Faculty Bibliography

BACKGROUND: Discharge summaries are essential for safe transitions from hospital to home. OBJECTIVE: To conduct a comprehensive quality assessment of discharge summaries. DESIGN: Prospective cohort study. SUBJECTS: Three hundred seventy-seven patients discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MEASURES: Discharge summaries were assessed for timeliness of dictation, transmission of the summary to appropriate outpatient clinicians, and presence of key content including elements required by The Joint Commission and elements endorsed by 6 medical societies in the Transitions of Care Consensus Conference (TOCCC). RESULTS: A total of 376 of 377 patients had completed discharge summaries. A total of 174 (46.3%) summaries were dictated on the day of discharge; 93 (24.7%) were completed more than a week after discharge. A total of 144 (38.3%) discharge summaries were not sent to any outpatient physician. On average, summaries included 5.6 of 6 The Joint Commission elements and 4.0 of 7 TOCCC elements. Summaries dictated by hospitalists were more likely to be timely and to include key content than summaries dictated by housestaff or advanced practice nurses. Summaries dictated on the day of discharge were more likely to be sent to outside physicians and to include key content. No summary met all 3 quality criteria of timeliness, transmission, and content. CONCLUSIONS: Discharge summary quality is inadequate in many domains. This may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes. However, improving discharge summary timeliness may also improve content and transmission.

BACKGROUND: Reducing readmissions is a national priority, but many hospitals lack practical tools to identify patients at increased risk of unplanned readmission. OBJECTIVE: To estimate the association between a composite measure of patient condition at discharge, the Rothman Index (RI), and unplanned readmission within 30 days of discharge. SUBJECTS: Adult medical and surgical patients in a major teaching hospital in 2011. MEASURES: The RI is a composite measure updated regularly from the electronic medical record based on changes in vital signs, nursing assessments, Braden score, cardiac rhythms, and laboratory test results. We developed 4 categories of RI and tested its association with readmission within 30 days, using logistic regression, adjusted for patient age, sex, insurance status, service assignment (medical or surgical), and primary discharge diagnosis. RESULTS: Sixteen percent of the sample patients (N=2730) had an unplanned readmission within 30 days of discharge. The risk of readmission for a patient in the highest risk category (RI<70) was >1 in 5 while the risk of readmission for patients in the lowest risk category was about 1 in 10. In multivariable analysis, patients with an RI<70 (the highest risk category) or 70-79 (medium risk category) had 2.65 (95% confidence interval, 1.72-4.07) and 2.40 (95% confidence interval, 1.57-3.67) times higher odds of unplanned readmission, respectively, compared with patients in the lowest risk category. CONCLUSION: Clinicians can use the RI to help target hospital programs and supports to patients at highest risk of readmission.

OBJECTIVES: To compare levels of social isolation in aging veterans with and without the human immunodeficiency virus (HIV) and determine associations with hospital admission and mortality. DESIGN: Longitudinal data analysis. SETTING: The Veterans Aging Cohort Study (VACS), at eight VA Medical Centers nationally. PARTICIPANTS: Veterans aged 55 and older enrolled in VACS from 2002 to 2008 (N = 1,836). MEASUREMENTS: A Social Isolation Score (SIS) was created using baseline survey responses about relationship status; number of friends and family and frequency of visits; and involvement in volunteer work, religious or self-help groups, and other community activities. Scores were compared according to age and HIV status, and multivariable regression was used to assess effects of SIS on hospital admission and all-cause mortality. RESULTS: Mean SIS was higher for HIV-positive (HIV+) individuals, with increasing difference according to age (P = .01 for trend). Social isolation was also more prevalent for HIV+ (59%) than uninfected participants (51%, P < .001). In multivariable regression analysis of HIV+ and uninfected groups combined, adjusted for demographic and clinical features, isolation was independently associated with greater risk of incident hospitalization (hazard rate (HR) = 1.25, 95% confidence interval (CI) = 1.09-1.42) and risk of all-cause mortality (HR=1.28, 95% CI = 1.06-1.54). Risk estimates calculated for HIV+ and uninfected groups separately were not significantly different. CONCLUSION: Social isolation is associated with greater risk of hospitalization and death in HIV+ and uninfected older veterans. Despite similar effects in both groups, the population-level effect of social isolation may be greater in those who are HIV+ because of the higher prevalence of social isolation, particularly in the oldest individuals.

OBJECTIVE: To gather qualitative data to elucidate the reasons for readmissions in a high-risk population of underserved patients. DESIGN: We created an instrument with 27 open-ended questions based on current interventions. SETTING: Yale-New Haven Hospital. PATIENTS: Patients at the Yale Adult Primary Care Center (PCC). MEASUREMENTS: We conducted semi-structured qualitative interviews of patients who had four or more admissions in the previous 6 months and were currently readmitted to the hospital. RESULTS: We completed 17 interviews and identified themes relating to risk of readmission. We found that patients went directly to the emergency department (ED) when they experienced a change in health status without contacting their primary provider. Reasons for this included poor telephone or urgent care access and the belief that the PCC could not treat acute illness. Many patients could not name their primary provider. Conversely, every patient except one reported being able to obtain medications without undue financial burden, and every patient reported receiving adequate home care services. CONCLUSIONS: These high-risk patients were receiving the formal services that they needed, but were making the decision to go to the ED because of inadequate access to care and fragmented primary care relationships. Formal transitional care services are unlikely to be adequate in reducing readmissions without also addressing primary care access and continuity.

IMPORTANCE: With growing national focus on reducing readmissions, there is a need to comprehensively assess the quality of transitional care, including discharge practices, patient perspectives, and patient understanding. OBJECTIVE: To conduct a multifaceted evaluation of transitional care from a patient-centered perspective. DESIGN: Prospective observational cohort study, May 2009 through April 2010. SETTING: Urban, academic medical center. PARTICIPANTS: Patients 65 years and older discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MAIN OUTCOMES AND MEASURES: Discharge practices, including presence of follow-up appointment and patient-friendly discharge instructions; patient understanding of diagnosis and follow-up appointment; and patient perceptions of and satisfaction with discharge care. RESULTS: The 395 enrolled patients (66.7% of those eligible) had a mean age of 77.2 years. Although 349 patients (95.6%) reported understanding the reason they had been in the hospital, only 218 patients (59.6%) were able to accurately describe their diagnosis in postdischarge interviews. Discharge instructions routinely included symptoms to watch out for (98.4%), activity instructions (97.3%), and diet advice (89.7%) in lay language; however, 99 written reasons for hospitalization (26.3%) did not use language likely to be intelligible to patients. Of the 123 patients (32.6%) discharged with a scheduled primary care or cardiology appointment, 54 (43.9%) accurately recalled details of either appointment. During postdischarge interviews, 118 patients (30.0%) reported receiving less than 1 day's advance notice of discharge, and 246 (66.1%) reported that staff asked whether they would have the support they needed at home before discharge. CONCLUSIONS AND RELEVANCE: Patient perceptions of discharge care quality and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear. However, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor. Patient perceptions and written documentation do not adequately reflect patient understanding of discharge care.

BACKGROUND: Reducing hospital readmissions is a national priority, and many hospitals are participating in quality collaboratives or campaigns. OBJECTIVE: To describe and compare the current use of hospital strategies to reduce readmissions in 2 prominent quality initiatives-STAAR (State Action on Avoidable Rehospitalization) and H2H (Hospital-to-Home Campaign). DESIGN: Cross-sectional. METHODS: Web-based survey of hospitals that had enrolled in H2H or STAAR from May 2009 through June 2010, conducted from November 1, 2010 through June 30, 2011 (n = 599, response rate of 91%). We used standard frequency analysis and multivariable logistic regression to describe differences between STAAR and H2H hospitals. RESULTS: Many hospitals were not implementing several of the recommended strategies. Although STAAR hospitals tended to be more likely to implement several strategies, differences were attenuated when we adjusted for region and ownership type. In multivariable models, STAAR hospitals compared with H2H hospitals were more likely to ensure outpatient physicians were alerted within 48 hours of patient discharge (63% vs 38%, P < 0.001), and more likely to provide skilled nursing facilities the direct contact number of the inpatient treating physician for patients transferred (53% vs 34%, P = 0.001). H2H hospitals were more likely to assign responsibility for medication reconciliation to nurses usually or always (80% vs 54%, P = 0.001) and more likely to give most or all discharged patients referrals to cardiac rehabilitation services (59% vs 41%, P = 0.001). CONCLUSIONS: Substantial opportunity for improvement exists for hospitals engaged in STAAR or H2H quality initiatives.

BACKGROUND: Hospitalists are key providers of care to medical inpatients, and sign-out is an integral part of providing safe, high-quality inpatient care. There is little known about hospitalist-to-hospitalist sign-out. OBJECTIVE: To evaluate the quality of hospitalist/physician-extender sign-outs by assessing how well the sign-out prepares the night team for overnight events and to determine attributes of effective sign-out. DESIGN: Analysis of a written-only sign-out protocol on a nonteaching hospitalist service using prospective data collected by an attending physician survey during overnight shifts. SETTING: Yale-New Haven Hospital, a 966-bed, urban, academic medical center in New Haven, Connecticut with approximately 13,700 hospitalist discharges annually. RESULTS: We recorded 124 inquiries about 96 patients during 6 days of data collection in 2012. Hospitalists referenced the sign-out for 89 (74%) inquiries, and the sign-out was considered sufficient in isolation to respond to 27 (30%) of these inquiries. Hospitalists physically saw the patient for 14 (12%) of inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]), and clinical changes (26 [21%]). Ninety-five (77%) inquiries were considered to be "somewhat" or "very" clinically important by the hospitalist. CONCLUSIONS: Overall, we found that attending hospitalists rely heavily on written sign-out to address overnight inquiries, but that those sign-outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign-out is needed to help improve the safety of overnight care.

OBJECTIVES: To determine whether high performing hospitals with low 30 day risk standardized readmission rates have a lower proportion of readmissions from specific diagnoses and time periods after admission or instead have a similar distribution of readmission diagnoses and timing to lower performing institutions. DESIGN: Retrospective cohort study. SETTING: Medicare beneficiaries in the United States. PARTICIPANTS: Patients aged 65 and older who were readmitted within 30 days after hospital admission for heart failure, acute myocardial infarction, or pneumonia in 2007-09. MAIN OUTCOME MEASURES: Readmission diagnoses were classified with a modified version of the Centers for Medicare and Medicaid Services' condition categories, and readmission timing was classified by day (0-30) after hospital discharge. Hospital 30 day risk standardized readmission rates over the three years of study were calculated with public reporting methods of the US federal government, and hospitals were categorized with bootstrap analysis as having high, average, or low readmission performance for each index condition. High and low performing hospitals had >/= 95% probability of having an interval estimate respectively less than or greater than the national 30 day readmission rate over the three year period of study. All remaining hospitals were considered average performers. RESULTS: For readmissions in the 30 days after the index admission, there were 320,003 after 1,291,211 admissions for heart failure (4041 hospitals), 102,536 after 517,827 admissions for acute myocardial infarction (2378 hospitals), and 208,438 after 1,135,932 admissions for pneumonia (4283 hospitals). The distribution of readmissions by diagnosis was similar across categories of hospital performance for all three conditions. High performing hospitals had fewer readmissions for all common diagnoses. Median time to readmission was similar by hospital performance for heart failure and acute myocardial infarction, though was 1.4 days longer among high versus low performing hospitals for pneumonia (P<0.001). Findings were unchanged after adjustment for other hospital characteristics potentially associated with readmission patterns. CONCLUSIONS: High performing hospitals have proportionately fewer 30 day readmissions without differences in readmission diagnoses and timing, suggesting the possible benefit of strategies that lower risk of readmission globally rather than for specific diagnoses or time periods after hospital stay.