Healthcare-The Journal of Delivery Science and Innovation最新文献

Background

Judicious opioid prescribing and patient counseling, including in the postoperative context, are important efforts to address the U.S. opioid crisis. In discussions with patients and loved ones, there is commonly an emphasis on addiction risk. From a behavioral science standpoint, presenting addiction risk information represents a fear appeal. Clinicians may also seek to build trust and confidence by presenting balanced views of benefits and risks. However, little is known about if and how addiction risk information evokes negative emotions, affects perceptions of quality, and influences perspectives on judicious opioid prescribing.

Methods

We conducted a four-arm, randomized survey of U.S. adults involving a vignette about post-appendectomy pain management for a friend, including the quantity of opioids commonly prescribed. Participants were given either no additional information (control), addiction risk information, addiction plus health risk information, or addiction plus death risk information. We compared evoked affect, agreement with a reduced opioid prescription compared to common practice, and perceptions of quality.

Results

Among 1,546 participants (56% men, mean age 39), 78% agreed with reducing the quantity of opioids prescribed, relative to common practices. Compared to the control, providing addiction risk information did not impact the degree of evoked negative emotions or the likelihood of agreement with reduced opioid prescriptions. Providing opioid risk information increased the likelihood of high surgeon quality ratings.

Conclusions

Among a sample of U.S. adults, presenting addiction risk did not effectively appeal to fear, nor increase agreement with judicious opioid prescribing. Alternative communication strategies may be needed for those purposes.

In this article, we describe how innovation contests—a vehicle to crowdsource ideas and problem-solving efforts—propelled frontline employees to exert discretionary efforts in organizational problem-solving at Massachusetts General Hospital. As designers and administrators of four innovation contests in three disease centers, we share firsthand knowledge of how the contests enabled clinicians and administrative staff, whose primary job is delivering high-quality patient care, to become involved in ideation, selection, and implementation of their own ideas. We describe the processes that we designed and implemented, ideas that these processes generated, and findings from interviewing employees about their experiences afterwards. Our findings suggest that the benefits of implementing innovation contests were multifaceted. To employees, the contests provided a platform to voice suggestions and participate in any aspect of the innovation process that they found interesting. To managers, the contests revealed real, empirical issues affecting operation and patient care based on frontline employees’ knowledge. To the organization as a whole, the contests promoted collaborative problem-solving among likeminded, innovative employees.

Background

Responding to the shift toward value-based care, hospitals engaged in widespread experimentation of implementing transitional care (TC) strategies to improve patient experience and reduce unnecessary readmissions. However, which groups of these strategies are most strongly associated with better outcomes remains unknown.

Methods

Using a retrospective longitudinal design, we collected hospitals' TC strategy implementation data for 370 U S. hospitals and obtained claims data for 2.4 million Medicare fee-for-service beneficiaries hospitalized at them from 2009 to 2014. We applied estimated mixed-effects regression models controlling for patient, hospital, and community covariates to assess relationships between TC strategy groups and trends in hospitals’ 30-day hospital readmissions, with observation stay and mortality rates as secondary outcomes.

Results

Hospitals' adoption of TC groups was associated with higher readmission rates at baseline and larger readmission rate reductions compared to not adopting any of 5 TC groups. The TC group including timely information exchange across care settings, engaging patients and caregivers in education, and/or identifying and addressing patients’ transition needs was associated with the largest reductions. Hospitals not implementing any of the 5 TC groups had higher mortality rates and lower observation stay rates throughout the study period.

Conclusions

Our findings suggest that timely information sharing among providers across the care continuum and engaging patients in discharge planning and education may correspond with reduced readmissions.

Implications

Our research suggests that hospitals responded to shifts in policy by implementing a diversity of TC strategy combinations; it also provides guidance regarding which combinations of TC strategies corresponded with larger readmission reductions.

This analysis of a 2020 nationally representative sample of 1003 U.S. Black and Hispanic/Latino households shows that experiencing racism in healthcare is associated with significantly worse quality of healthcare and lower trust in doctors reported by patients. These findings emphasize that improving healthcare for Black and Hispanic/Latino patients will require major efforts to eliminate racism on the part of health professionals and healthcare institutions.

Background

Population risk segmentation and technology-enabled preventive care workflows are core competencies for Accountable Care Organizations (ACOs) that may also have relevance for public health emergencies.

Methods

During the early weeks of the COVID-19 pandemic, we aimed to leverage existing ACO capabilities to support 467 primary care practices across 27 states with pandemic response. We used Medicare claims and electronic health records to identify patients with increased COVID-19 vulnerability, for proactive outreach and guidance for “Staying Well at Home.”

Results

302,125 patients met intervention criteria; 45% were reached within the first 6 weeks. Engagement in the initiative was uneven among ACO-participating practices. ACO staff identified prior practice engagement in core ACO workflows as a major facilitator of success and staffing shortages as a major barrier. Small practice size, non-metropolitan location, penetration of value-based payment models in the practice, and pre-pandemic Annual Wellness Visit completion rates were independently associated with successful outreach to COVID-vulnerable patients.

Conclusions

Rapid adaptation of ACO infrastructure assisted independent practices across the country to reach vulnerable patients with proactive guidance for staying well at home. The initiative was most successful in smaller, non-metropolitan practices and those with greater engagement in core ACO initiatives pre-pandemic.

Implications

Our experience suggests that primary care participation in accountable care models can contribute to preparedness for future public health crises.

Primary care is the largest healthcare delivery platform in the US. Facing the Artificial Intelligence and Machine Learning technology (AI/ML) revolution, the primary care community would benefit from a roadmap revealing priority areas and opportunities for developing and integrating AI/ML-driven clinical tools. This article presents a framework that identifies five domains for AI/ML integration in primary care to support care delivery transformation and achieve the Quintuple Aims of the healthcare system. We concluded that primary care plays a critical role in developing, introducing, implementing, and monitoring AI/ML tools in healthcare and must not be overlooked as AI/ML transforms healthcare.

Background

Evidence-based strategies are needed to support appropriate use of telemedicine for initial outpatient subspecialty consultative visits. To inform such strategies we performed a survey of general pediatricians and pediatric subspecialists about use of telemedicine for patients newly referred for pediatric subspecialty care.

Methods

We developed and fielded an e-mail and postal survey of a national sample of 840 general pediatricians and 840 pediatric subspecialists in May and June 2020.

Results

Of 266 completed surveys (17% response rate), 204 (76%) thought telemedicine should be offered for some and 29 (11%) thought telemedicine should be offered for all initial subspecialist visits. Most respondents who indicated telemedicine should be offered for some initial consultations believed this decision should be made by subspecialty attendings (176/204, 86%). Respondents prioritized several data elements to inform this decision, including clinical information and family-based contextual information (e.g., barriers to in-person care, interest in telemedicine, potential communication barriers). Factors perceived to reduce appropriateness of telemedicine for subspecialty consultation included need for interpreter services and prior history of frequent no-shows. Responses from generalists and subspecialists rarely differed significantly.

Conclusions

Survey results suggest potential opportunities to support the appropriate use of telemedicine for initial outpatient pediatric subspecialty visits through structured transfer of specific clinical and contextual information at the time of referral and through strategies to mitigate perceived communication or engagement barriers.

Implication

Pediatric physician beliefs about telemedicine for initial outpatient subspecialty consultative visits may inform future interventions to support appropriate telemedicine use.

Level of evidence

Survey of a national sample of clinicians.