Author Interviews, Brigham & Women's - Harvard, Cost of Health Care, JAMA, Outcomes & Safety / 10.10.2016
Study Evaluates Hospital-at-Home For Low Risk Medical Conditions
MedicalResearch.com Interview with:
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Dr. Jared Conley[/caption]
Jared Conley, MD, PhD, MPH
Department of Emergency Medicine
Massachusetts General Hospital
Harvard Medical School
Boston, MA 02114
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: As the U.S. healthcare system seeks to improve the health of populations and individual patients, there is increasing interest to better align healthcare needs of patients with the most appropriate setting of care—particularly as it relates to hospital-based care (accounting for 1/3 of total U.S. healthcare costs).
Avoiding hospitalization—as long as safety and quality are not compromised—is often preferred by patients and the added benefit of potentially making care more affordable further promotes such care redesign efforts. There is a growing body of research studying alternative management strategies to hospitalization; we sought to comprehensively review and analyze this work. Alternative management strategies reviewed include outpatient management, quick diagnostic units, observation units, and hospital-at-home.
Dr. Jared Conley[/caption]
Jared Conley, MD, PhD, MPH
Department of Emergency Medicine
Massachusetts General Hospital
Harvard Medical School
Boston, MA 02114
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: As the U.S. healthcare system seeks to improve the health of populations and individual patients, there is increasing interest to better align healthcare needs of patients with the most appropriate setting of care—particularly as it relates to hospital-based care (accounting for 1/3 of total U.S. healthcare costs).
Avoiding hospitalization—as long as safety and quality are not compromised—is often preferred by patients and the added benefit of potentially making care more affordable further promotes such care redesign efforts. There is a growing body of research studying alternative management strategies to hospitalization; we sought to comprehensively review and analyze this work. Alternative management strategies reviewed include outpatient management, quick diagnostic units, observation units, and hospital-at-home.
Dr. Sahil Agrawal[/caption]
Sahil Agrawal MD, MD
Heart and Vascular Center
St. Luke’s University Health Network
Bethlehem, PA 18015
MedicalResearch.com: What is the background for this study?
Dr. Agrawal: Patients admitted on a weekend have previously been known to have poorer outcomes compared to patients admitted on weekdays for various acute illnesses. With the advent of early fibrinolytic therapy and subsequently, emergent primary percutaneous coronary interventions (PCI), such discrepancies in outcomes have been largely resolved for ST-segment elevation myocardial infarctions (STEMI). In contrast, treatment of non-ST segment elevation myocardial infarction (NSTEMI) has remained less stringent such that invasive coronary angiography and potential intervention is often delayed for those presenting on a weekend rather than a week day. According to current ACC/AHA guidelines for NSTEMI, an early invasive strategy (EIS) is the preferred method of management unless barred by presence of contraindications (comorbid conditions) or patients’ preference. We were interested in investigating differences in utilization of EIS between patients admitted on a weekend versus those admitted on a weekday for an NSTEMI, and to evaluate the impact of such differences on in-hospital mortality in such patients.
Nate Miersma[/caption]
MedicalResearch.com: What is the background of the Stryker Surgicount Safety-Sponge System?
Mr. Miersma: Retained surgical sponges are the number one reported surgical never event, occurring roughly a dozen times per day in the United States. SurgiCount helps hospitals eliminate retained sponges by supplementing and verifying the manual count of sponges using a unique bar code for each sponge.
• The traditional manual sponge-counting method expects nurses and surgical technicians to track sponges with extreme precision using only a whiteboard and dry-erase marker. Though the majority of nurses and surgical technicians are experienced and thorough, the fast-paced, high-pressure environment of an operating room creates the risk for false-correct counts caused by distraction, exhaustion or personnel changes. At a rate of 11 times per day, the ‘white board while multi-tasking’ method clearly isn’t sufficient.
• When using SurgiCount, a nurse or surgical technician scans the barcodes to enter them into the computer’s backup count. During the closing count at the end of the procedure, a nurse or surgical technician scans each bar code again, while the computer tracks which sponges have been counted out and which remain. If the counts do not match, the SurgiCount scanner identifies which sponge or sponges are still unaccounted for, and directs staff to resolve the count by locating the outstanding sponge or sponges. Numerous clinical studies indicate that the primary cause of retained surgical sponges is false-correct counts. SurgiCount ensures that these false-correct counts no longer occur during the busy closing process.
• The scanner never gets tired or distracted, and can’t accidentally count the same sponge out twice, or count out a sponge which was accidentally introduced to the case possibly from another room, or from a sponge which was hidden and left over from a previous case.
Dr. Daniel Murphy[/caption]
Daniel R. Murphy, M.D., M.B.A.
Assistant Professor - Interim Director of GIM at Baylor Clinic
Department of Medicine
Health Svc Research & General Internal Medicine
Baylor College of Medicine
Houston, TX
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Murphy: Electronic health records (EHRs) have improved communication in health care, but they have not eliminated the problem of patients failing to receive appropriate and timely follow up after abnormal test results. For example, after a chest x-ray result where a radiologist identifies a potentially cancerous mass and suggests additional evaluation, about 8% of patients do not receive follow-up imaging or have a visit with an appropriate specialist within 30 days. Identifying patients experiencing a delay with traditional methods, like randomly reviewing charts, is not practical. Fortunately, EHRs collect large amounts of data each day that can be useful in automating the process of identifying such patients.
We evaluated whether an electronic “trigger” algorithm designed to detect delays in follow up of abnormal lung imaging tests could help medical facilities identify patients likely to have experienced a delay. Of 40,218 imaging tests performed, the trigger found 655 with a possible delay. Reviewing a subset of these records showed that 61% were truly delays in care that required action. We also found that the trigger had a sensitivity of 99%, indicating that it missed very few actual delays.
Dr. Taylor-Phillips[/caption]
Dr Sian Taylor-Phillips PhD
Assistant Professor of Screening and Test Evaluation
Division of Health Sciences
Warwick Medical School
University of Warwick
Coventry
MedicalResearch.com: What is the background for this study?
Dr Taylor-Phillips : Psychologists have been investigating a phenomenon of a drop in performance with time on a task called ‘the vigilance decrement’ since World War 2. In those days radar operators searched for enemy aircraft and submarines (appearing as little dots of light on a radar screen). People thought that the ability to spot the dots might go down after too much time spent on the task. Many psychology experiments have found a vigilance decrement, but most of this research has not been in a real world setting.
In this research we wanted to know whether there was a drop in performance with time on a task for breast screening readers looking at breast x-rays for signs of cancer. (Breast x-rays or mammograms show lots of overlapping tissue and cancers can be quite difficult to spot). This was a real-world randomised controlled study in UK clinical practice.
In the UK NHS Breast Screening Programme two readers examine each woman’s breast x-rays separately for signs of cancer. They look at batches of around 35 women’s x-rays. At the moment both readers look at the x-rays in the same order as each another, so if they both experience a drop in performance, it will happen at the same time. We tested a really simple idea of reversing the batch order for one of the readers, so that if they have a low ebb of performance it happens when they are looking at different women’s breast x-rays.
Dr. Serene Chen[/caption]
Serene I. Chen MD
Dr. Chen is an emergency medicine resident at Highland Hospital, in Oakland, California. She was a student at the Yale School of Medicine when this research was conducted.
MedicalResearch.com: What is the background for this study?
Dr. Chen: To address the rise in U.S. drug shortages, the Food and Drug Administration Safety and Innovation Act (FDASIA) was passed in 2012—and early evidence does suggest that the overall number of new shortages have decreased. However, we found that drugs that are frequently used emergency departments and other acute settings are still affected by more frequent and increasingly prolonged shortages.
Michael Daniel[/caption]
Michael Daniel
The Johns Hopkins University School of Medicine
M.D. Candidate 2016
Michael G. Daniel is a graduating medical student at the Johns Hopkins School of Medicine. He will be attending the Osler Internal Medicine Residency Training Program next year at the Johns Hopkins Hospital. His research focus is on Patient Safety, Quality, and Outcomes improvement.
Summary:
Medical error ranks as the third leading cause of death in the United States, but is not recognized in national vital statistics because of a flawed reporting process. Using recent studies on preventable medical error and extrapolating the results to the 2013 U.S. hospital admissions we calculated a mortality rate or 251,454 deaths per year.
MedicalResearch.com: What made you want to research this topic?
Response: I decided to study medicine because I wanted to improve patient health. However, I realized that improving patient health is not only about curing a disease but is sometimes about fixing the way we deliver healthcare.
MedicalResearch.com: Is this news surprising to you?
Response: Yes, because all previous estimates of medical error were much lower and when I started the research I couldn’t use the CDC statistics to get current data.
Dr. Rivera Hernandez[/caption]
Maricruz Rivera-Hernandez, PhD
Investigator
Department of Health Services, Policy & Practice
Center for Gerontology and Health Care Research
Brown University, Providence, RI
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Rivera-Hernandez: Over three-quarters of Medicare-eligible residents in Puerto Rico enroll in Medicare Advantage plans, making them the primary source of health care coverage for the island’s seniors. Puerto Rican Medicare Advantage plans have a long history of receiving lower payments than Medicare Advantage plans located in the United States.
The study’s purpose was to compare the quality of care provided to Medicare Advantage enrollees in Puerto Rico with that delivered to Medicare Advantage enrollees in the 50 states and the District of Columbia.
We found significantly worse quality for Puerto Rican Medicare Advantage enrollees compared to their US counterparts for 15 of the 17 quality indicators. These indicators measured whether patients received the recommended treatment and achieved desired outcomes in diabetes care, cardiovascular disease, and cancer screening and whether they received any inappropriate medications in 2011.
