Publications by authors named "Jeffrey Schnipper"

178 Publications

Implementation strategies in the context of medication reconciliation: a qualitative study.

Implement Sci Commun 2021 Jun 10;2(1):63. Epub 2021 Jun 10.

Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, 2525 West End Ave, Suite 1200, Nashville, TN, 37203, USA.

Background: Medication reconciliation (MedRec) is an important patient safety initiative that aims to prevent patient harm from medication errors. Yet, the implementation and sustainability of MedRec interventions have been challenging due to contextual barriers like the lack of interprofessional communication (among pharmacists, nurses, and providers) and limited organizational capacity. How to best implement MedRec interventions remains unclear. Guided by the Expert Recommendations for Implementing Change (ERIC) taxonomy, we report the differing strategies hospital implementation teams used to implement an evidence-based MedRec Toolkit (the MARQUIS Toolkit).

Methods: A qualitative study was conducted with implementation teams and executive leaders of hospitals participating in the federally funded "Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety" (known as MARQUIS2) research study. Data consisted of transcripts from web-based focus groups and individual interviews, as well as meeting minutes. Interview data were transcribed and analyzed using content analysis and the constant comparison technique.

Results: Data were collected from 16 hospitals using 2 focus groups, 3 group interviews, and 11 individual interviews, 10 sites' meeting minutes, and an email interview of an executive. Major categories of implementation strategies predominantly mirrored the ERIC strategies of "Plan," "Educate," "Restructure," and "Quality Management." Participants rarely used the ERIC strategies of finance and attending to policy context. Two new non-ERIC categories of strategies emerged-"Integration" and "Professional roles and responsibilities." Of the 73 specific strategies in the ERIC taxonomy, 32 were used to implement the MARQUIS Toolkit and 11 new, and non-ERIC strategies were identified (e.g., aligning with existing initiatives and professional roles and responsibilities).

Conclusions: Complex interventions like the MARQUIS MedRec Toolkit can benefit from the ERIC taxonomy, but adaptations and new strategies (and even categories) are necessary to fully capture the range of approaches to implementation.
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http://dx.doi.org/10.1186/s43058-021-00162-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193884PMC
June 2021

Predictors and Reasons Why Patients Decline to Participate in Home Hospital: a Mixed Methods Analysis of a Randomized Controlled Trial.

J Gen Intern Med 2021 May 5. Epub 2021 May 5.

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.

Background: Acute care at home ("home hospital") compared to traditional hospital care has been shown to lower cost, utilization, and readmission and improve patient experience and physical activity. Despite these benefits, many patients decline to enroll in home hospital.

Objective: Describe predictors and reasons why patients decline home hospital.

Design: Mixed methods evaluation of a randomized controlled trial.

Participants: Patients in the emergency department who required admission and were accepted for home hospital by the home hospital attending, but ultimately declined to enroll.

Intervention: Home hospital care, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.

Approach: We conducted a thematic content analysis of verbatim reasons for decline. We performed bivariate comparisons then multivariable logistic regression to identify patient characteristics associated with declining participation.

Key Results: Two hundred forty-eight patients were eligible to enroll, and 157 (63%) declined enrollment. Patients who declined and enrolled were of similar age (median age, 74 vs 75 years old; p = 0.27), sex (32% vs 36% female; p = 0.49), and race/ethnicity (p = 0.26). In multivariable analysis, patients were significantly more likely to decline if they initially presented at the community hospital compared to the academic medical center (53% vs 42%; adjusted OR, 2.2 [95% CI, 1.2 to 4.2]) and if single (37% v 24%; adjusted OR, 2.5 [95% CI, 1.2 to 5.1]). We formulated 10 qualitative categories describing reasons patients ultimately declined. Many patients declined because they felt it was easier to remain in the hospital (20%) or felt safer in the hospital than in their home (20%).

Conclusions: Patients who declined to enroll in a home hospital intervention had similar sociodemographic characteristics as enrollees except partner status and declined most often for perceptions surrounding safety at home and the ease of remaining in the hospital.

Trial Registration: NCT03203759.
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http://dx.doi.org/10.1007/s11606-021-06833-2DOI Listing
May 2021

The Pharmacist Discharge Care (PHARM-DC) study: A multicenter RCT of pharmacist-directed transitional care to reduce post-hospitalization utilization.

Contemp Clin Trials 2021 Jul 28;106:106419. Epub 2021 Apr 28.

Brigham Health Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.

Background: Older adults commonly face challenges in understanding, obtaining, administering, and monitoring medication regimens after hospitalization. These difficulties can lead to avoidable morbidity, mortality, and hospital readmissions. Pharmacist-led peri-discharge interventions can reduce adverse drug events, but few large randomized trials have examined their effectiveness in reducing readmissions. Demonstrating reductions in 30-day readmissions can make a financial case for implementing pharmacist-led programs across hospitals.

Methods/design: The PHARMacist Discharge Care, or the PHARM-DC intervention, includes medication reconciliation at admission and discharge, medication review, increased communication with caregivers, providers, and retail pharmacies, and patient education and counseling during and after discharge. The intervention is being implemented in two large hospitals: Cedars-Sinai Medical Center and the Brigham and Women's Hospital. To evaluate the intervention, we are using a pragmatic, randomized clinical trial design with randomization at the patient level. The primary outcome is utilization within 30 days of hospital discharge, including unforeseen emergency department visits, observation stays, and readmissions. Randomizing 9776 patients will achieve 80% power to detect an absolute reduction of 2.5% from an estimated baseline rate of 27.5%. Qualitative analysis will use interviews with key stakeholders to study barriers to and facilitators of implementing PHARM-DC. A cost-effectiveness analysis using a time-and-motion study to estimate time spent on the intervention will highlight the potential cost savings per readmission.

Discussion: If this trial demonstrates a business case for the PHARM-DC intervention, with few barriers to implementation, hospitals may be much more likely to adopt pharmacist-led peri-discharge medication management programs.

Trial Registration: ClinicalTrials.gov Identifier: NCT04071951.
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http://dx.doi.org/10.1016/j.cct.2021.106419DOI Listing
July 2021

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

BMJ Qual Saf 2021 Apr 29. Epub 2021 Apr 29.

Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: The first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals.

Methods: We conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression.

Results: A total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions.

Conclusion: A multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.
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http://dx.doi.org/10.1136/bmjqs-2020-012709DOI Listing
April 2021

Discharge Practices for COVID-19 Patients: Rapid Review of Published Guidance and Synthesis of Documents and Practices at 22 US Academic Medical Centers.

J Gen Intern Med 2021 06 9;36(6):1715-1721. Epub 2021 Apr 9.

Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: There are currently no evidence-based guidelines that provide standardized criteria for the discharge of COVID-19 patients from the hospital.

Objective: To address this gap in practice guidance, we reviewed published guidance and collected discharge protocols and procedures to identify and synthesize common practices.

Design: Rapid review of existing guidance from US and non-US public health organizations and professional societies and qualitative review using content analysis of discharge documents collected from a national sample of US academic medical centers with follow-up survey of hospital leaders SETTING AND PARTICIPANTS: We reviewed 65 websites for major professional societies and public health organizations and collected documents from 22 Academic Medical Centers (AMCs) in the US participating in the HOspital MEdicine Reengineering Network (HOMERuN).

Results: We synthesized data regarding common practices around 5 major domains: (1) isolation and transmission mitigation; (2) criteria for discharge to non-home settings including skilled nursing, assisted living, or homeless; (3) clinical criteria for discharge including oxygenation levels, fever, and symptom improvement; (4) social support and ability to perform activities of daily living; (5) post-discharge instructions, monitoring, and follow-up.

Limitations: We used streamlined methods for rapid review of published guidance and collected discharge documents only in a focused sample of US academic medical centers.

Conclusion: AMCs studied showed strong consensus on discharge practices for COVID-19 patients related to post-discharge isolation and transmission mitigation for home and non-home settings. There was high concordance among AMCs that discharge practices should address COVID-19-specific factors in clinical, functional, and post-discharge monitoring domains although definitions and details varied.
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http://dx.doi.org/10.1007/s11606-021-06711-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034037PMC
June 2021

Racial/Ethnic Disparities in Interhospital Transfer for Conditions With a Mortality Benefit to Transfer Among Patients With Medicare.

JAMA Netw Open 2021 03 1;4(3):e213474. Epub 2021 Mar 1.

Harvard Medical School, Boston, Massachusetts.

Importance: Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Racial/ethnic disparities are prevalent throughout US health care, but their presence in IHT is not well characterized.

Objective: To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit.

Design, Setting, And Participants: This cross-sectional analysis used 2013 data from the Center for Medicare & Medicaid Services 100% Master Beneficiary Summary and Inpatient Claims merged with 2013 American Hospital Association data. Individuals with Medicare aged 65 years or older continuously enrolled in Medicare Part A and B with an inpatient hospitalization claim in 2013 for primary diagnosis of acute myocardial infarction, stroke, sepsis, or respiratory diseases were included. Data analysis occurred from November 2019 through July 2020.

Exposures: Race/ethnicity.

Main Outcomes And Measures: The primary outcome of interest was IHT. For the primary analysis, a series of logistic regression models were created to estimate the adjusted odds of IHT for Black and Hispanic patients compared with White patients, controlling for patient clinical and demographic variables and incorporating hospital fixed effects. In secondary analyses, subgroup analyses were conducted by diagnosis, hospital teaching status, and hospitalization to hospitals in the top decile of Black and Hispanic patient proportion.

Results: Among 899 557 patients, 734 958 patients were White (81.7%), 84 544 patients were Black (9.4%), and 47 588 patients were Hispanic (5.3%); there were 418 683 men (46.5%), and 306 215 patients (34.0%) were older than 84 years. The mean (SD) age was 76.8 (7.5) years. Among all patients, 20 171 White patients (2.7%), 1913 Black patients (2.3%), and 1062 Hispanic patients (2.2%) underwent IHT. After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT (adjusted odds ratio, 0.87; 95% CI, 0.81-0.92; P < .001), while Hispanic patients had higher odds of IHT (adjusted odds ratio, 1.14; 95% CI, 1.05-1.24; P = .002) compared with White patients.

Conclusions And Relevance: This national evaluation of IHT among patients hospitalized with diagnoses previously found to have mortality benefit with transfer found that, compared with White patients, Black patients had persistently lower adjusted odds of transfer after accounting for patient and hospital characteristics and measured across various hospital settings. Meanwhile, Hispanic patients had higher adjusted odds of transfer. This research highlights the need for the development of strategies to mitigate disparate transfer practices by patient race/ethnicity.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.3474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7998076PMC
March 2021

Tools and tactics for postdischarge medication management interventions.

Am J Health Syst Pharm 2021 03;78(7):619-632

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.

Purpose: To identify interventions for organizational pharmacist-leaders and frontline pharmacy staff to optimize peri- and postdischarge medication management.

Summary: An evidence-based toolkit was systematically constructed on the basis of findings of 3 systematic overviews of systematic reviews. The interventions were reviewed by a technical expert panel and categorized as either tools or tactics. The identified tools are instruments such as diagrams, flow charts, lists, tables, and templates used in performing a distinct operation, whereas identified tactics reflect broader methods (eg, reduced dosing frequency). Tools and tactics were chosen on the basis of their potential to improve postdischarge medication management, with a focus on interventions led by pharmacy staff that may reduce hospital readmissions among older, sicker patients. Overall, 23 tools and 2 tactics were identified. The identified tools include items such as education, text messaging, and phone calls. The tactics identified are dose simplification and monetary incentives. Practical information has also been provided to facilitate implementation.

Conclusion: Several tools and tactics are available to optimize peri- and postdischarge medication management. Organizational pharmacist-leaders and frontline pharmacy staff can implement these interventions to improve patient outcomes.
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http://dx.doi.org/10.1093/ajhp/zxab010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970403PMC
March 2021

Hospital-Level Care at Home for Acutely Ill Adults: a Qualitative Evaluation of a Randomized Controlled Trial.

J Gen Intern Med 2021 Jan 21. Epub 2021 Jan 21.

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.

Background: Substitutive hospital-level care in a patient's home ("home hospital") has been shown to lower cost, utilization, and readmission compared to traditional hospital care. However, patients' perspectives to help explain how and why interventions like home hospital accomplish many of these results are lacking.

Objective: Elucidate and explain patient perceptions of home hospital versus traditional hospital care to better describe the different perceptions of care in both settings.

Design: Qualitative evaluation of a randomized controlled trial.

Participants: 36 hospitalized patients (19 home; 17 control).

Intervention: Traditional hospital ("control") versus home hospital ("home"), including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.

Approach: We conducted a thematic content analysis of semi-structured interviews. Team members developed a coding structure through a multiphase approach, utilizing a constant comparative method.

Key Results: Themes clustered around 3 domains: clinician factors, factors promoting healing, and systems factors. Clinician factors were similar in both groups; both described beneficial interactions with clinical staff; however, home patients identified greater continuity of care. For factors promoting healing, home patients described a locus of control surrounding their sleep, activity, and environmental comfort that control patients lacked. For systems factors, home patients experienced more efficient processes and logistics, particularly around admission and technology use, while both noted difficulty with discharge planning.

Conclusions: Compared to control patients, home patients had better experiences with their care team, had more experiences promoting healing such as better sleep and physical activity, and had better experiences with systems factors such as the admission processes. Potential explanations include continuity of care, the power and familiarity of the home, and streamlined logistics. Future improvements include enhanced care transitions and ensuring digital interfaces are usable.

Trial Registration: NCT03203759.
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http://dx.doi.org/10.1007/s11606-020-06416-7DOI Listing
January 2021

Evaluation of electronic health record-integrated digital health tools to engage hospitalized patients in discharge preparation.

J Am Med Inform Assoc 2021 Mar;28(4):704-712

Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: To evaluate the effect of electronic health record (EHR)-integrated digital health tools comprised of a checklist and video on transitions-of-care outcomes for patients preparing for discharge.

Materials And Methods: English-speaking, general medicine patients (>18 years) hospitalized at least 24 hours at an academic medical center in Boston, MA were enrolled before and after implementation. A structured checklist and video were administered on a mobile device via a patient portal or web-based survey at least 24 hours prior to anticipated discharge. Checklist responses were available for clinicians to review in real time via an EHR-integrated safety dashboard. The primary outcome was patient activation at discharge assessed by patient activation (PAM)-13. Secondary outcomes included postdischarge patient activation, hospital operational metrics, healthcare resource utilization assessed by 30-day follow-up calls and administrative data and change in patient activation from discharge to 30 days postdischarge.

Results: Of 673 patients approached, 484 (71.9%) enrolled. The proportion of activated patients (PAM level 3 or 4) at discharge was nonsignificantly higher for the 234 postimplementation compared with the 245 preimplementation participants (59.8% vs 56.7%, adjusted OR 1.23 [0.38, 3.96], P = .73). Postimplementation participants reported 3.75 (3.02) concerns via the checklist. Mean length of stay was significantly higher for postimplementation compared with preimplementation participants (10.13 vs 6.21, P < .01). While there was no effect on postdischarge outcomes, there was a nonsignificant decrease in change in patient activation within participants from pre- to postimplementation (adjusted difference-in-difference of -16.1% (9.6), P = .09).

Conclusions: EHR-integrated digital health tools to prepare patients for discharge did not significantly increase patient activation and was associated with a longer length of stay. While issues uncovered by the checklist may have encouraged patients to inquire about their discharge preparedness, other factors associated with patient activation and length of stay may explain our observations. We offer insights for using PAM-13 in context of real-world health-IT implementations.

Trial Registration: NIH US National Library of Medicine, NCT03116074, clinicaltrials.gov.
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http://dx.doi.org/10.1093/jamia/ocaa321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973476PMC
March 2021

The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial.

J Hosp Med 2021 01;16(1):15-22

Harvard Medical School, Boston, Massachusetts.

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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http://dx.doi.org/10.12788/jhm.3513DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7768916PMC
January 2021

COVID-19 coagulopathy and thrombosis: Analysis of hospital protocols in response to the rapidly evolving pandemic.

Thromb Res 2020 12 16;196:355-358. Epub 2020 Sep 16.

Division of Hospital Medicine, University of California, San Francisco, CA, USA. Electronic address:

As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines.
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http://dx.doi.org/10.1016/j.thromres.2020.09.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492800PMC
December 2020

Association of patterns of multimorbidity with length of stay: A multinational observational study.

Medicine (Baltimore) 2020 Aug;99(34):e21650

Harvard Medical School, Boston, MA.

The aim of this study was to identify the combinations of chronic comorbidities associated with length of stay (LOS) among multimorbid medical inpatients.Multinational retrospective cohort of 126,828 medical inpatients with multimorbidity, defined as ≥2 chronic diseases (data collection: 2010-2011). We categorized the chronic diseases into comorbidities using the Clinical Classification Software. We described the 20 combinations of comorbidities with the strongest association with prolonged LOS, defined as longer than or equal to country-specific LOS, and reported the difference in median LOS for those combinations. We also assessed the association between the number of diseases or body systems involved and prolonged LOS.The strongest association with prolonged LOS (odds ratio [OR] 7.25, 95% confidence interval [CI] 6.64-7.91, P < 0.001) and the highest difference in median LOS (13 days, 95% CI 12.8-13.2, P < 0.001) were found for the combination of diseases of white blood cells and hematological malignancy. Other comorbidities found in the 20 top combinations had ORs between 2.37 and 3.65 (all with P < 0.001) and a difference in median LOS of 2 to 5 days (all with P < 0.001), and included mostly neurological disorders and chronic ulcer of skin. Prolonged LOS was associated with the number of chronic diseases and particularly with the number of body systems involved (≥7 body systems: OR 21.50, 95% CI 19.94-23.18, P < 0.001).LOS was strongly associated with specific combinations of comorbidities and particularly with the number of body systems involved. Describing patterns of multimorbidity associated with LOS may help hospitals anticipate resource utilization and judiciously allocate services to shorten LOS.
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http://dx.doi.org/10.1097/MD.0000000000021650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447409PMC
August 2020

I-PASS Mentored Implementation Handoff Curriculum: Frontline Provider Training Materials.

MedEdPORTAL 2020 06 22;16:10912. Epub 2020 Jun 22.

Deputy Director, Education, Training, and Research, Walter Reed National Military Medical Center; Professor, Department of Pediatrics, Uniformed Services University of the Health Sciences.

Introduction: The I-PASS Handoff Program is a comprehensive handoff curriculum that has been shown to decrease rates of medical errors and adverse events during patient handoffs. Frontline providers are the key individuals participating in handoffs of patient care. It is important they receive robust handoff training.

Methods: The I-PASS Mentored Implementation Handoff Curriculum frontline provider training materials were created as part of the original I-PASS Study and adapted for the Society of Hospital Medicine (SHM) I-PASS Mentored Implementation Program. The adapted materials embrace a flipped classroom approach with an emphasis on adult learning theory principles. The training includes an overview of I-PASS handoff techniques, TeamSTEPPS team communication strategies, verbal handoff simulation scenarios, and a printed handoff document exercise.

Results: As part of the SHM I-PASS Mentored Implementation Program, 2,735 frontline providers were trained at 32 study sites (16 adult and 16 pediatric) across North America. At the end of their training, 1,762 frontline providers completed the workshop evaluation form (64% response rate). After receiving the training, over 90% agreed/strongly agreed that they were able to distinguish a good- from a poor-quality handoff, articulate the elements of the I-PASS mnemonic, construct a high-quality patient summary, advocate for an appropriate environment for handoffs, and participate in handoff simulations. Universally, the training provided them with knowledge and skills relevant to their patient care activities.

Discussion: The I-PASS frontline training materials were rated highly by those trained and are an integral part of a successful I-PASS Handoff Program implementation.
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http://dx.doi.org/10.15766/mep_2374-8265.10912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375701PMC
June 2020

Identifying Racial/Ethnic Disparities in Interhospital Transfer: an Observational Study.

J Gen Intern Med 2020 10 22;35(10):2939-2946. Epub 2020 Jul 22.

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.

Background: Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ethnic disparities in IHT have been suggested but are not well-characterized.

Objective: To evaluate the association between race/ethnicity and IHT.

Design: Cross-sectional analysis of 2016 National Inpatient Sample data.

Patients: Patients aged ≥ 18 years old with common medical diagnoses at transfer, including acute myocardial infarction, congestive heart failure, arrhythmia, stroke, sepsis, pneumonia, and gastrointestinal bleed.

Main Measures: We performed a series of logistic regression models to estimate adjusted odds of transfer by race/ethnicity controlling for patient demographics, clinical variables, and hospital characteristics and to identify potential mediators. In secondary analyses, we estimated adjusted odds of transfer among patients at community hospitals (those more likely to transfer patients) and performed subgroup analyses by region and primary medical diagnosis.

Key Results: Of 5,774,175 weighted hospital admissions, 199,015 (4.5%) underwent IHT, including 4.7% of White patients, compared with 3.9% of Black patients and 3.8% of Hispanic patients. Black (OR 0.83, 95% CI 0.78-0.89) and Hispanic (OR 0.81, 95% CI 0.75-0.87) patients had lower crude odds of transfer compared with White patients, but this became non-significant after adjusting for hospital-level characteristics. In secondary analyses among patients hospitalized at community hospitals, Hispanic patients had lower adjusted odds of transfer (aOR 0.89, 95% CI 0.79-0.98). Disparities in IHT by race/ethnicity varied by region and medical diagnosis.

Conclusions: Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.
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http://dx.doi.org/10.1007/s11606-020-06046-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572909PMC
October 2020

Post-Discharge Adverse Events Among African American and Caucasian Patients of an Urban Community Hospital.

J Racial Ethn Health Disparities 2021 04 17;8(2):439-447. Epub 2020 Jun 17.

Department of Family Medicine & Public Health Sciences, Wayne State University School of Medicine, 3939 Woodward Ave, Room 327, Detroit, MI, 48201, USA.

Background: Patient safety during the post-discharge period is a major public health concern. Racial differences on incidence and risk factors associated with post-discharge adverse events (AEs) are understudied. The aim of the study was to examine the differences on the incidence of post-discharge AEs and the associated risk factors between African American and Caucasian patients.

Methods: This was a prospective cohort study of patients at risk for post-discharge AEs from December 2011 to October 2012. We included 589 patients who were African American or Caucasian and discharged home from an urban community hospital. The patients spoke English and could be contacted after discharge for evaluation. Two nurses performed 30-day post-discharge telephone interviews, and two physicians adjudicated health records to determine AEs using a previously established methodology.

Results: African American patients had a slightly higher incidence of post-discharge AEs than Caucasian patients (30.6 vs. 29.9%), although the difference did not show statistical significance. The multivariable logistic regression model indicated that post-discharge AEs were associated with timely follow-up and the number of secondary discharge diagnoses. In subgroup analyses of the risk factors in each racial group separately, only timely follow-up ambulatory visits were associated with post-discharge AEs.

Conclusion: Post-discharge AEs were experienced by a large proportion of both African American and Caucasian patients, and there was no statistically significant difference in these proportions by race.
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http://dx.doi.org/10.1007/s40615-020-00800-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744302PMC
April 2021

Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative.

Am J Med 2020 05;133 Suppl 1:1-27

Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.

Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.
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http://dx.doi.org/10.1016/j.amjmed.2019.12.001DOI Listing
May 2020

Interactive Digital Health Tools to Engage Patients and Caregivers in Discharge Preparation: Implementation Study.

J Med Internet Res 2020 04 28;22(4):e15573. Epub 2020 Apr 28.

Brigham and Women's Hospital, Boston, MA, United States.

Background: Poor discharge preparation during hospitalization may lead to adverse events after discharge. Checklists and videos that systematically engage patients in preparing for discharge have the potential to improve safety, especially when integrated into clinician workflow via the electronic health record (EHR).

Objective: This study aims to evaluate the implementation of a suite of digital health tools integrated with the EHR to engage hospitalized patients, caregivers, and their care team in preparing for discharge.

Methods: We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify pertinent research questions related to implementation. We iteratively refined patient and clinician-facing intervention components using a participatory process involving end users and institutional stakeholders. The intervention was implemented at a large academic medical center from December 2017 to July 2018. Patients who agreed to participate were coached to watch a discharge video, complete a checklist assessing discharge readiness, and request postdischarge text messaging with a physician 24 to 48 hours before their expected discharge date, which was displayed via a patient portal and bedside display. Clinicians could view concerns reported by patients based on their checklist responses in real time via a safety dashboard integrated with the EHR and choose to open a secure messaging thread with the patient for up to 7 days after discharge. We used mixed methods to evaluate our implementation experience.

Results: Of 752 patient admissions, 510 (67.8%) patients or caregivers participated: 416 (55.3%) watched the video and completed the checklist, and 94 (12.5%) completed the checklist alone. On average, 4.24 concerns were reported per each of the 510 checklist submissions, most commonly about medications (664/2164, 30.7%) and follow-up (656/2164, 30.3%). Of the 510 completed checklists, a member of the care team accessed the safety dashboard to view 210 (41.2%) patient-reported concerns. For 422 patient admissions where postdischarge messaging was available, 141 (33.4%) patients requested this service; of these, a physician initiated secure messaging for 3 (2.1%) discharges. Most patient survey participants perceived that the intervention promoted self-management and communication with their care team. Patient interview participants endorsed gaps in communication with their care team and thought that the video and checklist would be useful closer toward discharge. Clinicians participating in focus groups perceived the value for patients but suggested that low awareness and variable workflow regarding the intervention, lack of technical optimization, and inconsistent clinician leadership limited the use of clinician-facing components.

Conclusions: A suite of EHR-integrated digital health tools to engage patients, caregivers, and clinicians in discharge preparation during hospitalization was feasible, acceptable, and valuable; however, important challenges were identified during implementation. We offer strategies to address implementation barriers and promote adoption of these tools.

Trial Registration: ClinicalTrials.gov NCT03116074; https://clinicaltrials.gov/ct2/show/NCT03116074.
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http://dx.doi.org/10.2196/15573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218608PMC
April 2020

An initiative to improve advanced notification of inter-hospital transfers.

Healthc (Amst) 2020 Jun 18;8(2):100423. Epub 2020 Mar 18.

Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.

Poor communication during inter-hospital transfer (IHT, the transfer of patients between acute care hospitals) is common. Clinicians often report feeling unprepared to care for IHT patients due to inadequate advance notification. The aim of this project was to improve advance notification of general medicine service patient transfers to a tertiary care referral hospital. We used quality improvement principles to design and implement two interventions: (1) Use of a checklist; (2) Redesign role/responsibilities within the Access Center and Bed Control Department. Data on frequency of advance notification was collected over 9 months and plotted on a statistical process control chart with evaluation for special cause variation. We also evaluated barriers/facilitators to implementation and surveyed clinicians on information received with the advance notification. 103 patients underwent IHT during the study. Frequency of advance notification increased from a baseline of 63.6%-85.4% post-intervention. Several contributors to successful implementation were identified, including ensuring key stakeholder input and leveraging existing systems structure, among others. Survey results highlighted potential targets for future IHT improvements such as improved clinical information available to admitting clinicians in advance of patient transfer. In conclusion, we successfully improved advance notification of IHT, an essential step to improve communication. Next steps include sustainment and automation of these efforts and ongoing targeted process improvement efforts with an ultimate goal of improving patient outcomes during IHT.
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http://dx.doi.org/10.1016/j.hjdsi.2020.100423DOI Listing
June 2020

Patterns of multimorbidity in medical inpatients: a multinational retrospective cohort study.

Intern Emerg Med 2020 10 16;15(7):1207-1217. Epub 2020 Mar 16.

Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.

Multimorbidity is frequent and represents a significant burden for patients and healthcare systems. However, there are limited data on the most common combinations of comorbidities in multimorbid patients. We aimed to describe and quantify the most common combinations of comorbidities in multimorbid medical inpatients. We used a large retrospective cohort of adults discharged from the medical department of 11 hospitals across 3 countries (USA, Switzerland, and Israel) between 2010 and 2011. Diseases were classified into acute versus chronic. Chronic diseases were grouped into clinically meaningful categories of comorbidities. We identified the most prevalent combinations of comorbidities and compared the observed and expected prevalence of the combinations. We assessed the distribution of acute and chronic diseases and the median number of body systems in relationship to the total number of diseases. Eighty-six percent (n = 126,828/147,806) of the patients were multimorbid (≥ 2 chronic diseases), with a median of five chronic diseases; 13% of the patients had ≥ 10 chronic diseases. Among the most frequent combinations of comorbidities, the most prevalent comorbidity was chronic heart disease. Other high prevalent comorbidities included mood disorders, arthropathy and arthritis, and esophageal disorders. The ratio of chronic versus acute diseases was approximately 2:1. Multimorbidity affected almost 90% of patients, with a median of five chronic diseases. Over 10% had ≥ 10 chronic diseases. This identification and quantification of frequent combinations of comorbidities among multimorbid medical inpatients may increase awareness of what should be taken into account when treating such patients, a growth in the need for special care considerations.
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http://dx.doi.org/10.1007/s11739-020-02306-2DOI Listing
October 2020

Clinicians' Attitudes and System Capacity Regarding Transitional Care Practices Within a Health System: Survey Results From the Partners-PCORI Transitions Study.

J Patient Saf 2020 Mar 13. Epub 2020 Mar 13.

From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.

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.
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http://dx.doi.org/10.1097/PTS.0000000000000664DOI Listing
March 2020

Assessing the cognitive and work load of an inpatient safety dashboard in the context of opioid management.

Appl Ergon 2020 May 31;85:103047. Epub 2020 Jan 31.

Healthcare Systems Engineering Institute, Northeastern University, Boston, MA, USA; College of Engineering, Northeastern University, Boston, MA, USA. Electronic address:

For health information technology to realize its potential to improve flow, care, and patient safety, applications should be intuitive to use and burden neutral for frontline clinicians. We assessed the impact of a patient safety dashboard on clinician cognitive and work load within a simulated information-seeking task for safe inpatient opioid medication management. Compared to use of an electronic health record for the same task, the dashboard was associated with significantly reduced time on task, mouse clicks, and mouse movement (each p < 0.001), with no significant increases in cognitive load nor task inaccuracy. Cognitive burden was higher for users with less experience, possibly partly attributable to usability issues identified during this study. Findings underscore the importance of assessing the usability, cognitive, and work load analysis during the design and implementation of health information technology applications.
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http://dx.doi.org/10.1016/j.apergo.2020.103047DOI Listing
May 2020

Best Definitions of Multimorbidity to Identify Patients With High Health Care Resource Utilization.

Mayo Clin Proc Innov Qual Outcomes 2020 Feb 14;4(1):40-49. Epub 2020 Jan 14.

Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.

Objective: To compare different definitions of multimorbidity to identify patients with higher health care resource utilization.

Patients And Methods: We used a multinational retrospective cohort including 147,806 medical inpatients discharged from 11 hospitals in 3 countries (United States, Switzerland, and Israel) between January 1, 2010, and December 31, 2011. We compared the area under the receiver operating characteristic curve (AUC) of 8 definitions of multimorbidity, based on codes defining health conditions, the Deyo-Charlson Comorbidity Index, the Elixhauser-van Walraven Comorbidity Index, body systems, or Clinical Classification Software categories to predict 30-day hospital readmission and/or prolonged length of stay (longer than or equal to the country-specific upper quartile). We used a lower (yielding sensitivity ≥90%) and an upper (yielding specificity ≥60%) cutoff to create risk categories.

Results: Definitions had poor to fair discriminatory power in the derivation (AUC, 0.61-0.65) and validation cohorts (AUC, 0.64-0.71). The definitions with the highest AUC were number of (1) health conditions with involvement of 2 or more body systems, (2) body systems, (3) Clinical Classification Software categories, and (4) health conditions. At the upper cutoff, sensitivity and specificity were 65% to 79% and 50% to 53%, respectively, in the validation cohort; of the 147,806 patients, 5% to 12% (7474 to 18,008) were classified at low risk, 38% to 55% (54,484 to 81,540) at intermediate risk, and 32% to 50% (47,331 to 72,435) at high risk.

Conclusion: Of the 8 definitions of multimorbidity, 4 had comparable discriminatory power to identify patients with higher health care resource utilization. Of these 4, the number of health conditions may represent the easiest definition to apply in clinical routine. The cutoff chosen, favoring sensitivity or specificity, should be determined depending on the aim of the definition.
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http://dx.doi.org/10.1016/j.mayocpiqo.2019.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011007PMC
February 2020

Use, Perceived Usability, and Barriers to Implementation of a Patient Safety Dashboard Integrated within a Vendor EHR.

Appl Clin Inform 2020 01 15;11(1):34-45. Epub 2020 Jan 15.

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States.

Background: Preventable adverse events continue to be a threat to hospitalized patients. Clinical decision support in the form of dashboards may improve compliance with evidence-based safety practices. However, limited research describes providers' experiences with dashboards integrated into vendor electronic health record (EHR) systems.

Objective: This study was aimed to describe providers' use and perceived usability of the Patient Safety Dashboard and discuss barriers and facilitators to implementation.

Methods: The Patient Safety Dashboard was implemented in a cluster-randomized stepped wedge trial on 12 units in neurology, oncology, and general medicine services over an 18-month period. Use of the Dashboard was tracked during the implementation period and analyzed in-depth for two 1-week periods to gather a detailed representation of use. Providers' perceptions of tool usability were measured using the Health Information Technology Usability Evaluation Scale (rated 1-5). Research assistants conducted field observations throughout the duration of the study to describe use and provide insight into tool adoption.

Results: The Dashboard was used 70% of days the tool was available, with use varying by role, service, and time of day. On general medicine units, nurses logged in throughout the day, with many logins occurring during morning rounds, when not rounding with the care team. Prescribers logged in typically before and after morning rounds. On neurology units, physician assistants accounted for most logins, accessing the Dashboard during daily brief interdisciplinary rounding sessions. Use on oncology units was rare. Satisfaction with the tool was highest for perceived ease of use, with attendings giving the highest rating (4.23). The overall lowest rating was for quality of work life, with nurses rating the tool lowest (2.88).

Conclusion: This mixed methods analysis provides insight into the use and usability of a dashboard tool integrated within a vendor EHR and can guide future improvements and more successful implementation of these types of tools.
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http://dx.doi.org/10.1055/s-0039-3402756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6962088PMC
January 2020

Impact of Medications for Opioid Use Disorder on Discharge Against Medical Advice Among People Who Inject Drugs Hospitalized for Infective Endocarditis.

Am J Addict 2020 03 12;29(2):155-159. Epub 2020 Jan 12.

Harvard Medical School, Boston, Massachusetts.

Background And Objectives: The impact of medications for opioid use disorder (MOUD) on against medical advice (AMA) discharges among people who inject drugs (PWID) hospitalized for endocarditis is unknown.

Methods: A retrospective review of all PWID hospitalized for endocarditis at our institution between 2016 and 2018 (n = 84).

Results: PWID engaged with MOUD at admission, compared with those who were not, were less likely to be discharged AMA but this did not reach statistical significance in adjusted analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.033-1.41; P  = .11). Among out-of-treatment individuals, newly initiating MOUD did not lead to significantly fewer AMA discharges (OR, 0.98; 95% CI, 0.26-3.7; P = .98).

Conclusion And Scientific Significance: PWID hospitalized for endocarditis are at high risk for discharge AMA but more research is needed to understand the impact of MOUD. (Am J Addict 2020;29:155-159).
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http://dx.doi.org/10.1111/ajad.13000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035155PMC
March 2020

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

Am J Health Syst Pharm 2020 01;77(2):128-137

Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, and Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN.

Purpose: High-quality medication reconciliation reduces medication discrepancies, but smaller hospitals serving rural patients may have difficulty implementing this because of limited resources. We sought to adapt and implement an evidence-based toolkit of best practices for medication reconciliation in smaller hospitals, evaluate the effect on unintentional medication discrepancies, and assess facilitators and barriers to implementation.

Methods: We conducted a 2-year mentored-implementation quality improvement feasibility study in 3 Veterans Affairs (VA) hospitals serving rural patients. The primary outcome was unintentional medication discrepancies per medication per patient, determined by comparing the "gold standard" preadmission medication history to the documented preadmission medication list and admission and discharge orders.

Results: In total, 797 patients were included; their average age was 68.7 years, 94.4% were male, and they were prescribed an average of 9.6 medications. Sites 2 and 3 implemented toolkit interventions, including clarifying roles among clinical personnel, educating providers on taking a best possible medication history, and hiring pharmacy professionals to obtain a best possible medication history and perform discharge medication reconciliation. Site 1 did not implement an intervention. Discrepancies improved in intervention patients compared with controls at Site 3 (adjusted incidence rate ratio [IRR], 0.55; 95% confidence interval [CI], 0.45-0.67) but increased in intervention patients compared with controls at Site 2 (adjusted IRR, 1.22; 95% CI, 1.08-1.36).

Conclusions: An evidence-based toolkit for medication reconciliation adapted to the VA setting was adopted in 2 of 3 small, rural, resource-limited hospitals, resulting in both reduced and increased unintentional medication discrepancies. We highlight facilitators and barriers to implementing evidence-based medication reconciliation in smaller hospitals.
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http://dx.doi.org/10.1093/ajhp/zxz275DOI Listing
January 2020

Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial.

Ann Intern Med 2020 01 17;172(2):77-85. Epub 2019 Dec 17.

Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (D.M.L., K.O., B.B., A.S., J.L.S.).

Background: Substitutive hospital-level care in a patient's home may reduce cost, health care use, and readmissions while improving patient experience, although evidence from randomized controlled trials in the United States is lacking.

Objective: To compare outcomes of home hospital versus usual hospital care for patients requiring admission.

Design: Randomized controlled trial. (ClinicalTrials.gov: NCT03203759).

Setting: Academic medical center and community hospital.

Patients: 91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions.

Intervention: Acute care at home, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.

Measurements: The primary outcome was the total direct cost of the acute care episode (sum of costs for nonphysician labor, supplies, medications, and diagnostic tests). Secondary outcomes included health care use and physical activity during the acute care episode and at 30 days.

Results: The adjusted mean cost of the acute care episode was 38% (95% CI, 24% to 49%) lower for home patients than control patients. Compared with usual care patients, home patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%). Home patients spent a smaller proportion of the day sedentary (median, 12% vs. 23%) or lying down (median, 18% vs. 55%) and were readmitted less frequently within 30 days (7% vs. 23%).

Limitation: The study involved 2 sites, a small number of home physicians, and a small sample of highly selected patients (with a 63% refusal rate among potentially eligible patients); these factors may limit generalizability.

Conclusion: Substitutive home hospitalization reduced cost, health care use, and readmissions while increasing physical activity compared with usual hospital care.

Primary Funding Source: Partners HealthCare Center for Population Health and internal departmental funds.
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http://dx.doi.org/10.7326/M19-0600DOI Listing
January 2020

Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center.

J Am Med Inform Assoc 2020 02;27(2):301-307

Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: The objective of this paper is to share challenges, recommendations, and lessons learned regarding the development and implementation of a Patient Safety Learning Laboratory (PSLL) project, an innovative and complex intervention comprised of a suite of Health Information Technology (HIT) tools integrated with a newly implemented Electronic Health Record (EHR) vendor system in the acute care setting at a large academic center.

Materials And Methods: The PSLL Administrative Core engaged stakeholders and study personnel throughout all phases of the project: problem analysis, design, development, implementation, and evaluation. Implementation challenges and recommendations were derived from direct observations and the collective experience of PSLL study personnel.

Results: The PSLL intervention was implemented on 12 inpatient units during the 18-month study period, potentially impacting 12,628 patient admissions. Challenges to implementation included stakeholder engagement, project scope/complexity, technology/governance, and team structure. Recommendations to address each of these challenges were generated, some enacted during the trial, others as lessons learned for future iterative refinements of the intervention and its implementation.

Conclusion: Designing, implementing, and evaluating a suite of tools integrated within a vendor EHR to improve patient safety has a variety of challenges. Keys to success include continuous stakeholder engagement, involvement of systems and human factors engineers within a multidisciplinary team, an iterative approach to user-centered design, and a willingness to think outside of current workflows and processes to change health system culture around adverse event prevention.
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http://dx.doi.org/10.1093/jamia/ocz193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647251PMC
February 2020

Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.

BMJ Open 2019 11 2;9(11):e030834. Epub 2019 Nov 2.

Vanderbilt Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States.

Objectives: Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, we evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.

Design: We conducted a cross-sectional observational study using a web survey (contextual factors) and a national hospital database (hospital characteristics).

Setting: Hospitals participating in the second Multi-Centre Medication Reconciliation Quality Improvement Study (MARQUIS2).

Participants: Implementation team members of 18 participating MARQUIS2 hospitals.

Outcomes: Primary outcome: contextual factor ratings (ie, organisational capacity, leadership support, goal alignment, staff involvement, patient safety climate and team cohesion). Secondary outcome: differences in contextual factors by hospital characteristics.

Results: Fifty-five team members from the 18 participating hospitals completed the survey. Ratings of contextual factors differed significantly by domain (p<0.001), with organisational capacity scoring the lowest (mean=4.0 out of 7.0) and perceived team cohesion and goal alignment scoring the highest (mean~6.0 out of 7.0). No statistically significant differences were observed in contextual factors by hospital characteristics (p>0.05). Respondents in the pharmacy profession gave lower ratings of leadership support than did those in the nursing or other professions group (p=0.01).

Conclusions: Hospital size, type and location did not drive differences in contextual factors, suggesting that tailoring MedRec QI implementation to hospital characteristics may not be necessary. Strong team cohesion suggests the use of interdisciplinary teams does not detract from cohesion when conducting mentored QI projects. Organisational leaders should particularly focus on supporting pharmacy services and addressing their concerns during MedRec QI initiatives. Future research should correlate contextual factors with implementation success to inform how best to prepare sites to implement complex QI interventions such as MedRec.
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http://dx.doi.org/10.1136/bmjopen-2019-030834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830625PMC
November 2019