BACKGROUND: Most research on transitions of care has focused on the transition from acute to outpatient care. Little is known about the transition from outpatient to acute care. We conducted a systematic review of the literature on the transition from outpatient to acute care, focusing on provider-to-provider communication and its impact on quality of care. METHODS: We searched the MEDLINE, CINAHL, Scopus, EMBASE, and Cochrane databases for English-language articles describing direct communication between outpatient providers and acute care providers around patients presenting to the emergency department or admitted to the hospital. We conducted double, independent review of titles, abstracts, and full text articles. Conflicts were resolved by consensus. Included articles were abstracted using standardized forms. We maintained search results via Refworks (ProQuest, Bethesda, MD). Risk of bias was assessed using a modified version of the Downs' and Black's tool. RESULTS: Of 4009 citations, twenty articles evaluated direct provider-to-provider communication around the outpatient to acute care transition. Most studies were cross-sectional (65 %), conducted in the US (55 %), and studied communication between primary care and inpatient providers (62 %). Of three studies reporting on the association between communication and 30-day readmissions, none found a significant association; of these studies, only one reported a measure of association (adjusted OR for communication vs. no communication, 1.08; 95 % CI 0.92-1.26). DISCUSSION: The literature on provider-to-provider communication at the transition from outpatient to acute care is sparse and heterogeneous. Given the known importance of communication for other transitions of care, future studies are needed on provider-to-provider communication during this transition. Studies evaluating ideal methods for communication to reduce medical errors, utilization, and optimize patient satisfaction at this transition are especially needed.KEY WORDS: care transitions; continuity of care; provider-to-provider communication.
BackgroundImproving continuity between primary care and cancer care is critical for improving cancer outcomes and curbing cancer costs. A dimension of continuity, we investigated how regularly patients receive their primary care and surgical care for colon cancer from the same hospital and whether this affects mortality and costs.MethodsUsing Surveillance, Epidemiology, and End Results Program Registry (SEER)-Medicare data, we performed a retrospective cohort study of stage I-III colon cancer patients diagnosed between 2000 and 2009. There were 23,305 stage I-III colon cancer patients who received primary care in the year prior to diagnosis and underwent operative care for colon cancer. Patients were assigned to the hospital where they had their surgery and to their primary care provider’s main hospital, and then classified according to whether these two hospitals were same or different. Outcomes examined were hazards for all-cause mortality, subhazard for colon cancer specific mortality, and generalized linear estimate for costs at 12 months, from propensity score matched models.ResultsFifty-two percent of stage I-III colon patients received primary care and surgical care from the same hospital. Primary care and surgical care from the same hospital was not associated with reduced all-cause or colon cancer specific mortality, but was associated with lower inpatient, outpatient, and total costs of care. Total cost difference was $8,836 (95% CI $2,746–$14,577), a 20% reduction in total median cost of care at 12 months.ConclusionsReceiving primary care and surgical care at the same hospital, compared to different hospitals, was associated with lower costs but still similar survival among stage I-III colon cancer patients. Nonetheless, health care policy which encourages further integration between primary care and cancer care in order to improve outcomes and decrease costs will need to address the significant proportion of patients receiving health care across more than one hospital.
Implementation of a multi-disciplinary approach can facilitate ACP. However, challenges still arise because in more than half of the cases, advance care efforts led only to a discussion.
QUESTION ASKED: Do mortality and cost differ for patients with cancer who get readmitted to the hospital within 30 days after their initial cancer surgery on the basis of whether they are admitted to the same hospital where they had their surgery or to a different hospital?SUMMARY ANSWER: Patients with colon cancer who had a 30-day readmission to a different hospital than the one where they received their cancer surgery did not experience higher all-cause mortality, colon cancer-specific mortality, or costs compared with patients who were readmitted to the hospital where they underwent their cancer surgery. However, patients readmitted to a different hospital did have a higher risk of short-term (90-day) mortality. METHODS:We used SEER-Medicare linked data of patients with colon cancer diagnosed between 2000 and 2009. Our cohort consisted of patients with stage I to III disease who received colon cancer surgery and were subsequently readmitted within 30 days of their initial discharge. We compared patients who were readmitted to the same hospital as where their surgery was performed and those admitted to a different hospital. We performed propensity score-weighted doubly robust models to examine the association with all-cause mortality, cancer-specific mortality, 90-day all-cause mortality, 90-day cancer-specific mortality, and costs (Table 2). Our models were adjusted for patient, physician, and hospital characteristics. We used Cox proportional hazard models for all-cause mortality, the method of Fine and Gray for competing risk regression for colon cancer-specific mortality, and log transformed generalized linear models with gamma distribution to model costs. BIAS/CONFOUNDING FACTOR(S), DRAWBACKS:The choice of both the initial hospital where patients received surgery and the subsequent hospital where they were readmitted is unlikely to be random. Though we used propensity score adjusted models, we were unable to account for the reasons why patients selected one hospital versus another and were unable to assess factors such as travel distance. In addition, we were unable to determine whether hospitals were part of an integrated network, which may bias our findings toward the null. Finally, the generalizability of our sample is limited to Medicare fee-for-service beneficiaries and to patients who were not transferred during their initial hospital admission. REAL-LIFE IMPLICATIONS:Readmission after cancer surgery is a costly problem, and a large number of clinical initiatives and policy efforts have centered on reducing rates of readmission. Less attention has been focused on whether it matters where patients get readmitted. We were concerned that patients who are readmitted to a different hospital from where they received their cancer surgery may be more likely to experience poorly coordinated and costly care and be subject to poor outcomes. We focus on readmissions after colon cancer, the third most common cancer and one for which surgery is the cornerstone of treatment of patients with stage I to III disease....
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