Crowdsourced ratings such as Facebook reviews reflect patient experience better than clinical quality, and hospitals can push back.
Crowdsourced ratings of the "best overall" hospitals produce scores similar to Hospital Compare's ratings, but crowdsourced ratings are less reliable as indicators of clinical quality and patient safety, recent research shows.
The research, which was published in the journal Health Services Research, examined hospital ratings on Facebook, Google Reviews, and Yelp. The findings show crowdsourced ratings reflect patient experience rather than other factors.
"For the most part, what we found is that the social media scores tell us about patient experience, but they don't tell us about the best and worst hospitals on the basis of clinical quality or patient safety," the lead author of the research, Victoria Perez, PhD, told HealthLeaders last week.
The study has significant implications for how patients should view crowdsource ratings, said Perez, who is an assistant professor at Indiana University in Bloomington. "We wish that people would understand that even if hospitals are not scoring well on Facebook in user reviews, they could have excellent clinical scores."
Addressing bad reviews
If a hospital has generated negative reviews on a crowdsourcing site, there are ways to counteract the negative publicity, Perez said. "Hospitals can advertise that they score well on Hospital Compare and establish marketing strategies to respond to social media scores."
Hospital leaders also need to be aware that crowdsourcing scores are based largely on patient experience, she said.
"If hospitals are worried that patients are just looking at social media scores, they need to realize the scores reflect patient experience rather than clinical quality and patient safety. Other than advertising they don't have a lot of control over this. The options are marketing and engaging on the social media platform."
There are ways to shift the online focus of patients toward clinical quality and patient safety, Perez said.
"Hospitals can share Hospital Compare clinical quality and patient safety scores on their homepage, on their Facebook page, and on Twitter. Many hospitals have a social media presence, so they can definitely share clinical quality and patient safety information, and they can encourage patients to look at Hospital Compare."
Research findings
The research, which examined data from nearly 3,000 acute care hospitals, has several key findings:
For best-ranked hospitals on the crowdsourcing sites, 50% to 60% were ranked best in Hospital Compare's overall rating.
For best-ranked hospitals on the crowdsourcing sites, 20% ranked worst in Hospital Compares overall rating.
For clinical quality and patient safety, hospitals ranked best on crowdsourced sites were only ranked best on Hospital Compare about 30% of the time.
Perez said Hospital Compare, which combines as many as 57 metrics for patient experience and clinical quality, was used to gauge the accuracy of the crowdsourcing sites for several reasons.
"The clinical quality and patient safety measures are based on Medicare claims data, which means there is a lot of information about patients and they can do risk adjustment," she said of Hospital Compare.
Risk adjustment is crucial when comparing hospitals, Perez said. "Rather than being concerned that some hospitals are treating a sicker pool of patients and have worse outcomes as a result, the Hospital Compare data can be adjusted for the health of the patient mix."
The crowdsourcing sites are more prone to bias, she said. "A concern when you look at social media is that people only write reviews when they have really good or really bad patient outcomes."
As opposed to the general-purpose house call of the past, contemporary house calls can generate targeted benefits such as hospital readmission reductions.
Opportunity is knocking for physicians willing to make house calls.
Carefully targeted house calls can reduce patient anxiety, decrease hospital readmissions, improve patient safety, and increase physician familiarity with patients, says William Frishman, MD, of New York Medical College and Westchester Medical Center in Valhalla, New York.
"People spend more time at home than they do in a hospital or a clinic. You really have to see what their living conditions are like. It helps with the long-term care of the patient," Frishman says.
"When heart attack patients go home from the hospital, they are scared stiff. The husband or the wife doesn't know how to handle it. Having a doctor come to the home is extremely reassuring," he says.
Beyond reducing patient and caregiver anxiety, research published by The Journal of Thoracic and Cardiovascular Surgery has shown that house calls can effectively reduce 30-day hospital readmissions for cardiac surgery patients.
The research found that a physician assistant home care program including house calls reduced the 30-day readmission rate by 25%. The most common house call intervention was medication adjustment.
Another study found that house calls are a crucial component of managing care and boosting care quality for geriatric patients who are homebound.
Assessing patient safety should be a primary house call objective for physicians and nurses, Frishman says.
"Older patients in the home should not have to bend down to get something. They should not have to get up on a stool to get a dish. Everything should be at a level where the patient does not have to go up or bend over."
Physicians can learn essential information about their patients during house calls, he says.
"Unless you have a sense of what is happening in the home, you are missing something in your relationships with patients. … When I see them in the office later, I know the patients better. House calls give you another look at how the patients are doing."
Patient selection
Physicians need to make judgment calls when deciding which patients are most appropriate for house calls, Frishman says.
"If someone is having chest pain, you wouldn't make a house call. You would tell them to get to an emergency room. The traditional house calls from 50 years ago are different from house calls today. Part of today's house call is finding ways to keep people from coming back to the hospital."
Selecting patients for house calls must be an individualized process, he says.
"There is not the universal, middle ground patient. Even in the middle ground, there are some patients you will send to the hospital and others you can wait to see until the next day. It relates to your experience with the patient and your judgment. For new patients, I generally would not go to the house. I would tell them to come to the office or to the hospital."
Post-heart attack visit: For patients who have had their first heart attack, Frishman makes a house call about a week after hospital discharge. In addition to addressing patient and caregiver anxiety, these visits focus on medication reviews, care-related questions, and a walk with the patient.
Post-heart failure visit: After hospitalization for heart failure with or without a heart attack, Frishman's house calls focus on medications, diet, and body weight. As is the case with heart attacks, he takes a walk with the patient.
Geriatric visit: For new geriatric patients, Frishman makes house calls for homebound people. The primary goals of these visits include assessing fall risks and getting to know the patients more completely through observations in the home setting.
Post-funeral visit: After a patient's death, Frishman makes a house call to the family a few days later to help avoid years of psychopathology among the survivors. The primary objective of these visits is to reassure family members that they are not to blame for the loss of their loved one.
Electronic health records contribute to physician burnout and writing shorter case notes can ease the EHR burden.
Electronic health records (EHRs) have become a primary driver of physician burnout, a recent research article says.
Earlier research found physician burnout rose from 45.5% of doctors in 2011 to 54.4% in 2014. The time period corresponds with the introduction of mandatory use of EHRs.
The recent research article, which was published in The American Journal of Medicine, says EHRs contribute to all three elements of physician burnout—lack of enthusiasm, lack of accomplishment, and cynicism.
"The hours spent cloning notes in a mandated doctor-computer relationship leaves the physician unable to experience the best part of being a doctor. No humanistic physician gets up with zeal in the morning, hopeful for a chance to have a meaningful relationship with Epic or MEDITECH. Rational people should feel cynical if the institutional accomplishment for the day is to produce 20 cloned medical records," the researchers wrote.
Less is more
Writing shorter case notes is one of the key strategies to address EHR-related physician burnout, the researchers say.
Earlier research found that primary care physicians spend more time interfacing with EHRs than working with their patients. "Primary care physicians spend more than one-half of their workday, nearly six hours, interacting with the EHR during and after clinic hours."
Case notes can be shorter without compromising the quality of the information, the lead author of The American Journal of Medicine article told HealthLeaders this week.
"Shorter notes do not imply incomplete or partial notes," said Andrew Alexander, MD, associate dean at the University of California's Riverside School of Medicine in Riverside, California.
He said there are several best practices for taking shorter case notes:
The physician should record the patient's presenting complaint and all pertinent data that helps the doctor formulate the differential diagnosis (DDx) and a plan for concluding the visit.
Pertinent data can include testing, consultation, procedures, or medications.
Further documentation can degrade the quality of care because the doctor must attend to the computer keyboard and occupy the record with templated data that confound and camouflage the key patient care issues the next time a doctor sees the chart or the patient.
Take notes as the questions are being asked and look at the patient while inputting information into the EHR.
Use a basic template that auto-populates medications, vital signs, and simple exams.
Have separate templates for children and gynecological exams.
When formulating assessments or diagnoses, omit templates and hand-enter problems or assessments with alternative diagnoses. Physicians should include why preferred and alternative diagnoses are possible, which will help explain diagnosis reasoning in future viewings of the record.
The main pitfall of shorter notes is omitting the creation and chart entry of a differential diagnosis when there is uncertainty about a patient's diagnosis, Alexander said.
"Failure to create a DDx would force the physician to review the lab results, which arrive days later, without context. An on-call partner or a consultant might see the patient and repeat all testing and X-rays as they attempt to replicate the same logical clinical inquiry that you failed to document," he said.
San Diego's healthcare collaborative cut acute myocardial infarction hospitalizations through clinical care improvement and increased engagement with patients and community organizations.
A healthcare collaborative in San Diego achieved a 22% reduction in heart attack hospitalization rates compared to an 8% reduction in the rest of California, research published this week says.
The collaborative—Be There San Diego—launched in 2011. The 22% reduction in heart attack hospitalization rates was attained from 2011 to 2014, avoiding about 3,800 hospitalizations and attaining an estimated $86 million in savings.
The collaborative was designed to decrease cardiovascular events through spreading best practices for better control of hypertension, lipid levels, and blood sugar. Be There San Diego (BTSD) also sought to increase engagement with patients and community organizations.
The researchers, who published their study in Health Affairs, say the BTSD model can be recreated across the country.
"Although this type of collaborative might be more challenging to execute in geographic areas that have larger populations or are more spread out—with a greater number of healthcare systems—than is the case in San Diego County, the basic organization and implementation of BTSD should be generally applicable elsewhere," they wrote.
Clinical care
BTSD features physician groups, health plans, federally qualified health centers, and health systems that provide care for two-thirds of San Diego County's 3.3 million residents.
The clinical care efforts of the collaborative are focused on identifying and modifying risk factors, improving quality of care, and implementing best practices:
Use of a simplified hypertension treatment to improve management of hypertension, lipid levels, and blood sugar
Adoption of a medication bundle to boost medication adherence and reduce cardiovascular events among patients at high risk of heart attack
Expansion of health-coach services
Holding monthly meetings to share best practices among clinicians and community organizations, including the review of key clinical metrics
Sharing information through the Data for Quality project, which gives healthcare organizations the ability to share aggregated quality metric data confidentially
Patient engagement
Health coaches are playing a key role in BTSD's patient engagement efforts, particularly in increasing the use of medications for hypertension and hypercholesteremia.
The health coaches, who are deployed by healthcare organizations and trained by BTSD, engage patients with monthly phone calls to lower barriers to medication adherence and increase goal achievement.
Community engagement
BTSD has established a faith-based partnership with African American churches in Southeastern San Diego, which is one of the county's most socioeconomically disadvantaged communities. The partnership is designed to serve as a "cardiovascular learning community," the Health Affairs researchers wrote.
"This learning community consists of faith leaders who meet to discuss efforts to improve their congregants' cardiovascular health through changes such as improved organizational nutrition policies, promoting healthy behaviors through walking clubs and other organized activities, and linking congregants who have high blood pressure to clinical care."
Breast cancer survivors with lymphedema face high long-term costs, and there are several strategies for healthcare providers to help.
Many breast cancer survivors carry a crushing economic burden long after their initial treatment, new research shows.
Costs associated with ongoing care are particularly heavy for breast cancer survivors with lymphedema, the researchers wrote this month in the journal Supportive Care in Cancer.
"Interviews suggested that the cascading nature of economic burden on long-term savings and work opportunities—and insufficiency of insurance to cover lymphedema-related needs—drove cost differences. Higher costs delayed retirement, reduced employment, and increased inability to access lymphedema care."
The research featured a mixed-methods study of 129 breast cancer survivors from New Jersey and Pennsylvania.
Excluding productivity losses, annual out-of-pocket costs for breast cancer survivors with lymphedema totaled $2,306 compared to $1,090 for patients without lymphedema. When productivity losses were included, annual out-of-pocket costs for patients with lymphedema totaled $3,325 compared to $2,792 for patients without lymphedema.
The ongoing cost of care resulted in many patients foregoing treatment such as compression garments, the researchers wrote. "When patients could not cover their costs, family members or social service organizations were sometimes able to help, but often patients simply went without the care they needed."
Easing the burden
Earlier research and policy statements give guidance on how healthcare providers can help breast cancer patients manage and reduce treatment costs.
A recentstudy published in the Journal of the National Cancer Institute suggests three ways that healthcare providers can help cancer patients with the cost of care:
Oncologists should make sure they recommend care that has maximal value as opposed to interventions with low benefits and high costs.
Oncologists should initiate conversations about cost. These discussions can help direct patients to financial resources and give physicians opportunities to advocate for patients with insurance companies.
Oncologists should be prepared to help patients deal with financial costs. This preparation includes gaining familiarity with cost issues such as using the American Society of Clinical Oncology Value Framework. Physicians should also enlist other members of their care team such as pharmacists who can help patients address cost challenges.
There are several other recommendations for healthcare providers to help cancer patients who struggle with the cost of care:
A recent study in the Journal of Cancer Research and Clinical Oncology says that physicians can improve health outcomes and reduce financial burdens by encouraging patients to modify health-related factors such as sedentary lifestyles.
A policy statementfrom the American Society of Clinical Oncology makes multiple suggestions to ease the financial burden on patients such as tackling obesity, providing evidence-based care, optimizing cancer prevention techniques, and including patients in all decision making.
To gauge readmission risk for patients with acute myocardial infarction, clinicians can easily assess seven variables during the first day of a hospital admission.
A new risk model provides a simple and inexpensive way to determine whether acute myocardial infarction patients are at high risk for hospital readmission.
Research published by the Healthcare Cost and Utilization Project shows that about 1 in 6 AMI patients are readmitted to a hospital within 30 days of discharge, with annual healthcare costs estimated at $1 billion.
Targeting AMI patients who are at high-risk of readmission also helps hospitals avoid financial penalties under the federal Hospital Readmissions Reduction Program and promotes cost-effective interventions, the JAHA researchers wrote.
"Although federal readmission penalties have incentivized readmissions reduction intervention strategies (known as transitional care interventions), these interventions are resource intensive, are most effective when implemented well before discharge, and have been only modestly successful when applied indiscriminately to all inpatients."
The risk model, which is detailed in a recent study published in the Journal of the American Heart Association (JAHA), features seven variables that can be scored in as little as five minutes during a patient's first day of hospital admission.
With a simple calculation at the bedside or in an electronic health record, physicians can determine whether a heart attack patient is at high risk for readmission and order interventions that can help patients avoid a return to the hospital after discharge.
"The acute myocardial infarction READMITS score (renal function, elevated brain natriuretic peptide, age, diabetes mellitus, nonmale sex, intervention with timely percutaneous coronary intervention, and low systolic blood pressure) is the best at identifying patients at high risk for 30‐day hospital readmission; is easy to implement in clinical settings; and provides actionable data in real time," the researchers wrote.
The AMI READMITS risk model is superior to other models, they wrote. "The few currently available AMI readmission risk prediction models have poor-to-modest predictive ability and are not readily actionable in real time."
Key findings
The JAHA research, which examined health outcomes for 826 AMI patients at six hospitals in North Texas, has several key findings:
The AMI READMITS score accurately predicts which heart attack patients are at high risk or low risk of readmission. In the JAHA research, about one third of AMI patients that were deemed at high risk through the AMI READMITS score had a 30-day readmission. Only 2% of patients considered at low risk experienced a readmission.
The AMI READMITS score can accurately predict readmission risk during the first 24 hours of a hospital inpatient admission, which gives clinicians the ability to make timely interventions.
Clinical severity metrics such as shock, heart strain or failure, and renal dysfunction as well as timely percutaneous coronary intervention were strongly associated with readmission risk.
Why this model matters
Assessing the readmission risk of AMI patients during the first day of hospital admission is crucial, says Oahn Nguyen, MD, MAS, the lead author of the JAHA research and an assistant professor at UT Southwestern Medical Center in Dallas.
"[The model] gives you more time to intervene and try to prevent someone from having to come back to the hospital. It gives you more time to optimize someone's path to recovery," she told HealthLeaders.
She said development of the AMI READMITS risk model is the first step toward significantly reducing readmissions for AMI patients. "Studies of interventions to reduce readmissions for other conditions suggest that the earlier you can intervene the better. One caveat is those interventions have yet to be assessed in acute myocardial infarction."
The current primary strategy to prevent readmissions for heart attack patients is transitional care intervention, and the AMI READMITS score helps physicians target patients for this intervention, she said.
"Transitional care intervention is a bundle of care to promote a safe transition from hospital to home. One way I like to think of it is deploying a medical SWAT team in the hospital to make sure that everything you can do for a patient is being done to ensure the transition from the hospital to the community is as smooth as possible," Nguyen said.
A "SWAT team" approach to care is often costly, so the capability of the AMI READMITS score to target patients who are at high risk of readmission improves the cost-effectiveness of care.
There are several primary elements to transitional care intervention:
Medication counseling to make sure AMI patients know how to take them
Making sure patients get their medications when they leave the hospital
Connecting patients with the most appropriate outpatient care such as setting up clinic appointments
Conducting phone calls to the homes of patients to check on their health status after discharge
Major strengths of the AMI READMITS score include the risk model's simplicity and low cost, she said.
"Our goal in creating this model was creating something that was simple and pragmatic; so, it's parsimonious because there are only seven variables that go into it. The seven variables are also information that is commonly and routinely collected during most hospitalizations."
The AMI READMITS risk model does not require sophisticated support systems, Nguyen said.
"In an age when there is a lot of hype about machine learning and big data, we were able to distill the big data of an electronic health record down to small, simple, parsimonious data that is easily applied at the bedside by clinicians," she said.
Expense is minimal for the AMI READMITS risk model.
"It's low cost because a clinician could look at our [research], then see how many of the seven factors a patient has in the hospital. You can literally spend less than five minutes summing up the points in the model scale, add them up, and determine whether a patient is at high risk or not. It does not take a fancy new IT infrastructure to implement," Nguyen said.
Despite recommendations against screening low-risk patients for ovarian cancer, personal experiences with cancer can prompt physicians to act outside the guidelines.
Physicians who have had personal experiences with cancer have a higher likelihood than their peers of ordering ovarian cancer screening against established recommendations, new research says.
Unrecommended screening exposes patients to risks of harm associated with testing procedures as well as surgery following a false positive test, according to the research, which was published this month in the Journal of Women's Health.
The lead author of the research, Margaret Ragland, MD, MS, of the University of Colorado Hospital in Aurora, says physicians who have had cancer themselves or in their social circles are biased toward ordering too many preventative cancer services.
"My hypothesis is that a doctor's personal experience may influence their assessment of risk. You see a patient in front of you and you may assess the risk to be higher than it actually is," she said in a prepared statement.
Ordering ovarian cancer screening outside established guidelines is problematic, according to the U.S. Preventative Services Task Force:
USPSTF has given routine ovarian cancer screening a "D" grade—a designation for medical services deemed ineffective or unlikely to generate benefits that outweigh potential harms.
The tests for ovarian cancer—transvaginal ultrasound and cancer antigen 125—have low positive predictive value and high false positive rates.
There is scant evidence that screening improves morbidity or mortality.
Screening for ovarian cancer is not recommended for women at low risk or the general population of women.
Earlier research found significant risks of patient harm associated with ovarian cancer screening such as bleeding, fainting, nausea, and bruising. This research also found that 5% of women screened for ovarian cancer experienced false positive tests, which resulted in unnecessary major surgery for many patients.
Other earlier research questioned the cost of ovarian cancer screening because the low prevalence of ovarian cancer in the general population of women limits the cost-effectiveness of routine testing.
Bias found
The Journal of Women's Health research features survey data collected from 504 physicians. The survey included a vignette of a woman at average risk of ovarian cancer.
In an unadjusted analysis, 86.0% of physicians who lacked personal experience with cancer reported following ovarian cancer screening guidelines. Among physicians who had personal experience with cancer, 69.2% reported following the screening guidelines.
After adjusting the data for factors including patient age, race,
insurance status, and requests for ovarian cancer screening, physicians who had personal experience with cancer were 0.82 times more likely to order testing outside recommended guidelines.
Raising awareness of the potential for bias in ovarian cancer screening is the primary recommendation of the Journal of Women's Health researchers.
"Results from this study can increase physician awareness of and improve training about factors that may unintentionally influence their clinical practices," the researchers wrote.
New research sheds light on the characteristics of patients who are placed in physical restraint while receiving emergency room care.
Most patients restrained in emergency departments fall into two categories—a relatively young and predominantly male group presenting with alcohol or drug use, and an older group with medical complaints, recent research shows.
"Our data found strong association of alcohol or drug use with physical restraints and identified a unique elderly population with behavioral disturbances in the ED," the researchers wrote this month in Annals of Emergency Medicine.
Knowing which agitated patients in the ED could require restraint is valuable information because of a steadily growing number of behavioral emergencies and grave risks associated with restraint.
Behavioral emergencies in EDs have skyrocketed in recent years, with national estimates of a 50% increase in ED visits for behavioral disorders between 2006 and 2011 compared with an 8.6% increase in the total number visits. Agitation is often associated with behavioral ED visits, with 1.7 million events occurring annually.
Although the use of patient restraint is common in the ED setting, negative health outcomes and potential liability can be severe.
"Adverse events have been cited in the restraint process, including blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest. In addition, a survey of ED patients found that 66% reported experiencing severe psychological distress and lasting consequences in regard to care-seeking behavior after physical restraint," the Annals of Emergency Medicine researchers wrote.
Restraint patients
The researchers conducted the first large-scale study to characterize the kinds of patients who are restrained in the ED setting. Their study features 3,739 patients who were restrained in the emergency rooms of five hospitals.
For the vast majority of patients in the study, the researchers found there were two groupings of restrained patients with significantly different characteristics:
The larger grouping accounted for two-thirds of restrained patients, with a median age of 39. The smaller grouping of restrained patients had a median age of 64.
About 70% of the larger grouping were men, compared to about 60% male sex in the small grouping.
About 30% of patients in the larger grouping were black, compared to 20% in the smaller grouping.
About 60% of patients in the larger grouping had Medicaid coverage, and about 49% in the smaller grouping had Medicare coverage.
Homelessness was much higher in the larger grouping at 8.9%, compared to 0.9% in the smaller grouping.
Chief complaints varied widely between the two patient categories, with about 50% of the larger grouping complaining of drug or alcohol use and about 80% of the smaller grouping presenting with medical complaints.
The researchers say ED staff should take a cautious approach when deciding whether to restrain both kinds of patients.
An earlier study showed ED staff had strong sentiments of frustration and resentment toward patients with alcohol or drug use, psychiatric illness, homelessness, and frequent ED visits—all qualities associated with the larger grouping of patients in the Annals of Emergency Medicine research.
"These negative sentiments highlight a potential pitfall for implicit bias and stigmatization by ED health workers of an already marginalized population because of their underlying health conditions," the researchers wrote.
The researchers say there is significant risk associated with restraining older adults.
"Two previous retrospective studies of elderly ED patients with behavioral emergencies reported significant rates of cognitive impairment and multiple comorbidities that may be affected by sedation and restraint use," the researchers wrote.
Best practices
The Joint Commission has 10 primary standards for restraint and seclusion of patients:
Restraint and seclusion should be used only when clinically justified or when patient behavior poses a physical danger to the patient or others.
Patient restraint or seclusion should be implemented safely based on hospital policy as well as laws and regulations.
Restraint or seclusion should be based on an individual order for specific patients, not standing orders. If the attending physician did not make the restraint or seclusion order, he or she should be consulted as soon as possible.
Medical staff should monitor restrained or secluded patients.
Hospitals should have written guidelines for restraint and seclusion.
Patients who are restrained or secluded should be evaluated repeatedly.
Patients who are both restrained and secluded should be monitored continually.
Use of restraint or seclusion should be documented.
Staff should be trained in the safe use of restraint and seclusion.
Deaths linked to restraint or seclusion should be reported to the Centers for Medicare & Medicaid Services.
After careful screening of patients in the emergency department, outpatient management of blood clots is less costly and more convenient for patients compared to inpatient care.
Acute pulmonary embolism patients deemed at low-risk for adverse events can be treated safely at home after receiving therapy in an emergency room, recent research indicates.
Acute PE is the third top cause of cardiovascular death, and inpatient treatment has been the historical standard of care for patients. However, a study in CHEST featuring 200 acute PE patients found they could be treated safely at home with outpatient management and anticoagulant medication.
The study's lead author, Joseph Bledsoe, MD, of Stanford University and Intermountain Medical Center, told HealthLeaders this week that home therapy is less costly and more convenient for patients.
"Home-based treatment is really about patient convenience and patient cost savings. Patients are able to sleep in their own beds, spend time with their families, eat their own food, and go to work. By not missing work, they don't have loss of income; and by avoiding the hospitalization, they avoid the associated bills," Bledsoe said.
Treatment at home also avoids risks associated with inpatient care, he said. "Medical errors and hospital acquired infections are an unfortunate complication of hospital admission that can be avoided by home treatment."
Bledsoe and his colleagues, who included researchers from the University of Utah, say their study's 200-patient sample size is small but significant because patients were drawn from five diverse hospitals. "Enrollment of patients from a large tertiary referral hospital and four suburban community hospitals suggests generalizability of our results," they wrote.
Screening patients
Thorough assessments of acute PE patients in the ER are crucial to determine which patients are safe to send home, Bledsoe said.
"PE can be safely treated at home for patients who have been appropriately risk stratified. Using mortality-risk prediction scores, echocardiograms, whole leg ultrasound, cardiac monitoring, and other risk stratification is important to ensure patients will be safely treated at home and minimize the risk of a complication."
Earlier research supports the safety of sending carefully screened acute PE patients home after treatment at an ER, the CHEST study says. "Retrospective analysis has suggested a low PE mortality rate among select patients with PE treated on an outpatient basis, and patients with PE with a good prognosis are unlikely to benefit from inpatient care."
Treating patients
Acute PE patients who participated in the home care study received standardized care.
Patients were observed for 12 to 24 hours either in an ER bed or a hospital bed under outpatient observation status
They underwent transthoracic echocardiography and compression ultrasound of both legs as well as compression ultrasound of symptomatic arms
Treatment featured therapeutic anticoagulation with medications such as enoxaparin and rivaroxaban
A physician specializing in thrombosis care consulted with each patient while they were under observation
Outpatient follow-up with a thrombosis physician or the patient's primary care physician was set up before patients were discharged
Follow-up appointments and patient education are key factors to ensure safety, Bledsoe said.
"Educating patients about their diagnosis and treatment, including the possible bleeding risks of treatment, as well as timely outpatient follow-up are important to ensure patient safety. Home treatment of PE is not as simple as identifying the disease, treating, and sending patients home. It takes a thoughtful approach and robust communication with patients."
The disparity between rural and urban cancer patients is best explained by differences in access to care, not demographics or lifestyle factors, recent research suggests.
Rural cancer patients generally have worse outcomes than their urban counterparts, and physician leaders seeking to address the disparity should boost access to care rather than focusing on other factors.
A study published this month in JAMA Open Network found similar outcomes between rural and urban patients enrolled in clinical trials, which suggests lack of access to high-quality care in rural areas is the reason for the outcome disparity.
"If rural and urban patients with cancer receiving similar care also have similar outcomes, then a reasonable inference is that the best means by which to improve outcomes for rural patients with cancer may be to improve their access to quality care," the researchers wrote.
The research examined mortality outcomes in 17 groupings of rural and urban cancer patients enrolled in clinical trials. Mortality outcomes between the patients only varied in one grouping, with rural patients experiencing higher mortality for adjuvant-stage estrogen receptor–negative and progesterone receptor–negative breast cancer.
The research featured nearly 37,000 patients from across the country enrolled in clinical trials over a 26-year period. Closely reflecting national demographics, 19.4% of the patients were from rural areas.
Clinical trials were the focal point of the research because they generally provide consistent high-quality care.
"Patients receiving care in this setting are uniformly staged, treated, and followed up under protocol-specific guidelines, reducing the potential influences of inconsistent pretreatment evaluation, care, and post-treatment surveillance," the researchers wrote.
Earlier research demonstrated a significant level of disparity in cancer mortality rates between rural and urban areas, with 180.4 cancer deaths per 100,000 people in rural areas compared to 157.8 cancer deaths per 100,000 in urban areas.
Closing the gap
The JAMA Open Network researchers made five recommendations for physician leaders and healthcare organizations to address the disparity in cancer treatment outcomes between rural and urban patients:
Improve access to affordable health insurance
Expand access to screening and prevention tools
Boost access to oncology specialists
Increase transportation resources for rural patients who travel long distances to access quality care
Adopt innovation care networks to give rural patients access to new treatments and clinical trials
The researchers say two network models for oncology care—one in the United States and another in Australia—could help address the rural-urban cancer care disparity in this country:
Australia's Regional Cancer Centers of Excellence are designed to offer multidisciplinary care, boost support services, and increase clinical trial participation. This program has improved access to care, with increased treatment of rural patients in their communities.
