS: High reliability principles are applicable in a resource limited healthcare system. Improved clinical and operational results were achieved through goal setting, improvement teams, and data driven projects leading to creation of an office of operational excellence.
Assuntos
Liderança , Segurança do Paciente , Melhoria de Qualidade , Provedores de Redes de Segurança , Humanos , Provedores de Redes de Segurança/organização & administração , Provedores de Redes de Segurança/normas , Centros Médicos Acadêmicos/organização & administração , Cultura Organizacional , Reprodutibilidade dos Testes , Gestão da Segurança/normasRESUMO
BACKGROUND: A single dose of dexamethasone is routinely given during general anesthesia for postoperative nausea and vomiting (PONV) prophylaxis, although the exact dosage and timing of administration may vary between practitioners. The authors aimed to standardize the dosage and timing of this medication when given to adult patients undergoing general anesthesia for elective surgery. METHODS: Baseline data for 7,483 preintervention cases were analyzed. The researchers attempted to use a standard dose of 8 to 10 mg induction of anesthesia, which, based on a literature review, was effective for PONV prophylaxis, had a similar safety profile as a 4 to 5 mg dose (including in diabetic patients), and may confer additional benefits such as improved prophylaxis and quality of recovery. The interventions included standardizing the medication concentration vials, altering electronic health record quick-select button options, simplifying the intraoperative charting process, and educating the anesthesia providers. The research team then tracked compliance with the standard of care for 2,167 cases after the interventions. RESULTS: Overall compliance with the standard of care increased from 21.2% preintervention to 53.7% postintervention. The number of patients not receiving dexamethasone was reduced from 29.7% to 19.4%. Patients receiving a compliant dose at a noncompliant time increased from 16.3% to 23.8%. Postanesthesia care unit antiemetic administration also decreased after the interventions. CONCLUSION: This study showed improvements in compliance with the dosage of medication with the interventions. However, compliance with the timing of administration remains challenging.
Assuntos
Antieméticos , Dexametasona , Náusea e Vômito Pós-Operatórios , Humanos , Dexametasona/administração & dosagem , Náusea e Vômito Pós-Operatórios/prevenção & controle , Antieméticos/administração & dosagem , Provedores de Redes de Segurança/normas , Masculino , Feminino , Anestesia Geral/normas , Adulto , Pessoa de Meia-Idade , Esquema de Medicação , Fidelidade a Diretrizes , Registros Eletrônicos de Saúde , Idoso , Procedimentos Cirúrgicos EletivosRESUMO
BACKGROUND: Communication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States. METHODS: A retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient's self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video). RESULTS: A total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers. CONCLUSIONS: Encounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.
Assuntos
Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Idioma , Proficiência Limitada em Inglês , Oftalmologia , Ambulatório Hospitalar , Humanos , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Assistência Ambulatorial/normas , Assistência Ambulatorial/estatística & dados numéricos , Provedores de Redes de Segurança/normas , Provedores de Redes de Segurança/estatística & dados numéricos , Ambulatório Hospitalar/normas , Ambulatório Hospitalar/estatística & dados numéricos , Estados Unidos/epidemiologia , Oftalmologia/normas , Oftalmologia/estatística & dados numéricos , Estudos RetrospectivosRESUMO
Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against their peers in order to win bonuses or face penalties in payment. Yet luck has the potential to affect performance assessment through randomness in the sorting of patients among providers or through random events during the evaluation period. To investigate the impact luck can have on the assessment of performance, we investigated its role in assigning penalties under Medicare's Hospital Readmissions Reduction Policy (HRRP), a program that penalizes hospitals with excess readmissions. We performed simulations that estimated program hospitals' 2015 readmission penalties in 1,000 different hypothetical fiscal years. These hypothetical fiscal years were created by: (a) randomly varying which patients were admitted to each hospital and (b) randomly varying the readmission status of discharged patients. We found significant differences in penalty sizes and probability of penalty across hypothetical fiscal years, signifying the importance of luck in readmission performance under the HRRP. Nearly all of the impact from luck arose from events occurring after hospital discharge. Luck played a smaller role in determining penalties for hospitals with more beds, teaching hospitals, and safety-net hospitals.
Assuntos
Economia Hospitalar/normas , Hospitais/normas , Medicare/economia , Readmissão do Paciente/economia , Qualidade da Assistência à Saúde , Reembolso de Incentivo/normas , Provedores de Redes de Segurança/normas , Idoso , Humanos , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Estados UnidosRESUMO
BACKGROUND: The performance of existing predictive models of readmissions, such as the LACE, LACE+, and Epic models, is not established in urban safety-net populations. We assessed previously validated predictive models of readmission performance in a socially complex, urban safety-net population, and if augmentation with additional variables such as the Area Deprivation Index, mental health diagnoses, and housing access improves prediction. Through the addition of new variables, we introduce the LACE-social determinants of health (SDH) model. METHODS: This retrospective cohort study included adult admissions from July 1, 2016, to June 30, 2018, at a single urban safety-net health system, assessing the performance of the LACE, LACE+, and Epic models in predicting 30-day, unplanned rehospitalization. The LACE-SDH development is presented through logistic regression. Predictive model performance was compared using C-statistics. RESULTS: A total of 16,540 patients met the inclusion criteria. Within the validation cohort (n=8314), the Epic model performed the best (C-statistic=0.71, P<0.05), compared with LACE-SDH (0.67), LACE (0.65), and LACE+ (0.61). The variables most associated with readmissions were (odds ratio, 95% confidence interval) against medical advice discharge (3.19, 2.28-4.45), mental health diagnosis (2.06, 1.72-2.47), and health care utilization (1.94, 1.47-2.55). CONCLUSIONS: The Epic model performed the best in our sample but requires the use of the Epic Electronic Health Record. The LACE-SDH performed significantly better than the LACE and LACE+ models when applied to a safety-net population, demonstrating the importance of accounting for socioeconomic stressors, mental health, and health care utilization in assessing readmission risk in urban safety-net patients.
Assuntos
Readmissão do Paciente/tendências , Medição de Risco/normas , Provedores de Redes de Segurança/normas , Adulto , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Readmissão do Paciente/estatística & dados numéricos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Provedores de Redes de Segurança/métodos , Provedores de Redes de Segurança/estatística & dados numéricos , Serviços Urbanos de Saúde/organização & administração , Serviços Urbanos de Saúde/estatística & dados numéricosRESUMO
OBJECTIVE: To determine eligibility for discontinuation of cervical cancer screening. METHODS: Women aged 64 with employer-sponsored insurance enrolled in a national database between 2016 and 2018, and those aged 64-66 receiving primary care at a safety net health center in 2019 were included. Patients were evaluated for screening exit eligibility by current guidelines: no evidence of cervical cancer or HIV-positive status and no evidence of cervical precancer in the past 25 years, and had evidence of either hysterectomy with removal of the cervix or evidence of fulfilling screening exit criteria, defined as two HPV screening tests or HPV plus Pap co-tests or three Pap tests within the past 10 years without evidence of an abnormal result. RESULTS: Of the 590,901 women in the national claims database, 131,059 (22.2%) were eligible to exit due to hysterectomy (1.6%) or negative screening (20.6%). Of the 1544 women from the safety net health center, 528 (34.2%) were eligible to exit due to hysterectomy (9.3%) or negative screening (24.9%). Most women did not have sufficient data available to fulfill exit criteria: 382,509 (64.7%) in the national database and 875 (56.7%) in the safety net hospital system. Even among women with 10 years of insurance claims data, only 41.5% qualified to discontinue screening. CONCLUSIONS: Examining insurance claims in a national database and electronic medical records at a safety net institution led to remarkably similar findings: two thirds of women fail to qualify for screening exit. Additional steps to ensure eligibility prior to screening exit may be necessary to decrease preventable cervical cancers among women aged >65. CLINICAL TRIAL REGISTRATION: N/A.
Assuntos
Detecção Precoce de Câncer/normas , Definição da Elegibilidade/normas , Infecções por Papillomavirus/diagnóstico , Neoplasias do Colo do Útero/diagnóstico , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Idoso , Estudos de Coortes , Detecção Precoce de Câncer/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Definição da Elegibilidade/estatística & dados numéricos , Feminino , Humanos , Histerectomia/estatística & dados numéricos , Cobertura do Seguro/normas , Cobertura do Seguro/estatística & dados numéricos , Pessoa de Meia-Idade , Teste de Papanicolaou/estatística & dados numéricos , Infecções por Papillomavirus/patologia , Infecções por Papillomavirus/virologia , Guias de Prática Clínica como Assunto , Provedores de Redes de Segurança/normas , Provedores de Redes de Segurança/estatística & dados numéricos , Estados Unidos , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/prevenção & controle , Neoplasias do Colo do Útero/virologia , Esfregaço Vaginal/estatística & dados numéricosRESUMO
BACKGROUND: High hospital safety-net burden has been associated with inferior clinical outcomes. We aimed to characterize the association of safety-net burden with outcomes in a national cohort of patients undergoing carotid interventions. METHODS: The 2010-2017 Nationwide Readmissions Database was used to identify adults undergoing carotid endarterectomy and carotid artery stenting. Hospitals were classified as low (LBH), medium, or high safety-net burden (HBH) based on the proportion of uninsured or Medicaid patients. Multivariable models were developed to evaluate associations between HBH and outcomes. RESULTS: Of an estimated 540,558 hospitalizations for a carotid intervention, 28.5% were at HBH. Patients treated at HBH were more likely to be admitted non-electively (28.7% vs 20.2%, P < .001), have symptomatic presentation (11.0% vs 7.7%, P < .001), and undergo carotid artery stenting (18.7% vs 8.9%, P < .001). After adjustment, HBH remained associated with increased odds of postoperative stroke (AOR 1.19, P = .023, Ref = LBH), non-home discharge (AOR 1.10, P = .026), 30-day readmissions (AOR 1.14, P < .001), and 31-90-day readmissions (AOR 1.13, P < .001), but not in-hospital mortality (AOR 1.18, P = .27). HBH was linked to increased hospitalization costs (ß +$2,169, P = .016). CONCLUSION: HBH was associated with postoperative stroke, non-home discharge, readmissions, and increased hospitalization costs after carotid revascularization. Further studies are warranted to alleviate healthcare inequality and improve outcomes at safety-net hospitals.
Assuntos
Endarterectomia das Carótidas/estatística & dados numéricos , Provedores de Redes de Segurança/estatística & dados numéricos , Idoso , Implante de Prótese Vascular/efeitos adversos , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Provedores de Redes de Segurança/normas , Stents , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
The COVID-19 pandemic has brought about a precipitous transformation in health care delivery in the nation's safety-net, primary care system of federally qualified health centers (FQHCs). This study uses electronic health record data to quantify the extent of changes to visit volume in 36 FQHCs across 19 states as well as changes in quality metrics. We found a steep decline in in-person visits in March 2020 accompanied by a sharp increase in telehealth visits; however, combined volume remained 23% below pre-pandemic levels. The implications for public health are significant, as preventive and chronic care deferral could lead to exacerbations of health disparities. Our examination of the impact on quality measures suggests that gaps in care are already emerging. Services that cannot be readily performed virtually are most affected. As FQHC visit numbers recover, concerted efforts are needed to encourage access and re-engage at-risk groups that fell out of care.
Assuntos
COVID-19 , Registros Eletrônicos de Saúde , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde , Provedores de Redes de Segurança/estatística & dados numéricos , Assistência Odontológica/tendências , Governo Federal , Humanos , Provedores de Redes de Segurança/normas , Telemedicina/tendências , Estados UnidosRESUMO
Importance: Safety-net hospitals (SNHs) operate under limited financial resources and have had challenges providing high-quality care. Medicaid expansion under the Affordable Care Act led to improvements in hospital finances, but whether this was associated with better hospital quality, particularly among SNHs given their baseline financial constraints, remains unknown. Objective: To compare changes in quality from 2012 to 2018 between SNHs in states that expanded Medicaid vs those in states that did not. Design, Setting, and Participants: Using a difference-in-differences analysis in a cohort study, performance on quality measures was compared between SNHs, defined as those in the highest quartile of uncompensated care in the pre-Medicaid expansion period, in expansion vs nonexpansion states, before and after the implementation of Medicaid expansion. A total of 811 SNHs were included in the analysis, with 316 in nonexpansion states and 495 in expansion states. The study was conducted from January to November 2020. Exposures: Time-varying indicators for Medicaid expansion status. Main Outcomes and Measures: The primary outcome was hospital quality measured by patient-reported experience (Hospital Consumer Assessment of Healthcare Providers and Systems Survey), health care-associated infections (central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections following colon surgery) and patient outcomes (30-day mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia). Secondary outcomes included hospital financial measures (uncompensated care and operating margins), adoption of electronic health records, provision of safety-net services (enabling, linguistic/translation, and transportation services), or safety-net service lines (trauma, burn, obstetrics, neonatal intensive, and psychiatric care). Results: In this difference-in-differences analysis of a cohort of 811 SNHs, no differential changes in patient-reported experience, health care-associated infections, readmissions, or mortality were noted, regardless of Medicaid expansion status after the Affordable Care Act. There were modest differential increases between 2012 and 2016 in the adoption of electronic health records (mean [SD]: nonexpansion states, 99.4 [7.4] vs 99.9 [3.8]; expansion states, 94.6 [22.6] vs 100.0 [2.2]; 1.7 percentage points; P = .02) and between 2012 and 2018 in the number of inpatient psychiatric beds (mean [SD]: nonexpansion states, 24.7 [36.0] vs 23.6 [39.0]; expansion states: 29.3 [42.8] vs 31.4 [44.3]; 1.4 beds; P = .02) among SNHs in expansion states, although they were not statistically significant at a threshold adjusted for multiple comparisons. In subgroup analyses comparing SNHs with higher vs lower baseline operating margins, an isolated differential improvement was noted in heart failure readmissions among SNHs with lower baseline operating margins in expansion states (mean [SD], 22.8 [2.1]; -0.53 percentage points; P = .001). Conclusions and Relevance: This difference-in-differences cohort study found that despite reductions in uncompensated care and improvements in operating margins, there appears to be little evidence of quality improvement among SNHs in states that expanded Medicaid compared with those in states that did not.
Assuntos
Medicaid/normas , Provedores de Redes de Segurança/normas , Estudos de Coortes , Humanos , Medicaid/tendências , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/normas , Patient Protection and Affordable Care Act/tendências , Satisfação do Paciente , Provedores de Redes de Segurança/tendências , Estados UnidosRESUMO
BACKGROUND: How clinical teams function varies across sites and may affect follow-up of abnormal fecal immunochemical test (FIT) results. AIMS: This study aimed to identify the characteristics of clinical practices associated with higher diagnostic colonoscopy completion after an abnormal FIT result in a multi-site integrated safety-net system. METHODS: We distributed survey questionnaires about tracking and follow-up of abnormal FIT results to primary care team members across 11 safety-net clinics from January 2017 to April 2017. Surveys were distributed at all-staff clinic meetings and electronic surveys sent to those not in attendance. Participants received up to three reminders to complete the survey. RESULTS: Of the 501 primary care team members identified, 343 (68.5%) completed the survey. In the four highest-performing clinics, nurse managers identified at least two team members who were responsible for communicating abnormal FIT results to patients. Additionally, team members used a clinic-based registry to track patients with abnormal FIT results until colonoscopy completion. Compared to higher-performing clinics, lower-performing clinics more frequently cited competing health issues (56% vs. 40%, p = 0.03) and lack of patient priority (59% vs. 37%, p < 0.01) as barriers and were also more likely to discuss abnormal results at a clinic visit (83% vs. 61%, p < 0.01). CONCLUSIONS: Our findings suggest organized and dedicated efforts to communicate abnormal FIT results and track patients until colonoscopy completion through registries is associated with improved follow-up. Increased utilization of electronic health record platforms to coordinate communication and navigation may improve diagnostic colonoscopy rates in patients with abnormal FIT results.
Assuntos
Assistência ao Convalescente/normas , Colonoscopia/normas , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/normas , Atenção Primária à Saúde/normas , Idoso , Estudos Transversais , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sangue Oculto , Padrões de Prática Médica/normas , Provedores de Redes de Segurança/normas , Inquéritos e Questionários , Fluxo de TrabalhoRESUMO
BACKGROUND: Pay-for-performance reimbursement ties hospital payments to standardized quality-of-care metrics. To the authors' knowledge, the impact of pay-for-performance reimbursement models on hospitals caring primarily for uninsured or underinsured patients remains poorly defined. The objective of the current study was to evaluate how standardized quality-of-care metrics vary by a hospital's propensity to care for uninsured or underinsured patients and demonstrate the potential impact that pay-for-performance reimbursement could have on hospitals caring for the underserved. METHODS: The authors identified 1,703,865 patients with cancer who were diagnosed between 2004 and 2015 and treated at 1344 hospitals. Hospital safety-net burden was defined as the percentage of uninsured or Medicaid patients cared for by that hospital, categorizing hospitals into low-burden, medium-burden, and high-burden hospitals. The authors evaluated the impact of safety-net burden on concordance with 20 standardized quality-of-care measures, adjusting for differences in patient age, sex, stage of disease at diagnosis, and comorbidity. RESULTS: Patients who were treated at high-burden hospitals were more likely to be young, male, Black and/or Hispanic, and to reside in a low-income and low-educated region. High-burden hospitals had lower adherence to 13 of 20 quality measures compared with low-burden hospitals (all P < .05). Among the 350 high-burden hospitals, concordance with quality measures was found to be lowest for those caring for the highest percentage of uninsured or Medicaid patients, minority patients, and less educated patients (all P < .001). CONCLUSIONS: Hospitals caring for uninsured or underinsured individuals have decreased quality-of-care measures. Under pay-for-performance reimbursement models, these lower quality-of-care scores could decrease hospital payments, potentially increasing health disparities for at-risk patients with cancer.
Assuntos
Qualidade da Assistência à Saúde/normas , Reembolso de Incentivo/normas , Provedores de Redes de Segurança/normas , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
PURPOSE: The objective of this research is to synthesize evidence on the relationship between context, strategies and performance in the context of federally qualified health centers (FQHCs), a core safety net health services provider in the United States. The research also identifies prior approaches to measure contextual factors, FQHC strategy and performance. Gaps in the research are identified, and directions for future research are provided. DESIGN/METHODOLOGY/APPROACH: A systematic review of peer-reviewed journal articles published between the years 1997 and 2017 was conducted using a bibliographic search of PubMed, Business Source Premier and ABI/Inform databases. FINDINGS: 28 studies were selected for the analysis. Results supported associations among contextual factors (organizational and environmental) and FQHC strategy and FQHC performance. The research also indicates that previous research was primarily emphasized on clinical performance with less focus on other types of FQHC performance. In addition, there exists a wide variability in terms of measuring context, FQHC strategy and performance. ORIGINALITY/VALUE: Operating in resource-scarce and highly constraining environments, FQHCs have demonstrated the ability to stay innovative and competent as serving often unhealthier and costlier patient populations. To date, there has been no study that reviewed the relationships between context, FQHC strategy and FQHC performance. In addition, there is an absence of consensus on how context, FQHC strategy and FQHC performance are measured. This study is the first that examined context-strategy-performance relationships in the context of FQHCs.
Assuntos
Eficiência Organizacional , Provedores de Redes de Segurança/organização & administração , Provedores de Redes de Segurança/normas , Estados UnidosRESUMO
BACKGROUND: Patients within safety-net settings are less likely to access health information on patient portals, despite expressed interest. Family and friends are important resources to assist these patients (ie, Medicaid recipients, older patients, patients with limited English proficiency) in navigating health systems, and provider support of the use of patient portals among these groups may also facilitate caregivers' use of their patients' portal. OBJECTIVE: Because safety net providers work closely with caregivers to care for their patients, we used qualitative methods to explore safety net providers' perspectives on portal use among caregivers for their patients, especially as there is limited literature about caregivers' use of portals in the safety net. METHODS: We conducted 45- to 60-min semistructured telephone interviews with providers from three large California safety-net health systems. The interviews focused on providers' experiences with caregivers, caregiver roles, and how the portal could be leveraged as a tool to support caregivers in their responsibilities. A total of three coders analyzed the interview transcripts using both deductive and inductive approaches and established a consensus regarding major themes. RESULTS: Of the 16 participants interviewed, 4 specialized in geriatrics, and all held a leadership or administrative role. We described themes highlighting providers' recognition of potential benefits associated with caregiver portal use and specific challenges to caregiver engagement. CONCLUSIONS: Providers recognized the potential for portals to improve information delivery and communication by helping caregivers assist socially and medically complex patients in the safety net. Providers in safety net sites also discussed a clear need for better ways to keep in touch with patients and connect with caregivers, yet security and privacy are perhaps of higher importance in these settings and may pose challenges to portal adoption. They noted that caregivers of patients in the safety net likely face similar communication barriers as patients, especially with respect to digital literacy, health literacy, and English proficiency. Further research is needed to assess and support caregivers' interest and ability to access portals across barriers in health and digital literacy, and English proficiency. Portal platforms and health systems must also address specific strategies to uphold patient preferences while maintaining privacy and security.
Assuntos
Cuidadores/normas , Portais do Paciente/normas , Médicos/normas , Atenção Primária à Saúde/métodos , Provedores de Redes de Segurança/normas , Feminino , Humanos , Entrevistas como Assunto , MasculinoRESUMO
BACKGROUND: Pediatric brain injuries are common, but current management of patients with mild traumatic intracranial hemorrhage (T-ICH) is suboptimal, often including unnecessary repeat head CT (RHCT) and neurosurgical consultation (NSC). Brain Injury Guidelines (BIG) have been developed to standardize the management of TBI, and recent work suggests they may be applied to children. The aim of this study was to apply BIG to a low-risk pediatric TBI population to further determine whether the framework can be safely applied to children in a way that reduces overutilization of RHCTs and NSC. METHODS: A retrospective chart review of a Level I Adult and Pediatric Trauma Center's pediatric registry over 4 y was performed. BIG was applied to these patients to evaluate the utility of RHCT and need for neurosurgical intervention (NSG-I) in those meeting BIG-1 criteria. Those with minor skull fracture (mSFx) who otherwise met BIG-1 criteria were also included. RESULTS: Twenty-eight patients with low-risk T-ICH met criteria for review. RHCT was performed in seven patients, with only two being prompted by clinical neurologic change/deterioration. NSC occurred in 21 of the cases. Ultimately, no patient identified by BIG-1 ± mSFx required NSG-I. CONCLUSIONS: Application of BIG criteria to children with mild T-ICH appears capable of reducing RHCT and NSC safely. Additionally, those with mSFx that otherwise fulfill BIG-1 criteria can be managed similarly by acute care surgeons. Further prospective studies should evaluate the application of BIG-1 in larger patient populations to support the generalizability of these findings.
Assuntos
Tomada de Decisão Clínica/métodos , Hemorragia Intracraniana Traumática/cirurgia , Procedimentos Neurocirúrgicos/normas , Provedores de Redes de Segurança/normas , Centros de Traumatologia/normas , Adolescente , Encéfalo/irrigação sanguínea , Encéfalo/diagnóstico por imagem , Criança , Pré-Escolar , Feminino , Fidelidade a Diretrizes/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Hemorragia Intracraniana Traumática/diagnóstico , Masculino , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Provedores de Redes de Segurança/estatística & dados numéricos , Tomografia Computadorizada por Raios X/normas , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Resultado do TratamentoRESUMO
INTRODUCTION: Providing high-quality health care to poor and uninsured individuals has been a challenge to the US health care system for decades. Often, patients do not seek care until they are in a crisis, or they seek care at a health care system while not addressing their primary care needs. OBJECTIVE: To report on a community that has sought to change this dynamic with the development of an all-volunteer practitioner-run clinic model. METHODS: Perspective on a successful volunteer-run safety-net clinic. RESULTS: Volunteers in Medicine on Hilton Head Island, SC, provides free health care, with more than 28,000 eligible patient visits annually, for the underserved population. This clinic is self-funded through donations and charity events and accepts no federal money. The patients are not asked to pay a fee for service. Most medical specialties are represented at the clinic, and many partnerships are in place for referrals for more advanced procedures such as surgery. All health care clinicians are volunteers, including physicians, nurses, dentists, and mental health professionals. DISCUSSION: The quality of care meets or exceeds national recommendations on many measurements, including mammography and Papanicolaou test screening rates. CONCLUSION: Safety-net clinics such as Volunteers in Medicine are a needed and viable option to the provision of health care to the vulnerable, often unseen members of society.
Assuntos
Pessoas sem Cobertura de Seguro de Saúde , Pobreza , Qualidade da Assistência à Saúde/organização & administração , Provedores de Redes de Segurança/organização & administração , Voluntários , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Serviços Preventivos de Saúde/organização & administração , Indicadores de Qualidade em Assistência à Saúde , Qualidade da Assistência à Saúde/normas , Provedores de Redes de Segurança/economia , Provedores de Redes de Segurança/normasRESUMO
Hepatitis C (HCV) care cascades have been described in diverse clinical settings, patient populations and countries, highlighting the steps in HCV care where improvements can be made and resources allocated. However, more research is needed to examine barriers to HCV treatment in rural, underserved populations and in Federally Qualified Health Centers (FQHCs). As part of a quality improvement (QI) project, this study aimed to describe and evaluate the HCV treatment cascade in an FQHC serving a large rural patient population in the Western United States. Standardized chart abstraction was utilized to aggregate data regarding patient demographics, the percentage of patients achieving each step in the treatment cascade, and relevant patient (i.e., viral load) and service variables (i.e., whether and when patients received treatment or medication). 389 patients were identified as having HCV and 86% were aware of their diagnosis. Fifty-five percent had their infection confirmed via viral load, 21% were staged for liver disease, 24% received a prescription for treatment, and 19% achieved cure. Compared to national data, the current regional sample had greater rates of diagnosis awareness and access to care, as well as sustained virologic response (SVR), but lower rates of viral load confirmation. Current findings suggest that rural patients living with HCV who receive care at FQHCs struggle to navigate the treatment cascade and achieve a cure, particularly with regard to infection confirmation, liver staging, and prescription. However, compared to national estimates, patients had greater rates of diagnosis awareness/treatment access and SVR.
Assuntos
Hepatite C/terapia , Serviços de Saúde Rural/organização & administração , Provedores de Redes de Segurança/organização & administração , Antivirais/uso terapêutico , Conhecimentos, Atitudes e Prática em Saúde , Acessibilidade aos Serviços de Saúde/organização & administração , Hepatite C/diagnóstico , Humanos , Área Carente de Assistência Médica , Serviços de Saúde Rural/normas , Provedores de Redes de Segurança/normas , Resposta Viral Sustentada , Estados Unidos , Carga Viral , Populações VulneráveisRESUMO
Recent guidelines recommend direct acting oral anticoagulants (DOAC) over vitamin-k antagonist (VKA) for acute venous thromboembolism (VTE). Non-adherence to anticoagulation has been associated with increased frequency of VTE or stroke. This study evaluated 90 day persistence among patients prescribed rivaroxaban or warfarin for the treatment of acute VTE at an academic safety net hospital. We conducted a single center, retrospective cohort study of 314 consecutive patients newly prescribed rivaroxaban or warfarin for acute VTE between January 2016 and July 2017. Primary outcome was 90 day persistence, and secondary outcomes included 90 day readmission and/or ED visit, time to 90 m day readmission and/or ED visits, and attendance of direct oral anticoagulant education class. Of 314 patients, 78 were prescribed warfarin and 236 rivaroxaban. Patients had a mean age of 52 years, 62% were men, and 96% were diagnosed with deep vein thrombosis and/or pulmonary embolism. Persistence at 90 days was 52.6% among patients prescribed warfarin compared to 45.3% for patients prescribed rivaroxaban (p = 0.2678). Persistencewas associated with decreased 90 day hospital or ED readmission. Among patients prescribed rivaroxaban, attending a pharmacist led educational class was associated with a 2.5 fold increase in persistence (p < 0.0001). Among patients with new onset venous thromboembolism, 90 day persistence with anticoagulation was similarly low with either rivaroxaban or warfarin therapy. Participation in a pharmacist led DOAC class was associated with a 2.5-fold increase in persistence on rivaroxaban.
Assuntos
Centros Médicos Acadêmicos/normas , Adesão à Medicação , Rivaroxabana/administração & dosagem , Provedores de Redes de Segurança/normas , Tromboembolia Venosa/tratamento farmacológico , Varfarina/administração & dosagem , Centros Médicos Acadêmicos/métodos , Adulto , Idoso , Anticoagulantes/administração & dosagem , Inibidores do Fator Xa/administração & dosagem , Feminino , Humanos , Masculino , Adesão à Medicação/psicologia , Pessoa de Meia-Idade , Alta do Paciente/normas , Estudos Retrospectivos , Provedores de Redes de Segurança/métodos , Tromboembolia Venosa/psicologiaRESUMO
BACKGROUND: Guidelines urge primary care practices to routinely provide tobacco cessation care, but quality indicators for the provision of advice and assistance to quit smoking lag. This study evaluated the implementation of a systems-based strategy to improve performance of tobacco cessation care in primary care clinics. METHODS: Changes to the electronic health record (EHR) facilitated staff to document when they ask about tobacco use, advise the patient to quit, offer to connect the patient to a quitline (QL) counselor, and refer interested patients to receive a call from a QL. Medical assistants (MAs) were trained to use the new sections of the EHR, and their roles were expanded to include the provision of brief cessation advice and activation of the QL referral. Primary outcomes were change in tobacco cessation processes preimplementation vs. one, three, and six months postimplementation of the strategy. RESULTS: The increase in performance of tobacco cessation care was significant and sustained at six months postimplementation for assessing smoking status (50.9% vs. 76.3%; odds ratio [OR]â¯=â¯3.04; 95% confidence interval [CI]â¯=â¯2.80-3.31), providing advice (15.1% vs. 92.7%; ORâ¯=â¯69.3; 95% CIâ¯=â¯51.88-92.60), assessing readiness to quit (22.8% vs. 76.6%; ORâ¯=â¯10.80; 95% CIâ¯=â¯8.92-13.08), and accepting a referral to the QL (1.3% vs. 21.7%; ORâ¯=â¯20.31; 95% CIâ¯=â¯4.91-84.05). CONCLUSION: Key stakeholder engagement informed a system change intervention that includes an EHR-supported role expansion of MAs for QL referrals; these changes substantially increased the provision of tobacco cessation care.