A Population Health Approach to Transitional Care Management for High-Risk Patients with Diabetes: Outcomes at a Rural Hospital

2020 ◽  
Vol 23 (4) ◽  
pp. 278-285
Author(s):  
Yhenneko J. Taylor ◽  
Jason Roberge ◽  
Whitney Rossman ◽  
Jennifer Jones ◽  
Colleen Generoso ◽  
...  
Keyword(s):  
High Risk ◽  
Population Health ◽  
Care Management ◽  
Transitional Care ◽  
Rural Hospital ◽  
High Risk Patients ◽  
Diabetes Outcomes ◽  
Patients With Diabetes ◽  
Risk Patients

Association of infrapopliteal medial arterial calcification with lower-limb amputations in high-risk patients: A systematic review and meta-analysis

2020 ◽  
pp. 1358863X2097973
Author(s):  
Fabrizio Losurdo ◽  
Roberto Ferraresi ◽  
Alessandro Ucci ◽  
Anna Zanetti ◽  
Giacomo Clerici ◽  
...  
Keyword(s):  
Risk Factor ◽  
High Risk ◽  
Lower Limb ◽  
Fixed Effects ◽  
Meta Analysis ◽  
Arterial Calcification ◽  
High Risk Patients ◽  
Patients With Diabetes ◽  
Risk Patients ◽  
Medial Arterial Calcification

Medial arterial calcification (MAC) is a known risk factor for cardiovascular morbidity. The association between vascular calcifications and poor outcome in several vascular districts suggest that infrapopliteal MAC could be a risk factor for lower-limb amputation (LLA). This study’s objective is to review the available literature focusing on the association between infrapopliteal MAC and LLA in high-risk patients. The PubMed and Embase databases were systematically searched. We selected original studies reporting the association between infrapopliteal MAC and LLAs in patients with diabetes and/or peripheral artery disease (PAD). Estimates were pooled using either a fixed-effects or a random-effects model meta-analysis. Heterogeneity was evaluated using the Q and I2 statistics. Publication bias was investigated with a funnel plot and Egger test. The trim-and-fill method was designed to estimate the possibly missing studies. Influence analysis was conducted to search studies influencing the final result. Test of moderators was used to compare estimates in good versus non-good-quality studies. Fifteen articles satisfied the selection criteria ( n = 6489; median follow-up: 36 months). MAC was significantly associated with LLAs (pooled adjusted risk ratio (RR): 2.27; 95% CI: 1.89–2.74; I2 = 25.3%, Q-test: p = 0.17). This association was kept in the subgroup of patients with diabetes (RR: 2.37; 95% CI: 1.76–3.20) and patients with PAD (RR: 2.48; 95% CI: 1.72–3.58). The association was maintained if considering as outcome only major amputations (RR: 2.11; 95% CI: 1.46–3.06). Our results show that infrapopliteal MAC is associated with LLAs, thus suggesting MAC as a possible new marker of the at-risk limb.

Cardiovascular risk assessment in diabetes and pre-diabetes

ESC CardioMed ◽  
2018 ◽  
pp. 923-924
Author(s):  
Nikolaus Marx
Keyword(s):  
Risk Assessment ◽  
Cardiovascular Risk ◽  
High Risk ◽  
Target Organ Damage ◽  
Risk Scores ◽  
High Risk Patients ◽  
Patients With Diabetes ◽  
Risk Patients ◽  
Artery Disease ◽  
Very High

Patients with diabetes exhibit an increased propensity to develop cardiovascular disease with an increased mortality. Early risk assessment, especially for coronary artery disease, is important to initiate therapeutic strategies to reduce cardiovascular risk. This chapter reviews the current literature on risk scores in patients with type 1 and type 2 diabetes and summarizes the role of risk assessment based on biomarkers and different imaging strategies. Current guidelines recommend that patients with diabetes are characterized as high-risk or very high-risk patients. In the presence of target organ damage or other risk factors such as smoking, marked hypercholesterolaemia, or hypertension, patients with diabetes are classified as very high-risk patients while most other people with diabetes are categorized as high-risk patients.

scholarly journals Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation

2019 ◽  
Vol 28 (10) ◽  
pp. 835-842 ◽  
Author(s):  
Shirley V Wang ◽  
James R Rogers ◽  
Yinzhu Jin ◽  
David DeiCicchi ◽  
Sara Dejene ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Usual Care ◽  
Population Health ◽  
Primary Care Providers ◽  
Health Intervention ◽  
Stepped Wedge ◽  
High Risk Patients ◽  
Population Health Intervention ◽  
Risk Patients

BackgroundClinical guidelines recommend anticoagulation for patients with atrial fibrillation (AF) at high risk of stroke; however, studies report 40% of this population is not anticoagulated.ObjectiveTo evaluate a population health intervention to increase anticoagulation use in high-risk patients with AF.MethodsWe used machine learning algorithms to identify patients with AF from electronic health records at high risk of stroke (CHA2DS2-VASc risk score ≥2), and no anticoagulant prescriptions within 12 months. A clinical pharmacist in the anticoagulation service reviewed charts for algorithm-identified patients to assess appropriateness of initiating an anticoagulant. The pharmacist then contacted primary care providers of potentially undertreated patients and offered assistance with anticoagulation management. We used a stepped-wedge design, evaluating the proportion of potentially undertreated patients with AF started on anticoagulant therapy within 28 days for clinics randomised to intervention versus usual care.ResultsOf 1727 algorithm-identified high-risk patients with AF in clinics at the time of randomisation to intervention, 432 (25%) lacked evidence of anticoagulant prescriptions in the prior year. After pharmacist review, only 17% (75 of 432) of algorithm-identified patients were considered potentially undertreated at the time their clinic was randomised to intervention. Over a third (155 of 432) were excluded because they had a single prior AF episode (transient or provoked by serious illness); 36 (8%) had documented refusal of anticoagulation, the remainder had other reasons for exclusion. The intervention did not increase new anticoagulant prescriptions (intervention: 4.1% vs usual care: 4.0%, p=0.86).ConclusionsAlgorithms to identify underuse of anticoagulation among patients with AF in healthcare databases may not capture clinical subtleties or patient preferences and may overestimate the extent of undertreatment. Changing clinician behaviour remains challenging.

Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach

2020 ◽  
pp. bmjqs-2020-011204
Author(s):  
Kirstin A Manges ◽  
Roman Ayele ◽  
Chelsea Leonard ◽  
Marcie Lee ◽  
Emily Galenbeck ◽  
...  
Keyword(s):  
High Risk ◽  
Best Practices ◽  
Transitional Care ◽  
Readmission Rates ◽  
High Performing ◽  
High Risk Patients ◽  
Ethnographic Approach ◽  
Care Processes ◽  
Risk Patients ◽  
Postacute Care

BackgroundDespite the increased focus on improving patient’s postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between hospital-SNF pairs with high or low 30-day readmission rates.DesignWe used a rapid ethnographic approach with intensive multiday observations and key informant interviews at high-performing and low-performing hospitals, and their most commonly used SNF. We used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals.Setting and participantsHospitals were classified as high or low performers based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals (n=2 high performing, n=2 low performing) and corresponding SNFs (n=5).FindingsWe identified variation in five major processes prior to SNF discharge that could affect care transitions: recognising need for postacute care, deciding level of care, selecting an SNF, negotiating patient fit and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: (1) earlier, ongoing, systematic identification of high-risk patients; (2) discussing the decision to go to an SNF as an iterative team-based process and (3) anticipating barriers with knowledge of transitional and SNF care processes.ConclusionIdentifying variations in processes used to prepare patients for SNF provides critical insight into the best practices for transitioning patients to SNFs and areas to target for improving care of high-risk patients.

scholarly journals The Impact of Pharmacist-delivered Motivational Interviewing on Chronic Kidney Disease Identification and Management in Patients with Diabetes Mellitus and Low Socioeconomic Status

2019 ◽  
Vol 10 (4) ◽  
pp. 8
Author(s):  
Keri Lillian DePatis ◽  
Catherine Harrington
Keyword(s):  
Diabetes Mellitus ◽  
Chronic Kidney Disease ◽  
High Risk ◽  
Kidney Disease ◽  
Motivational Interviewing ◽  
Urinary Albumin ◽  
Secondary Outcome ◽  
High Risk Patients ◽  
Patients With Diabetes ◽  
Risk Patients

Purpose: Chronic kidney disease (CKD) is a common complication among patients with diabetes mellitus; however, noncompliance with the recommended annual screening is common. Increased screening among high-risk patients is important to identify the early stages CKD, potentially resulting in earlier treatment, slower progression, fewer complications, and decreased healthcare expenditures. Motivational interviewing (MI) has previously been shown to be effective for various behaviors, such as smoking cessation and cholesterol level control. The objective of this study is to evaluate the effectiveness of pharmacist-delivered MI compared to typical education (TE) methods in increasing CKD screening and subsequent angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) initiation in high-risk patient populations. Methods: Pharmacists screened diabetic patients within their chronic disease management clinic to identify patients that are at high-risk for CKD, indicated by a score of 4 or greater on the validated SCORED screening tool. High-risk patients were randomized to one of four groups to receive either one or two face-to-face education sessions from a pharmacist or student pharmacist using either MI or TE methods. Patients were then given the option to have their urine tested with a dipstick to detect albumin and creatinine, provided at no cost. The primary outcome was to determine the rate of urinary albumin testing, and the secondary outcome was to determine the rate of ACE-I or ARB initiation in patients found to have albuminuria. Results: There were no significant differences in the rates of urinary albumin screening (87% in TE vs. 100% in MI, P = 0.4828) or subsequent ACE-I/ARB initiation (100% in TE and 50% in MI, P = 1.000) between education groups. Of the high-risk patients who underwent urinary albumin screening, 54% (n=15) were found to have proteinuria Conclusions: While it appears that MI does not impact patient acceptance rates of microalbuminuria screening and ACE-I/ARB initiation, this study demonstrates the feasibility of pharmacist-delivered microalbuminuria screening in patients at high-risk for CKD in the outpatient setting.   Article Type: Practice-Based Research

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