ObjectivePoor quality of healthcare contributes to impaired health and excess mortality in individuals with severe mental disorders. The authors tested a population-based medical care management ...intervention designed to improve primary medical care in community mental health settings.
MethodA total of 407 subjects with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care.
ResultsAt a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% versus 27.7%) and were more likely to have a primary care provider (71.2% versus 51.9%). The intervention group showed significant improvement on the SF-36 mental component summary (8.0% versus a 1.1% decline in the usual care group) and a nonsignificant improvement on the SF-36 physical component summary. Among subjects with available laboratory data, scores on the Framingham Cardiovascular Risk Index were significantly better in the intervention group (6.9%) than the usual care group (9.8%).
ConclusionsMedical care management was associated with significant improvements in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.
Objective:Behavioral health homes provide primary care health services to patients with serious mental illness treated in community mental health settings. The objective of this study was to compare ...quality and outcomes of care between an integrated behavioral health home and usual care.Method:The study was a randomized trial of a behavioral health home developed as a partnership between a community mental health center and a Federally Qualified Health Center. A total of 447 patients with a serious mental illness and one or more cardiometabolic risk factors were randomly assigned to either the behavioral health home or usual care for 12 months. Participants in the behavioral health home received integrated medical care on-site from a nurse practitioner and a full-time nurse care manager subcontracted through the health center.Results:Compared with usual care, the behavioral health home was associated with significant improvements in quality of cardiometabolic care, concordance of treatment with the chronic care model, and use of preventive services. For most cardiometabolic and general medical outcomes, both groups demonstrated improvement, although there were no statistically significant differences between the two groups over time.Conclusions:The results suggest that it is possible, even under challenging real-world conditions, to improve quality of care for patients with serious mental illness and cardiovascular risk factors. Improving quality of medical care may be necessary, but not sufficient, to improve the full range of medical outcomes in this vulnerable population.
Background
Interhospital care fragmentation, when a patient is readmitted to a different hospital than they were originally discharged from, occurs in 20%–25% of readmissions. Mode of transport to ...the hospital, specifically ambulance use, may be a risk factor for fragmented readmissions. Our study seeks to further understand the relationship between ambulance transport and fragmented readmissions in older adults, a population that is at increased risk for poor outcomes following fragmented readmissions.
Methods
We analyzed inpatient claims from Medicare beneficiaries in 2018 who had a hospital admission for select Hospital Readmission Reduction Program Conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia) as well as dehydration, syncope, urinary tract infection, or behavioral issues. We evaluated the associations between ambulance transport and a fragmented readmission using logistic regression models adjusted for demographic, clinical, and hospital characteristics.
Results
The study included 1,186,600 30‐day readmissions. Of these, 46.8% (n = 555,847) required ambulance transport. In fully adjusted models, taking an ambulance to the readmission hospital increased the odds of a fragmented readmission by 38% (95% CI 1.32, 1.44). When this association was examined by readmission major diagnostic category (MDC), the strongest associations were seen for Factors Influencing Health Status and Other Contacts with Health Services (i.e., rehabilitation, aftercare) (AOR 3.66, 95% CI 3.11, 4.32), Mental Diseases and Disorders (AOR 2.69, 95% CI 2.44, 2.97), and Multiple Significant Trauma (AOR 2.61, 95% CI 1.56, 4.35). When the model was stratified by patient origin, ambulance use remained associated with fragmented readmissions across all locations.
Conclusions
Ambulance use is associated with increased odds of a fragmented readmission, though the strength of the association varies by readmission diagnosis and origin. Patient‐, hospital‐, and system‐level interventions should be developed, implemented, and evaluated to address this modifiable risk factor.
To assess in-hospital mortality, length of stay, and costs associated with interhospital fragmentation in 30-day readmissions and to determine whether these associations were more or less pronounced ...for patients with specific high-prevalence conditions.
Cross-sectional analysis using the Agency for Healthcare Research and Quality's National Readmissions Database for 2013 and 2014.
All patients 18 years and older with a 30-day readmission in 2014 were included. We assessed if readmission to a hospital different from that of the index admission was associated with in-hospital mortality, length of stay, and costs of readmission, separately by whether the readmission occurred for the same or different major diagnostic category. Patients with 1 of 3 common diagnoses (congestive heart failure CHF, chronic obstructive pulmonary disease COPD, or myocardial infarction) were studied for disease-specific trends. The same analyses were performed on 2013 data as a sensitivity analysis.
In 2014, among 792,596 patients with a 30-day readmission, 22.2% experienced fragmentation. Compared with patients whose readmission occurred at the index hospital, patients readmitted to a different hospital experienced 20% higher odds of dying in hospital (P = .02 for same diagnosis readmission; P = .03 for different diagnosis readmission), a half-a-day longer length of stay (P < .001 for both same and different diagnosis readmissions), and more than $1000 higher costs (P < .001 for both same and different diagnosis readmissions). For patients with a CHF or COPD index admission, mortality was consistently higher for fragmented readmissions for a different condition.
Fragmented readmissions were associated with higher in-hospital mortality and cost. Clinical variation across conditions warrants further investigation to optimize pre- and postdischarge operations and policy.
Uncontrolled hypertension remains a widely prevalent cardiovascular risk factor in the U.S. team-based care, established by adding new staff or changing the roles of existing staff such as nurses and ...pharmacists to work with a primary care provider and the patient. Team-based care has the potential to improve the quality of hypertension management. The goal of this Community Guide systematic review was to examine the effectiveness of team-based care in improving blood pressure (BP) outcomes.
An existing systematic review (search period, January 1980-July 2003) assessing team-based care for BP control was supplemented with a Community Guide update (January 2003-May 2012). For the Community Guide update, two reviewers independently abstracted data and assessed quality of eligible studies.
Twenty-eight studies in the prior review (1980-2003) and an additional 52 studies from the Community Guide update (2003-2012) qualified for inclusion. Results from both bodies of evidence suggest that team-based care is effective in improving BP outcomes. From the update, the proportion of patients with controlled BP improved (median increase=12 percentage points); systolic BP decreased (median reduction=5.4 mmHg); and diastolic BP also decreased (median reduction=1.8 mmHg).
Team-based care increased the proportion of people with controlled BP and reduced both systolic and diastolic BP, especially when pharmacists and nurses were part of the team. Findings are applicable to a range of U.S. settings and population groups. Implementation of this multidisciplinary approach will require health system-level organizational changes and could be an important element of the medical home.
Identify contextual and implementation factors impacting the effectiveness of an organizational-level intervention to reduce preventable hospital readmissions from affiliated skilled nursing ...facilities (SNFs).
Observational study of the implementation of Interventions to Reduce Acute Care Transfers tools in 3 different cohorts.
SNFs.
SNFs belonging to 1 of 2 corporate entities and a group of independent SNFs that volunteered to participate in a Quality Improvement Organization (QIO) training program.
Two groups of SNFs received INTERACT II training and technical assistance from corporate staff, and 1 group of SNFs received training from QIO staff.
Thirty-day acute care hospital readmissions from Medicare fee-for-service claims, contextual factors using the Model for Understanding Success in Quality framework.
All 3 cohorts were able to deliver the INTERACT training program to their constituent facilities through regional events as well as onsite technical assistance, but the impact on readmission rates varied. Facilities supported by the QIO and corporation A were able to achieve statistically significant reductions in 30-day readmission rates. A review of contextual factors found that although all cohorts were challenged by staff turnover and workload, corporation B facilities struggled with a less mature quality improvement (QI) culture and infrastructure.
Both corporations demonstrated a strong corporate commitment to implementing INTERACT II, but differences in training strategies, QI culture, capacity, and competing pressures may have impacted the effectiveness of the training. Proactively addressing these factors may help long-term care organizations interested in reducing acute care readmission rates increase the likelihood of QI success.
Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence ...with high potential for future harm (potential ADEs).
To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge.
Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021)
Two tertiary care academic hospitals.
Adults hospitalized with acute coronary syndromes or acute decompensated heart failure.
Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge.
The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs.
Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 95% CI, 0.77 to 1.10) or ADEs (unadjusted incidence rate ratio, 1.09 CI, 0.86 to 1.39). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 CI, 0.61 to 1.04).
The characteristics of the study hospitals and participants may limit generalizability.
Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention.
National Heart, Lung, and Blood Institute.
Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital ...participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions.
Medicare Fee-for-Service Data, 2018.
We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics.
We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason.
In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other.
There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.
This paper examined the recent evidence from economic evaluations of team-based care for controlling high blood pressure.
The search covered studies published from January 2011 through January 2021 ...and was limited to those based in the U.S. and other high-income countries. This yielded 35 studies: 23 based in the U.S. and 12 based in other high-income countries. Analyses were conducted from May 2021 through February 2023. All monetary values reported are in 2020 U.S. dollars.
The median intervention cost per patient per year was $438 for U.S. studies and $299 for all studies. The median change in healthcare cost per patient per year after the intervention was −$140 for both U.S. studies and for all studies. The median net cost per patient per year was $439 for U.S. studies and $133 for all studies. The median cost per quality-adjusted life year gained was $12,897 for U.S. studies and $15,202 for all studies, which are below a conservative benchmark of $50,000 for cost-effectiveness.
Intervention cost and net cost were higher in the U.S. than in other high-income countries. Healthcare cost averted did not exceed intervention cost in most studies. The evidence shows that team-based care for blood pressure control is cost-effective, reaffirming the favorable cost-effectiveness conclusion reached in the 2015 systematic review.
Background
Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal.
Objective
The aim of this ...study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge.
Design
Randomized, controlled trial with concealed allocation and blinded outcome assessors
Setting
Two tertiary care academic medical centers
Participants
Adults hospitalized with a diagnosis of ACS and/or ADHF
Intervention
Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge
Main Measures
The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95 % confidence intervals (CI) are reported.
Key Results
A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women’s Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95 % CI 0.78-1.39). There was an interaction of treatment effect by site (
p
= 0.04 for interaction); VUH aHR = 0.77, 95 % CI 0.51-1.15; BWH aHR = 1.44 (95 % CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95 % CI 0.17-1.00). There was no difference in treatment effect by patient cognition.
Conclusion
A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.
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