Better Care, Same Cost — Reducing Unplanned Care for Multi-visit Patients: A Payer-Provider ModelHanmer, Janel; Liu, Yushu; Leon-Jhong, Anita; Bui, Thuy; Meltzer, Avery; Kogan, Jane; Schuster, James; Fischer, Gary S.; Bryk, Jodie
2024 Journal of General Internal Medicine
doi: 10.1007/s11606-024-09006-zpmid: 39227542
ImportanceMany interventions implemented for multi-visit patients (MVP) have been developed to address patient-centric needs of these individuals and reduce unplanned care for ambulatory-sensitive conditions. More rigorous research is needed to better understand the impact of these interventions on changes in care utilization including unplanned care.ObjectiveTo evaluate the impact of the Enhanced Care Program (ECP), a payer-provider collaborative model, on unplanned care use and cost of care.DesignUsing propensity methods, a comparison group was constructed using insurer membership files. Comparisons were performed using a difference-in-differences analysis.ParticipantsPatients enrolled in ECP through December 2019 were considered eligible for the study (n = 357). All patients had five or more ED visits in the past year or two or more inpatient hospitalizations in the past year prior to enrollment.ExposuresECP is a high-intensity outpatient intervention intended to reduce avoidable unplanned care such as ED visits and inpatient hospital stays through home visits, chronic/acute disease management, and intensive care coordination.Main MeasuresThe primary outcomes of interest were events per 100 members per year of ED use with return to home, unplanned inpatient and observational status admissions, and unplanned behavioral health inpatient admission, and cost of care per member per month.Key ResultsOverall total unplanned care encounters were significantly reduced with a difference-in-difference of 320 unplanned care encounters per 100 members per year in the intervention group (p < 0.05). The ECP group showed statistically significant decreases in costs of unplanned ED, unplanned observation admission, and unplanned inpatient behavioral medicine costs, but statistically significant increases in overall pharmacy costs and lab costs. Changes in total costs of care for the ECP group were not statistically different than the control group (p = 0.55).ConclusionsECP showed significant reduction of unplanned care for MVP patients.
Charting Diagnostic Safety: Exploring Patient-Provider Discordance in Medical Record DocumentationGiardina, Traber D.; Vaghani, Viral; Upadhyay, Divvy K.; Scott, Taylor M.; Korukonda, Saritha; Spitzmueller, Christiane; Singh, Hardeep
2024 Journal of General Internal Medicine
doi: 10.1007/s11606-024-09007-ypmid: 39237788
BackgroundThe 21st Century Cures Act enables patients to access their medical records, thus providing a unique opportunity to engage patients in their diagnostic journey.ObjectiveTo explore the concordance between patients’ self-reported diagnostic concerns and clinician-interpreted information in their electronic health records.DesignWe conducted a mixed-methods analysis of a cohort of 467 patients who completed a structured data collection instrument (the Safer Dx Patient) to identify diagnostic concerns while reviewing their clinician’s notes. We conducted a qualitative content analysis of open-ended responses on both the tools and the case summaries. Two clinical chart reviewers, blinded to patient-reported diagnostic concerns, independently conducted chart reviews using a different structured instrument (the Revised Safer Dx Instrument) to identify diagnostic concerns and generate case summaries. The primary outcome variable was chart review–identified diagnostic concerns. Multivariate logistic regression tested whether the primary outcome was concordant with patient-reported diagnostic concerns.SettingGeisinger, a large integrated healthcare organization in rural and semi-urban Pennsylvania.ParticipantsCohort of adult patients actively using patient portals and identified as “at-risk” for diagnostic concerns using an electronic trigger algorithm based on unexpected visit patterns in a primary care setting.ResultsIn 467 cohort patients, chart review identified 31 (6.4%) diagnostic concerns, of which only 11 (21.5%) overlapped with 51 patient-reported diagnostic concerns. Content analysis revealed several areas of discordant understanding of the diagnostic process between clinicians and patients. Multivariate logistic regression analysis showed that clinician-identified diagnostic concerns were associated with patients who self-reported “I feel I was incorrectly diagnosed during my visit” (odds ratio 1.65, 95% CI 1.17–2.3, p < 0.05).ConclusionPatients and clinicians appear to have certain differences in their mental models of what is considered a diagnostic concern. Efforts to integrate patient perspectives and experiences with the diagnostic process can lead to better measurement of diagnostic safety.
Using Dashboards to Support Continuous Quality Improvement in Undergraduate and Graduate Medical EducationDufault, Carolyn L.; Colson, Eve R.; Dallaghan, Gary L. Beck; Buchanan, April O.; Aagaard, Eva M.; Blaylock, Leslie; Wroblewski, Matthew; Osterberg, Lars; Roman, Brenda J. B.; Coplit, Lisa
2024 Journal of General Internal Medicine
doi: 10.1007/s11606-024-09011-2pmid: 39230808
Like other complex systems, medical education programs require a systematic continuous quality improvement (CQI) approach to drive effective improvement. Accreditation bodies in both undergraduate medical education (UME) and graduate medical education (GME) require programs to have effective CQI processes. Dashboards facilitate visualization and tracking of key metrics that impact medical education programming, thus driving excellence. Keys to developing useful dashboards include using existing program evaluation frameworks to identify desired outputs, determine acceptable evidence, and identify key data sources. In developing dashboards, it is important to consider data management including oversight and appropriate sharing of reports. When effectively developed and delivered to key parties, data dashboards serve as valuable tools to drive improvement of medical education programing. The purpose of this paper is to provide guidance for dashboard implementation and use in medical education, with a focus on UME and GME, based on available literature and experiences in our own institutions.
Development and Evaluation of a Direct Care Hospitalist Service Internal Medicine Sub-internship RotationMolitch-Hou, Ethan; Anderson, Irsk; Tewari, Arti; Kowalczyk, Nicholas S.; Feaster, Nia; Martin, Shannon K.
2024 Journal of General Internal Medicine
doi: 10.1007/s11606-024-08878-5pmid: 39285072
BackgroundDirect Care Hospitalist Services (DCHS) can increase internal medicine (IM) sub-internship rotation availability while providing hospitalists additional teaching opportunities.AimImplement and evaluate a DCHS sub-internship.SettingUrban Academic Medical School.ParticipantsIM sub-interns, hospitalists.Program DescriptionOne to two sub-interns were paired with three hospitalists on 3 weeks of day service and five nights in an apprenticeship model. Sub-interns admitted and followed patients on days and cross-covered and admitted on nights.Program EvaluationDCHS sub-intern rotation satisfaction and skills preparedness were surveyed over 2 years. Sub-interns rotating on resident-covered service (RCS) were surveyed in year 2, and results compared to DCHS. Hospitalists were surveyed year 1 to rate satisfaction. Year 2 DCHS cross-cover paging data was tabulated to evaluate clinical content. DCHS and RCS sub-interns rated satisfaction and preparedness similarly. DCHS sub-interns rated time management (3.86 vs 4.33, p = 0.19) and calling consults (4.4 vs 4.8, p = 0.56) lower, but cross-cover higher (4.14 to 3.67, p = 0.34) than RCS. DCHS sub-interns averaged 39.4 (SD 4.1) nightly cross-cover pages with most related to acute symptoms (46%). Hospitalists were highly satisfied with their rotation experience.DiscussionSub-interns were highly satisfied with DCHS sub-internship. Future work will target gaps in preparedness for urgent patient care issues.
Latino Enclaves and Healthcare Accessibility: An Ecologic Study Across Five StatesGuan, Alice; Shariff-Marco, Salma; Henry, Kevin A.; Lin, Katherine; Meltzer, Dan; Canchola, Alison J.; Arizpe, Angel; Rathod, Aniruddha B.; Hughes, Amy E.; Kroenke, Candyce H.; Gomez, Scarlett L.; Hiatt, Robert A.; Stroup, Antoinette M.; Pinheiro, Paulo S.; Boscoe, Francis; Zhu, Hong; Pruitt, Sandi L.
2024 Journal of General Internal Medicine
doi: 10.1007/s11606-024-08974-6pmid: 39285075
BackgroundHispanic or Latino populations (hereafter, “Latinos”) are a rapidly expanding U.S. demographic and have documented inequities in preventable diseases and conditions. Many Latinos reside in ethnic enclaves, and understanding the context and healthcare accessibility within these places is critical.ObjectiveThis study described the neighborhood social and built environment attributes of Latino enclaves and evaluated associations between enclaves and geographic healthcare accessibility.DesignCross-sectional ecologic analysis.SubjectsOur unit of analysis was all neighborhoods (n ~ 20,000 census tracts) in California, Florida, New Jersey, New York, and Texas in years 2000 and 2010.Main measuresThe primary exposure of interest, “Latino enclaves,” was defined using neighborhood-level data on the percentage of Latino residents, foreign-born Latinos, Spanish speakers with limited English proficiency, and linguistically isolated Spanish-speaking households. The primary outcome was a neighborhood-level measure of geographic healthcare accessibility of primary care physicians, which accounted for both the supply of physicians and population demand for healthcare (i.e., population size within driving distance).ResultsApproximately 30% of neighborhoods were classified as Latino enclaves, 87% of which were enclaves in both 2000 and 2010. Compared with non-enclaves, Latino enclaves had more markers of structural disadvantage including having higher proportions of poverty, uninsured individuals, crowded housing, and higher crime scores. Results from multivariable models suggest that more culturally distinct neighborhoods (i.e., higher enclave score) had lower healthcare accessibility, though when stratified, this association persisted only in high (≥ 20%) poverty neighborhoods.ConclusionThis study highlights several neighborhood structural disadvantages within Latino enclaves, including higher poverty, uninsured individuals, and crime compared to non-enclave neighborhoods. Moreover, our findings point to the need for interventions aimed at improving healthcare accessibility particularly within socioeconomically disadvantaged Latino enclaves. Addressing these inequities demands multifaceted approaches that consider both social and structural factors to ensure equitable healthcare access for Latino populations.
Night Shift Work Associates with All-Cause and Cause-Specific Mortality: A Large Prospective Cohort StudyChang, Qinyu; Zhu, Yiqun; Liang, Huaying; Cheng, Jun; Li, Dianwu; Lin, Fengyu; Zhou, Xin; Pan, Pinhua; Ma, Fangyu; Zhang, Yan
2024 Journal of General Internal Medicine
doi: 10.1007/s11606-024-08946-wpmid: 39254778
BackgroundHealth problems associated with shift work and night shift work are gaining increasing public attention.ObjectiveTo investigate the association between night shift work and the hazard of mortality.DesignProspective cohort study.ParticipantsA total of 283,579 individuals with paid employment or self-employment aged 37–73 years were included from the UK Biobank with a median follow-up period of 14.0 years.Main MeasuresParticipants were divided into day workers and shift workers, including the frequency of night shifts, to evaluate the association between baseline work schedules and all-cause and cause-specific mortality using the Cox proportional hazards model. Additionally, 75,760 participants with work histories were assessed for the association between average frequency and cumulative years of exposure to night shift work and all-cause and cause-specific mortality.Key ResultsCompared with that of day workers, the adjusted hazard of all-cause mortality was increased by 12.0% (hazard ratio [HR], 1.12; 95% confidence interval [CI], 1.07–1.18) in shift workers, particularly in those with no or rare night shifts (approximately 16.1%; HR, 1.16; 95% CI, 1.08–1.25) and those with irregular night shifts (approximately 9.2%; HR, 1.09; 95% CI, 1.00–1.19). Moreover, a non-linear relationship was identified between cumulative night shift years and all-cause and cause-specific mortality. Only individuals who worked night shifts for 20–30 years exhibited a substantially increased hazard of all-cause (HR, 1.52; 95% CI, 1.15–2.00) and cardiovascular disease (CVD; HR, 2.08; 95% CI, 1.16–3.71) mortality.ConclusionsShift workers, particularly those with rare or irregular night shifts, exhibited an increased hazard of mortality. Additionally, participants who worked night shifts for 20–30 years exhibited a substantially increased hazard of all-cause and CVD mortality.Graphical Abstract[graphic not available: see fulltext]