NEJM catalyst innovations in care delivery最新文献

Hospital readmission remains a common and costly event. For patients, hospital readmission is often associated with adverse outcomes in the short and long term. Despite broad interest in reducing hospital readmissions and the implementation of a wide range of programs to combat unplanned preventable readmissions, progress has been challenging. Multipronged, complex interventions have demonstrated effectiveness in published studies, yet they typically target a particular patient population (e.g., older adults), condition (e.g., heart failure), or hospital unit and are seldom implemented at the whole-hospital level. There is a pressing need for implementation studies of hospital-wide, comprehensive discharge care interventions. This article describes the design and first 2 years of implementation of the Discharge Care Center (DCC), a hospital-wide intervention designed to reduce readmissions at Vanderbilt University Hospital. Structured around a nurse-led Triage Team and a multidisciplinary Care Coordination Team specialized in post-discharge response to patient needs, the DCC utilizes a combination of automated surveillance and risk-based support to provide comprehensive and personalized coverage to adult patients discharged from the hospital to home. In its first 2 years of implementation, the DCC has cared for patients after 80,247 hospital discharges, providing 57,352 clinically relevant interventions. Vanderbilt University Hospital has seen a highly promising impact on readmissions, from a baseline (July 2019-June 2021) monthly mean 30-day unplanned readmission rate of 10.6% to a new rate of 9.9%, sustained for 2 consecutive years (July 2021-October 2023). This article presents the key functions of the DCC, the forms of implementation adopted, and practical advice for other healthcare systems aiming to implement a successful discharge care intervention at scale.

The complexity of care for decompensated liver disease often necessitates the transfer of patients to tertiary care hospitals (TCHs) for management by advanced liver care teams. However, TCHs often have a wait list for transfers, which can lead to delays in timely care. These delays can increase the risk of medical errors, which can be compounded by the multiple handoffs and uncertainty during the transfer process. To address these limitations and reduce reliance on transfers, the Indiana University Health Hepatology team, based at the academic health center (AHC), implemented a remote inpatient telehepatology (INP-TH) consultation service for comanaging patients with advanced liver disease while they remain hospitalized at one of the integrated health care system's community hospitals. In this article, the authors describe the logistics, feasibility, and selected outcomes of the INP-TH service across three of the community hospitals. Multiple stakeholders at the community hospitals and from the health system leadership were engaged before establishing the service. The service was implemented at minimal additional cost, utilizing existing clinical staff and two patient-facing iPads at each community hospital. AHC-based dedicated inpatient hepatology physician assistants and hepatology attendings participated in the INP-TH consultations. Patients under evaluation in the ED or those receiving care in the ICU were not eligible for the INP-TH consultation request. The results presented are from the virtual consultations offered to 155 patients from July 1, 2022, to December 31, 2023. On establishing INP-TH, only 12 patients (8%) were transferred to the AHC at the discretion of the INP-TH team for reasons related to the severity of illness or specialized services only available at the AHC; the other 143 (92%) were comanaged locally. Of the 155 patients, 57% had an outpatient hepatology follow-up within 30 days, 28% were readmitted to a hospital within 30 days, and 8% died within 30 days, which included nine as inpatients and four as outpatients. Provider engagement and satisfaction surveys revealed strong support and high satisfaction levels from both hepatology providers and hospitalists, with no readily evident risk to the patients. The INP-TH initiative models an approach for locally comanaging patients with complex or advanced diseases by establishing the feasibility and efficacy of comanagement of patients with decompensated cirrhosis at community hospitals without the need for physical transfer. To enhance its scale and breadth, the adaptation and expansion of the service to other health care systems should be explored.

Health care systems are increasingly recognizing the environmental harms generated by medical care and are seeking to reduce their carbon footprints. They can accomplish measurable reductions in greenhouse gas emissions while maintaining high quality and even improving care by pursuing cobenefits - programs that simultaneously reduce environmental harm and benefit patients' health. The authors describe Advanced Comprehensive Diabetes Care (ACDC), an evidence-based telehealth program for diabetes patients in the U.S. Department of Veterans Affairs (VA) system that has concurrently improved patient care and reduced the VA's carbon footprint. Designed for patients with poor diabetes control, the program leverages existing clinical infrastructure to provide nurse-delivered telemonitoring, self-management support, and provider-aided medication management. ACDC has improved patient outcomes while reducing patient travel time, out-of-pocket costs, and greenhouse gas emissions. ACDC served 576 patients between 2017 and 2022. The authors estimate that the program has prevented over 200,000 miles of driving, saving around US$20,000 in gasoline costs for patients and 82 metric tons of carbon dioxide emission compared with equivalent in-person care. ACDC provides a template for improving health outcomes and patient as well as provider satisfaction while saving money and producing measurable reductions in carbon footprint.

Cystic fibrosis (CF) affects more than 160,000 individuals globally and has seen improved survival rates due to multidisciplinary care models and pharmacotherapy innovations. However, the associated costs remain substantial, prompting the authors to study and evaluate the expense of CF ambulatory care to understand how care structure influences costs. People with CF (PwCF) at large pediatric CF centers in both the United States and Ireland were recruited for parallel observational, prospective studies. Based upon the process of care, the lead clinicians at both sites identified and agreed on three strata of patients (0-11 months, 1-5 years, and 6-17 years of age). Process maps were developed for each of the age cohorts at each site, and the costs of ambulatory care - with emphasis on routine CF clinic visits - were measured utilizing time-driven activity-based costing (TDABC). A dollar-per-minute capacity cost rate (CCR) was calculated for all resources used in the care cycle. The total direct cost was obtained by multiplying the CCR for each resource by the time the resource was used during the patient's care cycle. The cost was summed across all resource types to obtain the cost over the entire care cycle for each site. Service operations were benchmarked to one site and variance analysis was performed. In total, 58 PwCF were included in the analysis (49 in the United States and 9 in Ireland); 4 were 0-11 months, 17 were 1-5 years, and 37 were 6-17 years of age. Physicians (United States) and respiratory consultants (Ireland) had the highest CCRs. Physicians and registered dietitians spent the most time with patients in the United States, compared with the clinical nurse specialists and dietitians in Ireland. The total variance in cost for clinical visits was largest in the 6- to 17-year-old group (28% variance, with 100% in the United States vs. 128% in Ireland). In the 6- to 17-year-old group, the largest drivers in total variance were quantity variance (variance in duration of time spent with patients), which was 108% greater in Ireland); the skill mix variance (variance in clinician type performing service for a given time), which was 49% greater in the United States; and the rate variance (variance in compensation levels across sites), which was 31% greater in the United States. The authors' use of TDABC to characterize the cost of multidisciplinary care during ambulatory clinic visits for PwCF, in combination with variance analysis (the quantitative investigation of the difference between actual and expected costs), provides new and innovative ways to compare costs across similar health care service delivery sites, providing insights into the distinctive features of each. A granular understanding of cost and comparison of resource utilization between centers provides valuable, organizationally relevant insights.

Black Americans experience end-stage kidney disease (ESKD) at a disproportionately higher rate than other racial and ethnic groups in the United States. Kidney transplantation provides the best outcomes for patients with ESKD. However, Black patients frequently have decreased access to kidney transplantation. This article summarizes the robust literature on disparities in transplantation for Black patients and presents a practical solution to this complex issue by redesigning the transplant access process for Black patients challenged by structural and institutional barriers. The authors provide a detailed overview of a novel African American Transplant Access Program (AATAP) with its pillars of cultural congruency, trust, health literacy, and psychosocial support. This overview includes a thorough description of the program's conceptualization, the process of creating the program, the preliminary results, and guidance to establish similarly culturally congruent transplant access programs.