Use of hospital services by age and comorbidity after an index heart failure admission in England: an observational study

© Published by the BMJ Publishing Group Limited.Objectives To describe hospital inpatient, emergency department (ED) and outpatient department (OPD) activity for patients in the year following their first emergency admission for heart failure (HF). To assess the proportion receiving specialist assessment within 2â €...weeks of hospital discharge, as now recommended by guidelines. Design Observational study of national administrative data. Setting All acute NHS hospitals in England. Participants 82â €...241 patients with an index emergency admission between April 2009 and March 2011 with a primary diagnosis of HF. Main outcome measures Cardiology OPD appointment within 2â €...weeks and within a year of discharge from the index admission; emergency department (ED) and inpatient use within a year. Results 15.1% died during the admission. Of the 69â €...848 survivors, 19.7% were readmitted within 30â €...days and half within a year, the majority for non-HF diagnoses. 6.7% returned to the ED within a week of discharge, of whom the majority (77.6%) were admitted. The two most common OPD specialties during the year were cardiology (24.7% of the total appointments) and anticoagulant services (12.5%). Although half of all patients had a cardiology appointment within a year, the proportion within the recommended 2â €...weeks of discharge was just 6.8% overall and varied by age, from 2.4% in those aged 90+ to 19.6% in those aged 18-45 (p<0.0001); appointments in other specialties made up only some of the shortfall. More comorbidity at any age was associated with higher rates of cardiology OPD follow-up. Conclusions Patients with HF are high users of hospital services. Postdischarge cardiology OPD follow-up rates fell well below current National Institute for Health and Care Excellence guidelines, particularly for the elderly and those with less comorbidity

Repeat prescribing of medications: a system-centred risk management model for primary care organisations

Rationale, aims and objectives: Reducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care. Methods: All 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web-based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses. Results: Across the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1-33; SD = 7.13). Seven hundred sixty-seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0-34; SD = 8.0). Conclusions: The risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System-wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally

Master of Science

thesisThere is a high risk for communication failures at the hospital discharge. Discharge summaries (DCS) can mitigate these risks by describing not only the hospital course but also follow-up plans. Improvement in the DCS may play a crucial role to improve communication at this transition of care. This research identifies gaps between the local standard of practice and best practices reported in the literature. It also identifies specific components of the DCS that could be improved through enhanced use of health information technology. A manual chart review of 188 DCS was performed. The medication reconciliations were analyzed for completeness and for medical reasoning. The pending results reported in the DCS were compared to those identified in the enterprise data warehouse (EDW). Documentation of follow-up arrangements was analyzed. Report of patient preferences, patient goals, lessons learned, and the overall handover tone were also noted. Patients were discharged on an average of 9.8 medications. Only 3% of the medication reconciliations were complete regarding which medications were continued, changed, new, and discontinued; 94% were incomplete and medical reasoning was frequently absent. There were 358 pending results in 188 hospital discharges. 14% of those results were in the DCS while 86% were only found in the EDW. Less than 50% iv of patients had clear documentation of scheduled follow-up. Patient preferences, patient goals, and lessons learned were rarely (6%, 1%, and 3% respectively) included. There was a handover tone in only 17% of the DCS. The quality gaps in the DCS are consistent with the literature. Medication reconciliations were frequently incomplete, pending results were rarely available, and documentation of follow-up care occurred less than half of the time. Evaluating the DCS primarily as a clinical handover is novel. Information necessary for safe handovers and to promote continuity of care is frequently missing. Future improvements should reshape the DCS to improve continuity of care

Institute for Quality and Efficiency in Health Care: Germany

Provides an overview of evidence-based policy making in the German healthcare system. Focuses on the Institute for Quality and Efficiency in Health Care, which evaluates comparative effectiveness of drugs and medical services for decisions on coverage

Effectiveness of a patient mediated intervention in increasing the use of cochrane reviews of evidence in clinical practice : a controlled clinical trial in COPD

Interventions are needed to improve health outcomes by increasing the practice of evidence based medicine ( EBM ). Patient mediated interventions have been little studied but hold promise : they target identified barriers to EBM and particular types of patient mediated intervention have shown success. Furthermore, consumers are now being given information about evidence but the effects of this on EBM have yet to be properly assessed. The aim of this study was to show whether informing patients about research evidence leads to improved application of that evidence in their medical care. The study trialed a relatively low cost manual, developed using current best practice, which summarised Cochrane Reviews of evidence. The study focused on chronic obstructive pulmonary disease ( COPD ), a high - cost, high - burden chronic disease, showing a large gap between evidence and clinical practice. The study comprised a controlled before - and - after trial and a process evaluation. The trial assessed the success of this manual in changing medical practice for three indicator treatments ( influenza vaccination, bone density testing and pulmonary rehabilitation ) and in changing patient quality of life, knowledge, communication with doctor, satisfaction with information and anxiety. Results were analysed by median split of socioeconomic disadvantage. At 3 months the manual was associated with lower anxiety for participants with lowest socioeconomic disadvantage. At 12 months the manual was associated with higher pulmonary rehabilitation enrolment for participants with greatest socioeconomic disadvantage. Other outcome measures showed no significant change. Limitations included loss of power from unexpectedly good baseline care and adjustments for baseline differences. The process evaluation showed that the manual was read more than a control pamphlet at both 3 and 12 months but a minority of manual recipients reported talking to their doctor about topics from the manual. Very little treatment change was reported. Patient attitudes to evidence and doctor / patient communication norms appeared to be barriers for this patient group. New protocols for the design of behavioural interventions provide a framework for overcoming these barriers in future interventions.Thesis (Ph.D.)--School of Medicine, 2006

A Clinical Audit of Discharge Summaries: Conformity to Set Guidelines in the Department of Psychiatry and Mental Health at Mmuhimbili National Hospital Dar es Salaam Tanzania.

Patients‟ records are the most basic clinical tools that are required in every consultation. Discharge summary as a document collect patient‟s information about inpatients care. The primary function is to support continuity of care as the patient returns to next health provider. Improvement in the care of mentally ill patients may be enhanced by improving discharge summaries writing in terms of its contents and timing. There is paucity of data that shows deficits in writing discharge summaries in the developing countries including Tanzania. Systematically reviewing and auditing care against explicit criteria and set of guidelines is a quality improvement process that seeks to improve the patient care and outcomes. Implementing best-practice guidelines for managing mental illnesses is demanding but rewarding. Identifying deficits in writing discharge summaries as done in this clinical audit is pertinent to ensure improvement of quality of patients‟ care and good outcome. To determine the extent to which discharge summaries conform to the guideline for best practice of mental health service delivery in Department of Psychiatry and Mental Health at Muhimbili National Hospital (MNH) A cross sectional retrospective, clinical audit of a discharge summary looking at the contents and timing of discharge summary writing was conducted in the Department of Psychiatry and Mental Health at the MNH A chart review of all new admission discharge summaries in 2010 was done. A total of 200 planned discharge summaries were reviewed. Data was collected using a discharge check list that was extracted from guideline for best practice of mental health service delivery at MNH. The conformity level was considered at a cutoff point of ≥88% of overall contents of discharge summary as from other studies.The results were tabulated, grouped and statistically analyzed using the descriptive statistics reported as proportions, frequencies, and comparative statistic using Pearson Chi square/fisher‟s exact test to detect whether there is a significant statistical difference between different categorical variables. The P value of less than or equal to 0.05 was considered statistically significant for differences examined. This study found that, of 200 systematically selected planned discharge summaries; “documented review with patient diagnosis” 100% (n=200) and “documented date of return to outpatient clinic” 90.82% (n=178) are the only two items that were in conformity with standard discharge guidelines. The other ten items studied were found not conforming to standard guidelines. Again to determine the timing of discharge summary writing, the results of this study have identified that about 93% (n=186) of the discharge summaries were written within two weeks of admission while others were before/after two weeks of admission. Conclusion and Implementing good clinical practice in metal health in the department of psychiatry and mental health at MNH remains a challenge for clinicians. Discharging clinician‟s should follow standard guidelines for good clinical practice as agreed by the department to reduce areas of deficits in clinical practice in mental health. Interventions are needed to ensure clinicians are conforming to the standard guidelines when writing discharge summaries

Bills Passed by the 2008 Session of the General Assembly

A legislative summary about the bills that passed in the 2008 Virginia General Assembl

Bills Passed by the 2008 Session of the General Assembly

A legislative summary about the bills that passed in the 2008 Virginia General Assembl

Improving Transitions of Care From Hospital to Community Provider for Patients with Type II Diabetes Mellitus

Poorly coordinated care transitions result in nearly half of discharged patients’ experiencing at least 1 medication error and 1 in 5 Medicare beneficiaries readmitted within 30 days. Repercussions of suboptimal transitions of care greatly impact the nation’s economy costing between $12 billion and$44 billion annually. Ineffective handoffs between providers at hospital discharge contribute to suboptimal patient outcomes; therefore, strategies to improve transitions of care are necessary to provide quality care while decreasing health care expenditure. A quality improvement project was conducted on an inpatient surgical unit to decrease hospital readmissions and emergency department visits. Proposed interventions for patients with type II diabetes mellitus discharged home included (1) a follow-up appointment arranged with an outpatient provider prior to discharge and (2) receipt of a follow-up phone call within 48 to 72 hours. A process for providing discharge information to outpatient providers was assessed. A total of 58 patients met inclusion criteria: 91% patients received at least 1 intervention, 48.2% had a follow-up appointment arranged prior to discharge, and 29.3% received a discharge phone call within the proposed timeframe. There was a significant negative correlation with the number of interventions a patient received and decreased hospital readmissions (r = -.131). Health care in the United States has become increasingly fragmented and highly complex. Nurses have a pivotal role for ensuring patients’ experience a seamless transition throughout the continuum of care. In accordance with achieving a safe, timely, effective, efficient, equitable, patient-centered health care system a bundled intervention methodology may in fact serve to improve patient outcomes while decreasing health care expenditure