Care management, attending supervision, and more

Summaries from ACP Hospitalist Weekly.

Intensive care management for high-risk VA patients didn't affect overall costs

An intensive care management program provided to high-risk patients through Veterans Affairs (VA) medical centers slightly reduced inpatient costs but increased outpatient costs for no net change.

The trial included 2,210 VA patients who had recently had a hospital admission or ED visit and who were considered high risk for admission within 90 days according to a validated risk-prediction algorithm. Their mean age was 63 years, 90% were men, and they had an average of seven chronic conditions. Half of the patients were randomized to usual care while the other half received locally tailored intensive management including care coordination, goals assessment, health coaching, medication reconciliation, and home visits by an interdisciplinary team. Results were published by Annals of Internal Medicine on June 5 and appeared in the June 19 issue.

Fewer than half (44%) of the patients assigned to intensive management actually received intensive outpatient care as defined by the study (three or more encounters in person or by phone), while 18% received limited management and 37% had no encounters. Compared to before the intervention, mean inpatient costs decreased in the intensive management group while increasing in the usual care group, but the difference between groups was not statistically significant (difference-in-difference, −$2,164; 95% CI, −$7,916 to $3,587). The opposite pattern was seen in outpatient costs, with a mean increase among the intensive management group (difference-in-difference, $2,636; 95% CI, $524 to $4,748), which the researchers attributed to greater use of primary care, home care, telephone care, and telehealth. Overall, the mean total costs were similar in both groups before and after the intervention.

“Our finding that patients in the intensive management group did not have lower acute care or total costs implies that the promise of cost savings from such programs remains elusive,” the study authors said. They noted that the most frequently used intensive management services were social work and mental health care and that patients who used more services were older with more comorbid conditions, higher rates of baseline primary care utilization, and lower rates of substance use and serious mental health disorders, suggesting that patients with such disorders might benefit more from some other intervention.

Regarding the 37% of patients who were assigned to the intensive group but didn't use its services, the authors said that was “mostly because the management teams felt these patients would not benefit from them” and that the targeted patient population may have been too broad, but that a narrower focus would have been difficult using only EHR data.

Increased attending supervision on rounds didn't significantly reduce medical errors

Direct attending supervision during rounds did not significantly reduce the rate of medical errors but led to subjective decreases in resident autonomy compared to no attending supervision, a recent study found.

On an inpatient general medical service at one large academic medical center, 22 faculty members participated in separate two-week arms in random order over a nine-month period. In the standard supervision arm, attendings joined bedside presentations of newly admitted patients but did not join resident work rounds on established patients. In the intervention arm, they provided more direct supervision by joining both new patient presentations and work rounds on previously admitted patients.

Researchers examined the rate of medical errors, the primary safety outcome, in 1,259 patients (5,772 patient-days). Since most errors were anticipated to be minor, they chose a 40% reduction in errors for clinical significance. They also assessed resident education by evaluating resident participation on rounds and measuring resident and attending educational ratings in surveys. Results were published June 4 by JAMA Internal Medicine and appeared in the July issue.

The medical error rate per 1,000 patient-days was not significantly different between the standard and increased supervision arms (107.6 vs. 91.1; 15% relative reduction; 95% CI, −36% to 9%; P=0.21). In a time-motion study of 161 work rounds, there was no significant difference in mean length of time spent discussing patients between the two models.

Interns spoke significantly less when an attending physician joined rounds (64 min [95% CI, 60 to 68 min] vs. 55 min [95% CI, 49 to 60 min]; P=0.008). When attendings were present, a lower proportion of interns reported feeling efficient (55% vs. 73%; P=0.02) and autonomous (72% vs. 91%; P=0.001). Residents also reported lower rates of feeling autonomous with an attending present (58% vs. 97%; P<0.001). However, attendings said the quality of care was higher (100% vs. 80%; P=0.04) and that they knew the team's plan of care better (100% vs. 60%; P=0.002) when they joined work rounds.

The study authors noted limitations, such as the single-center design and the potential for limited generalizability to other settings. They added that their methodology could have missed relevant errors and reduced the overall power to detect statistically significant reductions.

An accompanying editorial echoed these limitations, calling for more research on the effects of supervision on medical errors and on residency training. “A one-size-fits-all model may not be appropriate. Yet, that may be exactly what we are doing in the current era of internal medicine training in which academic hospitalists are serving as the primary educators,” the editorialists wrote.

Supervision of trainees should not be viewed as a hindrance to education but as a challenge of balancing mentorship and autonomy, they said. “To help guide young physicians toward independent practice, we need as much time with our trainees as we can get, but really only as much as they need,” they wrote. “Our faculty need the training as educators to provide that highly nuanced and balanced approach.”

More hospitals require annual flu vaccination for staff, but most VA facilities still do not

The number of hospitals with mandatory influenza vaccination requirements for their health care personnel increased in recent years, whereas nearly all Veterans Affairs (VA) hospitals continued to lack such policies, a recent study found.

Image by Thinkstock
Image by Thinkstock

Researchers used data from an ongoing national panel survey of 1,062 infection preventionists at VA and non-VA hospitals. The survey began in 2005, and subsequent waves took place in 2009, 2013, and 2017. The response rate declined over time, from 69.3% in 2013 to 59.1% in 2017. Results were published online on June 1 by JAMA Network Open.

Among all responding hospitals, the proportion with mandatory influenza vaccination requirements for health care personnel increased during the study period, from 37.1% in 2013 to 61.4% in 2017 (difference, 24.3%; 95% CI, 18.4% to 30.2%; P<0.001).

This change was driven by an increase in the proportion of non-VA hospitals with policies requiring vaccination, from 44.3% (171 of 386) in 2013 to 69.4% (365 of 526) in 2017 (P<0.001). At VA hospitals, the increase in the proportion with policies requiring vaccination was not significant during the study period (1.3% [1 of 77] in 2013 to 4.1% [3 of 73] in 2017; P=0.29).

The study authors noted limitations, such as the decrease in response rates during the study period and the possibility that the results may not be generalizable to all hospitals. They added that they obtained responses in 2017 from a different (yet still nationally representative) sample of hospitals than in the previous survey waves and that slight wording differences between the surveys may have affected results.

In addition, a vaccination “mandate” was not clearly defined by the study, an accompanying editorial noted. Not all respondents with requirement policies reported having penalties for noncompliance, and some allowed staff to decline without a specified reason, the editorial said. Therefore, “it is not clear how many programs described in this survey should appropriately be referred to as mandatory—the number may be higher or lower than that reported, although an increase over time seems likely,” the editorialist wrote.

Another limitation of this and other studies on influenza vaccination of health care personnel is a lack of data on patient outcomes, the editorial stated.

Many patients referred to care management not good candidates

Fewer than two-thirds of the medically complex patients referred for intensive care management were good candidates for the intervention, according to a recent study of care managers.

The mixed-methods study included 35 care managers (10 licensed social workers and 25 registered nurses) working in intensive care management programs for Kaiser Permanente Northern California. They were asked to review up to 50 patients referred to them in the prior year and to categorize each as 1) a good candidate for care management, 2) not needing intensive care management, or 3) needing more than traditional care management could provide. A total of 1,178 patients were reviewed, and results were published by the Journal of General Internal Medicine on May 24.

Overall, 62% of referred patients were considered good candidates for intensive care management; 18% did not need it, and 19% needed something more intensive, according to the care managers. Compared to the other two categories, good candidates were older (76.2 years vs. 73.2 and 69.8 years, respectively; P<0.001), were prescribed more medications (P=0.02), and had more prior-year outpatient visits (P=0.04). The patients judged to need more than care management had the most hospital and ED admissions in the prior year, followed by the good candidates and the patients who didn't need care management. A logistic regression model using available EHR data predicted good candidate designation with a c statistic of 0.75.

The researchers also interviewed the care managers and found some themes that they had used to determine the appropriateness of care management, including availability of social support, patient motivation, nonmedical transitions, recent trajectory of medical condition, and psychiatric or substance use issues. The results indicate “that there remains substantial room for improvement” in selection of patients for care management and that not all relevant factors are included in the EHR, the study authors said. For example, “complex patients who did not have current social support but could have supports recruited to help with their care were often the best candidates for care management,” they said.

Accurately identifying patients who would benefit from care management is important not only for patient care but also for studying whether such interventions are effective, the authors noted. To improve referrals, health care systems will need to systematically collect data related to the themes identified by the care managers, which go “beyond the traditional domains of medical conditions and prior utilization,” the authors recommended.