Publications

OBJECTIVES: Provider organizations are increasingly entering risk-based payment contracts with incentives to minimize medical expenditures. Little is known about physicians' role in controlling costs. This systematic review aims to identify and characterize physician-mediated cost-management interventions in risk-bearing organizations, assess their effectiveness, and evaluate the quality of the literature.

STUDY DESIGN: Systematic literature review.

METHODS: We searched PubMed and EconLit for studies published between 2000 and 2021 reporting physician-mediated interventions intended to reduce medical expenditures in risk-bearing provider organizations. We included quantitative studies evaluating single interventions, quantitative survey-based studies, and qualitative case studies. The quality of the quantitative studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.

RESULTS: Twenty-seven studies were identified, including 12 quantitative evaluations, across diverse provider settings and payment models. We found 5 types of interventions: decision support and performance review, individual financial incentives, physician-led care management, expanded access, and provider-facing price transparency. All but 1 evaluation study found a statistically significant reduction in spending or utilization, but no intervention achieved substantial savings relative to total medical expenditures. The quality of this literature is low, with only 3 studies using a randomized controlled design. Generalizability of results to different provider contexts and payment models remains unclear.

CONCLUSIONS: There is a striking scarcity of high-quality studies on physician-mediated interventions to manage total medical expenditures. The limited evidence to date suggests that no single intervention has a substantial impact on total medical expenditures. Risk-bearing providers have limited guidance in the literature on the most effective practices clinicians can adopt to improve cost-related performance in risk-based contracts.

BACKGROUND: Patients can report respiratory discomfort (dyspnoea) on a 0-10 scale. Patients reporting dyspnoea at admission have a four-fold risk of in-hospital death. We asked whether assessing dyspnoea throughout hospitalisation identifies additional patients at risk of death or other poor outcomes.

METHODS: We conducted a retrospective cohort study of non-intensive care unit patients at a tertiary care hospital. On each shift, bedside nurses documented patients' pain and dyspnoea ratings. We tested associations with inpatient mortality, 2-year mortality and other outcomes.

RESULTS: We evaluated 9785 admissions; 18% of patients reported dyspnoea at admission and 10% developed post-admission dyspnoea. Patients with post-admission-onset dyspnoea had six-fold greater odds of death during hospitalisation (OR 6.0, 95% CI 4.2-8.5, p<0.0001) versus patients without dyspnoea. Compared with those without dyspnoea, patients with dyspnoea had 50% greater mortality during the following 2 years, and those with dyspnoea on the day of discharge had even greater mortality (HR 2.6, 95% CI 2.1-3.2, p<0.0001). Higher patient dyspnoea ratings predicted higher in-hospital and 2-year mortality. Pain (reported by 72% of patients) was not significantly associated with mortality. Dyspnoea was also related to greater length of stay, rapid response team activation, transfer to the intensive care unit and discharge to extended care.

CONCLUSIONS: In contrast to pain, both admission dyspnoea and post-admission-onset dyspnoea were associated with substantially increased odds of poor patient outcomes during hospitalisation and following discharge. Documenting dyspnoea throughout hospitalisation provides a powerful alarm of clinical compromise that may warrant additional attention and outpatient follow-up.

INTRODUCTION: Patients admitted for hip fracture surgery may receive care from a team led either by the operating surgeon or a hospitalist.

OBJECTIVE: To describe the prevalence of the hospitalist care model for hip fracture admissions and its association with patient outcomes.

DESIGN: We conducted a retrospective cohort study of patients admitted in 2018-2019 for fracture of the head and neck of the femur (ICD10 S72.0x-2x). We compared outcomes at hospitals with low versus high use of the hospitalist care model. Our exposure was the hospital-level adoption of hospitalist care, categorized into quartiles.

PARTICIPANTS: Fee-for-service Medicare patients 66 years old or greater.

MAIN MEASURES: Length of stay (LOS), professional services (Part B) inpatient spending, specialty consultation, discharge to home, all-cause 7- and 30-day readmissions, and 30-day mortality.

KEY RESULTS: A total of 294,150 patients with hip fracture were admitted to 2466 hospitals. Patients cared for in low-use (Q1) versus high-use (Q4) hospitals did not differ meaningfully in demographic characteristics or comorbidities. Hospitals ranged in use of the hospitalist care model from 12% in low-use (Q1) hospitals to 81% in high-use (Q4) hospitals. Low-use hospitals had significantly higher inpatient consult use (unadjusted: Q1 vs Q4, 1.06 vs 0.63 consults, p < 0.0001; adjusted: -0.36, p < 0.001) and length of stay (unadjusted: Q1 vs Q4, 6.04 vs 5.94 days, p < 0.0001; adjusted: -0.09 days, p < 0.05), but no significant difference in adjusted analyses for spending, likelihood of discharge home, 7- and 30-day readmission, or 30-day mortality.

CONCLUSIONS: Hospitalist care for older adults admitted for hip fracture surgery is both common and associated with slightly shorter length of stay.

PURPOSE: Oncologic urgent care centers (UCCs) have been shown to reduce emergency department (ED) visits. However, their impact on potentially preventable (PP) presentations, including those with diagnoses in CMS' OP-35 (OP-35) quality metric, has not been evaluated. This study assesses the impact of a specialty-specific UCC on PP ED visits in patients receiving chemotherapy.

METHODS: In this retrospective, single-center analysis, patients were included if they received parenteral or oral chemotherapy within 30 days of ED presentation between March 2019 and June 2021. A UCC tailored toward managing patients with COVID-19 symptoms was opened between March 2020 and June 2021 (intervention period). Outcomes compared before and during the intervention period included weekly incidence of PP ED visits, defined as visits that would be captured in OP-35. Interrupted time series design was utilized.

RESULTS: A total of 2272 ED visits occurred in the study period. Most were for patients > 55 years old (n = 1706, 75%), female (n = 1227, 54%), and with gastrointestinal cancer (n = 637, 28%). Overall 928 (41%) ED visits during the study period were PP. There were 3.8 (95% CI, 0.6 to 7.0) PP weekly ED visits during the intervention period versus 11.0 (95% CI, 9.4 to 12.6) before the intervention period, reflecting a reduction in 7.2 weekly visits (95% CI, - 10.8 to - 3.6).

CONCLUSION: The opening of an oncologic UCC was associated with a reduction in PP ED visits. UCCs can be important in an oncologic service line to reduce unnecessary ED usage, but prospective evaluations are needed to confirm this finding.

OBJECTIVES: ICU-acquired weakness affects 50% of critically ill patients. Early mobility programs have been shown to improve functional status at hospital discharge, shorten duration of mechanical ventilation, prevent delirium, and reduce length of stay. Despite these benefits, early mobility is one of the most difficult parts of the ABCDEF bundle to incorporate into practice. This project sought to use a multidisciplinary intervention to improve mobility in the ICU.

DESIGN: Randomized, pragmatic design quality improvement study.

SETTING: Two ICUs at a large academic medical center between July 2023 and February 2024.

PATIENTS: Five hundred seventy-four ICU patients with 271 in the intervention ICU and 276 in the control ICU.

INTERVENTIONS: A multidisciplinary quality improvement initiative focused on increasing education, raising awareness, and addressing barriers.

MEASUREMENTS AND MAIN RESULTS: Our primary outcome was achievement of an intensity-specific mobility goal with nursing staff on a patient-day level. A difference-in-differences model was used to evaluate the association between the mobility intervention and mobility goal achievement. The percentage of daily mobility goals met increased from 48.6% pre-intervention to 65.4% post-intervention in the intervention ICU (p < 0.001). There was no significant difference in daily mobility goal adherence between the intervention and control ICU pre-intervention, but post-intervention, the intervention ICUs adherence was significantly higher (65.4% vs. 43.0%; p < 0.001). After controlling for demographic, clinical, and ICU characteristics, the intervention ICU was 1.96 times more likely to reach the daily mobility goal on a patient-day level (p = 0.017). There was no significant change in ICU length of stay, inpatient length of stay, discharge to home, or in-hospital mortality between patients treated in the intervention vs. control ICU.

CONCLUSIONS: A multidisciplinary quality improvement initiative can improve adherence to daily mobility goals.

BACKGROUND: Limited evidence exists on the additive risk of bradycardia in children with respiratory syncytial virus (RSV) bronchiolitis receiving dexmedetomidine (DMED). We aim to study the association between RSV bronchiolitis and bradycardia during DMED administration.

METHODS: This retrospective cohort study included 273 children under 2 years old admitted to the intensive care units at Boston Children's Hospital with severe bronchiolitis and sedated with DMED from 2009 to 2022. Children were classified as RSV or non-RSV based on confirmed laboratory results. The primary outcome was a composite measure of clinically significant bradycardia, defined as either a heart rate <60 beats per minute or need for medical intervention(s). The secondary outcome was the minimum heart rate after DMED initiation. Subgroup analyses assessed potential effect modification by age, DMED doses, ventilation mode and pre- versus post-COVID-19.

RESULTS: The median (Q1, Q3) age was 8.0 (4.0, 13.7) months. Of the children studied, 85 (31.1%) had RSV bronchiolitis and 170 (62.3%) underwent invasive mechanical ventilation (IMV) at DMED initiation. Clinically significant bradycardia was observed in 71 (26.0%) patients with no significant difference between the RSV and non-RSV cohorts (OR: 1.80; 95% CI: 0.95 to 3.39; p = 0.07). Subgroup analyses showed effect modification with an increased likelihood of clinically significant bradycardia in the RSV group undergoing IMV (OR: 2.99 vs 0.45; Χ2 1=3.6, p=0.04) or admitted before the COVID-19 pandemic (OR: 2.94 vs 0.51; Χ2 1=4.7, p=0.03). The RSV cohort experienced a significantly greater heart rate reduction after DMED initiation (-8.07 bpm; 95% CI: -13.71 to -2.43; p = 0.005).

CONCLUSIONS: Children with RSV bronchiolitis experienced greater heart rate reduction after DMED initiation, with a higher likelihood of clinically significant bradycardia if IMV is in use at DMED initiation or if admitted before the COVID-19 pandemic. Caution is warranted when treating RSV bronchiolitis patients with DMED.

RATIONALE: Barriers to recognizing and treating acute respiratory distress syndrome (ARDS) exist. Prior studies have not investigated whether these barriers differ between academic and community settings, nor whether there were differences in critical care clinicians' reported ARDS management strategies during the COVID-19 pandemic.

OBJECTIVES: Grounded in the Consolidated Framework for Implementation Research, we sought to determine whether there are differences between academic and community critical care clinicians in their team- and ICU-based culture; interprofessional communication; knowledge, attitudes, and perceived barriers to ARDS recognition and management; and their ICU organization and ARDS management associated with the COVID-19 pandemic.

METHODS: Multidisciplinary survey from September, 2020 to April, 2021 of critical care physicians, nurses, advanced practice providers, and respiratory therapists (RTs) in six academic and nine community hospitals across the United States and Canada. Individual item and cumulative domain scores were compared between academic and community clinicians. Statistical adjustment was performed for multiple comparisons.

RESULTS: 1,906 clinicians responded to at least one survey item (53% response rate). Mean (SD) culture scores were higher for community physicians vs. academic physicians (5.3 [1.8] vs. 4.4 [2.0], P<0.001) and community nurses vs. academic nurses (4.4 [2.2] vs. 3.8 [2.1], P=0.007). Academic nurses and RTs had higher knowledge scores compared to community nurses and RTs (P<0.001 for each comparison). Community physicians, nurses, and RTs reported higher mean (SD) number of changes in ICU organization and practice during the COVID-19 pandemic compared to academic clinicians (e.g., community physicians: 13.7 [2.7] changes vs. academic physicians: 11.8 [4.3] changes, P=0.001). While academic physicians, nurses, and RTs were approximately twice as likely to care for ARDS patients daily or several days per week compared to community clinicians, ARDS management, attitudes, and belief in evidence was similar between academic and community clinicians in most respects.

CONCLUSIONS: A large, multidisciplinary survey identified differences between academic and community critical care clinicians' culture and knowledge in the care of ARDS patients. The COVID-19 pandemic had a greater impact on community ICU organization and ARDS management. Multifaceted implementation strategies should target implementation barriers differently in academic and community settings.