Faculty Bibliography

OBJECTIVE:To examine predictors for understanding reason for hospitalization. METHODS:This was a retrospective analysis of a prospective, observational cohort study of patients 65 years or older admitted for acute coronary syndrome, heart failure, or pneumonia and discharged home. Primary outcome was complete understanding of diagnosis, based on post-discharge patient interview. Predictors assessed were the following: jargon on discharge instructions, type of medical team, whether outpatient provider knew if the patient was admitted, and whether the patient reported more than one day notice before discharge. RESULTS:Among 377 patients, 59.8% of patients completely understood their diagnosis. Bivariate analyses demonstrated that outpatient provider being aware of admission and having more than a day notice prior to discharge were not associated with patient understanding diagnosis. Presence of jargon was not associated with increased likelihood of understanding in a multivariable analysis. Patients on housestaff and cardiology teams were more likely to understand diagnosis compared to non-teaching teams (OR 2.45, 95% CI 1.30-4.61, p<0.01 and OR 3.83, 95% CI 1.92-7.63, p<0.01, respectively). CONCLUSIONS:Non-teaching team patients were less likely to understand their diagnosis. Further investigation of how provider-patient interaction differs among teams may aid in development of tools to improve hospital to community transitions.

BACKGROUND:Hospital readmission rates are publicly reported by the Centers for Medicare & Medicaid Services (CMS); however, the implications of emergency department (ED) visits following hospital discharge on readmissions are uncertain. We describe the frequency, diagnoses, and hospital-level variation in ED visitation following hospital discharge, including the relationship between risk-standardized ED visitation and readmission rates. METHODS:This is a cross-sectional analysis of Medicare beneficiaries hospitalized for acute myocardial infarction (AMI), heart failure, and pneumonia between July 2011 and June 2012. We used Medicare Standard Analytic Files to identify admissions, readmissions, and ED visits consistent with CMS measures. Postdischarge ED visits were defined as treat-and-discharge ED services within 30 days of hospitalization without readmission. We utilized hierarchical generalized linear models to calculate hospital risk-standardized postdischarge ED visit rates and readmission rates. RESULTS:We included 157,035 patients hospitalized at 1656 hospitals for AMI, 391,209 at 3044 hospitals for heart failure, and 342,376 at 3484 hospitals for pneumonia. After hospitalization for AMI, heart failure, and pneumonia, there were 14,714 (9%), 31,621 (8%), and 26,681 (8%) ED visits, respectively. Hospital-level variation in postdischarge ED visit rates was substantial: AMI (median: 8.3%; 5th and 95th percentile: 2.8%-14.3%), heart failure (median: 7.3%; 5th and 95th percentile: 3.0%-13.3%), and pneumonia (median: 7.1%; 5th and 95th percentile: 2.4%-13.2%). There was statistically significant inverse correlation between postdischarge ED visit rates and readmission rates: AMI (-0.23), heart failure (-0.29), and pneumonia (-0.18). CONCLUSIONS:Following hospital discharge, ED treatand- discharge visits are half as common as readmissions for Medicare beneficiaries. There is wide hospital-level variation in postdischarge ED visitation, and hospitals with higher ED visitation rates demonstrated lower readmission rates.

BACKGROUND:Hospitalization and readmission rates have decreased in recent years, with the possible consequence that hospitals are increasingly filled with high-risk patients. OBJECTIVE:We studied whether readmission reduction has affected the risk profile of hospitalized patients and whether readmission reduction was similarly realized among hospitalizations with low, medium, and high risk of readmissions. DESIGN/METHODS:Retrospective study of hospitalizations between January 2009 and June 2015. PATIENTS/METHODS:Hospitalized fee-for-service Medicare beneficiaries, categorized into 1 of 5 specialty cohorts used for the publicly reported hospital-wide readmission measure. MEASUREMENTS/METHODS:Each hospitalization was assigned a predicted risk of 30-day, unplanned readmission using a risk-adjusted model similar to publicly reported measures. Trends in monthly mean predicted risk for each cohort and trends in monthly observed to expected readmission for hospitalizations in the lowest 20%, middle 60%, and highest 20% of risk of readmission were assessed using time series models. RESULTS:Of 47,288,961 hospitalizations, 16.2% (n = 7,642,161) were followed by an unplanned readmission within 30 days. We found that predicted risk of readmission increased by 0.24% (P = .03) and 0.13% (P = .004) per year for hospitalizations in the surgery/ gynecology and neurology cohorts, respectively. We found no significant increase in predicted risk for hospitalizations in the medicine (0.12%, P = .12), cardiovascular (0.32%, P = .07), or cardiorespiratory (0.03%, P = .55) cohorts. In each cohort, observed to expected readmission rates steadily declined, and at similar rates for patients at low, medium, and high risk of readmission. CONCLUSIONS:Hospitals have been effective at reducing readmissions across a range of patient risk strata and clinical conditions. The risk of readmission for hospitalized patients has increased for 2 of 5 clinical cohorts.

BACKGROUND:Whether types of hospitals with high readmission rates also have high overall postdischarge acute care utilization (including emergency department and observation care) is unknown. DESIGN/METHODS:Cross-sectional analysis. SUBJECTS/METHODS:Nonfederal United States acute care hospitals. MEASURES/METHODS:Using methodology established by the Centers for Medicare & Medicaid Services, we calculated each hospital's "excess days in acute care" for fee-for-service (FFS) Medicare beneficiaries aged over 65 years discharged after hospitalization for acute myocardial infarction, heart failure (HF), or pneumonia, representing the mean difference between predicted and expected total days of acute care utilization in the 30 days following hospital discharge, per 100 discharges. We assessed the multivariable association of 8 hospital characteristics with excess days in acute care and the proportion of hospitals with each characteristic that were statistical outliers (95% credible interval estimate does not include 0). RESULTS:We included 2184 hospitals for acute myocardial infarction [228 (10.4%) better than expected, 549 (25.1%) worse than expected], 3720 hospitals for HF [484 (13.0%) better and 840 (22.6%) worse], and 4195 hospitals for pneumonia [673 (16.0%) better, 1005 (24.0%) worse]. Results for all conditions were similar. Worse than expected outliers for pneumonia included: 18.8% of safety net hospitals versus 26.1% of nonsafety net hospitals; 16.7% of public hospitals versus 33.1% of for-profit hospitals; 19.5% of nonteaching hospitals versus 52.2% of major teaching hospitals; 7.9% of rural hospitals versus 42.1% of large urban hospitals; 5.9% of hospitals with 24-<50 beds versus 58% of hospitals with >500 beds; and 29.0% of hospitals with nurse-to-bed ratios >1.0-1.5 versus 21.7% of hospitals with ratios >2.0. CONCLUSIONS:Including emergency department and observation stays in measures of postdischarge utilization produces similar results as measuring only readmissions in that major teaching, urban and for-profit hospitals still perform disproportionately poorly versus nonteaching or public hospitals. However, it enables identification of more outliers and a more granular assessment of the association of hospital factors and outcomes.

PURPOSE: To better understand the decision making behind the ordering of CT pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE) in the emergency department. METHODS: We conducted semistructured interviews with our institution's emergency medicine (EM) providers and radiologists who read CTPAs performed in the emergency department. We employed the Theoretical Domains Framework-a formal, structured approach used to better understand the motivations and beliefs of physicians surrounding a complex medical decision making-to categorize the themes that arose from our interviews. RESULTS: EM providers were identified as the main drivers of CTPA ordering. Both EM and radiologist groups perceived the radiologist's role as more limited. Experience- and gestalt-based heuristics were the most important factors driving this decision and more important, in many cases, than established algorithms for CTPA ordering. There were contrasting views on the value of d-dimer in the suspected PE workup, with EM providers finding this test less useful than radiologists. EM provider and radiologist suggestions for improving the appropriateness of CTPA ordering consisted of making this process more arduous and incorporating d-dimer tests and prediction rules into a decision support tool. CONCLUSION: EM providers were the main drivers of CTPA ordering, and there was a marginalized role for the radiologist. Experience- and gestalt-based heuristics were the main influencers of CTPA ordering. Our findings suggest that a more nuanced intervention than simply including a d-dimer and a prediction score in each preimaging workup may be necessary to curb overordering of CTPA in patients suspected of PE.

BACKGROUND: Interventions to reduce readmissions following acute heart failure hospitalization require early identification of patients. The purpose of this study was to develop and test accuracies of various approaches to identify patients with acute decompensated heart failure (ADHF) using data derived from the electronic health record. METHODS AND RESULTS: We included 37,229 hospitalizations of adult patients at a single hospital in 2013-2015. We developed four algorithms to identify hospitalization with a principal discharge diagnosis of ADHF: 1) presence of one of three clinical characteristics; 2) logistic regression of 31 structured data elements; 3) machine learning with unstructured data; 4) machine learning with both structured and unstructured data. In data validation, Algorithm 1 had a sensitivity of 0.98 and positive predictive value (PPV) of 0.14 for ADHF. Algorithm 2 had an area under the receiver operating characteristic curve (AUC) of 0.96, while both machine learning algorithms had AUCs of 0.99. Based on a brief survey of three providers who perform chart review for ADHF, we estimated providers spent 8.6 minutes per chart review; using this this parameter, we estimated providers would spend 61.4, 57.3, 28.7, and 25.3 minutes on secondary chart review for each case of ADHF if initial screening was done with algorithms 1, 2, 3, and 4, respectively. CONCLUSION: Machine learning algorithms with unstructured notes had best performance for identification of ADHF and can improve provider efficiency for delivery of quality improvement interventions.

BACKGROUND: Hospitalized medical patients undergoing transition of care by house staff teams at the end of a ward rotation are associated with an increased risk of mortality, yet best practices surrounding this transition are lacking. AIM: To assess the impact of a warm handoff protocol for end-of-rotation care transitions. SETTING: A large, university-based internal medicine residency using three different training sites. PARTICIPANTS: PGY-2 and PGY-3 internal medicine residents. PROGRAM DESCRIPTION: Implementation of a warm handoff protocol whereby the incoming and outgoing residents meet at the hospital to sign out in-person and jointly round at the bedside on sicker patients using a checklist. PROGRAM EVALUATION: An eight-question survey completed by 60 of 99 eligible residents demonstrated that 85% of residents perceived warm handoffs to be safer for patients (p < 0.001), while 98% felt warm handoffs improved their knowledge and comfort level of patients on day 1 of an inpatient rotation (p < 0.001) as compared to prior handoff techniques. Finally, 88% felt warm handoffs were worthwhile despite requiring additional time (p < 0.001). DISCUSSION: A warm handoff protocol represents a novel strategy to potentially mitigate the known risks associated with end-of-rotation care transitions. Additional studies analyzing patient outcomes will be needed to assess the impact of this strategy.