RESUMEN
OBJECTIVES: Successful efforts to improve transitional care depend in part on local attitudes, workload, and training. Before implementing a multifaceted transitions intervention within an Accountable Care Organization, an understanding of contextual factors among providers involved in care transitions in inpatient and outpatient settings was needed. METHODS: As part of the Partners-Patient-Centered Outcomes Research Institute (PCORI) Transitions Study, we purposefully sampled inpatient and outpatient providers within the Accountable Care Organization. Survey questions focused on training and feedback on transitional tasks and opinions on the quality of care transitions. We also surveyed unit- and practice-level leadership on current transitional care practices. Results are presented using descriptive statistics. RESULTS: Among 387 providers surveyed, 220 responded (response rate = 57%) from 15 outpatient practices and 26 inpatient units. A large proportion of respondents reported to have never received training (50%) or feedback (68%) on key transitional care activities, and most (58%) reported insufficient time to complete these tasks. Respondents on average reported transitions processes led to positive outcomes some to most of the time (mean scores = 4.70-5.16 on a 1-7 scale). Surveys of leadership showed tremendous variation by unit and by practice in the performance of various transitional care activities. CONCLUSIONS: Many respondents felt that training, feedback, and time allotted to key transitional care activities were inadequate. Satisfaction with the quality of the transitions process was middling. Understanding these results, especially variation by location, was important to customizing implementation of the intervention and will be key to understanding variation in the success of the intervention across locations.
Asunto(s)
Cuidado de Transición , Actitud del Personal de Salud , Humanos , Evaluación del Resultado de la Atención al Paciente , Transferencia de Pacientes , Encuestas y CuestionariosRESUMEN
BACKGROUND: Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission. OBJECTIVES: To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events. DESIGN, SETTING, AND PARTICIPANTS: Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO). INTERVENTIONS: Multicomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient "discharge advocate" and a primary care "responsible outpatient clinician," postdischarge phone calls, and postdischarge primary care visit. MAIN OUTCOMES AND MEASURES: The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission. RESULTS: Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates. CONCLUSION: A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.
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Cuidados Posteriores , Transferencia de Pacientes , Adulto , Humanos , Conciliación de Medicamentos , Alta del Paciente , Readmisión del Paciente , Método Simple CiegoRESUMEN
Hospitals are under great pressure to reduce readmissions of patients. Being able to reliably predict patients at increased risk for rehospitalization would allow for tailored interventions to be offered to them. This requires the creation of a functional predictive model specifically designed to support real-time clinical operations. A predictive model for readmissions within 30 days of discharge was developed using retrospective data from 45,924 MGH admissions between 2/1/2012 and 1/31/2013 only including factors that would be available by the day after admission. It was then validated prospectively in a real-time implementation for 3,074 MGH admissions between 10/1/2013 and 10/31/2013. The model developed retrospectively had an AUC of 0.705 with good calibration. The real-time implementation had an AUC of 0.671 although the model was overestimating readmission risk. A moderately discriminative real-time 30-day readmission predictive model can be developed and implemented in a large academic hospital.
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Readmisión del Paciente , Centros Médicos Académicos , Área Bajo la Curva , Hospitales Generales , Humanos , Massachusetts , Modelos Teóricos , Oportunidad Relativa , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Carotid duplex ultrasonography (DUS) is routinely performed prior to coronary artery bypass graft surgery (CABG) on all patients > 65 years old because of the reported associated risk of finding concomitant carotid artery stenosis. Identifying risk factors that correlate with severe carotid stenosis may result in more cost-effective screening for patients with asymptomatic carotid artery disease prior to CABG. We performed a retrospective study to identify risk factors for significant carotid artery disease in patients scheduled to undergo CABG between March 2005 and March 2008 at the Massachusetts General Hospital. Patients with carotid stenosis >or= 70% identified by DUS (n = 50) were matched by age and sex to control patients who had < 50% stenosis (n = 50). Data were analyzed using the chi-squared test or analysis of variance as appropriate. Logistic regression was used to examine multivariate correlates of carotid stenosis. A total of 643 patients were screened to arrive at the patient cohorts described below. This produced a prevalence of 7.7% for significant (> 70%) carotid disease. The patient cohorts were predominantly male with no significant difference in the incidence of diabetes, hypertension, extent of coronary artery disease (CAD) (i.e. left main coronary artery disease (LMCA) and one, two-, or three-vessel CAD) or lipid abnormalities in the two groups. Univariate analysis identified the presence of peripheral arterial disease (PAD, p = 0.001), a cervical bruit (p < 0.0001), a prior neurological event (p = 0.020), and the presence of an abdominal aortic aneurysm (AAA; p = 0.046) as significant predictors of >or= 70% internal carotid artery stenosis. Logistic regression analysis revealed that the presence of a carotid bruit (p = 0.0068) and PAD (p = 0.0194) were associated with an increased risk of significant carotid artery disease. In conclusion, the presence of a carotid bruit or PAD predicts an increased likelihood of significant carotid artery disease in patients undergoing CABG. Unlike previous studies, LMCA or extent of CAD did not correlate with significant carotid artery disease. Using these predictive models, a prospective outcomes trial is required to validate these criteria.
Asunto(s)
Estenosis Carotídea/complicaciones , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Anciano , Boston , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/etiología , Estudios de Casos y Controles , Distribución de Chi-Cuadrado , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Femenino , Humanos , Modelos Logísticos , Masculino , Enfermedades Vasculares Periféricas/complicaciones , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Ultrasonografía Doppler DúplexRESUMEN
This study explores the use of mesenchymal stem cells (MSCs) for intervertebral disc regeneration. We used an in vivo model to investigate the feasibility of exogenous cell delivery, retention, and survival in the pressurized disc space. MSC injection into rat coccygeal discs was performed using 15% hyaluronan gel as a carrier. Injections of gel with or without MSCs were performed. Immediately after injection, fluorescently labeled stem cells were visible on sections of cell-injected discs. Seven and 14 days after injection, stem cells were still present within the disc, but their numbers were significantly decreased. At 28 days, a return to the initial number of injected cells was observed, and viability was 100%. A trend of increased disc height compared to blank gel suggests an increase in matrix synthesis. The results indicate that MSCs can maintain viability and proliferate within the rat intervertebral disc.