AMA Publishing Group: Hospital Epidemiology Topic Collection

Management Practices and the Quality of Care in Cardiac Units Management Practices in Cardiac Units

McConnell K, Lindrooth RC, Wholey DR, et al. — Mon, 22 Apr 2013 00:00:00 GMT

Importance

To improve the quality of health care, many researchers have suggested that health care institutions adopt management approaches that have been successful in the manufacturing and technology sectors. However, relatively little information exists about how these practices are disseminated in hospitals and whether they are associated with better performance.

Objectives

To describe the variation in management practices among a large sample of hospital cardiac care units; assess association of these practices with processes of care, readmissions, and mortality for patients with acute myocardial infarction (AMI); and suggest specific directions for the testing and dissemination of health care management approaches.

Design

We adapted an approach used to measure management and organizational practices in manufacturing to collect management data on cardiac units. We scored performance in 18 practices using the following 4 dimensions: standardizing care, tracking of key performance indicators, setting targets, and incentivizing employees. We used multivariate analyses to assess the relationship of management practices with process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for acute myocardial infarction (AMI).

Setting

Cardiac units in US hospitals.

Participants

Five hundred ninety-seven cardiac units, representing 51.5% of hospitals with interventional cardiac catheterization laboratories and at least 25 annual AMI discharges.

Main Outcome Measures

Process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for AMI.

Results

We found a wide distribution in management practices, with fewer than 20% of hospitals scoring a 4 or a 5 (best practice) on more than 9 measures. In multivariate analyses, management practices were significantly correlated with mortality (P = .01) and 6 of 6 process measures (P < .05). No statistically significant association was found between management and 30-day readmissions.

Conclusions and Relevance

The use of management practices adopted from manufacturing sectors is associated with higher process-of-care measures and lower 30-day AMI mortality. Given the wide differences in management practices across hospitals, dissemination of these practices may be beneficial in achieving high-quality outcomes.

Interventions to Decrease Hospital Readmissions Keys for Cost-effectiveness Interventions to Decrease Hospital Readmissions

Burke RE, Coleman EA. — Mon, 22 Apr 2013 00:00:00 GMT

Hospitals began paying financial penalties for high-risk–adjusted 30-day readmission rates for certain diagnoses in October 2012. Physician leaders seeking to reduce readmission rates will find that proven interventions often require substantial up-front financial and organizational investment. To reduce readmissions while minimizing the investment, leaders need to develop new and creative strategies guided by the evidence. This article describes 5 proposed strategies or “best practices” derived from critical evaluation of prior interventions and experience in the field. These practices include matching the intensity of the intervention to the patient's risk of readmission, avoiding commonly used but unproven interventions, using interventions with a durable effect, creating an effective team before selecting an intervention, and focusing on previously unrecognized high-risk patient groups.

Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients Derivation and Validation of a Prediction Model Potentially Avoidable 30-Day Hospital Readmissions

Donzé J, Aujesky D, Williams D, et al. — Mon, 22 Apr 2013 00:00:00 GMT

Importance

Because effective interventions to reduce hospital readmissions are often expensive to implement, a score to predict potentially avoidable readmissions may help target the patients most likely to benefit.

Objective

To derive and internally validate a prediction model for potentially avoidable 30-day hospital readmissions in medical patients using administrative and clinical data readily available prior to discharge.

Design

Retrospective cohort study.

Setting

Academic medical center in Boston, Massachusetts.

Participants

All patient discharges from any medical services between July 1, 2009, and June 30, 2010.

Main Outcome Measures

Potentially avoidable 30-day readmissions to 3 hospitals of the Partners HealthCare network were identified using a validated computerized algorithm based on administrative data (SQLape). A simple score was developed using multivariable logistic regression, with two-thirds of the sample randomly selected as the derivation cohort and one-third as the validation cohort.

Results

Among 10 731 eligible discharges, 2398 discharges (22.3%) were followed by a 30-day readmission, of which 879 (8.5% of all discharges) were identified as potentially avoidable. The prediction score identified 7 independent factors, referred to as the HOSPITAL score: h emoglobin at discharge, discharge from an o ncology service, s odium level at discharge, p rocedure during the index admission, i ndex t ype of admission, number of a dmissions during the last 12 months, and l ength of stay. In the validation set, 26.7% of the patients were classified as high risk, with an estimated potentially avoidable readmission risk of 18.0% (observed, 18.2%). The HOSPITAL score had fair discriminatory power (C statistic, 0.71) and had good calibration.

Conclusions and Relevance

This simple prediction model identifies before discharge the risk of potentially avoidable 30-day readmission in medical patients. This score has potential to easily identify patients who may need more intensive transitional care interventions.

Association of Self-reported Hospital Discharge Handoffs With 30-Day Readmissions Discharge Handoffs and 30-Day Readmissions

Oduyebo I, Lehmann CU, Pollack C, et al. — Mon, 22 Apr 2013 00:00:00 GMT

Importance

Poor health care provider communication across health care settings may lead to adverse outcomes.

Objective

To determine the frequency with which inpatient providers report communicating directly with outpatient providers and whether direct communication was associated with 30-day readmissions.

Design

We conducted a single-center prospective study of self-reported communication patterns by discharging health care providers on inpatient medical services from September 2010 to December 2011 at The Johns Hopkins Hospital.

Setting

A 1000-bed urban, academic center.

Participants

There were 13 954 hospitalizations in this time period. Of those, 9719 were for initial visits. After additional exclusions, including patients whose outpatient health care provider was the inpatient attending physician, those who had planned or routine admissions, those without outpatient health care providers, those who died in the hospital, and those discharged to other healthcare facilities, we were left with 6635 hospitalizations for analysis.

Interventions

Self-reported communication was captured from a mandatory electronic discharge worksheet field. Thirty-day readmissions, length of stay (LOS), and demographics were obtained from administrative databases.

Data Extraction

We used multivariable logistic regression models to examine, first, the association between direct communication and patient age, sex, LOS, race, payer, expected 30-day readmission rate based on diagnosis and illness severity, and physician type and, second, the association between 30-day readmission and direct communication, adjusting for patient and physician-level factors.

Results

Of 6635 included hospitalizations, successful direct communication occurred in 2438 (36.7%). The most frequently reported reason for lack of direct communication was the health care provider's perception that the discharge summary was adequate. Predictors of direct communication, adjusting for all other variables, included patients cared for by hospitalists without house staff (odds ratio [OR], 1.81 [95% CI, 1.59-2.08]), high expected 30-day readmission rate (OR, 1.18 [95% CI, 1.10-1.28] per 10%), and insurance by Medicare (OR, 1.35 [95% CI, 1.16-1.56]) and private insurance companies (OR, 1.35 [95% CI, 1.18-1.56]) compared with Medicaid. Direct communication with the outpatient health care provider was not associated with readmissions (OR, 1.08 [95% CI, 0.92-1.26]) in adjusted analysis.

Conclusions and Relevance

Self-reported direct communication between inpatient and outpatient providers occurred at a low rate but was not associated with readmissions. This suggests that enhancing interprovider communication at hospital discharge may not, in isolation, prevent readmissions.

Complexity Science and the Readmission Dilemma Comment on “Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients” and “Association of Self-reported Hospital Discharge Handoffs With 30-Day Readmissions” Complexity Science and the Readmission Dilemma

Marks E. — Mon, 22 Apr 2013 00:00:00 GMT

The increasing proliferation of articles dealing with hospital readmission is in no small part a response to the recommendations in the 2007 Medicare Payment Advisory Commission report to Congress (http:// www.medpac.gov/documents/Jun07_ EntireReport.pdf). These recommendations became the basis for the Hospital Readmissions Reduction Program in the Affordable Care Act altering the criteria for hospital payment reimbursement. Enforcement of these criteria by the Centers for Medicare & Medicaid Services reduces Medicare payments to hospitals that exceed preset all-cause readmission rates. As health care policy and aspects of care delivery are increasingly influenced by reimbursement, it is important to ensure that the attenuation of the overall health care financial burden is accomplished by research-driven improvements in the quality and safety of care that minimize the potential for unintended outcomes.