Background Electronic medical record–based interventions such as best practice alerts, or reminders, have been proposed to improve evidence‐based medication prescribing. Formal implementation evaluation including long‐term sustainment are not commonly reported. Preprocedural medication management is often a complex issue for patients taking antithrombotic medications. Methods We implemented a best practice alert (BPA) that recommended referral to an anticoagulation clinic before outpatient elective gastrointestinal (GI) endoscopies. Eligible patients were taking an oral anticoagulant (warfarin or direct oral anticoagulant [DOAC]) and/or antiplatelet medications. Patients referred to the anticoagulation clinic were compared to those managed by the ordering provider. Outcomes assessed included guideline‐adherent drug management before endoscopy, documentation of a medication management plan, guideline‐adherent rates of bridging for high‐risk patients taking warfarin, and evaluation for sustained use of BPA. Results Eighty percent of patients (553/691) were referred to the anticoagulation clinic during the initial 13‐month study period. Most referrals came from gastroenterologists (397/553; 71.8%) followed by primary care providers (127/554; 22.9%). Patients referred had improved rates of guideline‐adherent medication management compared to those who were not referred (97.4% vs 91.0%; P = .001). Documentation of medication plan was significantly higher in the referred group (99.1% vs 59.4%; P ≤ .001). There were no differences in rates of appropriate bridging for patients taking warfarin. Implementation of the BPA also resulted in sustained, consistent use over an additional 18 months following the initial study period. Conclusion Implementation of a BPA before elective outpatient GI endoscopies was associated with improved rates of guideline‐adherent medication management and documented management plan, while streamlining preprocedural medication management.
Background: BRIDGE is a cardiac transitional care program. In previous studies, lower socioeconomic status (SES) and mental health disorders (MHD) have been associated with higher readmission rates. No research has been done on the combined effects of low SES and MHD on outcomes. This study sought to describe outcomes (ED Visits, readmission, and death) of patients by SES and MHD. Methods: All patients referred to BRIDGE between 2008-2015 were included in this study. Data were analyzed in three ways: 1) by SES and then by presence (or absence) of MHD (depression, anxiety, substance abuse), 2) by MHD and then by SES, and 3) patients of low SES without MHD compared to patients of high SES with a MHD (data not shown in Table 1). High and low SES were defined as above or below the state of Michigan median household income ($46,859), estimated by patients’ home zip code. Demographics and outcomes were compared within and between groups. Results: Among 3051 patients divided first by SES, there were a number of significant differences in demographics and outcomes between patients with and without MHD. Regardless of SES, patients with MHD were more often younger, female, single, and had higher rates of ED visits and readmissions at 180 days post-discharge than patients without MHD. Among high SES patients, patients with MHD had higher rates of ED visits within 30 days despite lower Charlson Comorbidity scores. In contrast, when divided by presence or absence of MHD first, fewer differences existed between SES groups. Regardless of presence or absence of MHDs, patients of low SES were younger and more racially diverse than patients of high SES; however, there were no differences in outcomes between these SES groups. Among patients without a MHD, low SES patients were less likely to attend BRIDGE. Patients of low SES without MHD were more likely than patients of high SES with MHD to be male (61.4% v. 51.2%, p<0.001), married (60.8% v. 52.2%, p=0.013), and non-White (75.3% v. 89.5%, p<0.001), and were less likely to have an ED visit within 180 days (31.9% v. 43.9%, p<0.001). Conclusions: The presence of MHDs appears to be more strongly associated with negative outcomes than low SES. Efforts to develop and improve interventional care strategies that target patients with MHDs should be made to reduce these health disparities.
Background: Hospital readmissions are increasingly observed and reported as quality indicators. The literature is critical of studies that use all cause readmission definitions, suggesting that not every readmission is related to the index admission diagnosis. However, hospitals are not a therapeutic environment. Patients are often kept on ”nothing by mouth” (NPO) status, subjected to testing at irregular hours, placed on bed rest, and discharged on new medications. Thus, patients may be more vulnerable to adverse outcomes at discharge; some have characterized this phenomenon as “post-hospital syndrome.” This study sought to compare these inpatient stressors (NPO status, after-hours testing, new medications, and bed rest) to patient outcomes (ED visits, readmissions). Methods: A retrospective chart review of 100 randomly selected ACS patients referred to a cardiac transitional care program (BRIDGE) between 2014-2015 was conducted. Associations between hours NPO, number of new medications, number of tests at irregular hours (11pm-5am), prescribed bed rest and outcomes at 30 and 180 days were analyzed. Results: Of 100 patients, 72% were male with a mean age of 65.87 ± 12.33 and a mean Charlson comorbidity score of 5.42 ± 2.58. Bed rest was prescribed for 69% of patients. The average patient was prescribed 4.43 new medications at discharge, underwent 4.37 tests at irregular hours, and spent 11.40 hours NPO. Median length of stay was 3 days (range: 0-18 days). Number of tests at irregular hours was positively correlated with readmission at 30 days (r=0.272, p=0.006), and 180 day ED visits (r=0.282, p=0.004) and readmissions (r=0.363, p<0.001). No other significant correlations were observed between inpatient stressors and outcomes. Conclusions: NPO status and tests at irregular hours were correlated with negative short and longer-term outcomes. Efforts should be made to limit these inpatient stressors or to stabilize patients prior to discharge. Future research on post hospital syndrome is warranted to better understand potential longer-term relationships and to better plan for care transitions.
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