Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers.

BACKGROUND: Super-utilizers with 4 or more admissions per year frequently receive low-quality care and disproportionately contribute to healthcare costs. Inpatient care fragmentation (admission to multiple different hospitals) in this population has not been well described. OBJECTIVE: To determine the prevalence of super-utilizers who receive fragmented care across different hospitals and to describe associated risks, costs, and health outcomes. RESEARCH DESIGN: We analyzed inpatient data from the Health Care Utilization Project's State Inpatient and Emergency Department database from 6 states from 2013. After identifying hospital super-utilizers, we stratified by the number of different hospitals visited in a 1-year period. We determined how patient demographics, costs, and outcomes varied by degree of fragmentation. We then examined how fragmentation would influence a hospital's ability to identify super-utilizers. SUBJECTS: Adult patients with 4 or more inpatient stays in 1 year. MEASURES: Patient demographics, cost, 1-year hospital reported mortality, and probability that a single hospital could correctly identify a patient as a super-utilizer. RESULTS: Of the 167,515 hospital super-utilizers, 97,404 (58.1%) visited more than 1 hospital in a 1-year period. Fragmentation was more likely among younger, non-white, low-income, under-insured patients, in population-dense areas. Patients with fragmentation were more likely to be admitted for chronic disease management, psychiatric illness, and substance abuse. Inpatient fragmentation was associated with higher yearly costs and lower likelihood of being identified as a super-utilizer. CONCLUSIONS: Inpatient care fragmentation is common among super-utilizers, disproportionately affects vulnerable populations. It is associated with high yearly costs and a decreased probability of correctly identifying super-utilizers.

Inaccuracy in patient handoffs: discrepancies between resident-generated reports and the medical record.

A handoff is the transfer of a patient's care from one provider to another. It usually involves both a verbal and written exchange of information. Although written handoff sheets are critical to good patient care, there is little data on the quality of information they contain. We conducted a study to assess the accuracy of handoff sheets used in one Minneapolis internal medicine residency program. We compared the accuracy of information about code status, medication allergies, medications, and problems recorded on the handoff sheet with that in the patient's medical record. We found errors were common in resident handoff sheets. Only 83 (19%) of 428 handoff sheets contained no errors. The most common error was one of omission on the medication list (69% of the handoff sheets contained a medication omission). The percentage of patient handoff sheets with code-status errors was 5.7%, and the percentage with medication allergy errors was 2.8%. Important problems were omitted from the problem list in 22% of cases.

An entrustable professional activity (EPA) for handoffs as a model for EPA assessment development.

Medical education is moving toward assessment of educational outcomes rather than educational processes. The American Board of Internal Medicine and American Board of Pediatrics milestones and the concept of entrustable professional activities (EPA)--skills essential to the practice of medicine that educators progressively entrust learners to perform--provide new approaches to assessing outcomes. Although some defined EPAs exist for internal medicine and pediatrics, the continued development and implementation of EPAs remains challenging. As residency programs are expected to begin reporting milestone-based performance, however, they will need examples of how to overcome these challenges. The authors describe a model for the development and implementation of an EPA using the resident handoff as an example. The model includes nine steps: selecting the EPA, determining where skills are practiced and assessed, addressing barriers to assessment, determining components of the EPA, determining needed assessment tools, developing new assessments if needed, determining criteria for advancement through entrustment levels, mapping milestones to the EPA, and faculty development. Following implementation, 78% of interns at the University of Minnesota Medical School were observed giving handoffs and provided feedback. The authors suggest that this model of EPA development--which includes engaging stakeholders, an iterative process to describing the behavioral characteristics of each domain at each level of entrustment, and the development of specific assessment tools that support both formative feedback and summative decisions about entrustment--can serve as a model for EPA development for other clinical skills and specialty areas.

An interactive handoff workshop to improve intern readiness in patient care transitions.

INTRODUCTION: Patient handoffs are common during residency and are often performed with little or no training. We devised a simple intervention to improve the readiness of interns to perform handoffs. METHODS: We administered a 90-minute interactive workshop during intern orientation in 2009 and 2010. It consisted of a discussion, a case presentation, and a trigger video, followed by debriefing and a role-play exercise. The workshop required minimal technology and materials. Interns were surveyed on their readiness to perform handoffs before and after the workshop as well as 3 to 6 months after the workshop. RESULTS: Eighty-nine interns participated in the workshop during a 2-year period. Seventy-four survey responses were collected. Self-reported readiness to perform a handoff increased by 26%. A total of 91% and 81% of respondents in 2010 and 2009, respectively, reported using aspects of the workshop up to 6 months later. CONCLUSION: A brief workshop can improve interns' readiness to perform handoffs.

Automated assessment of medical training evaluation text.

Medical post-graduate residency training and medical student training increasingly utilize electronic systems to evaluate trainee performance based on defined training competencies with quantitative and qualitative data, the later of which typically consists of text comments. Medical education is concomitantly becoming a growing area of clinical research. While electronic systems have proliferated in number, little work has been done to help manage and analyze qualitative data from these evaluations. We explored the use of text-mining techniques to assist medical education researchers in sentiment analysis and topic analysis of residency evaluations with a sample of 812 evaluation statements. While comments were predominantly positive, sentiment analysis improved the ability to discriminate statements with 93% accuracy. Similar to other domains, Latent Dirichlet Analysis and Information Gain revealed groups of core subjects and appear to be useful for identifying topics from this data.