Background: Inpatient palliative care consultation (PCC) may reduce 30-day readmissions and inpatient mortality among seriously ill patients. Objective: To evaluate the impact of timing of PCC on 30-day readmissions and inpatient mortality. Design: Retrospective, observational study comparing risk-adjusted, observed-to-expected (O/E) 30-day readmissions and inpatient mortality among patients receiving inpatient PCC to all other inpatients. Setting/Subjects: Adult patients with hospital length of stay (LOS) <30 days, primary diagnoses of circulatory, infectious, respiratory, neoplasms, injury/poisoning, and digestive system were included from eight hospitals in a single health care system. Results: Compared with non-PCC patients (n = 43,463), PCC patients (n = 6043) had a greater proportion of African Americans, Medicare, LOS ‡7 days, intensive care unit stays, discharges to skilled nursing facility and hospice, primary diagnoses of infections and neoplasms, comorbidities of congestive heart failure, cancer, and dementia, Charlson comorbidity score ‡8 (p < 0.001), and fewer males (p = 0.03). Adjusted readmission reduction attributed to PCC among 0-2-, 3-6-, and 7-30-day subgroups was 14.1%, 19.2%, and 16.4%, respectively (usual care O/E = 0.904 vs. subgroup O/Es = 0.764, 0.713, 0.741, respectively). Adjusted mortality reductions attributed to PCC among the 0-2-and 3-6-day subgroups were 19.4% and 19.1%, respectively. A 12% mortality increase was observed in the 7-30-day subgroup (usual care O/E = 0.738 vs. subgroup O/Es = 0.544, 0.547, 0.858, respectively). Conclusions: Inpatient PCC reduces 30-day readmissions and inpatient mortality with the greatest impact demonstrated within six days of hospital admission. Early PCC should be encouraged for eligible patients.
Study Objectives: The current value-based medical climate has led to scrutiny of all medical costs. Given the relationship between obstructive sleep apnea (OSA) and many significant comorbid medical conditions, treating patients with OSA via positive airway pressure (PAP) therapy might reduce health care expenditures. Our goal was to determine the relationship between PAP use and acute care utilization and costs. Methods: This was a retrospective cohort study of adult patients who initiated PAP therapy after a diagnosis of moderate-severe OSA at a large integrated health system during 2014-2016. Results: The study consisted of 1,098 patients, of which 60% were on PAP > 4 h/night for ≥ 70% of the nights. The average h/night were 5.3 (standard deviation 2.4). Increasing PAP usage was associated with reduced inpatient (rate ratio [RR] 0.92, 95% confidence interval [CI] 0.86-0.98) and overall acute care visits (RR 0.96, 95% CI 0.92-0.99). The linear relationships were supported by the threshold effects identified in the categorical adherence measures. No linear association was identified with emergency department visits and inpatient stays. However, lower number of emergency department visits (RR 0.78, 95% CI 0.62-0.98) and inpatient stays (RR 0.56, 95% CI 0.35-0.91) were observed among adherent (> 4 h/night for ≥ 70% of the nights) patients. Conclusions: PAP usage was linearly associated with reduced number of inpatient and overall acute care visits, and lower likelihood of having positive costs from these visits. PAP usage was also associated with less emergency department visits and inpatient stays when comparing adherent patients to less adherent patients.
Hospital care is the single, largest contributor to health spending, yet evidence to guide value transformation is lacking. The large, real-world studies required to fill this void are challenging to conduct in the complex and fast-paced acute care environment. To address these challenges, we created a framework that combines Lean manufacturing methodology and Applied Research principles. We deployed this framework to design, pilot, and iteratively improve a study protocol testing the effectiveness of an innovative care pathway for patients hospitalized with acute exacerbations of Chronic Obstructive Pulmonary Disease. Over a three month period, the protocol was successfully piloted and refined at a single site, subsequently becoming the basis for a large system-wide randomized controlled trial. This framework combining Lean and Applied Research methods resulted in synergies that neither method could accomplish alone and may serve as a template for learning healthcare systems to efficiently generate real-world evidence in the acute care setting.
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