According to a study of 15 emergency departments, patients over age 80 who are admitted to intensive care are often not asked their opinion about admission. "The relationship between physicians and their patients has changed over the last decades and patients' empowerment has led to a greater self autonomy in medical decisions," but apparently not when it comes to moving elderly patients into an intensive care unit, said lead author Dr. Julien Le Guen of Universite Paris Descartes in France. Legally, no medical decision should be made without the patient's consent, Le Guen told Reuters Health by email.
In the summer of 2014, a 23-year-old pregnant woman entered the military hospital at Bagram Air Field in Afghanistan with a cut on her left cheek. The wound had been stitched up elsewhere, but she still wasn't quite right. She said she'd been hit in the face by a ricochet back in her home village. What hit her exactly, she couldn't say for sure. She was upset, though, because the vision was bad in her left eye, even though there had been no apparent trauma to it. "That was the only tip-off we had that something else was going on," says Dr. Travis Newberry, a head and neck surgeon and U.S. Air Force major who is now based at the San Antonio Military Medical Center in Texas.
Tuberculosis (TB) cases have fallen by roughly one-fifth among foreign-born people living in the U.S., and the decline appears to be largely due a lower disease burden and improved TB control in their countries of origin, according to a CDC report.
About two-thirds of the readmissions are preventable, one expert estimates. Identifying patients most at risk for readmission and focusing on best practices proven to keep patients out of the hospital can help.
This article first appeared in the January/February 2016 issue of HealthLeaders magazine.
With a mortality rate of 0.1% and relatively few complications, 30-day readmissions represent the one area in which bariatric surgery programs could improve, says John Morton, MD, director of bariatric surgery at Stanford (California) University School of Medicine and immediate past president of the American Society for Metabolic and Bariatric Surgery. Improving that rate requires identifying patients most at risk for readmission and focusing on best practices proven to keep patients out of the hospital.
John Morton, MD
About two-thirds of the readmissions are preventable, he says, and the most common reasons for readmission are dietary indiscretions and medication reconciliation.
Focusing on those two causes and other best practices enabled Stanford's bariatric program to reduce its readmission rates from 8% to 2.5% in four years. Stanford's 2008 pilot project on reducing readmissions evolved into the nationwide Decreasing Readmissions through Opportunities Provided program, which aims to reduce 30-day readmissions nationwide
by 20%.
"One thing that got my attention was a letter from an insurer saying that if our admission rate was above 5% we wouldn't be allowed to participate in the network anymore," Morton says. "I knew we had a problem, and we started looking at our data to find out what was wrong."
Success key No. 1: Identify at-risk patients
Identifying the patients most at risk of readmission early in the process will go a long way toward lowering readmission rates, Morton says, and that can guide whether the procedure is performed inpatient or outpatient. One rule of thumb is the 50/50 rule, which says a patient is at risk for readmission if the age or body mass index is greater than 50. A patient who has an established relationship with a primary care physician is at lower risk, he explains, because that doctor can help coordinate care.
Severity and comorbidities also can put a patient at risk for readmission. A hemoglobin A1c of 10% or the presence of more than three comorbidities should be a readmission warning sign, Morton says. Insurance status also plays a role, with Medicare and Medicaid patients more likely to be readmitted.
"A long case is another factor, because a long time in surgery can be a marker for technical difficulties," he says. "Probably the biggest risk for readmissions is going to be complications at the time of surgery."
Success key No. Key 2: Choose the right setting
Readmission rates also can be affected by where the surgery is performed, Morton notes. Only two of the three common bariatric procedures in the United States can safely be performed in an outpatient setting—the gastric band and, under some circumstances, the sleeve, he says.
"There's a potential for higher readmission rates in ambulatory surgery," Morton says. "There is a certain amount of patient education that takes place in an inpatient setting that may not be happening in ambulatory surgery. That's not to say that an ambulatory surgery center can't do the same level of education, but it's not routinely done."
Any risk factors identified in the patient evaluation should be considered carefully when determining whether outpatient surgery is acceptable or poses too much of a readmission risk for that patient, he says. The more risk factors a patient has, the less likely that outpatient surgery is the right choice.
Success key No. 3: Educate, educate, educate
Pilot projects at Stanford and other bariatric programs have shown that the level of patient education about bariatric surgery and postop requirements has a significant effect on readmissions. Key points to emphasize are the need to ensure that the patient stays hydrated, knows the right and wrong foods to eat, and avoids advancing the diet too quickly.
Stanford and other healthcare institutions have standardized their preop education, creating a video that provides consistent messaging. The video includes presentations from a range of disciplines, including nutrition, psychology, and pharmacy. Patients can watch it repeatedly, which Morton says is important not only for the reinforcement but also because patients may be distracted or stressed the first time they watch.
"We give that education when they are an inpatient, and give them a phone call the day after discharge to remind them and answer any questions," he says. "Part of that education process includes discussing their medications and how those may change after surgery."
Realizing that postop education and monitoring was critical to avoiding readmissions, Stanford made the postop phone call more than just a cursory "How are you doing?" Instead, Stanford budgeted nursing time for the calls and set expectations for what information was to be conveyed and collected.
"They're not doing it here and there, between things," Morton explains. "They have dedicated, focused time for doing this because we feel it is that important."
Joanne Prentice, RN, BSN
Stanford also sends a letter to the patient's primary care physician after surgery, discussing the patient's postop plan. Morton's team at Stanford found that dietary compliance could be improved, so in addition to pre- and postop education, now the patient also meets with a nutritionist at the two-week follow-up visit."One year we had nine readmissions related to diet, and following the implementation of the nutritionist visit it went to zero," he says. "It had real impact for our practice."
Success key No. 4: Engage pharmacists more
Research has shown that improved coordination with pharmacists—both preop and postop—will lower readmission rates in bariatric surgery, Morton says. About 90% of bariatric procedures in the United States are performed in hospitals accredited through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program from the American College of Surgeons and the ASMBS, and a hallmark of that program is multidisciplinary care that can include psychologists, nutritionists, and pharmacists.
"Medication reconciliation is particularly important for the bariatric patient because so many of them come in with multiple medical problems and multiple medications," Morton says. "The nice thing is that after surgery they're able to discontinue a lot of those medications, but it has to be done in a controlled, systematic way. That's where the pharmacist can really help out."
If the medications are not tapered properly, even a patient who won't need them after surgery can suffer an artificial drop in blood pressure or sugar levels to the point that they require hospitalization, he explains.
At MetroWest Medical Center, which comprises two hospitals and a network of supplementary service centers throughout Boston's western suburbs, when a new bariatric surgery director joined MetroWest Medical Center in Natick, Massachusetts, in 2014, the hospital used that opportunity to improve the bariatric program, notes that program's coordinator, Joanne Prentice, RN, BSN, CBN, CAPA. She met with the bariatric surgery head and discussed the importance of managing medications for comorbidities and pain.
"He asked that I take a detailed list of medications, including information like whether it was coated or long-acting pills, what form the patient was used to," she explains. "We want to be able to manage their comorbidities and not disrupt that ongoing care, but also to provide the pain medications our patients will need. That list is evaluated preop and provided to the hospital staff so that we know what to discharge the patient with."
MetroWest also determined that its bariatric patients' pain management was a leading cause of readmissions. In 2014, MetroWest implemented an initiative designed to make it easier for patients to comply with their discharge instructions regarding all medications.
"All medications, instead of being in pill form, are now in crushed, liquid, or chewable form for the first two or three months postop," Prentice explains. "We realized that patients were having a difficult time with the pills, with swallowing or with the medication upsetting their stomach, and so they weren't taking the pain medications the way they needed to. The resulting pain sometimes led to readmission." The improved partnership with the pharmacy is a primary reason that the readmission rate at MetroWest is low, she says, with no readmissions in the past 16 months.
Stanford also makes sure that the patient's postop medications are available in the clinic at the time of discharge. That helps ensure the patient begins the medications without any delay from going to a pharmacy.
Success key No. 5: Address hydration effectively
When the Stanford team analyzed its data on readmission rates to find the causes, hydration issues emerged as a leading factor: Patients would become dehydrated after surgery and that would lead to other complications and hospitalization. MetroWest came to the same realization, and now both organizations put more emphasis on hydration during patient education. At both facilities, patients are presented with branded water bottles and taught to carry them at all times.
That effort was to prevent dehydration, but Morton and his team also thought there was a better way to treat it.
"If you just bring them into a clinic or an infusion center, they can be hydrated and sent on their way. They don't require full admission," Morton says. "We make every effort to treat them outside the hospital if they just need hydration, but to do that we have to detect it before the dehydration causes other problems."
The nurse's phone call after surgery addresses hydration specifically, urging patients to drink water and educating them on how to recognize dehydration so that it can be treated promptly.
MetroWest also instituted a plan for hydrating postop patients in its outpatient clinics before they got to the point of needing hospitalization.
"The hydration effort is a good example of how you lower readmissions by looking for those problems that just get worse and cause the patient to spiral down until hospitalization is the only choice," Prentice says. "Patients will have some issues like that after surgery, but the key is to identify them and respond before it gets out of control."
In cases of accountable justification and peer comparison, study participants were less likely to prescribe antibiotics against guideline recommendations. From MedPage Today.
Having to justify an antibiotics prescription for acute respiratory tract infections, or being compared with their peers for number of scripts written, lowered rates of inappropriate antibiotic prescribing practices for up to 18 months among primary care physicians, researchers reported.
After receiving an educational intervention, primary care clinicians were randomized to intervention groups: In the electronic health records (EHR) system, they either received a suggestion prompt for a non-antibiotic (suggested alternatives), a justification prompt (accountable justification), or received emails showing how they ranked against their colleagues (peer comparison).
In the cases of accountable justification and peer comparison, study participants were less likely to prescribe antibiotics against guideline recommendations, wrote Jason N. Doctor, PhD, of the University of Southern California in Los Angeles, and colleagues in the Journal of the American Medical Association.
The mean antibiotic prescribing rates decreased as follows:
24.1% at the start of the intervention to 13.1% at month 18 (absolute difference −11.0%) for control practices
22.1% to 6.1% (absolute difference −16.0%) for suggested alternatives (difference in differences −5.0%, 95% CI −7.8% to 0.1%. P=0.66 for differences in trajectories)
23.2% to 5.2% (absolute difference −18.1%) for accountable justification (difference in differences −7.0, 95% CI −9.1% to −2.9%, P<0.001)
19.9% to 3.7% (absolute difference −16.3%) for peer comparison (difference in differences −5.2%, 95%CI −6.9% to −1.6%, P<0.001)
In an accompanying editorial, Jeffrey S. Gerber, MD, PhD, of The Children's Hospital of Philadelphia, noted that "even though the relative reductions in inappropriate prescribing rates were modest, they are real, important, and potentially sustainable."
"Even when an antibiotic is indicated, often the wrong one is chosen: roughly half of antibiotics for children are broad- spectrum, second-line agents, and the most commonly prescribed antibiotic for adults is azithromycin, despite this drug being recommended as the first-line choice for relatively few conditions" he stated.
Gerber called the results from these "simple interventions" promising. "Most importantly, this approach should easily translate across a variety of electronic health record platforms and might serve as the foundation of outpatient antimicrobial stewardship," he said.
Doctor's group randomized 47 primary care practices in Boston and Los Angeles, where, over the course of 18 months, 248 clinicians received one of three interventions, or none at all.
Upon enrollment, each of the clinicians was educated on guideline-concordant antibiotic prescribing for acute respiratory tract infections, nonspecific upper-respiratory infections, acute bronchitis, and influenza. The practices were compensated for physician participation.
Reference prescribing rates were taken from 14,753 patient visits during the 18 months prior to intervention, and compared with the antibiotic prescribing rates for 16,959 visits during the 18 months after interventions were implemented. Patients who had comorbid conditions or other infections were excluded.
The three interventions were:
In the EHR, an electronic order was set to suggest non-antibiotic treatments
In the EHR, an electronic order prompted clinicians to enter free-text explaining why they prescribed the antibiotics
Emails were sent to clinicians comparing his or her antibiotic prescribing rates with those of "top performers," a designation given to clinicians with the lowest inappropriate prescribing rates
Doctor and colleagues noted that peer comparison was different from traditional "audit-and-feedback interventions" because clinicians had their prescribing habits ranked against top-performing peers instead of average-performing peers.
While the two "socially motivated interventions" led to statistically significant reductions in inappropriate antibiotic prescribing, the one that lacks a social component (suggested alternatives) had no statistically significant effect, the authors noted.
"There were no statistically significant interactions between interventions; therefore, applying these interventions simultaneously might have additive effects on antibiotic prescribing," they pointed out.
However, return visits for possible bacterial infections within 30 days following visits for acute respiratory tract infection where antibiotic were not prescribed were significantly higher in the accountable justification plus peer comparison group (1.41%, 95% CI 1.06%-1.85%) versus control practices (0.43%, 95% CI 0.25%-0.70%). This held true in "both antibiotic-inappropriate and potentially antibiotic-appropriate" cases, the authors stated.
"No other intervention group (including the group applying all 3 interventions simultaneously) had a statistically significantly higher rate of such return visits," they wrote.
Study limitations included small cluster sizes and the fact that results were dependent on EHR and billing data. Gerber pointed out that clinicians were compensated $1,200 each for participation, "which might have influenced the buy-in of study participants and also potentially limits generalizability."
They have notoriously bad handwriting but their signatures are priceless. Especially in South Florida's Medicare rackets. Three Miami physicians have been charged in recent months with signing prescriptions for costly home healthcare services that federal prosecutors say were not needed or provided. They're accused of receiving kickbacks of $150 a patient on average in exchange for referrals to numerous Miami-Dade healthcare agencies that filed tens of millions of dollars in false claims with the taxpayer-funded Medicare program. Medicare, which still struggles with lax oversight after years of losing billions of dollars to fraud, routinely paid the bogus bills because of the physicians' signatures.