Explore the vast range of titles available.

BackgroundTime-sensitive alerts are among the many types of clinical notifications delivered to physicians’ secure InBaskets within commercial electronic health records (EHRs). A delayed alert review can impact patient safety and compromise care.ObjectiveTo characterize factors associated with opening of non-interruptive time-sensitive alerts delivered into primary care provider (PCP) InBaskets.Design and ParticipantsWe analyzed data for 799 automated alerts. Alerts highlighted actionable medication concerns for older patients post-hospital discharge (2010–2011). These were study-generated alerts sent 3 days post-discharge to InBaskets for 75 PCPs across a multisite healthcare system, and represent a subset of all urgent InBasket notifications.Main MeasuresUsing EHR access and audit logs to track alert opening, we performed bivariate and multivariate analyses calculating associations between patient characteristics, provider characteristics, contextual factors at the time of alert delivery (number of InBasket notifications, weekday), and alert opening within 24 h.Key ResultsAt the time of alert delivery, the PCPs had a median of 69 InBasket notifications and had received a median of 379.8 notifications (IQR 295.0, 492.0) over the prior 7 days. Of the 799 alerts, 47.1% were opened within 24 h. Patients with longer hospital stays (>4 days) were marginally more likely to have alerts opened (OR 1.48 [95% CI 1.00–2.19]). Alerts delivered to PCPs whose InBaskets had a higher number of notifications at the time of alert delivery were significantly less likely to be opened within 24 h (top quartile >157 notifications: OR 0.34 [95% CI 0.18–0.61]; reference bottom quartile ≤42). Alerts delivered on Saturdays were also less likely to be opened within 24 h (OR 0.18 [CI 0.08–0.39]).ConclusionsThe number of total InBasket notifications and weekend delivery may impact the opening of time-sensitive EHR alerts. Further study is needed to support safe and effective approaches to care team management of InBasket notifications.

Background Lower mammography screening rates among minority and low income women contribute to increased morbidity and mortality from breast cancer. Objective To evaluate the effect of a patient navigation intervention on adherence rates to biennial screening mammography among women engaged in primary care at an inner-city academic medical center. Design Quality improvement intervention with a concurrent control group, conducted from February to November of 2008. Study Subjects All women in a hospital-based primary care practice aged 51–70 years. Subjects were randomized at the level of their primary care provider, such that half of the patients in the practice received the intervention, while the other half received usual care. Interventions Intervention subjects whose last mammogram was >18 months prior received a combination of telephone calls and reminder letters from patient navigators trained to identify barriers to care. Navigators were integrated into primary care teams and interacted directly with patients, providers, and radiology to coordinate care. Navigators utilized an electronic report to track subjects. Adherence rates to biennial mammography were assessed in intervention and control groups at baseline and post-intervention. Key Results A total of 3,895 women were randomized to intervention (n = 1,817) and control (n = 2,078) groups. Mean age was 60, 71% were racial/ethnic minorities, 23% were non-English speaking, and 63% had public or no health insurance. At baseline, there was no difference in mammography adherence between the control and intervention groups (78%, respectively, p = 0.55). After the 9-month intervention, mammogram adherence was higher in the intervention group compared with the control group (87% vs. 76%, respectively, p < 0.001). Except among Hispanic women who demonstrated high rates in both the intervention and control groups (85% and 83%, respectively), all racial/ethnic and insurance groups demonstrated higher adherence in the intervention group. Conclusions Patient navigation improves biennial mammography rates for inner city, low income, minority populations.

BackgroundCessation counseling and pharmacotherapy are recommended for hospitalized smokers, but better coordination between cessation counselors and providers might improve utilization of pharmacotherapy and enhance smoking cessation.ObjectiveTo compare smoking cessation counseling combined with care coordination post-hospitalization to counseling alone on uptake of pharmacotherapy and smoking cessation.DesignUnblinded, randomized clinical trialParticipantsHospitalized smokers referred from primarily rural hospitalsInterventionsCounseling only (C) consisted of telephone counseling provided during the hospitalization and post-discharge. Counseling with care coordination (CCC) provided similar counseling supplemented by feedback to the smoker’s health care team and help for the smoker in obtaining pharmacotherapy. At 6 months post-hospitalization, persistent smokers were re-engaged with either CCC or C.Main MeasuresUtilization of pharmacotherapy and smoking cessation at 3, 6, and 12 months post-discharge.Key ResultsAmong 606 smokers randomized, 429 (70.8%) completed the 12-month assessment and 580 (95.7%) were included in the primary analysis. Use of any cessation pharmacotherapy between 0 and 6 months (55.2%) and between 6 and 12 months (47.1%) post-discharge was similar across treatment arms though use of prescription-only pharmacotherapy between months 6–12 was significantly higher in the CCC group (30.1%) compared with the C group (18.6%) (RR, 1.61 (95% CI, 1.08, 2.41)). Self-reported abstinence rates of 26.2%, 20.3%, and 23.4% at months 3, 6, and 12, respectively, were comparable across the two treatment arms. Of those smoking at month 6, 12.5% reported abstinence at month 12. Validated smoking cessation at 12 months was 19.3% versus 16.9% in the CCC and C groups, respectively (RR, 1.13 (95% CI, 0.80, 1.61)).ConclusionSupplemental care coordination, provided by counselors outside of the health care team, failed to improve smoking cessation beyond that achieved by cessation counseling alone. Re-engagement of smokers 6 months post-discharge can lead to new quitters, at which time care coordination might facilitate use of prescription medications.Trial RegistrationNCT01063972

ABSTRACT BACKGROUND Rehospitalizations within 30 days of discharge are responsible for a large portion of healthcare spending. One approach to preventing rehospitalizations is early follow-up, usually defined as an office visit with a primary care physician within 7 days of discharge—an approach that is being incentivized by health plans. However, evidence regarding its effectiveness is limited. OBJECTIVE We aimed to determine whether an office visit with a primary care physician within 7 days after discharge is associated with 30-day rehospitalization. DESIGN This was an observational study set within a randomized trial. PARTICIPANTS The study included patients age 65 and older receiving care from a multi-specialty group practice and discharged from hospital to home between 26 August 2010 and 25 August 2011. To control for confounding, we identified characteristics of patients and hospital stays that are predictive of rehospitalization, and also developed high-dimensional propensity scores. Analyses used Cox proportional hazards models and took into account varying amounts of opportunity time for office visits. MAIN MEASURES We looked at 30-day rehospitalizations at any hospital. KEY RESULTS Of 3,661 patients discharged to home during the study year, 707 (19.3 %) were rehospitalized within 30 days. Patients receiving an office visit within 7 days numbered 1,808 (49.4 %), and of these, 1,000 (27.3 %) were with a primary care physician. In models predicting rehospitalization, stratified on deciles of propensity score and controlling for additional confounders, the hazard ratios associated with office visits with a primary care physician within 7 days were 0.98 (95 % CI 0.80, 1.21); for visits with any physician, the hazard ratio was HR 1.04, (95 % CI 0.87, 1.25). CONCLUSIONS We found no protective effect for office visits within 7 days. Such visits may need to be specifically focused on a range of issues related to the specific reasons why patients are rehospitalized. It is likely that outpatient visits will need to be set within comprehensive transition programs.

ABSTRACT BACKGROUND Failure to follow up microbiology results pending at the time of hospital discharge can delay diagnosis and treatment of important infections, harm patients, and increase the risk of litigation. Current systems to track pending tests are often inadequate. OBJECTIVE To design, implement, and evaluate an automated system to improve follow-up of microbiology results that return after hospitalized patients are discharged. DESIGN Cluster randomized controlled trial. SUBJECTS Inpatient and outpatient physicians caring for adult patients hospitalized at a large academic hospital from February 2009 to June 2010 with positive and untreated or undertreated blood, urine, sputum, or cerebral spinal fluid cultures returning post-discharge. INTERVENTION An automated e-mail-based system alerting inpatient and outpatient physicians to positive post-discharge culture results not adequately treated with an antibiotic at the time of discharge. MAIN MEASURES Our primary outcome was documented follow-up of results within 3 days. Secondary outcomes included physician awareness and assessment of result urgency, impact on clinical assessments and plans, and preferred alerting scenarios. KEY RESULTS We evaluated the follow-up of 157 post-discharge microbiology results from patients of 121 physicians. We found documented follow-up in 27/97 (28%) results in the intervention group and 8/60 (13%) in the control group [aOR 3.2, (95% CI 1.3-8.4); p  = 0.01]. Of all inpatient physician respondents, 32/82 (39%) were previously aware of the results, 45/77 (58%) felt the results changed their assessments and plans, 43/77 (56%) felt the results required urgent action, and 67/70 (96%) preferred alerts for current or broader scenarios. CONCLUSION Our alerting system improved the proportion of important post-discharge microbiology results with documented follow-up, though the proportion remained low. The alerts were well received and may be expanded in the future.

Background Care transitions from hospital to community have been identified as risk points for the continuity of patient care. Without upstream information, the community pharmacist (CP) cannot ensure error-free drug dispensing. A hospital-to-community records transmission process would enable CPs to guarantee that all prescription drugs are ready to pick up at hospital discharge, and to improve their responses to patient health inquiries. Objective To evaluate the impact of a hospital-to-CP medication records scheme on post-discharge continuity of patient treatment. Setting A University Hospital Digestive Surgery Department. Method Prospective, single-center, randomized pilot study. Eligible adult Digestive Surgery department patients discharged home over a period of 4 months were included. The medication reconciliation procedure was the same in both arms of the study. For patients included in the intervention group, CPs were sent the discharge prescription, patient medication list, and clinical and biological data required for drug dispensing. At 7 ± 2 days post-discharge, the CPs were surveyed by questionnaire. Seamlessness of drug continuity, use of the discharge medication form, and CP satisfaction with the scheme were assessed. Main outcome measures Prevalence of medication shortages, i.e. CPs unable to supply the appropriate drugs at discharge, and CP satisfaction levels, analyzed using Chi squared test. Results 124 patients were included. Of 124 CPs surveyed, 104 returned a completed questionnaire. Analysis found medication shortage in 10 control-group patients and one intervention-group patient (p < 0.005), non-availability of the full prescription in 24 % of control-group patients and 6 % of intervention-group patients (p < 0.013). In terms of CP satisfaction, 96 % of the intervention-group CPs stated that they were satisfied with the new hospital-to-community liaison initiative, while just 24 % of control-group CPs were satisfied with the current level of hospital-to-community liaison. Mean hospital pharmacist time input required for this initiative was an estimated 21 min for the control group versus 35 min for the intervention group. Conclusion The results provide a strong rationale for embedding the process longer-term and extending it out to other healthcare services. A pre-project study is needed to define which service departments and patients groups should be given priority for this process initiative.

Background The intervention; “ Continuum of Care for Frail Older People ”, was designed to create an integrated continuum of care from the hospital emergency department through the hospital and back to the older person’s own home. The aim of this study is to evaluate the effects of the intervention on functional ability in terms of activities of daily living (ADL). Methods The study is a non-blinded controlled trial with participants randomised to either the intervention group or a control group with follow-ups at three-, six- and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the emergency department, the hospital wards and a multi-professional team for care and rehabilitation of the older people in the municipality with a case manager as the hub. Older people who sought care at the emergency department at Sahlgrenska University Hospital/Mölndal and who were discharged to their own homes in the municipality of Mölndal, Sweden were asked to participate. Inclusion criteria were age 80 and older or 65 to 79 with at least one chronic disease and dependent in at least one ADL. Analyses were made on the basis of the intention-to-treat principle. Outcome measures were ADL independence and eight frailty indicators. These were analysed, using Chi-square and odds ratio (OR). Results A total of 161 participated in the study, 76 persons allocated to the control group and 85 to the intervention group were analysed throughout the study. There were no significant differences between the groups with regards to change in frailty compared to baseline at any follow-up. At both the three- and twelve-month follow-ups the intervention group had doubled their odds for improved ADL independence compared to the control (OR 2.37, 95% CI; 1.20 – 4.68) and (2.04, 95% CI; 1.03 – 4.06) respectively. At six months the intervention group had halved their odds for decreased ADL independence (OR 0.52, 95% CI; 0.27 – 0.98) compared to the control group. Conclusions The intervention has the potential to reduce dependency in ADLs, a valuable benefit both for the individual and for society. Trial registration ClinicalTrials.gov: NCT01260493

Background Blood pressure (BP) control remains elusive for many Americans. Although home health nurses are uniquely positioned to help vulnerable individuals achieve BP control, hypertension (HTN) management has not been a high priority in post-acute care. Objective To examine the effects of two home-based interventions designed to improve BP outcomes among high-risk African-American patients. Design Cluster randomized controlled trial. Participants A total of 845 newly admitted patients with uncontrolled HTN (JNC7 stages 1 or 2). Interventions The “basic” intervention delivered key HTN information to clinicians and patients, and a home BP monitor to patients, while the patients received usual post-acute care. The “augmented” intervention provided more intensive and extensive HTN information, monitoring and feedback for 3 months beyond the index home care admission. Measures Primary: BP control. Secondary: reductions in mmHG SBP and DBP, improvements in proportions improving JNC7 stage or achieving clinically meaningful reductions in SBP and DBP. Methods Multivariate regression models. Key Results The basic intervention produced no significant BP improvements; the augmented intervention significantly improved stage 2 patients’ outcomes. Among stage 2 patients, the augmented intervention increased BP control by 8.7 percentage points relative to usual care (8.9% vs. 17.6%; p = 0.01), yielded an 8.3 mmHG relative reduction in SBP (p = 0.01), and increased the proportion achieving at least a 20 mmHG reduction in SBP by 16.4 percentage points (p = 0.01). Conclusion Among stage 2 patients, a nurse-led intervention providing additional HTN medication review and patient self-management support during the 3-month post-acute care period yielded significant improvements in 3-month BP control, plus improvements in secondary BP outcomes.

Coronavirus disease has disrupted tuberculosis services globally. Data from 33 centers in 16 countries on 5 continents showed that attendance at tuberculosis centers was lower during the first 4 months of the pandemic in 2020 than for the same period in 2019. Resources are needed to ensure tuberculosis care continuity during the pandemic.

Background Pakistan, being a developing country, presents the dismal picture of maternal and neonatal mortality and morbidity. The majority of maternal and neonatal deaths could be avoided if Continuum of Care (CoC) is provided in a structured pathway from pregnancy to birth and to the first week of life of the newborn child. This study aimed to analyse the trends of CoC at all three levels (antenatal care, skilled delivery and postpartum care) and to identify various factors affecting the continuation in receiving CoC in Pakistan during 2006 to 2012. Methods Secondary data analysis was performed on nationally representative data from the last two iterations of Pakistan Demographic and Health Survey (PDHS), conducted during 2006/07 to 2012/13. The analysis is limited to women of the reproductive age group (15–49 years) who gave birth during the last five years preceding both surveys. This leads to a sample size of 5,724 and 7,461 respondents from PDHS 2006/07 and 2012/13 respectively. The association between CoC and several factors, including individual attributes (reproductive status), family influences, community context, as well as cultural and social values was assessed in bivariate analyses in a first step. Furthermore, odds ratios and adjusted odds ratios with 95% confidence intervals using a binary and multivariable logistic regression were calculated. Results Our research presents the trends of a composite measure of CoC including antenatal care, delivery assistance and postpartum care. The largest gap in CoC was observed at antenatal care followed by delivery and postnatal care within 48 h after delivery. Results show that CoC completion rate has increased from 15% to 27% amongst women in Pakistan over time from 2006 to 2012. Women with high age at first birth, having less number of children, with higher education, belonging to richest quintile, living in Sindh province and urban areas, having high autonomy and exposure to mass media were most likely to avail complete CoC. Conclusions The findings show that women in Pakistan still lack the CoC. This calls for attention to develop and implement tailored interventions, focusing on the needs of women in Pakistan to provide CoC in an integrated manner, involving both public and private sectors by appropriately addressing the factors hindering CoC completion rates.