Noninitiation of Discharge Medications After Revascularization.

Background: Timely initiation of medication therapy after a cardiovascular event is vital to achieve optimal patient outcomes, yet there is a lack of insight on the frequency and predictors of discharge medications that are delayed or never initiated.

Objectives: To (a) describe how frequently patients do not fill newly prescribed discharge medications within 30 days after revascularization and (b) identify predictors of patients who did not fill their new medications.

Methods: A single-center, retrospective analysis was conducted of patients discharged after percutaneous coronary intervention or coronary artery bypass grafting.

Hospital palliative care consult improves value-based purchasing outcomes in a propensity score-matched cohort.

Background: Hospital-based palliative care consultation is consistently associated with reduced hospitalization costs and more importantly with improved patient quality of life. As healthcare systems move toward value-based purchasing rather than fee-for-service models, understanding how palliative care consultation is associated with value-based purchasing metrics can provide evidence for expanded health system support for a greater palliative care presence.

Aim: To understand how a palliative care consultation impacts rates of patient readmission and hospital-acquired infections associated with value-based purchasing metrics.

Data-driven approach to Early Warning Score-based alert management.

Background: Increasing adoption of electronic health records (EHRs) with integrated alerting systems is a key initiative for improving patient safety. Considering the variety of dynamically changing clinical information, it remains a challenge to design EHR-driven alerting systems that notify the right providers for the right patient at the right time while managing alert burden. The objective of this study is to proactively develop and evaluate a systematic alert-generating approach as part of the implementation of an Early Warning Score (EWS) at the study hospitals.

Outcomes associated with observation versus short-stay admission among chest pain patients in the Veterans Health Administration.

Background: To determine the extent to which 30- and 90-day hospital readmission and mortality rates differ as a function of whether a chest pain patient is placed in observation status or admitted to the hospital for a short-stay (<48 h).

Methods: Using 114,043 observation stays and short-stay admissions for chest pain at Veterans Health Administration hospitals between 2005 and 2013, we estimated event-level logistic regression models using a generalized estimating equation framework to predict 30 and 90-day readmissions and mortality as a function of whether the patient had an observation stay or a short-stay admission. We also adjusted for a variety of patient characteristics and unobserved time-invariant hospital factors.

Chest Pain Patients at Veterans Hospitals Are Increasingly More Likely to Be Observed Than Admitted for Short Stays.

Observation stays are an outpatient service used to diagnose and treat patients for extended periods of time while a decision is made regarding inpatient admission or discharge. Although the use of observation stays is increasing, little is known about which patients are observed and which are admitted for similar periods of time as inpatients. The aim was to identify patient characteristics associated with being observed rather than admitted for a short stay (<48 hours) within the Veterans Health Administration (VHA).

Patient, hospital, and local health system characteristics associated with the use of observation stays in veterans health administration hospitals, 2005 to 2012.

Recent studies have documented that a significant increase in the use of observation stays along with extensive variation in patterns of use across hospitals.The objective of this longitudinal observational study was to examine the extent to which patient, hospital, and local health system characteristics explain variation in observation stay rates across Veterans Health Administration (VHA) hospitals.Our data came from years 2005 to 2012 of the nationwide VHA Medical SAS inpatient and enrollment files, American Hospital Association Survey, and Area Health Resource File.

Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals.

Background: Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine.

Objective: Describe APPs role in inpatient medicine.

Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals.

Background: Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions.

Objective: To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration.

Impacts of organizational context on quality improvement.

Variation in how hospitals perform on similar quality improvement (QI) efforts argues for a need to understand how different organizational characteristics affect QI performance. The objective of this study was to use data-mining methods to evaluate relationships between measures of organizational characteristics and hospital QI performance. Organizational characteristics were extracted from 2 surveys and analyzed in 3 separate decision-tree models.

Cost of readmission: can the Veterans Health Administration (VHA) experience inform national payment policy?

Context: Scrutiny of hospital readmissions has led to the development and implementation of policies targeted at reducing readmission rates.

Objective: To assess whether historic hospital readmission rates predict risk-adjusted patient readmission and to measure the costs of readmission, thus informing reimbursement policies under consideration by non-Veterans Health Administration payers.

Design, Settings, And Participants: Multivariable hospital-fixed effects regression analyses of patients admitted to 129 Veterans Health Administration hospitals between 2005 and 2009 for 3 common conditions, acute myocardial infarction (AMI), community-acquired pneumonia (CAP), and congestive heart failure (CHF).

Findings from a national improvement collaborative: are improvements sustained?

Background: Despite considerable efforts to improve healthcare quality and patient safety, broad measures of patient outcomes show little improvement. Many factors, including limited programme evaluations and understanding of whether quality improvement (QI) efforts are sustained, potentially contribute to the lack of widespread improvements in quality. This study examines whether hospitals participating in a Veterans Health Affairs QI collaborative have made and then sustained improvements.

Guiding inpatient quality improvement: a systematic review of Lean and Six Sigma.

Background: Two popular quality improvement (QI) approaches in health care are Lean and Six Sigma. Hospitals continue to adopt these QI approaches-or the hybrid Lean Sigma approach-with little knowledge on how well they produce sustainable improvements. A systematic literature review was conducted to determine whether Lean, Six Sigma, or Lean Sigma have been effectively used to create and sustain improvements in the acute care setting.

Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission.

Background: With 1-2% of patients leaving the hospital against medical advice (AMA), the potential for these patients to suffer adverse health outcomes is of major concern.

Objective: To examine 30-day hospital readmission and mortality rates for medical patients who left the hospital AMA and identify independent risk factors associated with these outcomes.

Design: A 5-year retrospective cohort of all patients discharged from a Veterans Administration (VA) hospital.

Identifying medication misadventures: poor agreement among medical record, physician, nurse, and patient reports.

Study Objective: To analyze and compare four different methods of detecting medication misadventures in order to determine the optimal system for reporting clinically observed medication misadventures.

Design: Prospective cohort study.

Setting: Forty-eight-bed general internal medicine inpatient ward at a large academic teaching hospital with a decentralized pharmacy system.

Pulsatile release of biomolecules from polydimethylsiloxane (PDMS) chips with hydrolytically degradable seals.

We demonstrate, for the first time, a robust novel polydimethylsiloxane (PDMS) chip that can provide controlled pulsatile release of DNA based molecules, proteins and oligonucleotides without external stimuli or triggers. The PDMS chip with arrays of wells was constructed by replica molding. Poly(lactic acid-co-glycolic acid) (PLGA) polymer films of varying composition and thickness were used as seals to the wells.