Patients with rectal cancer treated at specialized or high-volume hospitals have better outcomes, but a minority of these patients are treated there. Physician recommendations are important ...considerations for patients with rectal cancer when making treatment decisions, yet little is known about the factors that affect these physician referral patterns.
Semistructured telephone interviews were conducted in 2018-2019 with Iowa gastroenterologists (GIs) and general surgeons (GSs) who performed colonoscopies in a community setting. A thematic approach was used to analyze and code qualitative data.
We interviewed 10 GIs and 6 GSs with self-reported averages of 15.5 y in practice, 1100 endoscopic procedures annually, and 6 rectal cancer diagnoses annually. Physicians believed surgeon experience and colorectal specialization were directly related to positive outcomes in rectal cancer resections. Most GSs performed resections on patients they diagnosed and typically only referred patients to colorectal surgeons (CRS) in complex cases. Conversely, GIs generally referred to CRS in all cases. Adhering to existing referral patterns due to the pressure of health care networks was a salient theme for both GIs and GSs.
While respondents believe that high volume/specialization is related to improved surgical outcomes, referral recommendations are heavily influenced by existing referral networks. Referral practices also differ by diagnosing specialty and suggest rural patients may be less likely to be referred to a CRS because more GSs perform colonoscopies in rural areas and tend to keep patients for resection. System-level interventions that target referral networks may improve rectal cancer outcomes at the population level.
Background
Telehealth has been proposed as one strategy to improve the quality of time‐sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the ...association between telehealth‐supplemented ED (tele‐ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs.
Methods
Cohort study using Medicare fee‐for‐service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital‐level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele‐ED–capable hospital and 30‐day total costs of care. In our supporting secondary analysis, we conducted a propensity‐matched analysis of patients who used tele‐ED with matched controls from non–tele‐ED–capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90‐day mortality, 28‐day hospital‐free days, and 30‐day inpatient readmissions.
Results
In our primary analysis, sepsis patients in tele‐ED–capable hospitals had 6.7% higher (95% confidence interval CI 2.1%–11.5%) total health care costs compared to those in non–tele‐ED–capable hospitals. In our propensity‐matched patient‐level analysis, total health care costs were 23% higher (95% CI 16.5%–30.4%) in tele‐ED cases than matched non–tele‐ED controls. Clinical outcomes were similar.
Conclusions
Tele‐ED capability in a mature rural tele‐ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural–urban sepsis care disparities and formalize systems of regionalized care.
Objective
To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this relationship influenced ...treatment retention.
Data Sources
National, secondary administrative data used from the Veterans Health Administration (VHA), 2008–2017.
Study Design
Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of a previous visit or medication prescribed by the provider in the 2 years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.
Data Collection/Extraction Methods
Adult Veterans (age ≥ 18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with documentation of a metastatic tumor diagnosis within 2 years prior to buprenorphine initiation, and those without geographical information on rurality.
Principal Findings
A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n = 16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider, and 24.9% (n = 7174) of Veterans previously had at least one prescription from that provider in the 2 years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95% CI: 0.96, 1.02) or medication history (aHR: 1.03; 95% CI: 1.00, 1.07).
Conclusions
Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran‐provider therapeutic relationships influences opioid use dependence management and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently, treatment initiation and retention.
X‐ray microbeam scattering is used to map the microstructure of the organic semiconductor along the channel length of solution‐processed bottom‐contact OFET devices. Contact‐induced nucleation is ...known to influence the crystallization behavior within the channel. We find that microstructural inhomogeneities in the center of the channel act as a bottleneck to charge transport. This problem can be overcome by controlling crystallization of the preferable texture, thus favoring more efficient charge transport throughout the channel.
Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes.
This study was conducted to describe the effect of ...telemedicine on management and clinical outcomes for trauma patients in North Dakota.
Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality.
Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval CI 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio aOR 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9).
ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.
Telehealth can expand and enhance access to school-based health care, but its use has been relatively limited. Recognizing that school-based health care is still not reaching many students, the ...Health Resources and Services Administration (HRSA) funded the School Based Telehealth Network Grant Program to expand telehealth in rural school-based settings to help to increase the availability and use of these services. The 19 grantees delivered telehealth to over 200 schools across 17 states, choosing which services they would deliver and how. Looking across the services, these fell into three categories – primary/urgent care, behavioral health, and other more specialized services. The majority of grantees offered multiple telehealth services with the combination of behavioral health and primary/urgent care the most common. The current study adds to the literature by elucidating that telehealth in schools can address multiple clinical conditions through separate services even though doing so involves using various combinations of clinicians providing different services.
Due to limited community resources for mental health and long travel distances, emergency departments (EDs) serve as the safety net for many rural residents facing crisis mental health care. In 2019, ...The Leona M. and Harry B. Helmsley Charitable Trust funded a project to establish and implement an ED-based telepsychiatry service for patients with mental health issues in underserved areas. The purpose of this study was to evaluate the implementation of this novel ED-based telepsychiatry service.
This was a mixed-methods study evaluating the new ED-based telepsychiatry consult service implemented in five EDs across three rural states that participated within a mature hub-and-spoke telemedicine network between June 2019 and December 2020. Quantitative evaluation in this study included characteristics of the telehealth encounters and the patient population for whom this service was used. For qualitative assessments, we identified key themes from interviews with key informants at the ED spokes to assess overall facilitators, barriers, and impact. Integrating the quantitative and qualitative findings, we explored emergent phenomena and identified insights to provide a comprehensive perspective of the implementation process.
There were 4130 encounters for 3932 patients from the EDs during the evaluation period. Approximately 54% of encounters involved female patients. The majority of patients seen were white (51%) or Native American (44%) reflecting the population of the communities where the EDs were located. Among the indications for the telepsychiatry consult, the most frequently identified were depression (28%), suicide/self-harm (17%), and schizophrenia (12%). Across sites, 99% of clinician-to-clinician consults were by phone, and 99% of clinical assessments/evaluations were by video. The distribution of encounters varied by the day of the week and the time of day. Facilitators for the service included increasing need, a supportive infrastructure, a straightforward process, familiarity with telemedicine, and a collaborative relationship. Barriers identified by respondents at the sites included the lack of clarity of process and technical limitations. The themes emerging from the impact of the telepsychiatry consultation in the ED included workforce improvement, care improvement, patient satisfaction, cost-benefit, facilitating COVID care, and access improvement.
Implementation of a telepsychiatry service in ED settings may be beneficial to the patient, local ED, and the underserved community. In this study, we found that implementing this service alleviated the burden of care during the COVID-19 pandemic, enhanced local site capability, and improved local ability to provide quality and effective care.
•EDs serve as a safety net for rural residents facing crisis mental health care.•Telepsychiatry facilitators include a supportive infrastructure and a straightforward process.•Telepsychiatry challenges include the clarity of process and technical limitations.•Telepsychiatry impact in the ED include improvement in workforce and care.•Implementation in the ED helped local sites with burden of care during the COVID-19 pandemic.
Objectives
Traumatic injury is a leading cause of death in the United States, and rural populations are at increased risk of injury and death. Rural residents have limited access to trauma care, and ...telemedicine has been proposed as one strategy to improve the provision of trauma care locally. The objective of this study was to describe patient‐level factors associated with telemedicine consultation in North Dakota critical‐access hospital (CAH) emergency departments (EDs) and to measure the association between telemedicine consultation and interhospital transfer.
Methods
Observational cohort study of all adult (age ≥ 18 years) trauma patients treated in North Dakota CAH EDs with an active telemedicine subscription between 2008 and 2014. Trauma cases were identified from the North Dakota Trauma Registry, and telemedicine‐enabled care was determined using a probabilistic linking algorithm with the call records of the predominant telemedicine network in North Dakota. Multivariable generalized estimating equations were used to identify factors associated with telemedicine consultation and to measure the association between telemedicine consultation and interhospital transfer, adjusting for patient, injury, and hospital factors.
Results
Of the 9,281 North Dakota trauma patients seen in CAHs, 2,837 were treated in an ED with an active telemedicine subscription. Telemedicine was consulted for 11% of all trauma patients in telemedicine‐capable EDs. Factors associated with telemedicine consultation included higher Injury Severity Score, penetrating injuries, burns, hypotension, tachycardia, and ambulance transport. Adjusting for severity of illness, injury mechanism, and type of injury, telemedicine use was not associated with interhospital transfer (adjusted odds ratio = 1.28, 95% confidence interval = 0.94 to 1.75).
Conclusion
Emergency department–based telemedicine consultation is requested for the most severely injured rural trauma patients, especially with those with penetrating trauma, burns, and abnormal presenting vital signs. Telemedicine consultation was not independently associated with increased probability of transfer. Future work should evaluate how telemedicine impacts the timeliness of care and specific care interventions.
A particularly useful model for examining implementation of quality improvement interventions in health care settings is the PARIHS (Promoting Action on Research Implementation in Health Services) ...framework developed by Kitson and colleagues. The PARIHS framework proposes three elements (evidence, context, and facilitation) that are related to successful implementation.
An evidence-based program focused on quality enhancement in health care, termed TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), has been widely promoted by the Agency for Healthcare Research and Quality, but research is needed to better understand its implementation. We apply the PARIHS framework in studying TeamSTEPPS implementation to identify elements that are most closely related to successful implementation.
Quarterly interviews were conducted over a 9-month period in 13 small rural hospitals that implemented TeamSTEPPS. Interview quotes that were related to each of the PARIHS elements were identified using directed content analysis. Transcripts were also scored quantitatively, and bivariate regression analysis was employed to explore relationships between PARIHS elements and successful implementation related to planning activities.
The current findings provide support for the PARIHS framework and identified two of the three PARIHS elements (context and facilitation) as important contributors to successful implementation.
This study applies the PARIHS framework to TeamSTEPPS, a widely used quality initiative focused on improving health care quality and patient safety. By focusing on small rural hospitals that undertook this quality improvement activity of their own accord, our findings represent effectiveness research in an understudied segment of the health care delivery system. By identifying context and facilitation as the most important contributors to successful implementation, these analyses provide a focus for efficient and effective sustainment of TeamSTEPPS efforts.
There is limited published data on the relationship between hospital volume and postoperative complications. The objectives of the current study are to examine the association between hospital volume ...and complications and also to examine the association between complications and in-hospital mortality following 5 complex surgical procedures.
The Nationwide Inpatient Sample for years 2000 to 2003 was used. Patients who underwent coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), elective abdominal aortic aneurysm repair (AAA), pancreatectomy (PAN), and esophagectomy (ESO) as primary procedures were selected. Hospital volumes were calculated as suggested by the Leapfrog Group evidence-based hospital referral criteria. The association between hospital volume and complications were examined by multivariable logistic regression analyses, adjusting for patient and hospital characteristics.
A total of 261551 CABG, 573072 PCI, 35104 AAA, 4931 PAN, and 2473 ESO procedures were selected for analysis. A total of 580 hospitals performed the CABG procedures during the study period in this dataset. The corresponding numbers of hospitals for PCI, AAA, PAN, and ESO were 714, 1207, 758, and 555 respectively. In-hospital complication rates following CABG, PCI, AAA, PAN, and ESO were 26.45%, 6.74%, 23.81%, 39.28%, and 46.30%, respectively. High-volume hospitals for all the procedures were associated with lower odds for in-hospital mortality when compared with low-volume hospitals (P < 0.05). High-volume hospitals were associated with significantly lower odds for at least one complication following 3 of the 5 procedures (PCI, AAA, and PAN) and specifically for significantly lower odds for respiratory complications following CABG, AAA, and PAN, digestive complications following PAN, hemorrhage/hematoma complications following PCI, and septicemia following PCI and PAN when compared with low-volume hospitals (P < 0.05).
Lower mortality rates in high-volume hospitals can be partly, though not completely, attributed to lower complication rates. Future studies must focus on identifying other potential pathways for reduced mortality in high-volume hospitals.
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