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INTRODUCTION: Interhospital fragmentation of care occurs when patients are admitted to different, disconnected hospitals. It has been hypothesized that this type of care fragmentation decreases the quality of care received and increases hospital costs and healthcare utilization. This systematic review aims to synthesize the existing literature exploring the association between interhospital fragmentation of care and patient outcomes. METHODS: MEDLINE, the Cochrane Library, EMBASE, and the Science Citation Index were systematically searched for studies published up to April 30, 2018 reporting the association between interhospital fragmentation of care and patient outcomes. We included peerreviewed observational studies conducted in adults that reported measures of association between interhospital care fragmentation and one or more of the following patient outcomes: mortality, hospital length of stay, cost, and subsequent hospital readmission. RESULTS: Seventy-nine full texts were reviewed and 22 met inclusion criteria. Nearly all studies defined fragmentation of care as a readmission to a different hospital than the patient was previously discharged from. The strongest association reported was that between a fragmented readmission and in-hospital or short-term mortality (adjusted odds ratio range 0.95-3.62). Over half of the studies reporting length-of-stay showed longer length of stay in fragmented readmissions. All three studies that investigated healthcare utilization suggested an association between fragmented care and odds of subsequent readmission. The study populations and exposures were too heterogenous to perform a meta-analysis. DISCUSSION: Our review suggests that fragmented hospital readmissions contribute to increased mortality, longer length-of-stay, and increased risk of readmission to the hospital.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States. 1 As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations. 2 The Accreditation Council for Graduate Medical Education (AC-GME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees. 3 The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns. 4 These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas. [5][6] Healthcare trainees described concerns for their safety and reported adverse emotional impact. [7][8][9] In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage. [10][11][12][13] The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we will draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we will propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

BackgroundPatients with frequent hospital readmissions, or high-utilizer patients (HUPs), are a major driver of rising healthcare costs in the United States. This group has a significant burden of medical illness, but less is known about whether or how social determinants of health may drive their increased healthcare use and poor health outcomes. Our study aimed to define the population of HUPs at a large, safety-net hospital system, to understand how these patients differ from patients who are not HUPs, and to analyze how their demographic, medical, and social factors contribute to their healthcare use and mortality rates.MethodsFor this case-control study, data were collected via retrospective chart review. We included 247 patients admitted three or more times in a single calendar year between 2011 and 2013 and 247 controls with one or two admissions in a single calendar year matched for age, sex, and year of high-utilization. We used multivariable logistic regression models to understand which demographic, clinical, and social factors were associated with HUP status, and if HUP status was independently associated with mortality.ResultsThe factors that contributed significant odds of being a HUP included having Medicaid (OR 3.34, 95% CI 1.50, 7.44) or Medicare (OR 3.39, 95% CI 1.50, 7.67), having a history of recreational drug use (OR 2.44, 95% 1.36, 4.38), and being homeless (OR 3.73, 95% CI 1.69, 8.23) The mortality rate among HUPs was 22.6% compared to 8.9% among controls (p < 0.0001).ConclusionsThese data show that social factors are related to high-utilization in this population. Future efforts to understand and improve the health of this population need to incorporate non-clinical patient factors.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2209-0) contains supplementary material, which is available to authorized users.

ImportanceConsistent medication use is critical for diabetes management. Population surveillance of consistency of medication use may identify opportunities to improve diabetes care.ObjectiveTo evaluate trends in longitudinal use of glucose-, blood pressure–, and lipid-lowering medications by adults with diabetes.Design, Setting, and ParticipantsThis serial cross-sectional study assessed trends in longitudinal use of glucose-, blood pressure–, and lipid-lowering medications by adults with diagnosed diabetes participating in the Medical Expenditure Panel Survey (MEPS), which allows serial cross-sections and 2-year longitudinal follow-up, between the 2005 to 2006 panel and 2018 to 2019 panel. Population-weighted, nationally representative estimates for the US were reported. Included individuals were adult MEPS participants with diagnosed diabetes during both years (ie, during 2005 and 2006 or during 2018 and 2019) who participated in all survey rounds. Data were analyzed from August 2021 to November 2022.Main Outcomes and MeasuresLongitudinal use over the 2 years was categorized as continued use (at least 1 fill per year), no use, inconsistent use, and new use by medication type (glucose-, blood pressure–, and lipid-lowering medications). New medications were defined as prescription fills for a medication type first prescribed and filled in year 2 of MEPS participation.ResultsA total of 15 237 participants with diabetes (7222 individuals aged 45-64 years [47.4%]; 8258 [54.2%] female participants; 3851 Latino [25.3%]; 3619 non-Latino Black (23.8%), and 6487 non-Latino White [42.6%]) were included in the analytical sample. A mean of 19.5% (95% CI, 18.6%-20.3%), 17.1% (95% CI, 16.2%-18.1%), and 43.3% (95% CI, 42.2%-44.3%) of participants did not maintain continuity in use of glucose-, blood pressure–, or lipid-lowering medications, respectively, during both years of follow-up. The proportion of participants who continued use of glucose-lowering medication in both years trended down from 84.5% (95% CI, 81.8%-87.3%) in 2005 to 2006 to 77.4% (95% CI, 74.8%-80.1%) in 2018 to 2019; this decrease coincided with rate increases in inconsistent use (3.3% [95% CI, 1.9%-4.7%] in 2005-2006 to 7.1% [95% CI, 5.6%-8.6%] in 2018-2019) and no use (8.1% [95% CI, 6.0%-10.1%] in 2005-2006 to 12.9% [95% CI, 10.9%-14.9%] in 2018-2019). Inconsistent use of blood pressure–lowering medications trended upward from 3.9% (95% CI, 1.8%-6.0%) in 2005 to 2006 to 9.0% (95% CI, 7.0%-11.0%) in 2016 to 2017. Inconsistent use of lipid-lowering medication trended up to a high of 9.9% (95% CI, 7.0%-12.7%) in 2017 to 2018.Conclusions and RelevanceThis study found that a mean of 19.5% of participants did not maintain continuity in use of glucose-lowering medication, with recent decreases, while a mean of 17.1% and 43.2% of participants did not maintain continuity of use of blood pressure– or lipid-lowering medications, respectively.