Objective

Interactive patient care systems (IPCS) at the bedside are becoming increasingly common, but evidence is limited as to their potential for innovative clinical trial implementation. The objective of this study was to test the hypothesis that the IPCS could feasibly be used to automate recruitment and enrolment for a clinical trial.

Methods

In medical-surgical units, we used the IPCS to randomise, recruit and consent eligible subjects. For participants not interacting with IPCS study materials within 48 hours, study staff-initiated recruitment in-person. Eligible study population included all caregivers and any patients >6 years old admitted to medical-surgical units and oncology units September 2015 to January 2016.

Outcomes

randomisation assessed using between-group comparisons of patient characteristics; recruitment success assessed by rates of consent; paperless implementation using successful acquisition of electronic signature and email address. We used χ² analysis to assess success of randomisation and recruitment.

Results

Randomisation was successful (n=1012 randomised, p>0.05 for all between-group comparisons). For the subset of eligible, randomised patients who were recruited, IPCS-only recruitment (consented: 2.4% of n=213) was less successful than in-person recruitment (61.4% of n=87 eligible recruited, p<0.001). For those consenting (n=61), 96.7% provided an electronic signature and 68.9% provided email addresses.

Conclusions

Our results suggest that as a tool at the bedside, the IPCS offers key efficiencies for study implementation, including randomisation and collecting e-consent and contact information, but does not offer recruitment efficiencies. Further research could assess the value that interactive technologies bring to recruitment when paired with in-person efforts, potentially focusing on more intensive user-interface testing for recruitment materials.

Trial registration number

NCT02491190.

Background

Health information technology (HIT) may improve health care quality and outcomes, in part by making information available in a timelier manner. However, there are few studies documenting the changes in timely availability of data with the use of a sophisticated electronic medical record (EMR), nor a description of how the timely availability of data might differ with different types of EMRs. We hypothesized that timely availability of data would improve with use of increasingly sophisticated forms of HIT.

Methods

We used an historical observation design (2004-2006) using electronic data from office visits in an integrated delivery system with three types of HIT: Basic, Intermediate, and Advanced. We calculated the monthly percentage of visits using the various types of HIT for entry of visit diagnoses into the delivery system's electronic database, and the time between the visit and the availability of the visit diagnoses in the database.

Results

In January 2004, when only Basic HIT was available, 10% of office visits had diagnoses entered on the same day as the visit and 90% within a week; 85% of office visits used paper forms for recording visit diagnoses, 16% used Basic at that time. By December 2006, 95% of all office visits had diagnoses available on the same day as the visit, when 98% of office visits used some form of HIT for entry of visit diagnoses (Advanced HIT for 67% of visits).

Conclusion

Use of HIT systems is associated with dramatic increases in the timely availability of diagnostic information, though the effects may vary by sophistication of HIT system. Timely clinical data are critical for real-time population surveillance, and valuable for routine clinical care.

Objectives

This study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race.

Methods

The National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals).

Results

There was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004).

Conclusions

In this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.

Background

In the context of the Affordable Care Act, there is extensive emphasis on making provider quality transparent and publicly available. Online public reports of quality exist, but little is known about how visitors find reports or about their purpose in visiting.

Objective

To address this gap, we gathered website analytics data from a national group of online public reports of hospital or physician quality and surveyed real-time visitors to those websites.

Methods

Websites were recruited from a national group of online public reports of hospital or physician quality. Analytics data were gathered from each website: number of unique visitors, method of arrival for each unique visitor, and search terms resulting in visits. Depending on the website, a survey invitation was launched for unique visitors on landing pages or on pages with quality information. Survey topics included type of respondent (eg, consumer, health care professional), purpose of visit, areas of interest, website experience, and demographics.

Results

There were 116,657 unique visitors to the 18 participating websites (1440 unique visitors/month per website), with most unique visitors arriving through search (63.95%, 74,606/116,657). Websites with a higher percent of traffic from search engines garnered more unique visitors (P=.001). The most common search terms were for individual hospitals (23.25%, 27,122/74,606) and website names (19.43%, 22,672/74,606); medical condition terms were uncommon (0.81%, 605/74,606). Survey view rate was 42.48% (49,560/116,657 invited) resulting in 1755 respondents (participation rate=3.6%). There were substantial proportions of consumer (48.43%, 850/1755) and health care professional respondents (31.39%, 551/1755). Across websites, proportions of consumer (21%-71%) and health care professional respondents (16%-48%) varied. Consumers were frequently interested in using the information to choose providers or assess the quality of their provider (52.7%, 225/427); the majority of those choosing a provider reported that they had used the information to do so (78%, 40/51). Health care professional (26.6%, 115/443) and consumer (20.8%, 92/442) respondents wanted cost information and consumers wanted patient narrative comments (31.5%, 139/442) on the public reports. Health care professional respondents rated the experience on the reports higher than consumers did (mean 7.2, SD 2.2 vs mean 6.2, SD 2.7; scale 0-10; P<.001).

Conclusions

Report sponsors interested in increasing the influence of their reports could consider using techniques to improve search engine traffic, providing cost information and patient comments, and improving the website experience for both consumers and health care professionals.

To describe recent, 10-year trends in pediatric hospital resource use with and without a psychiatric diagnosis and examine how these trends vary by type of psychiatric and medical diagnosis cooccurrence. A retrospective, longitudinal cohort analysis using hospital discharge data from 33 tertiary care US children's hospitals of patients ages 3 to 17 years from January 1, 2005 through December 31, 2014. The trends in hospital discharges, hospital days, and total aggregate costs for each psychiatric comorbid group were assessed by using multivariate generalized estimating equations. From 2005 to 2014, the cumulative percent growth in resource use was significantly (all P < .001) greater for children hospitalized with versus without a psychiatric diagnosis (hospitalizations: +137.7% vs +26.0%; hospital days: +92.9% vs 5.9%; and costs: +142.7% vs + 18.9%). During this time period, the most substantial growth was observed in children admitted with a medical condition who also had a cooccurring psychiatric diagnosis (hospitalizations: +160.5%; hospital days: +112.4%; costs: +156.2%). In 2014, these children accounted for 77.8% of all hospitalizations for children with a psychiatric diagnosis; their most common psychiatric diagnoses were developmental disorders (22.3%), attention-deficit/hyperactivity disorder (18.1%), and anxiety disorders (14.2%). The 10-year rise in pediatric hospitalizations in US children's hospitals is 5 times greater for children with versus without a psychiatric diagnosis. Strategic planning to meet the rising demand for psychiatric care in tertiary care children's hospitals should place high priority on the needs of children with a primary medical condition and cooccurring psychiatric disorders.

Background

Our goal was to compare hospital scores from the most widely used commercial website in the USA to hospital scores from more systematic measures of patient experience and outcomes, and to assess what drives variation in the commercial website scores.

Methods

For a national sample of US hospitals, we compared scores on Yelp.com, which aggregates website visitor ratings (1-5 stars), with traditional measures of hospital quality. We calculated correlations between hospital Yelp scores and the following: hospital percent high ratings (9 or 10, scale 0-10) on the 'Overall' item on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey; hospital individual HCAHPS domain scores (eg, nurse communication, pain control); hospital 30-day mortality; and hospital 30-day readmission rates.

Results

Of hospitals reporting HCAHPS (n=3796), 962 (25%) had scores on Yelp. Among hospitals with >5 Yelp ratings, the correlation of percent high ratings between Yelp and HCAHPS was 0.49 (p<0.001). The percent high ratings within each HCAHPS domain increased monotonically with increasing Yelp scores (p≤0.001 for all domains). Percent high ratings in Yelp and HCAHPS were statistically significantly correlated with lower mortality for myocardial infarction (MI; -0.19 for Yelp and -0.13 for HCAHPS) and pneumonia (-0.14 and -0.18), and fewer readmissions for MI (-0.17 and -0.39), heart failure (-0.31 and -0.39), and pneumonia (-0.18 and -0.27).

Conclusions

These data suggest that rater experiences for Yelp and HCAHPS may be similar, and that consumers posting ratings on Yelp may observe aspects of care related to important patient outcomes.

Objective

To identify an approach to summarizing publicly reported hospital performance data for acute myocardial infarction (AMI) or heart failure (HF) that best predicts current year hospital mortality rates.

Setting

A total of 1,868 U.S. hospitals reporting process and outcome measures for AMI and HF to the Centers for Medicare and Medicaid Services (CMS) from July 2005 to June 2006 (Year 0) and July 2006 to June 2007 (Year 1).

Design

Observational cohort study measuring the percentage variation in Year 1 hospital 30-day risk-adjusted mortality rate explained by denominator-based weighted composite scores summarizing hospital Year 0 performance.

Data collection

Data were prospectively collected from hospitalcompare.gov.

Results

Percentage variation in Year 1 mortality was best explained by mortality rate alone in Year 0 over other composites including process performance. If only Year 0 mortality rates were reported, and consumers using hospitals in the highest decile of mortality instead chose hospitals in the lowest decile of mortality rate, the number of deaths at 30 days that potentially could have been avoided was 1.31 per 100 patients for AMI and 2.12 for HF (p < .001).

Conclusion

Public reports focused on 30-day risk-adjusted mortality rate may more directly address policymakers' goals of facilitating consumer identification of hospitals with better outcomes.

Background

This study utilizes interviews of clinical medical physicists to investigate self-reported shortcomings of the current weekly chart check workflow and opportunities for improvement.

Methods

Nineteen medical physicists were recruited for a 30-minute semi-structured interview, with a particular focus placed on image review and the use of automated tools for image review in weekly checks. Survey-type questions were used to gather quantitative information about chart check practices and importance placed on reducing chart check workloads versus increasing chart check effectiveness. Open-ended questions were used to probe respondents about their current weekly chart check workflow, opinions of the value of weekly chart checks and perceived shortcomings, and barriers and facilitators to the implementation of automated chart check tools. Thematic analysis was used to develop common themes across the interviews.

Results

Physicists ranked highly the value of reducing the time spent on weekly chart checks (average 6.3 on a scale from 1 to 10), but placed more value on increasing the effectiveness of checks with an average of 9.2 on a 1-10 scale. Four major themes were identified: (1) weekly chart checks need to adapt to an electronic record-and-verify chart environment, (2) physicists could add value to patient care by analyzing images without duplicating the work done by physicians, (3) greater support for trending analysis is needed in weekly checks, and (4) automation has the potential to increase the value of physics checks.

Conclusion

This study identified several key shortcomings of the current weekly chart check process from the perspective of the clinical medical physicist. Our results show strong support for automating components of the weekly check workflow in order to allow for more effective checks that emphasize follow-up, trending, failure modes and effects analysis, and allow time to be spent on other higher value tasks that improve patient safety.

Objective

Patient-centred care has become a priority in many countries. It is unknown whether current tools capture aspects of care patients and their surrogates consider important. We investigated whether online narrative reviews from patients and surrogates reflect domains in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and we described additional potential domains.

Design

We used thematic analysis to assess online narrative reviews for reference to HCAHPS domains and salient non-HCAHPS domains and compared results by reviewer type (patient vs surrogate).

Setting

We identified hospitals for review from the American Hospital Association database using a stratified random sampling approach. This approach ensured inclusion of reviews of a diverse set of hospitals. We searched online in February 2013 for narrative reviews from any source for each hospital.

Participants

We included up to two narrative reviews for each hospital.

Exclusions

Outpatient or emergency department reviews, reviews from self-identified hospital employees, or reviews of <10 words.

Results

50.0% (n=122) of reviews (N=244) were from patients and 38.1% (n=93) from friends or family members. Only 57.0% (n=139) of reviews mentioned any HCAHPS domain. Additional salient domains were: Financing, including unexpected out-of-pocket costs and difficult interactions with billing departments; system-centred care; and perceptions of safety. These domains were mentioned in 51.2% (n=125) of reviews. Friends and family members commented on perceptions of safety more frequently than patients.

Conclusions

A substantial proportion of consumer reviews do not mention HCAHPS domains. Surrogates appear to observe care differently than patients, particularly around safety.