Identifying Actionable Causes of Potentially Avoidable Readmissions to an Oncology Service at a Safety Net Hospital

2020 ◽  
pp. OP.20.00593
Author(s):  
Vishal K. Gupta ◽  
Michael Dennis ◽  
Emily Mann ◽  
Joseph O. Jacobson ◽  
Naomi Y. Ko
Keyword(s):  
Pleural Fluid ◽  
Cancer Progression ◽  
Medical Center ◽  
Hospital Readmissions ◽  
Retrospective Chart Review ◽  
Safety Net ◽  
Outpatient Setting ◽  
Oncology Service ◽  
Safety Net Hospital ◽  
Avoidable Readmissions

PURPOSE: Hospital readmissions occur commonly in those receiving cancer care and result in impaired quality of life and increased costs. Causes of readmission in safety net hospitals that serve vulnerable populations are not well understood. The primary goal of this project was to identify potentially avoidable and intervenable causes of readmissions to an urban safety net hospital. METHODS: A retrospective chart review was performed on patients who were readmitted within 30 days of discharge from the hematology and oncology service at Boston Medical Center over the 6-month period between October 2018 and March 2019. Charts were reviewed by three internal medicine residents and discussed under the supervision of an attending oncologist. RESULTS: Two hundred ninety-one patient encounters involving 203 unique patients were identified in the 6-month study period. Of these 291 encounters, 80 encounters (27.5%) were followed by a readmission within 30 days and occurred in 61 (30.0%) unique patients. Nineteen (31.1%) of these 61 patients experienced two readmissions within 30 days of discharge. Twenty-five readmissions (31.3%) were classified as potentially avoidable, with the most common cause of potentially avoidable readmissions attributed to ascitic or pleural fluid reaccumulation (8, 32%). The majority of presumed nonpreventable readmissions were due to expected complications of cancer progression and treatment-related side effects. DISCUSSION: In conclusion, readmissions were common, and a modifiable reason for 30-day readmissions was identified. Addressing recurrent ascitic and pleural fluid reaccumulation in the outpatient setting could help to reduce inpatient hospital readmission on an inpatient oncology service.

Decreasing time to initiation of inpatient chemotherapy at LAC+USC medical center utilizing an admission checklist.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 262-262
Author(s):  
Ronak Patel ◽  
Victor Chiu ◽  
Darcy V. Spicer
Keyword(s):  
Medical Center ◽  
Intervention Group ◽  
Retrospective Chart Review ◽  
Safety Net ◽  
Outpatient Setting ◽  
Post Intervention ◽  
Safety Net Hospital ◽  
The Mean ◽  
Chemotherapy Initiation ◽  
Mean Time

262 Background: Delays in the initiation of chemotherapy for scheduled inpatient admissions cause excess lengths of stay and shift infusion start times to the evenings when hospital staffing is decreased. We sought to characterize delays in our admission process and assess the feasibility of using an admission checklist to shorten start times in a large academic safety-net hospital. Baseline data for scheduled chemotherapy admissions in July and August of 2017 (n = 25) showed a mean time to chemotherapy initiation of 14.6 hours and mean excess LOS was 0.7 midnights. Significant delays were identified in the time between ordering and resulting of pre-chemotherapy labs (average 2.6 hours), and the time required to obtain imaging to confirm peripheral-inserted central catheter (PICC) position (1.6 hours). Methods: We created a checklist of a standardized admission workflow for physicians, which included moving all pre-chemotherapy labs, pharmacy verification of chemotherapy regimen, and PICC imaging to the outpatient setting. We organized multiple staff in-services to introduce the admission workflow prior to implementation on May 1, 2018. We then performed a retrospective chart review of all scheduled inpatient chemotherapy admissions from May to August of 2018. Results: In the first 2 months after intervention, the mean time to chemotherapy initiation was 8.5 hrs, representing a 42% reduction. In the subsequent 2 months, the mean time to chemotherapy initiation was 11.6 hours, representing a 21% reduction from baseline. Mean excess LOS was 0.4 midnights and 0.5 midnights for those time periods, respectively. For the entire post-intervention group, 7 out of 26 patients obtained pre-chemotherapy labs in the outpatient setting. Conclusions: We observed an initial mean reduction of 6.1 hours in the time to start chemotherapy, as well as a reduction in mean excess length of stay with the introduction of a new admission workflow and admission checklist. We observed incomplete adoption of the checklist, and an increase in time to chemotherapy initiation after the first two months of implementation, suggesting that physician non-adherence represents a significant barrier to maintaining these reductions.

scholarly journals Associations Between Structural and Social Determinants of Health With COVID Infection Rates at a Safety Net Hospital.

2021 ◽  
Author(s):  
Dotun Ogunyemi ◽  
Rolando Mantilla ◽  
Abhinav Markus ◽  
Aubrey Reeves ◽  
Suyee Win ◽  
...  
Keyword(s):  
Predictive Value ◽  
Medical Center ◽  
Retrospective Chart Review ◽  
Positive Association ◽  
Safety Net ◽  
Individual Risk ◽  
Infection Rates ◽  
Significant Positive Association ◽  
Increased Risk ◽  
Safety Net Hospital

Abstract Background: The reported disproportionate impact of COVID-19 infections on minority populations may be due to living in disinvested communities with high level of poverty, pollution, inadequate unsafe employment, and overcrowded housing.Objective: To determine the association of county, city, and individual risk factors with COVID-19 infection ratesMethods: Retrospective chart review on COVID-19 tests performed from March through July 2020 at Arrowhead Regional Medical Center, Colton­, California. Results: A total of 7104 tests were performed with 69% in the drive-through testing center. The mean duration of test-to-results time was 2.36 (+0.02) days. COVID-19 positive tests occurred in 1095 (15.4%). At least one symptom occurred in 414 (33%) with sensitivity of 37.8, specificity of 86.02, positive predictive value of 33.01, and negative predictive value of 72.76. Individual factors significantly associated with testing positive for COVID-19 were diabetes, Hispanic ethnicity, and male gender. Younger age was significantly associated with testing COVID positive with the highest risk in children <10 years. COVID-19 positive persons significantly resided in cities with higher population density, household members, poverty, non-English speaking homes, disability, lower median household income, lack of health insurance and decreased access to a computer and WIFI services. County health rankings showed significant positive association between testing positive for COVID-19 with increased smoking, air pollution, violent crimes, physical inactivity, decreased education and access to exercise. Conclusion: Adverse county health rankings; socially and economically disadvantaged cities are associated with an increased risk of testing positive for COVD-19. This information can be used in strategic planning and invention mitigation.

Real-Time Risk Tool for Pharmacy Interventions

2020 ◽  
pp. 001857872097388
Author(s):  
Hanh L. Nguyen ◽  
Kristin S. Alvarez ◽  
Boryana Manz ◽  
Arun Nethi ◽  
Varun Sharma ◽  
...  
Keyword(s):  
High Risk ◽  
Prediction Models ◽  
Risk Model ◽  
Hospital Readmissions ◽  
Group Versus ◽  
Safety Net ◽  
Low Risk ◽  
Day Hospital ◽  
Significant Difference ◽  
Safety Net Hospital

Background: Adverse drug events (ADEs) result in excess hospitalizations. Thorough admission medication histories (AMHs) may prevent ADEs; however, the resources required oftentimes outweigh what is available in large hospital settings. Previous risk prediction models embedded into the Electronic Medical Record (EMR) have been used at hospitals to aid in targeting delivery of scarce resources. Objective: To determine if an AMH scoring tool used to allocate resources can decrease 30-day hospital readmissions. Design, Setting, and Participants: Propensity-matched cohort study, Medicine/Surgery patients in large academic safety-net hospital. Intervention or Exposure: Pharmacy-conducted AMHs identified by risk model versus standard of care AMH. Main Outcomes and Measures: A total of 30-day hospital readmissions and inpatient ADE prevention. Results: The model screened 87 240 hospitalizations between June 2017 and June 2019 and 4027 patients per group were included. There were significantly less 30 day readmissions among high-risk identified patients that received a pharmacy-conducted AMH compared to controls (11% vs 15%; P = 0.004) and no significant difference in readmission rates for low-risk patients. While there was significantly higher documentation of major ADE prevention in the pharmacy-led AMH group versus control (1656 vs 12; P < 0.001), there was no difference in electronically-detected inpatient ADEs between groups. Conclusions: A risk tool embedded into the EMR can be used to identify patients whom pharmacy teams can easily target for AMHs. This study showed significant reductions in readmissions for patients identified as high-risk. However, the same benefit in readmissions was not seen in those identified at low-risk, which supports allocating resources to those that will benefit the most.

Calcium and magnesium infusions for prevention of oxaliplatin-induced peripheral neuropathy.

2011 ◽  
Vol 29 (4_suppl) ◽  
pp. 387-387
Author(s):  
M. Bupathi ◽  
G. Mahmud ◽  
J. Kovar ◽  
E. Wang ◽  
T. E. O'Brien
Keyword(s):  
Peripheral Neuropathy ◽  
Cumulative Dose ◽  
Medical Center ◽  
Demographic Data ◽  
Performance Status ◽  
Safety Net ◽  
Control Group ◽  
Minority Population ◽  
Tumor Type ◽  
Safety Net Hospital

387 Background: Oxaliplatin plays an important role in chemotherapy regimens for colorectal and other GI malignancies. Debilitating peripheral neuropathy (PN) often develops with use of this drug. One study (Grothey A et al, ASCO 2009, abst #4025) has shown that pre- and post-oxaliplatin infusions with calcium (Ca) and magnesium (Mg) may reduce this toxicity. To confirm this in an unselected indigent minority population, a retrospective review was performed comparing development of PN in oxaliplatin exposed patients treated with or without Ca/Mg. Methods: Records of patients who received oxaliplatin from 1/2008 to 12/2009 at MetroHealth Medical Center, a large safety net hospital in Cleveland, OH, were reviewed. 47 patients received Ca/Mg + oxaliplatin and 46 oxaliplatin alone. Data collected included age, race, gender, insurance status, performance status, tumor type, stage, concomitant diseases (DM and EtOH), number of cycles and cumulative dose of oxaliplatin. PN was determined using the Common Terminology Criteria of Adverse Events (CTCAE) version 3.0. Patients were followed 6 months after completion of oxaliplatin. Results: Demographic data was similar between the two groups. Colorectal cancer compromised 77% of the treatment group and 85% of control group. Patients who received Ca/Mg had significantly less PN in all three grades (1-3) compared with the control group (grade 1 89.4% vs. 71.7%, grade II 10.6% vs. 19.6%, grade 3 0% vs. 8.7%, respectively). The cumulative dose of oxaliplatin did not differ between the two groups (Ca/Mg median 1,143 range 260-2,169; control median 1,425 range 137-2,635). The combined total grades 2 and 3 in both the treatment and control (10.6% vs. 28.3%, p = 0.038) favored use of Ca/Mg. Conclusions: This small, retrospective study confirms that Ca/Mg infusions reduce the incidence of clinically significant (grade 2/3) PN in pts receiving oxaliplatin. No significant financial relationships to disclose.

scholarly journals Patient and Provider Perspectives on 30-Day Readmissions, Preventability, and Strategies for Improving Transitions of Care for Patients with HIV at a Safety Net Hospital

2019 ◽  
Vol 18 ◽  
pp. 232595821982761
Author(s):  
Ank E. Nijhawan ◽  
Robin T. Higashi ◽  
Emily G. Marks ◽  
Yordanos M. Tiruneh ◽  
Simon Craddock Lee
Keyword(s):  
Hospital Readmissions ◽  
Case Manager ◽  
Safety Net ◽  
Transitions Of Care ◽  
Hiv Positive ◽  
People Living With Hiv ◽  
Medical Provider ◽  
Provider Perspectives ◽  
Safety Net Hospital ◽  
Reduction Strategies

Thirty-day hospital readmissions, a key quality metric, are common among people living with HIV. We assessed perceived causes of 30-day readmissions, factors associated with preventability, and strategies to reduce preventable readmissions and improve continuity of care for HIV-positive individuals. Patient, provider, and staff perspectives toward 30-day readmissions were evaluated in semistructured interviews (n = 86) conducted in triads (HIV-positive patient, medical provider, and case manager) recruited from an inpatient safety net hospital. Iterative analysis included both deductive and inductive themes. Key findings include the following: (1) The 30-day metric should be adjusted for safety net institutions and patients with AIDS; (2) Participants disagreed about preventability, especially regarding patient-level factors; (3) Various stakeholders proposed readmission reduction strategies that spanned the inpatient to outpatient care continuum. Based on these diverse perspectives, we outline multiple interventions, from teach-back patient education to postdischarge home visits, which could substantially decrease hospital readmissions in this underserved population.

scholarly journals 3220 Can you read me now? Clinician variations in managing and responding to secure messages from patients

2019 ◽  
Vol 3 (s1) ◽  
pp. 59-59
Author(s):  
Joy Li-Yueh Lee ◽  
Michael Weiner ◽  
Marianne Matthias
Keyword(s):  
Primary Care ◽  
Medical Center ◽  
Safety Net ◽  
Patient Centeredness ◽  
Cognitive Approach ◽  
Electronic Communications ◽  
Secure Messaging ◽  
Safety Net Hospital ◽  
Primary Care Clinicians

OBJECTIVES/SPECIFIC AIMS: To identify areas of variation in primary care clinician responses to secure messaging and to assess the quality of secure messages by clinicians. METHODS/STUDY POPULATION: This mixed-methods study included twenty one primary care clinicians from a Midwestern safety net hospital and Veterans Affairs medical center. Participants were presented with five short clinical vignettes and corresponding secure messages from hypothetical patients and asked to compose responses. Participants were interviewed about their cognitive approach to the responses as well as perspectives on quality of care as related to electronic communications. RESULTS/ANTICIPATED RESULTS: Every participant recalled having patients who misused secure messaging for urgent issues, suggesting the need for more patient education and the possible adverse consequences of overlooked messages. The study also uncovered key differences in several areas, include clinician timeliness, message management, the circumstances in which they would use messaging, and the content of the messages (including patient-centeredness). While participants agreed that messages about clinical issues should not be resolved via secure messaging, there was a lack of consensus regarding emotionally charged messages and messages dealing with medication adjustments. Some participants spoke of the need for more guidance in knowing when best to use secure messaging. “Sometimes,” one physician said, “it feels like we’re just making up [rules for secure messaging].” Although clinician responses were uniformly respectful, the patient-centeredness varied in the use of jargon and social talk, as well as clarity for patients. DISCUSSION/SIGNIFICANCE OF IMPACT: This study revealed variations in provider approaches to secure messaging, and the content of responses. These variations reflect lack of consensus about how care is delivered via secure messaging, and reveal the need for clinician guidance. They also suggest possible negative patient consequences if secure messaging is used ineffectively. The extent to which variations are undesirable remains unknown. Future work will explore the consequences of such variations.

scholarly journals Predicting diabetes-related hospitalizations based on electronic health records

2018 ◽  
Vol 28 (12) ◽  
pp. 3667-3682 ◽  
Author(s):  
Theodora S Brisimi ◽  
Tingting Xu ◽  
Taiyao Wang ◽  
Wuyang Dai ◽  
Ioannis Ch Paschalidis
Keyword(s):  
New England ◽  
Medical Center ◽  
Computational Cost ◽  
Safety Net ◽  
New Method ◽  
Supervised Machine Learning ◽  
Support Vector ◽  
Large Set ◽  
Machine Learning Classification ◽  
Safety Net Hospital

Objective: To derive a predictive model to identify patients likely to be hospitalized during the following year due to complications attributed to Type II diabetes. Methods: A variety of supervised machine learning classification methods were tested and a new method that discovers hidden patient clusters in the positive class (hospitalized) was developed while, at the same time, sparse linear support vector machine classifiers were derived to separate positive samples from the negative ones (non-hospitalized). The convergence of the new method was established and theoretical guarantees were proved on how the classifiers it produces generalize to a test set not seen during training. Results: The methods were tested on a large set of patients from the Boston Medical Center – the largest safety net hospital in New England. It is found that our new joint clustering/classification method achieves an accuracy of 89% (measured in terms of area under the ROC Curve) and yields informative clusters which can help interpret the classification results, thus increasing the trust of physicians to the algorithmic output and providing some guidance towards preventive measures. While it is possible to increase accuracy to 92% with other methods, this comes with increased computational cost and lack of interpretability. The analysis shows that even a modest probability of preventive actions being effective (more than 19%) suffices to generate significant hospital care savings. Conclusions: Predictive models are proposed that can help avert hospitalizations, improve health outcomes and drastically reduce hospital expenditures. The scope for savings is significant as it has been estimated that in the USA alone, about $5.8 billion are spent each year on diabetes-related hospitalizations that could be prevented.

ChemoPalRx: Development and implementation of a chemotherapy mobile provider order entry system in a safety net hospital.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18071-e18071
Author(s):  
Kin Wai (Tony) Hung ◽  
Natasha Banerjee
Keyword(s):  
Los Angeles ◽  
Mobile Application ◽  
Medical Center ◽  
Hospital Setting ◽  
Safety Net ◽  
Quality Improvement Initiative ◽  
Order Entry ◽  
Development Environment ◽  
Safety Net Hospital ◽  
Safety Parameters

e18071 Background: Computerized provider order entry (CPOE) systems have been shown to enhance the safety and efficiency of prescribing chemotherapy over the handwritten ordering process. However, many institutions lack the financial ability, technological capability, or operational flexibility to invest in and implement such a system. In particular, Olive View-UCLA Medical Center (OVMC), a Los Angeles County safety net hospital, is among these institutions with unique restrictions that preclude the use of chemotherapy CPOE and mandate handwritten orders. Methods: In an effort to bridge the gap for safe chemotherapy prescribing, we aimed to develop and implement an effective, scalable, and sustainable chemotherapy provider order entry solution that was operationally sensitive to institutions without a chemotherapy CPOE. The solution was designed as a mobile application using Xcode, the integrative development environment of Apple Inc., with the Swift programing language. Results: On September 5th, 2018, we launched a free, chemotherapy provider order entry solution on the worldwide Apple App Store – ChemoPalRx. Using ChemoPalRx, providers can search, customize, and print common chemotherapy regimens in prescription format. Along with a reference library of over 120 order set and 450 medications, ChemoPalRx is equipped with the functions to automate dosage calculation, suggest pre-medications and safety parameters, and trigger alerts for missing prescribing information. As a quality improvement initiative, we implemented ChemoPalRx at OVMC. Implementation stages include obtaining administrative buy-in, consulting with multidisciplinary staffs, investing $100 USD for a prescription printer, and encouraging providers to download ChemoPalRx on their own mobile devices. An ongoing prospective cohort study is being conducted to determine ChemoPalRx effectiveness in reducing errors compared to handwritten orders. Conclusions: ChemoPalRx is developed to enhance the safety and efficiency of chemotherapy prescribing. Implementation of this mobile application is feasible in the safety-net hospital setting and has the potential to transform oncology practices globally.

Evaluation of Direct Oral Anticoagulant Dosing and Monitoring in Two Geriatric Outpatient Clinics

2019 ◽  
Vol 34 (3) ◽  
pp. 192-205
Author(s):  
Michelle A. Howerton ◽  
Erin M. Suhrie ◽  
Amelia S. Gennari ◽  
Nancy Jones ◽  
Christine M. Ruby
Keyword(s):  
Medical Center ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Retrospective Chart Review ◽  
Office Visit ◽  
Outpatient Setting ◽  
Primary Objective ◽  
Improvement Project ◽  
Care Institute ◽  
Geriatric Center

OBJECTIVE: This study was conducted to evaluate direct oral anticoagulants (DOACs) prescribed to elderly patients in an outpatient setting, specifically evaluating if Food and Drug Administration (FDA) -approved dosing recommendations are followed.<br/> DESIGN: This study was a retrospective quality improvement project.<br/> SETTING: This study was conducted at geriatric hospital-based primary care clinics at the University of Pittsburgh Medical Center (UPMC), UPMC Senior Care Institute and UPMC Benedum Geriatric Center.<br/> PATIENTS: Subjects included were 65 years of age or older; had an office visit at UPMC Senior Care Institute or UPMC Benedum Geriatric Center from September 1, 2015, to August 31, 2017; and had a DOAC on their home medications.<br/> INTERVENTIONS: Data were obtained through retrospective chart review.<br/> MAIN OUTCOME MEASURE: The primary objective of the study was to evaluate the appropriateness of dosing of DOACs based on FDA-labeled recommendations.<br/> RESULTS: Of 232 patients included in analysis, 42.7% were found to have dosing inconsistent with FDAlabeled recommendations (47.3% apixaban, 35.8% rivaroxaban, and 31.6% dabigatran). No patients were prescribed edoxaban. The majority (72.7%) were dosed lower than FDA-recommended doses. Of all patients, the most frequent parameter (54.5%) for inappropriate dosing was patients meeting only 1 of 3 dose-reduction criteria when prescribed reduced-dose apixaban. Geriatrician and nongeriatrician prescribers had similar rates of prescribing DOACs with doses inconsistent with FDA-labeled recommendations (44.0% vs. 40.8%; P = 0.62).<br/> CONCLUSION: Results suggest that DOACs used in outpatient geriatric patients are frequently dosed inconsistent with FDA-approved dosing recommendations. Further research is needed regarding clinical outcomes in older patients receiving DOACs and in those with dose adjustments inconsistent with FDA-labeled recommendations.<br/>

Abstract 15128: Clinical Outcomes in Heart Failure Patients With Concurrent Cocaine Use

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Jonah D Garry ◽  
Anjali Thakkar ◽  
Yifei Ma ◽  
Rebecca Scherzer ◽  
Priscilla Hsue
Keyword(s):  
Heart Failure ◽  
San Francisco ◽  
Hospital Readmissions ◽  
Safety Net ◽  
Chronic Obstructive ◽  
Day Hospital ◽  
Cocaine Use ◽  
Significant Difference ◽  
Safety Net Hospital ◽  
The Impact

Background: While cocaine use is associated with heart failure (HF) with reduced ejection fraction, the impact of cocaine use on HF outcomes including 30-day hospital readmission and survival has not been well described. Accordingly, this study evaluated the impact of cocaine use on 30-day hospital readmissions (heart failure and all cause) and mortality. Methods: We performed a case control study of HF patients with an index HF hospitalization at an academic safety net hospital in San Francisco between 2001-2019. 746 HF patients with history of cocaine use were matched to 746 HF patients without cocaine use, based on age, gender, and date of index hospitalization. We compared clinical characteristics, readmission rates, and mortality between these two groups. Results: Average age was 53 years and 79% were male. HF patients with cocaine use were more likely to be African American (69.6% vs. 29.8%, p<0.01), have hypertension, liver disease and concurrent use of methamphetamines and opioids. Rates of coronary artery disease, diabetes, chronic kidney disease, HIV, and chronic obstructive pulmonary disease were similar between the groups. There was no significant difference in prescription of guideline directed medical therapies at discharge. Within 30 days of index HF hospitalization, HF patients with cocaine use were more likely to attend follow up (91.8% vs 86.9%, p<0.01), but were more likely to be readmitted for HF (12.1% vs 7.4%, OR 1.75, p<0.01) or other causes (22.4% vs 14.7%, OR 1.67, p<0.01). Over the study period, cocaine use was associated with greater likelihood of death (27.9% vs 20.1%, p<0.01). Conclusions: HF patients with comorbid cocaine use were found to have higher likelihood of readmission or death following index HF hospitalization compared to HF patients without cocaine use. As cocaine use continues to grow it is critical to understand the mechanisms underlying cocaine induced cardiovascular pathophysiology, and to identify factors affecting readmission and mortality in this high risk group.

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