Faculty Bibliography

BACKGROUND:While Medicare is a federal health insurance program, managed Medicare limits access to healthcare services to networks within states or territories. However, if a natural disaster requires evacuation, displaced patients are at risk of losing coverage for their benefits. Previous literature has discussed the quality of managed Medicare plans within Puerto Rico but has not addressed the adequacy of this coverage if residents are displaced to the continental United States. We explore Hurricane Maria's impact on a resident of Puerto Rico with chronic health problems, and the challenges he faces seeking healthcare in New York. CASE PRESENTATION/METHODS:A 59-year-old male with a history of diabetes mellitus type II, coronary artery disease, peripheral vascular disease status post right foot amputation, and end-stage kidney disease on hemodialysis was admitted in October of 2017 for chest pain and swelling of legs for 5 days. The patient had missed his last three dialysis sessions after Hurricane Maria forced him to leave Puerto Rico. In examining this patient's treatment, we observe the effect of Hurricane Maria on the medical management of Puerto Rican residents and identify challenges managed Medicare may pose to patients who cross state or territory lines. CONCLUSIONS:We employ this patient's narrative to frame a larger discussion of Puerto Rican managed Medicare and provide additional recommendations for healthcare providers. Moreover, we consider this case in the context of disaster-related continuity of care for patients with complex medical conditions or treatment regimens. To address the gaps in the care of these patients, this article proposes (1) developing system-based approaches for screening displaced patients, (2) increasing the awareness of Special Enrollment Periods related to Medicare among healthcare providers, and (3) creating policy solutions to assure access to care for patients with complex medical conditions.

Objective: To compare morbidity and mortality of Acute Coronary Syndrome (ACS) patients, with hemoglobin level above 7g/dl in transfused or not transfused groups.
Method(s): We conducted a retrospective cohort study of patients admitted with ACS to both campuses of NYU Langone Hospital. Of 1080 patients screened in, 82 met inclusion criteria and were included in our analysis. Patients with hemoglobin less than 7 g/dL or greater than 10 g/dL during their ischemic event were excluded. The outcomes of interest were length of stay (LOS) and negative clinical events as ascertained by physician chart review. The Mann-Whitney U test, was used to compare continuous variables, and the chi-squared test compared categorical variables.
Result(s): 54 patients were transfused, and 28 were not transfused. Mean age (72.5 vs 74.4 years), and race did not differ significantly between groups. Proportion with heart failure, known anemia and mean baseline hemoglobin of anemic patients prior to admission were similar between both groups. ACS diagnosis and proportion of patients receiving medical management were similar between groups as well. However, transfused patients were more likely to be male, have Chronic Kidney Disease (51.9% vs 28.6%), have known Coronary Artery Disease (77.8 vs 42.6%) and those with Congestive Heart Failure had a lower baseline ejection fraction (34.5 vs 57.5%). For outcomes, blood transfusion was associated with a longer LOS (mean 11.48 vs 6.36 days, p=0.002). Furthermore, transfusion was associated with a higher likelihood to have a combined negative outcome which included new or worsening respiratory distress, hypoxia, volume overload, upgrade to the Intensive Care Unit and death (79% vs 24%, RR=3.29, P<0.001), driven by a significant increase in volume overload (40.7 vs 4.0% P<0.001) and a non-significant tendency towards increased mortality (16.7 vs 4.0%, p=0.12).
Conclusion(s): ACS patients who underwent blood transfusion had worse outcomes, namely longer LOS, increased risk for volume overload and a pronounced but not significant trend towards increased mortality. This effect was confounded by more severe comorbidities in the transfused group. However, given the size and significance of this harmful association, it is possible or perhaps even likely that transfusion itself was a factor in the worsened outcomes in the transfused group. Though transfusion for a hemoglobin > 7g/dl and even > 8g/dl is common in ACS patients, the harms associated with blood transfusions may outweigh the possible risk of worsened myocardial ischemia in the setting of lower oxygen carrying capacity

Background: Discharge to skilled nursing facilities (SNF) is common in patients with heart failure (HF). The goal of a SNF stay is to improve functional status to allow patients to return home safely. However, the second transition from SNF to home may also be risky. Here, we examine the association between receipt of home health care (HHC) and readmission risk among patients discharged from SNF to home following HF hospitalization.
Method(s): We examined all Medicare fee-for-service beneficiaries 65 and older admitted 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. The primary outcome was unplanned read-mission within 30 days of SNF to home discharge, using CMS's HF read-mission methodology. We plotted time to readmission with Kaplan-Meier curves and compared these groups with a log-rank test. Then, we compared time to readmission using an adjusted Cox model; this model included a frailty term to account for correlation of patient outcome by SNF.
Result(s): There were 67,585 HF hospitalizations discharged to SNF and subsequently discharged home; 13,257 (19.6%) were discharged with HHC, 54,328 (80.4%) without. Patients discharged home from SNF with HHC had lower 30-day readmission rates than patients discharged without HHC (22.8% vs 24.5%, p< 0.0001). Kaplan-Meier curves demonstrated that patients discharged home from SNF with HHC have a longer unadjusted time to readmission. Of those readmitted within 30 days, median time to readmission for those discharged home from SNF with HHC was 11 days and 9 days for those discharged home without HHC (p< 0.0001). After risk-adjustment, patients discharged home with HHC still had a lower hazard of 30-day readmission.
Conclusion(s): Patients who received HHC were less likely to be readmitted within 30 days compared to those discharged home without HHC. This is unexpected as patients discharged with HHC likely have more functional impairments and therefore at higher readmission risk. Since patients requiring a SNF stay after hospital discharge may have additional needs, they may be especially likely to benefit from restorative therapy through HHC; however only about 20% received such services

Statement of Problem Or Question (One Sentence): The increasing complexity of admitted patients, shorter hospital stays and post-acute care adverse events demand a more sophisticated and effective coordination of care between hospitalists and Primary care providers (PCPS). Objectives of Program/Intervention (No More Than Three Objectives): 1. Standardizing communication between Hospitalist and PCP during hospitalization will lower the rate of readmission due to lack of PCP follow up and post-acute care adverse events. 2. Implementing this practice into our daily workflow will improve PCP satisfaction and increase referrals to our institution. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We reviewed a root-cause survey of 30 day readmissions between 1/2018-4/2018 as well as readmission rates for each of our hospitalists. We surveyed our PCPS' satisfaction with communication experiences with our hospitalist group. Finally, we conducted a semi-structured interview of the hospitalist with the lowest readmission (8% vs 12% average for other hospitalists) and highest PCP satisfaction rates, Dr. A, to develop best practices for closed loop communication. Based on this data, we designed a protocol and piloted on 5/1/2018, where the hospitalist contacts the PCP via phone call on admission and delivers a discharge narrative to the PCP via our EMR's routing capability. We used a trackable smart phrase to document the communication. For the prospective phase, we will operationalize these best practices in a study group, Family Health Center PCPS. A control group (community PCPS) will receive usual practice. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will compare readmission rates between the study group and control group, monitoring the proportion and absolute number of readmissions attributed to no PCP follow up or medication errors. Follow up satisfaction surveys will be sent to the PCPS 6 months after our revised communication practice. Finally, we will monitor the hospitalists' compliance with the smart phrase. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): A review of our institution's 30 day readmissions between 1/2018-4/2018 found that 19% were attributed to lack of PCP/outpatient provider follow-up. Surveys of our community PCPS showed 70% reported being contacted by the hospitalist group in less than 25% of the time. Results from Dr. A's interview revealed that after her encounter with the patient, she calls the patient's PCP highlighting the admitting diagnosis, significant events, pertinent labs, imaging and medications. Dr. A then delivers a discharge narrative to the PCP on the day of discharge highlighting any medication changes, incidental findings and follow up. On a random audit of 100 charts between 5/1/2018-10/30/2018 our preliminary data show that there was 88% compliance with using the smart phrase by the hospitalists. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Using a "positive deviance" approach, we identified best practices for hospitalist-PCP closed loop communication to develop an intervention to improve this aspect of care. If we are successful in reducing readmission rates and improving PCP satisfaction, we will expand to all of our PCPS and ultimately expand to other services to implement this program as best practice

OBJECTIVE:Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less. DESIGN/METHODS:Retrospective cohort study. SETTING AND PARTICIPANTS/METHODS:All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. MEASURES/METHODS:Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge. RESULTS:Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78). CONCLUSIONS/IMPLICATIONS/CONCLUSIONS:The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.