By age 55, nearly half of physicians have been sued for malpractice, with general surgeons and obstetricians-gynecologists facing the highest lawsuit risks, according to data from the America Medical Association.

Investigators with the AMA surveyed 3,500 postresidency physicians who were not employed by the federal government. Findings show that the probability of getting sued increases with age, and that male doctors are more likely to be sued than female physicians. For example, only 8% of doctors under 40 have been sued, compared to nearly half of physicians over age 54, the study found. In addition, nearly 40% of male physicians have been sued over the course of their careers, compared with 23% of female doctors.

In a second report, an analysis showed the average expense incurred during a medical liability claim is $54,165 – a 65% increase since 2006. For the study, the AMA analyzed data from PIAA, a trade association for the medical professional liability insurance industry, and evaluated payments, expenses, and claim disposition within a sample of 90,473 medical liability claims that closed between 2006 and 2015.

[email protected]

By age 55, nearly half of physicians have been sued for malpractice, with general surgeons and obstetricians-gynecologists facing the highest lawsuit risks, according to data from the America Medical Association.

Investigators with the AMA surveyed 3,500 postresidency physicians who were not employed by the federal government. Findings show that the probability of getting sued increases with age, and that male doctors are more likely to be sued than female physicians. For example, only 8% of doctors under 40 have been sued, compared to nearly half of physicians over age 54, the study found. In addition, nearly 40% of male physicians have been sued over the course of their careers, compared with 23% of female doctors.

In a second report, an analysis showed the average expense incurred during a medical liability claim is $54,165 – a 65% increase since 2006. For the study, the AMA analyzed data from PIAA, a trade association for the medical professional liability insurance industry, and evaluated payments, expenses, and claim disposition within a sample of 90,473 medical liability claims that closed between 2006 and 2015.

[email protected]

By age 55, nearly half of physicians have been sued for malpractice, with general surgeons and obstetricians-gynecologists facing the highest lawsuit risks, according to data from the America Medical Association.

Investigators with the AMA surveyed 3,500 postresidency physicians who were not employed by the federal government. Findings show that the probability of getting sued increases with age, and that male doctors are more likely to be sued than female physicians. For example, only 8% of doctors under 40 have been sued, compared to nearly half of physicians over age 54, the study found. In addition, nearly 40% of male physicians have been sued over the course of their careers, compared with 23% of female doctors.

In a second report, an analysis showed the average expense incurred during a medical liability claim is $54,165 – a 65% increase since 2006. For the study, the AMA analyzed data from PIAA, a trade association for the medical professional liability insurance industry, and evaluated payments, expenses, and claim disposition within a sample of 90,473 medical liability claims that closed between 2006 and 2015.

[email protected]

Diplopia, commonly known as double vision, was depicted in a significantly higher percentage of drawings by children (aged 6-18 years) with pseudotumor cerebri than drawings by children with migraine, a recent study found. In all other respects, headache drawings by both groups of children were similar. In this study, children attending university hospital pediatric neurology clinics were asked to draw a picture of how their headache feels. Headache drawings of 21 children (16 females) with pseudotumor were compared with those of 518 children with migraine. Researchers found:

• Pseudotumor drawings depicted a variety of symptoms including pounding pain (n=11), pressure-like pain (n=3), photophobia (n=3), dizziness (n=1), and recumbency (n=1).
• Severe pain indicators included hammers, bombs, an anvil, and vise grip.
• Positive visual phenomena included scintillations, scotomata, or blurring (n=8).
• Negative visual phenomena included field defects (n=2).

Pseudotumor drawings were similar to migraine drawings except that 6 of 21 pseudotumor drawings (28.6%) depicted diplopia, whereas only 3 of 518 migraine drawings (0.6%) depicted diplopia.

Evidence of diplopia in children's headache drawings helps to differentiate pseudotumor cerebri from migraine. 2018;79:40-44. Pediatr Neurol.  doi:10.1016/j.pediatrneurol.2017.10.020.

Diplopia, commonly known as double vision, was depicted in a significantly higher percentage of drawings by children (aged 6-18 years) with pseudotumor cerebri than drawings by children with migraine, a recent study found. In all other respects, headache drawings by both groups of children were similar. In this study, children attending university hospital pediatric neurology clinics were asked to draw a picture of how their headache feels. Headache drawings of 21 children (16 females) with pseudotumor were compared with those of 518 children with migraine. Researchers found:

• Pseudotumor drawings depicted a variety of symptoms including pounding pain (n=11), pressure-like pain (n=3), photophobia (n=3), dizziness (n=1), and recumbency (n=1).
• Severe pain indicators included hammers, bombs, an anvil, and vise grip.
• Positive visual phenomena included scintillations, scotomata, or blurring (n=8).
• Negative visual phenomena included field defects (n=2).

Pseudotumor drawings were similar to migraine drawings except that 6 of 21 pseudotumor drawings (28.6%) depicted diplopia, whereas only 3 of 518 migraine drawings (0.6%) depicted diplopia.

Evidence of diplopia in children's headache drawings helps to differentiate pseudotumor cerebri from migraine. 2018;79:40-44. Pediatr Neurol.  doi:10.1016/j.pediatrneurol.2017.10.020.

Diplopia, commonly known as double vision, was depicted in a significantly higher percentage of drawings by children (aged 6-18 years) with pseudotumor cerebri than drawings by children with migraine, a recent study found. In all other respects, headache drawings by both groups of children were similar. In this study, children attending university hospital pediatric neurology clinics were asked to draw a picture of how their headache feels. Headache drawings of 21 children (16 females) with pseudotumor were compared with those of 518 children with migraine. Researchers found:

• Pseudotumor drawings depicted a variety of symptoms including pounding pain (n=11), pressure-like pain (n=3), photophobia (n=3), dizziness (n=1), and recumbency (n=1).
• Severe pain indicators included hammers, bombs, an anvil, and vise grip.
• Positive visual phenomena included scintillations, scotomata, or blurring (n=8).
• Negative visual phenomena included field defects (n=2).

Pseudotumor drawings were similar to migraine drawings except that 6 of 21 pseudotumor drawings (28.6%) depicted diplopia, whereas only 3 of 518 migraine drawings (0.6%) depicted diplopia.

Evidence of diplopia in children's headache drawings helps to differentiate pseudotumor cerebri from migraine. 2018;79:40-44. Pediatr Neurol.  doi:10.1016/j.pediatrneurol.2017.10.020.

Levetiracetam may be a superior initial treatment for infants with nonsyndromic epilepsy, a multicenter, prospective, observational study has shown.

“Our findings suggest that levetiracetam has superior effectiveness compared with phenobarbital as initial monotherapy for nonsyndromic epilepsy in infants,” wrote Zachary Grinspan, MD, director of the pediatric epilepsy program at Cornell University, New York, and his colleagues. “We estimate that for every 100 infants with epilepsy treated with levetiracetam instead of phenobarbital, 44 infants would be free from monotherapy failure instead of 16.”

To evaluate the effectiveness of levetiracetam vs. phenobarbital, Dr. Grinspan and his colleagues developed the Early Life Epilepsy Study, a multicenter, prospective, observational investigation of 155 children with nonsyndromic epilepsy. Patient information for this study was obtained from medical records and was collected from March 1, 2012, through April 30, 2015. All of the patients in the study were observed in the first 3 years of life.

Of the 155 children included in the analysis for this study, 117 were treated with levetiracetam and 38 with phenobarbital. There were some differences between the groups. Children treated with levetiracetam were, on average, 2 months older at seizure onset than were those in the phenobarbital group (5.2 months vs. 3.0 months; P less than .001). Infants treated with levetiracetam also tended to begin treatment further from the time of their first seizure and exhibited less developmental delay at the time of epilepsy diagnosis. There were some other differences of possible clinical importance (developmental structural brain abnormalities, head circumference) that did not reach statistical significance.

Freedom from monotherapy failure was greater in the levetiracetam group (47 [40.2%] vs. 6 [15.8%]; P = .01; odds ratio, 3.6; 95% confidence interval, 1.5-10). Overall, the researchers concluded that levetiracetam was superior to phenobarbital for nonsyndromic epilepsy in pediatric patients (OR, 4.2; 95% CI, 1.1-16; number needed to treat, 3.5 [95% CI, 1.7-60]).

Outcome information was missing for more infants treated with levetiracetam than for those treated with phenobarbital, which could have skewed the analyses, Dr. Grinspan and his associates said. The nature of nonsyndromic epilepsy also makes it difficult to study because of the intricate genetic interactions that can influence the disorder.

Although this study provides information that could potentially benefit infantile epilepsy patients, the investigators said that more work must be done on the topic.

“A prospective clinical trial is needed. Levetiracetam and phenobarbital are both commonly used for infantile-onset epilepsy, indicating community equipoise regarding their relative effectiveness,” they wrote. “However, the effect size in our analysis was surprisingly large (number needed to treat, 3.5), suggesting that a change in practice could meaningfully improve outcomes.”

The investigators reported receiving grants and fees and consulting with a range of institutions, and the complete list can be found on the JAMA Pediatrics website. This study was funded by the Pediatric Epilepsy Research Foundation.

[email protected]

SOURCE: Grinspan Z et al. JAMA Pediatr. 2018 Feb 12. doi: 10.1001/jamapediatrics.2017.5211.

Levetiracetam may be a superior initial treatment for infants with nonsyndromic epilepsy, a multicenter, prospective, observational study has shown.

“Our findings suggest that levetiracetam has superior effectiveness compared with phenobarbital as initial monotherapy for nonsyndromic epilepsy in infants,” wrote Zachary Grinspan, MD, director of the pediatric epilepsy program at Cornell University, New York, and his colleagues. “We estimate that for every 100 infants with epilepsy treated with levetiracetam instead of phenobarbital, 44 infants would be free from monotherapy failure instead of 16.”

To evaluate the effectiveness of levetiracetam vs. phenobarbital, Dr. Grinspan and his colleagues developed the Early Life Epilepsy Study, a multicenter, prospective, observational investigation of 155 children with nonsyndromic epilepsy. Patient information for this study was obtained from medical records and was collected from March 1, 2012, through April 30, 2015. All of the patients in the study were observed in the first 3 years of life.

Of the 155 children included in the analysis for this study, 117 were treated with levetiracetam and 38 with phenobarbital. There were some differences between the groups. Children treated with levetiracetam were, on average, 2 months older at seizure onset than were those in the phenobarbital group (5.2 months vs. 3.0 months; P less than .001). Infants treated with levetiracetam also tended to begin treatment further from the time of their first seizure and exhibited less developmental delay at the time of epilepsy diagnosis. There were some other differences of possible clinical importance (developmental structural brain abnormalities, head circumference) that did not reach statistical significance.

Freedom from monotherapy failure was greater in the levetiracetam group (47 [40.2%] vs. 6 [15.8%]; P = .01; odds ratio, 3.6; 95% confidence interval, 1.5-10). Overall, the researchers concluded that levetiracetam was superior to phenobarbital for nonsyndromic epilepsy in pediatric patients (OR, 4.2; 95% CI, 1.1-16; number needed to treat, 3.5 [95% CI, 1.7-60]).

Outcome information was missing for more infants treated with levetiracetam than for those treated with phenobarbital, which could have skewed the analyses, Dr. Grinspan and his associates said. The nature of nonsyndromic epilepsy also makes it difficult to study because of the intricate genetic interactions that can influence the disorder.

Although this study provides information that could potentially benefit infantile epilepsy patients, the investigators said that more work must be done on the topic.

“A prospective clinical trial is needed. Levetiracetam and phenobarbital are both commonly used for infantile-onset epilepsy, indicating community equipoise regarding their relative effectiveness,” they wrote. “However, the effect size in our analysis was surprisingly large (number needed to treat, 3.5), suggesting that a change in practice could meaningfully improve outcomes.”

The investigators reported receiving grants and fees and consulting with a range of institutions, and the complete list can be found on the JAMA Pediatrics website. This study was funded by the Pediatric Epilepsy Research Foundation.

[email protected]

SOURCE: Grinspan Z et al. JAMA Pediatr. 2018 Feb 12. doi: 10.1001/jamapediatrics.2017.5211.

Levetiracetam may be a superior initial treatment for infants with nonsyndromic epilepsy, a multicenter, prospective, observational study has shown.

“Our findings suggest that levetiracetam has superior effectiveness compared with phenobarbital as initial monotherapy for nonsyndromic epilepsy in infants,” wrote Zachary Grinspan, MD, director of the pediatric epilepsy program at Cornell University, New York, and his colleagues. “We estimate that for every 100 infants with epilepsy treated with levetiracetam instead of phenobarbital, 44 infants would be free from monotherapy failure instead of 16.”

To evaluate the effectiveness of levetiracetam vs. phenobarbital, Dr. Grinspan and his colleagues developed the Early Life Epilepsy Study, a multicenter, prospective, observational investigation of 155 children with nonsyndromic epilepsy. Patient information for this study was obtained from medical records and was collected from March 1, 2012, through April 30, 2015. All of the patients in the study were observed in the first 3 years of life.

Of the 155 children included in the analysis for this study, 117 were treated with levetiracetam and 38 with phenobarbital. There were some differences between the groups. Children treated with levetiracetam were, on average, 2 months older at seizure onset than were those in the phenobarbital group (5.2 months vs. 3.0 months; P less than .001). Infants treated with levetiracetam also tended to begin treatment further from the time of their first seizure and exhibited less developmental delay at the time of epilepsy diagnosis. There were some other differences of possible clinical importance (developmental structural brain abnormalities, head circumference) that did not reach statistical significance.

Freedom from monotherapy failure was greater in the levetiracetam group (47 [40.2%] vs. 6 [15.8%]; P = .01; odds ratio, 3.6; 95% confidence interval, 1.5-10). Overall, the researchers concluded that levetiracetam was superior to phenobarbital for nonsyndromic epilepsy in pediatric patients (OR, 4.2; 95% CI, 1.1-16; number needed to treat, 3.5 [95% CI, 1.7-60]).

Outcome information was missing for more infants treated with levetiracetam than for those treated with phenobarbital, which could have skewed the analyses, Dr. Grinspan and his associates said. The nature of nonsyndromic epilepsy also makes it difficult to study because of the intricate genetic interactions that can influence the disorder.

Although this study provides information that could potentially benefit infantile epilepsy patients, the investigators said that more work must be done on the topic.

“A prospective clinical trial is needed. Levetiracetam and phenobarbital are both commonly used for infantile-onset epilepsy, indicating community equipoise regarding their relative effectiveness,” they wrote. “However, the effect size in our analysis was surprisingly large (number needed to treat, 3.5), suggesting that a change in practice could meaningfully improve outcomes.”

The investigators reported receiving grants and fees and consulting with a range of institutions, and the complete list can be found on the JAMA Pediatrics website. This study was funded by the Pediatric Epilepsy Research Foundation.

[email protected]

SOURCE: Grinspan Z et al. JAMA Pediatr. 2018 Feb 12. doi: 10.1001/jamapediatrics.2017.5211.

Clinical question: Is rivaroxaban as effective and safe as warfarin immediately following minor acute ischemic stroke from atrial fibrillation?

Background: There is uncertainty regarding the best approach to anticoagulation acutely after ischemic stroke secondary to atrial fibrillation. To reduce the risk of intracranial hemorrhage, many physicians start aspirin immediately and delay initiating warfarin until days to weeks later. With their more predictable and rapid anticoagulant effect with potentially lower risk of intracranial hemorrhage, direct oral anticoagulants such as rivaroxaban are an attractive possible alternative to warfarin in the acute setting.

Study design: Multicenter, randomized, open-label superiority trial with blinded outcome assessment.

Setting: Fourteen academic hospitals in South Korea.

Synopsis: One hundred eighty-three patients with mild acute (within 5 days) ischemic stroke secondary to nonvalvular atrial fibrillation were randomized to immediately initiate either rivaroxaban or warfarin. The primary outcome (composite of new ischemic lesion or new intracranial hemorrhage on MRI at 4 weeks) occurred at similar frequency between groups (49.5% versus 54.5%, P = .49). Rates of adverse events were comparable in each group. Median hospitalization length was shorter in those randomized to rivaroxaban (4.0 versus 6.0 days, P less than .001). Limitations include a radiographic primary outcome that captured many asymptomatic lesions, homogenous study population, and lack of a delayed anticoagulation group.

Bottom line: In patients with mild acute stroke from nonvalvular atrial fibrillation, rivaroxaban and warfarin demonstrated comparable efficacy and safety. More study is needed to determine the optimal anticoagulation strategy in acute stroke.

Citation: Hong K-S et al. Rivaroxaban vs. warfarin sodium in the ultra-early period after atrial fibrillation-related mild ischemic stroke: A randomized clinical trial. JAMA Neurol. 2017; 74(10):1206-15.

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Is rivaroxaban as effective and safe as warfarin immediately following minor acute ischemic stroke from atrial fibrillation?

Background: There is uncertainty regarding the best approach to anticoagulation acutely after ischemic stroke secondary to atrial fibrillation. To reduce the risk of intracranial hemorrhage, many physicians start aspirin immediately and delay initiating warfarin until days to weeks later. With their more predictable and rapid anticoagulant effect with potentially lower risk of intracranial hemorrhage, direct oral anticoagulants such as rivaroxaban are an attractive possible alternative to warfarin in the acute setting.

Study design: Multicenter, randomized, open-label superiority trial with blinded outcome assessment.

Setting: Fourteen academic hospitals in South Korea.

Synopsis: One hundred eighty-three patients with mild acute (within 5 days) ischemic stroke secondary to nonvalvular atrial fibrillation were randomized to immediately initiate either rivaroxaban or warfarin. The primary outcome (composite of new ischemic lesion or new intracranial hemorrhage on MRI at 4 weeks) occurred at similar frequency between groups (49.5% versus 54.5%, P = .49). Rates of adverse events were comparable in each group. Median hospitalization length was shorter in those randomized to rivaroxaban (4.0 versus 6.0 days, P less than .001). Limitations include a radiographic primary outcome that captured many asymptomatic lesions, homogenous study population, and lack of a delayed anticoagulation group.

Bottom line: In patients with mild acute stroke from nonvalvular atrial fibrillation, rivaroxaban and warfarin demonstrated comparable efficacy and safety. More study is needed to determine the optimal anticoagulation strategy in acute stroke.

Citation: Hong K-S et al. Rivaroxaban vs. warfarin sodium in the ultra-early period after atrial fibrillation-related mild ischemic stroke: A randomized clinical trial. JAMA Neurol. 2017; 74(10):1206-15.

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

Clinical question: Is rivaroxaban as effective and safe as warfarin immediately following minor acute ischemic stroke from atrial fibrillation?

Background: There is uncertainty regarding the best approach to anticoagulation acutely after ischemic stroke secondary to atrial fibrillation. To reduce the risk of intracranial hemorrhage, many physicians start aspirin immediately and delay initiating warfarin until days to weeks later. With their more predictable and rapid anticoagulant effect with potentially lower risk of intracranial hemorrhage, direct oral anticoagulants such as rivaroxaban are an attractive possible alternative to warfarin in the acute setting.

Study design: Multicenter, randomized, open-label superiority trial with blinded outcome assessment.

Setting: Fourteen academic hospitals in South Korea.

Synopsis: One hundred eighty-three patients with mild acute (within 5 days) ischemic stroke secondary to nonvalvular atrial fibrillation were randomized to immediately initiate either rivaroxaban or warfarin. The primary outcome (composite of new ischemic lesion or new intracranial hemorrhage on MRI at 4 weeks) occurred at similar frequency between groups (49.5% versus 54.5%, P = .49). Rates of adverse events were comparable in each group. Median hospitalization length was shorter in those randomized to rivaroxaban (4.0 versus 6.0 days, P less than .001). Limitations include a radiographic primary outcome that captured many asymptomatic lesions, homogenous study population, and lack of a delayed anticoagulation group.

Bottom line: In patients with mild acute stroke from nonvalvular atrial fibrillation, rivaroxaban and warfarin demonstrated comparable efficacy and safety. More study is needed to determine the optimal anticoagulation strategy in acute stroke.

Citation: Hong K-S et al. Rivaroxaban vs. warfarin sodium in the ultra-early period after atrial fibrillation-related mild ischemic stroke: A randomized clinical trial. JAMA Neurol. 2017; 74(10):1206-15.

Dr. Kanjee is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.

The SVS Patient Safety Organization and the SVS Quality and Performance Measures Committee (QPMC) will hold a webinar at 8 p.m. Eastern Standard Time, Thursday, Feb. 15. It will help unravel the new Quality Payment Program (QPP) under Medicare, including what surgeons still can do for 2017 to avoid reimbursement penalties. Learn more here and register here.

The SVS Patient Safety Organization and the SVS Quality and Performance Measures Committee (QPMC) will hold a webinar at 8 p.m. Eastern Standard Time, Thursday, Feb. 15. It will help unravel the new Quality Payment Program (QPP) under Medicare, including what surgeons still can do for 2017 to avoid reimbursement penalties. Learn more here and register here.

The SVS Patient Safety Organization and the SVS Quality and Performance Measures Committee (QPMC) will hold a webinar at 8 p.m. Eastern Standard Time, Thursday, Feb. 15. It will help unravel the new Quality Payment Program (QPP) under Medicare, including what surgeons still can do for 2017 to avoid reimbursement penalties. Learn more here and register here.

Onerous prior authorization rules, Stark Law, and other issues are creating barriers to health care choice and competition, the American College of Rheumatology recently told the Department of Health & Human Services.

The agency recently issued an informal request for information seeking “input from the public on the extent to which existing state and federal laws, regulations, guidance, requirements, and policies limit choice and competition across all health care markets, and the identification of actions that states or the federal government could take to support the development and operations of a health care system that provides high-quality care at affordable prices for the American people.”

sndr/istockphoto.com

[email protected]

Onerous prior authorization rules, Stark Law, and other issues are creating barriers to health care choice and competition, the American College of Rheumatology recently told the Department of Health & Human Services.

The agency recently issued an informal request for information seeking “input from the public on the extent to which existing state and federal laws, regulations, guidance, requirements, and policies limit choice and competition across all health care markets, and the identification of actions that states or the federal government could take to support the development and operations of a health care system that provides high-quality care at affordable prices for the American people.”

sndr/istockphoto.com

[email protected]

Onerous prior authorization rules, Stark Law, and other issues are creating barriers to health care choice and competition, the American College of Rheumatology recently told the Department of Health & Human Services.

The agency recently issued an informal request for information seeking “input from the public on the extent to which existing state and federal laws, regulations, guidance, requirements, and policies limit choice and competition across all health care markets, and the identification of actions that states or the federal government could take to support the development and operations of a health care system that provides high-quality care at affordable prices for the American people.”

sndr/istockphoto.com

[email protected]

I was one of about 600 dermatologists sitting in a lecture hall during a meeting in Maui when our muted smartphones suddenly started howling in unison. A text message popped up stating, “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” We all assumed a nuclear weapon from North Korea was headed our way.

The lecture was interrupted. The confused and concerned attendees milled around. The immediate response was largely “this can’t be real.” Meanwhile, the text alarm went off again transmitting the same message. The hotel intercom repeated the message and warned us to get inside the ballroom.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I was one of about 600 dermatologists sitting in a lecture hall during a meeting in Maui when our muted smartphones suddenly started howling in unison. A text message popped up stating, “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” We all assumed a nuclear weapon from North Korea was headed our way.

The lecture was interrupted. The confused and concerned attendees milled around. The immediate response was largely “this can’t be real.” Meanwhile, the text alarm went off again transmitting the same message. The hotel intercom repeated the message and warned us to get inside the ballroom.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I was one of about 600 dermatologists sitting in a lecture hall during a meeting in Maui when our muted smartphones suddenly started howling in unison. A text message popped up stating, “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” We all assumed a nuclear weapon from North Korea was headed our way.

The lecture was interrupted. The confused and concerned attendees milled around. The immediate response was largely “this can’t be real.” Meanwhile, the text alarm went off again transmitting the same message. The hotel intercom repeated the message and warned us to get inside the ballroom.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

We all have one priority with all of our facial rejuvenation patients: Having happy, satisfied patients. With this in mind, I find I am torn by the armamentarium of noninvasive tightening devices to choose from. What are the critical factors in choosing a platform for your practice? Most practices look at pain, downtime, cost, and the number of treatments necessary to reach the expected outcome.

Dr. Lily Talakoub/McLean Dermatology

Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They have no relevant disclosures.

We all have one priority with all of our facial rejuvenation patients: Having happy, satisfied patients. With this in mind, I find I am torn by the armamentarium of noninvasive tightening devices to choose from. What are the critical factors in choosing a platform for your practice? Most practices look at pain, downtime, cost, and the number of treatments necessary to reach the expected outcome.

Dr. Lily Talakoub/McLean Dermatology

Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They have no relevant disclosures.

We all have one priority with all of our facial rejuvenation patients: Having happy, satisfied patients. With this in mind, I find I am torn by the armamentarium of noninvasive tightening devices to choose from. What are the critical factors in choosing a platform for your practice? Most practices look at pain, downtime, cost, and the number of treatments necessary to reach the expected outcome.

Dr. Lily Talakoub/McLean Dermatology

Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They have no relevant disclosures.

Is it time to use the P word about influenza? Your Medicare Part B drug pay earns a reprieve, a pregnancy-friendly psoriasis biologic is coming, and it’s good news, bad news for melanoma.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

Is it time to use the P word about influenza? Your Medicare Part B drug pay earns a reprieve, a pregnancy-friendly psoriasis biologic is coming, and it’s good news, bad news for melanoma.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

Is it time to use the P word about influenza? Your Medicare Part B drug pay earns a reprieve, a pregnancy-friendly psoriasis biologic is coming, and it’s good news, bad news for melanoma.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

From the Mayo Clinic, Rochester, MN.

Abstract

• Objective: To elicit patient perceptions of a computer tablet (“e-Board”) used to display information relevant to hospital discharge and to gather patients’ expectations and perceptions regarding hospital discharge.
• Methods: Adult patients discharged from 1 of 3 medical-surgical, noncardiac monitored units of a 1265-bed, academic, tertiary care hospital were interviewed during patient focus groups. Reviewer pairs performed qualitative analysis of focus group transcripts and identified key themes, which were grouped into categories.
• Results: Patients felt a novel e-Board could help with the discharge process. They identified coordination of discharge, communication about discharge, ramifications of unexpected admissions, and interpersonal interactions during admission as the most significant issues around discharge.
• Conclusions: Focus groups elicit actionable information from patients about hospital discharge. Using this information, e-tools may help to design a patient-centered discharge process.

Key words: hospitals; patient satisfaction; focus groups; acute inpatient care.

Transition from the hospital to home represents a critical time for patients after acute illness, and support of patients and their care partners can help decrease consequences of poor care transitions, such as readmissions [1]. Focused discharge planning may improve outcomes and increase patient satisfaction [2], which is a key metric in hospital value-based purchasing programs, which tie Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey scores to reimbursement. Although patient experience surveys explore several categories of patient satisfaction, HCAHPS may not reveal readily actionable opportunities that would allow clinicians to improve patient experience. Conducting focus groups and interviews can help discern patients’ perceptions and provide patient-centered opportunities to improve hospital discharge processes. Recent studies using these methodologies have revealed patients’ perceptions of barriers to inter-professional collaboration during discharge [3] and their desires and expectations of, as well as suggestions for improvement of, hospitalization [4].

Care transition bundles have been developed to facilitate the process of transitioning home [1,5], but none include e-health tools to help facilitate the discharge process. A study group leveraged available software at our institution to create a bedside “e-Board,” addressing opportunities that surfaced during previous patient focus groups regarding our institution’s discharge process. The software tools were loaded onto a tablet computer (Apple iPad; Cupertino, CA) and included displays of the patient’s physician and nurse, with estimated time of team bedside rounds; day and time of anticipated discharge; display of discharge medications; and a screening tool, I-MOVE, to assess mobility prior to return to independent living [6].

We conducted focus groups to gather patients’ insights for incorporation into a bedside e-health tool for discharge and into our hospital’s current discharge process. The primary objective of the current study was to elicit patient and family perceptions of a bedside e-Board, created to display information regarding discharge. Our secondary objective was to learn about patient expectations and perceptions regarding the hospital discharge process.

Methods

Setting

The study setting was 3 medical-surgical, non-cardiac monitored units of a 1265-bed, academic, tertiary care hospital in Rochester, MN. The study was considered a minimal risk study by the center’s institutional review board.

Participants

Patients aged 18 years or older discharged from 1 of the 3 study units during 2012–2013 were eligible to participate. Patients were excluded if they were not discharged home or to assisted living, were clinic employees, retirees or dependents of clinic employees, were hospitalized longer than 6 months prior to study entry, lived further than 60 miles from the town of Rochester, could not travel, or did not sign research consent.

There were 975 patients who met inclusion criteria. The institution’s survey research center randomly selected 300 eligible patients and contacted them by letter after discharge. The letter was followed up with a telephone call and verbal consent was obtained if the patient expressed interest in participation. Of the 17 patients who gave consent, 12 patients participated in focus group interviews.

E-Board Development

Prior focus group discussions facilitated by our institution’s marketing department (Mr. Kent Seltman, personal communication) explored patients’ perceptions of the discharge process from the institution’s primary hospital. The opportunities for improvement that surfaced during these focus groups included identifying the date of discharge, communication about the time of discharge, and discharging the patient at the identified time, not several hours later. The study group leveraged software available at our institution to create a bedside e-Board that could possibly mitigate these issues by improving communication about discharge. The software tools were loaded onto a tablet computer for patients to use as a resource during their admission. These tools included:

1. A photo display of the patient’s nurse and physician, with estimated time of bedside rounds
2. A display of the day and time of anticipated discharge. Providing anticipated day and time of discharge has been found to be an achievable goal for internal medicine and surgical services [7].
3. A medication display, named the “Durable Display at Discharge,” previously found to improve patient understanding of prescribed medications [8]
4. A display of a mobility tool, I-MOVE, designed to screen for debility that could prevent patients’ return to independent living [6].

Focus Groups

Facilitated interviews were conducted on 2 consecutive days in March 2014. Participants were divided into a focus group of 5 to 6 participants if they were functionally independent, or dyads of patient and care partner if they were functionally dependent. Interviews were both video- and audiotaped.

A trained facilitator led 1.5-hour sessions with each focus group. The sessions began with introductions and guidelines by which the focus groups were conducted, including explanations of the video and audio recording equipment, and a request for participants to speak one person at a time to facilitate recording. Discussions were carried out in 2 parts, guided by a facilitator script ( available from the authors). First, participants were asked to share their experiences regarding planning for discharge and the information they received leading up to their planned day and time of hospital discharge. Second, participants were shown a prototype of the e-Board. Participants were asked to reflect as to whether they had received similar information when they had been hospitalized, whether that information was helpful or useful, what information they did not receive that would have been helpful, how information was given, and whether information displayed via an e-Board would be better or worse than the ways they received information while in the hospital.

Data Analysis

Three teams, each comprised of 2 reviewers, met to analyze the video and audio recordings of each focus group. Unfortunately, the video files from the dyad interviews were not recoverable after the recorded sessions, and thus those groups were excluded from the study. Reviewers met prior to analyzing the focus group video and audio recordings to review the qualitative analysis protocol developed by the research team [9] (protocol available froom the authors). The teams then independently reviewed the video recordings and transcripts of the focus groups. The reviewer teams observed the focus group recordings and identified (1) themes regarding perceptions of the bedside e-Board and (2) experiences and perceptions around discharge. The protocol helped reviewer teams create a classification structure by identifying the key themes, which were then combined to create categories. The reviewer teams then compared their classification structures and by incorporating the most frequently identified categories, built a relational model of discharge perceptions.

Results

Eleven patients participated in 2 focus groups, one group of 5 patients and the other of 6 patients. Patient participants included 6 females and 5 males ranging in age from 22 to 84 years.

Using the qualitative analysis protocol, review teams grouped key themes from the focus group discussions about discharge into 4 categories. The categories, with themes listed below and representative patient comments in the Table, were

1.  Coordination and timing of discharge

• Giving patients the opportunity to prepare for discussion with clinician teams
•  Communicating the specific time of discharge
• Internal collaboration of inter-professional teams
• Preparing for transition out of the hospital

  2.  Communication

• Patient inclusion in care discussions
• Discharge summary delay and/or completeness
• Education at the time of discharge

  3. Ramifications of the unexpected and unknown

• Increased stress and frustration due to inability to plan, fear of the unknown, and lack of information

  4. Interpersonal interactions

• Both favorable and unfavorable interactions caused an emotional response that impacts perceptions of hospitalization and discharge

The reviewers also analyzed patients’ comments regarding the bedside e-Board. The medication display (“Durable Display at Discharge,” Figure 1) was universally considered to be the most relevant and best-liked of the 4 elements tested. The visual display of medications and their purpose were commonly referenced as the most positive aspects of the display, and patients and caregivers were readily able to generate multiple potential uses for the display. Several mentioned that the information on the medication display were so desirable and necessary that if not supplied by the hospital, they hand-crafted such reminder displays at home.

It was difficult for patients to see how the I-MOVE assessment (Figure 2) would apply to their discharge planning. They perceived I-MOVE as a tool for clinicians. One exception was a patient who had on a previous admission undergone heart surgery. She explained to the other patients that in such debilitated conditions, mobility independence assessments were important and commonly done.

Patients voiced some skepticism and concerns regarding the e-Board, including expense, privacy, security, and cleanliness. One patient observed the tablet was “more current than a printed piece of paper. It’s more up to date.” Other patients, however, questioned the process required to update information and wondered how much electronic displays added compared to the dry-erase board already in each patient’s room with which they were more familiar. They also voiced concern that the tablet would replace face-to-face interactions with their care teams. A patient shared that, “if we don’t have the conversation and we just get it through this, then I would hate that…you want to be able to give your input.”

Discussion

In this study, we used available software to create a bedside e-Board that addressed opportunities for patient-centered improvement in our institution’s discharge process. Patients felt that 3 of 4 software tools on the tablet could enhance the discharge experience. Additionally, we explored patients’ expectations and perceptions of our hospital discharge process.

Key information to inform our current discharge process was divulged by our patients during focus groups. Patients conveyed that the only time that matters to them is the time they get to walk out the door of the hospital, and that general statements (eg, “You’ll probably be going home today.”) create anxiety and dissatisfaction. Since family and care partners need to manage hospital discharge in combination with regular activities of daily life (eg, work schedules, child care), un-communicated changes to the discharge time are very difficult to accommodate and should be discussed in advance. Further, acknowledging the disruption of hospital admission to patients’, their families’, and care partners’ daily lives, as well as being mindful of the impact of interpersonal interactions with patients, remind clinicians of the impact hospitalization has on patients.

Focus group discussions revealed that an ideal patient-centered discharge process would include active patient participation, clear communication regarding the discharge process, especially changes in the specific discharge date and time, and education regarding discharge summary instructions. Further, patients voiced that the unexpected nature of admissions can be very disruptive to patients’ lives and that interpersonal interactions during admission cause emotional responses in patients that influence their perceptions of hospitalization.

Comments regarding poor coordination and communication of internal processes, opportunities to improve collaboration within and across care teams, and need to improve communication with patients regarding timing of discharge and plan of care are consistent with recent studies that used focus groups to explore patient perceptions and expectations around discharge [3,4]. The ramifications of unexpected admissions and the emotional responses patients expressed regarding interpersonal interactions during admission have not been reported by others conducting patient focus groups.

The unexpected nature of many admissions, and the uncertainty of the day-to-day activities during hospitalization, caused patients anxiety and stress. These emotions perhaps heightened their response and memories of both favorable and unfavorable interpersonal interactions. These memories left lasting impressions on patients and care teams may help alleviate anxiety and stress by providing consistency and routine such as rounding at the same time daily, and communicating this time with patients. In this regard, the e-Board was helpful in communicating the patients’ care team and their planned rounding time.

Regarding the ability of e-tools to facilitate information sharing and planning for discharge, patients felt that the display of medications would have been most beneficial when thinking about post-discharge care. They perceived a display of discharge date and time estimate display as very useful to coordinate the activities around physically leaving the hospital, but based on their experiences did not find anticipated discharge times to be believable.

Patients’ perceptions of the tool were assessed after a recent hospitalization, and our data would have been strengthened had patients and their care partners used the e-Board during the actual admission. On the other hand, post-discharge, patients had time to reflect on opportunities for improving their recent admission and had insight into gaps in their discharge that the tool could potentially fill. Because we were unable to access video recordings from our dyad groups, which led us to exclude these participants, we lost care partners’ perceptions of the e-Board and discharge process. Care partners likely have different perceptions of discharge processes compared to patients, and their insight would have augmented our findings.

Several patients observed that the e-Board presented much of the same information that was filled out by care teams on the in-room dry erase boards and questioned whether the tablet was needed. These observations provide future opportunity for studies comparing display of discharge information on in-room dry-erase boards to an electronic tablet display. E-tools have shown some benefit when used for patient self-monitoring [10], to increase patient engagement [11,12], or to improve patient education [12]. Computer tablets may be most useful when used in these manners, compared to information display.

Focus groups provide patient-provided information that is readily actionable, and this work presents patient insight into discharge processes elicited through focus groups. Patients discussed their perceptions of an e-tool that might address patient-identified opportunities to improve the discharge process. Future work in this area will explore e-tools, and how best to leverage their functionality to design a patient-centered discharge process.

Acknowledgments: Our thanks to Mr. Thomas J. (Tripp) Welch for the original suggestion of this study design, and to Ms. Heidi Miller and Ms. Lizann Williams for their invaluable contributions to this work. A special thanks to our exceptional colleagues of the Mayo Clinic Department of Medicine Clinical Research Office Clinical Trials Unit for their efforts in executing this study, and to the study participants who participated in this research, without whom this project would not have been possible.

Corresponding author: Deanne Kashiwagi, MD, MS, 200 First Street SW, Rochester, MN 55902, [email protected].

Financial disclosures: None.

From the Mayo Clinic, Rochester, MN.

Abstract

• Objective: To elicit patient perceptions of a computer tablet (“e-Board”) used to display information relevant to hospital discharge and to gather patients’ expectations and perceptions regarding hospital discharge.
• Methods: Adult patients discharged from 1 of 3 medical-surgical, noncardiac monitored units of a 1265-bed, academic, tertiary care hospital were interviewed during patient focus groups. Reviewer pairs performed qualitative analysis of focus group transcripts and identified key themes, which were grouped into categories.
• Results: Patients felt a novel e-Board could help with the discharge process. They identified coordination of discharge, communication about discharge, ramifications of unexpected admissions, and interpersonal interactions during admission as the most significant issues around discharge.
• Conclusions: Focus groups elicit actionable information from patients about hospital discharge. Using this information, e-tools may help to design a patient-centered discharge process.

Key words: hospitals; patient satisfaction; focus groups; acute inpatient care.

Transition from the hospital to home represents a critical time for patients after acute illness, and support of patients and their care partners can help decrease consequences of poor care transitions, such as readmissions [1]. Focused discharge planning may improve outcomes and increase patient satisfaction [2], which is a key metric in hospital value-based purchasing programs, which tie Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey scores to reimbursement. Although patient experience surveys explore several categories of patient satisfaction, HCAHPS may not reveal readily actionable opportunities that would allow clinicians to improve patient experience. Conducting focus groups and interviews can help discern patients’ perceptions and provide patient-centered opportunities to improve hospital discharge processes. Recent studies using these methodologies have revealed patients’ perceptions of barriers to inter-professional collaboration during discharge [3] and their desires and expectations of, as well as suggestions for improvement of, hospitalization [4].

Care transition bundles have been developed to facilitate the process of transitioning home [1,5], but none include e-health tools to help facilitate the discharge process. A study group leveraged available software at our institution to create a bedside “e-Board,” addressing opportunities that surfaced during previous patient focus groups regarding our institution’s discharge process. The software tools were loaded onto a tablet computer (Apple iPad; Cupertino, CA) and included displays of the patient’s physician and nurse, with estimated time of team bedside rounds; day and time of anticipated discharge; display of discharge medications; and a screening tool, I-MOVE, to assess mobility prior to return to independent living [6].

We conducted focus groups to gather patients’ insights for incorporation into a bedside e-health tool for discharge and into our hospital’s current discharge process. The primary objective of the current study was to elicit patient and family perceptions of a bedside e-Board, created to display information regarding discharge. Our secondary objective was to learn about patient expectations and perceptions regarding the hospital discharge process.

Methods

Setting

The study setting was 3 medical-surgical, non-cardiac monitored units of a 1265-bed, academic, tertiary care hospital in Rochester, MN. The study was considered a minimal risk study by the center’s institutional review board.

Participants

Patients aged 18 years or older discharged from 1 of the 3 study units during 2012–2013 were eligible to participate. Patients were excluded if they were not discharged home or to assisted living, were clinic employees, retirees or dependents of clinic employees, were hospitalized longer than 6 months prior to study entry, lived further than 60 miles from the town of Rochester, could not travel, or did not sign research consent.

There were 975 patients who met inclusion criteria. The institution’s survey research center randomly selected 300 eligible patients and contacted them by letter after discharge. The letter was followed up with a telephone call and verbal consent was obtained if the patient expressed interest in participation. Of the 17 patients who gave consent, 12 patients participated in focus group interviews.

E-Board Development

Prior focus group discussions facilitated by our institution’s marketing department (Mr. Kent Seltman, personal communication) explored patients’ perceptions of the discharge process from the institution’s primary hospital. The opportunities for improvement that surfaced during these focus groups included identifying the date of discharge, communication about the time of discharge, and discharging the patient at the identified time, not several hours later. The study group leveraged software available at our institution to create a bedside e-Board that could possibly mitigate these issues by improving communication about discharge. The software tools were loaded onto a tablet computer for patients to use as a resource during their admission. These tools included:

1. A photo display of the patient’s nurse and physician, with estimated time of bedside rounds
2. A display of the day and time of anticipated discharge. Providing anticipated day and time of discharge has been found to be an achievable goal for internal medicine and surgical services [7].
3. A medication display, named the “Durable Display at Discharge,” previously found to improve patient understanding of prescribed medications [8]
4. A display of a mobility tool, I-MOVE, designed to screen for debility that could prevent patients’ return to independent living [6].

Focus Groups

Facilitated interviews were conducted on 2 consecutive days in March 2014. Participants were divided into a focus group of 5 to 6 participants if they were functionally independent, or dyads of patient and care partner if they were functionally dependent. Interviews were both video- and audiotaped.

A trained facilitator led 1.5-hour sessions with each focus group. The sessions began with introductions and guidelines by which the focus groups were conducted, including explanations of the video and audio recording equipment, and a request for participants to speak one person at a time to facilitate recording. Discussions were carried out in 2 parts, guided by a facilitator script ( available from the authors). First, participants were asked to share their experiences regarding planning for discharge and the information they received leading up to their planned day and time of hospital discharge. Second, participants were shown a prototype of the e-Board. Participants were asked to reflect as to whether they had received similar information when they had been hospitalized, whether that information was helpful or useful, what information they did not receive that would have been helpful, how information was given, and whether information displayed via an e-Board would be better or worse than the ways they received information while in the hospital.

Data Analysis

Three teams, each comprised of 2 reviewers, met to analyze the video and audio recordings of each focus group. Unfortunately, the video files from the dyad interviews were not recoverable after the recorded sessions, and thus those groups were excluded from the study. Reviewers met prior to analyzing the focus group video and audio recordings to review the qualitative analysis protocol developed by the research team [9] (protocol available froom the authors). The teams then independently reviewed the video recordings and transcripts of the focus groups. The reviewer teams observed the focus group recordings and identified (1) themes regarding perceptions of the bedside e-Board and (2) experiences and perceptions around discharge. The protocol helped reviewer teams create a classification structure by identifying the key themes, which were then combined to create categories. The reviewer teams then compared their classification structures and by incorporating the most frequently identified categories, built a relational model of discharge perceptions.

Results

Eleven patients participated in 2 focus groups, one group of 5 patients and the other of 6 patients. Patient participants included 6 females and 5 males ranging in age from 22 to 84 years.

Using the qualitative analysis protocol, review teams grouped key themes from the focus group discussions about discharge into 4 categories. The categories, with themes listed below and representative patient comments in the Table, were

1.  Coordination and timing of discharge

• Giving patients the opportunity to prepare for discussion with clinician teams
•  Communicating the specific time of discharge
• Internal collaboration of inter-professional teams
• Preparing for transition out of the hospital

  2.  Communication

• Patient inclusion in care discussions
• Discharge summary delay and/or completeness
• Education at the time of discharge

  3. Ramifications of the unexpected and unknown

• Increased stress and frustration due to inability to plan, fear of the unknown, and lack of information

  4. Interpersonal interactions

• Both favorable and unfavorable interactions caused an emotional response that impacts perceptions of hospitalization and discharge

The reviewers also analyzed patients’ comments regarding the bedside e-Board. The medication display (“Durable Display at Discharge,” Figure 1) was universally considered to be the most relevant and best-liked of the 4 elements tested. The visual display of medications and their purpose were commonly referenced as the most positive aspects of the display, and patients and caregivers were readily able to generate multiple potential uses for the display. Several mentioned that the information on the medication display were so desirable and necessary that if not supplied by the hospital, they hand-crafted such reminder displays at home.

It was difficult for patients to see how the I-MOVE assessment (Figure 2) would apply to their discharge planning. They perceived I-MOVE as a tool for clinicians. One exception was a patient who had on a previous admission undergone heart surgery. She explained to the other patients that in such debilitated conditions, mobility independence assessments were important and commonly done.

Patients voiced some skepticism and concerns regarding the e-Board, including expense, privacy, security, and cleanliness. One patient observed the tablet was “more current than a printed piece of paper. It’s more up to date.” Other patients, however, questioned the process required to update information and wondered how much electronic displays added compared to the dry-erase board already in each patient’s room with which they were more familiar. They also voiced concern that the tablet would replace face-to-face interactions with their care teams. A patient shared that, “if we don’t have the conversation and we just get it through this, then I would hate that…you want to be able to give your input.”

Discussion

In this study, we used available software to create a bedside e-Board that addressed opportunities for patient-centered improvement in our institution’s discharge process. Patients felt that 3 of 4 software tools on the tablet could enhance the discharge experience. Additionally, we explored patients’ expectations and perceptions of our hospital discharge process.

Key information to inform our current discharge process was divulged by our patients during focus groups. Patients conveyed that the only time that matters to them is the time they get to walk out the door of the hospital, and that general statements (eg, “You’ll probably be going home today.”) create anxiety and dissatisfaction. Since family and care partners need to manage hospital discharge in combination with regular activities of daily life (eg, work schedules, child care), un-communicated changes to the discharge time are very difficult to accommodate and should be discussed in advance. Further, acknowledging the disruption of hospital admission to patients’, their families’, and care partners’ daily lives, as well as being mindful of the impact of interpersonal interactions with patients, remind clinicians of the impact hospitalization has on patients.

Focus group discussions revealed that an ideal patient-centered discharge process would include active patient participation, clear communication regarding the discharge process, especially changes in the specific discharge date and time, and education regarding discharge summary instructions. Further, patients voiced that the unexpected nature of admissions can be very disruptive to patients’ lives and that interpersonal interactions during admission cause emotional responses in patients that influence their perceptions of hospitalization.

Comments regarding poor coordination and communication of internal processes, opportunities to improve collaboration within and across care teams, and need to improve communication with patients regarding timing of discharge and plan of care are consistent with recent studies that used focus groups to explore patient perceptions and expectations around discharge [3,4]. The ramifications of unexpected admissions and the emotional responses patients expressed regarding interpersonal interactions during admission have not been reported by others conducting patient focus groups.

The unexpected nature of many admissions, and the uncertainty of the day-to-day activities during hospitalization, caused patients anxiety and stress. These emotions perhaps heightened their response and memories of both favorable and unfavorable interpersonal interactions. These memories left lasting impressions on patients and care teams may help alleviate anxiety and stress by providing consistency and routine such as rounding at the same time daily, and communicating this time with patients. In this regard, the e-Board was helpful in communicating the patients’ care team and their planned rounding time.

Regarding the ability of e-tools to facilitate information sharing and planning for discharge, patients felt that the display of medications would have been most beneficial when thinking about post-discharge care. They perceived a display of discharge date and time estimate display as very useful to coordinate the activities around physically leaving the hospital, but based on their experiences did not find anticipated discharge times to be believable.

Patients’ perceptions of the tool were assessed after a recent hospitalization, and our data would have been strengthened had patients and their care partners used the e-Board during the actual admission. On the other hand, post-discharge, patients had time to reflect on opportunities for improving their recent admission and had insight into gaps in their discharge that the tool could potentially fill. Because we were unable to access video recordings from our dyad groups, which led us to exclude these participants, we lost care partners’ perceptions of the e-Board and discharge process. Care partners likely have different perceptions of discharge processes compared to patients, and their insight would have augmented our findings.

Several patients observed that the e-Board presented much of the same information that was filled out by care teams on the in-room dry erase boards and questioned whether the tablet was needed. These observations provide future opportunity for studies comparing display of discharge information on in-room dry-erase boards to an electronic tablet display. E-tools have shown some benefit when used for patient self-monitoring [10], to increase patient engagement [11,12], or to improve patient education [12]. Computer tablets may be most useful when used in these manners, compared to information display.

Focus groups provide patient-provided information that is readily actionable, and this work presents patient insight into discharge processes elicited through focus groups. Patients discussed their perceptions of an e-tool that might address patient-identified opportunities to improve the discharge process. Future work in this area will explore e-tools, and how best to leverage their functionality to design a patient-centered discharge process.

Acknowledgments: Our thanks to Mr. Thomas J. (Tripp) Welch for the original suggestion of this study design, and to Ms. Heidi Miller and Ms. Lizann Williams for their invaluable contributions to this work. A special thanks to our exceptional colleagues of the Mayo Clinic Department of Medicine Clinical Research Office Clinical Trials Unit for their efforts in executing this study, and to the study participants who participated in this research, without whom this project would not have been possible.

Corresponding author: Deanne Kashiwagi, MD, MS, 200 First Street SW, Rochester, MN 55902, [email protected].

Financial disclosures: None.

From the Mayo Clinic, Rochester, MN.

Abstract

• Objective: To elicit patient perceptions of a computer tablet (“e-Board”) used to display information relevant to hospital discharge and to gather patients’ expectations and perceptions regarding hospital discharge.
• Methods: Adult patients discharged from 1 of 3 medical-surgical, noncardiac monitored units of a 1265-bed, academic, tertiary care hospital were interviewed during patient focus groups. Reviewer pairs performed qualitative analysis of focus group transcripts and identified key themes, which were grouped into categories.
• Results: Patients felt a novel e-Board could help with the discharge process. They identified coordination of discharge, communication about discharge, ramifications of unexpected admissions, and interpersonal interactions during admission as the most significant issues around discharge.
• Conclusions: Focus groups elicit actionable information from patients about hospital discharge. Using this information, e-tools may help to design a patient-centered discharge process.

Key words: hospitals; patient satisfaction; focus groups; acute inpatient care.

Transition from the hospital to home represents a critical time for patients after acute illness, and support of patients and their care partners can help decrease consequences of poor care transitions, such as readmissions [1]. Focused discharge planning may improve outcomes and increase patient satisfaction [2], which is a key metric in hospital value-based purchasing programs, which tie Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey scores to reimbursement. Although patient experience surveys explore several categories of patient satisfaction, HCAHPS may not reveal readily actionable opportunities that would allow clinicians to improve patient experience. Conducting focus groups and interviews can help discern patients’ perceptions and provide patient-centered opportunities to improve hospital discharge processes. Recent studies using these methodologies have revealed patients’ perceptions of barriers to inter-professional collaboration during discharge [3] and their desires and expectations of, as well as suggestions for improvement of, hospitalization [4].

Care transition bundles have been developed to facilitate the process of transitioning home [1,5], but none include e-health tools to help facilitate the discharge process. A study group leveraged available software at our institution to create a bedside “e-Board,” addressing opportunities that surfaced during previous patient focus groups regarding our institution’s discharge process. The software tools were loaded onto a tablet computer (Apple iPad; Cupertino, CA) and included displays of the patient’s physician and nurse, with estimated time of team bedside rounds; day and time of anticipated discharge; display of discharge medications; and a screening tool, I-MOVE, to assess mobility prior to return to independent living [6].

We conducted focus groups to gather patients’ insights for incorporation into a bedside e-health tool for discharge and into our hospital’s current discharge process. The primary objective of the current study was to elicit patient and family perceptions of a bedside e-Board, created to display information regarding discharge. Our secondary objective was to learn about patient expectations and perceptions regarding the hospital discharge process.

Methods

Setting

The study setting was 3 medical-surgical, non-cardiac monitored units of a 1265-bed, academic, tertiary care hospital in Rochester, MN. The study was considered a minimal risk study by the center’s institutional review board.

Participants

Patients aged 18 years or older discharged from 1 of the 3 study units during 2012–2013 were eligible to participate. Patients were excluded if they were not discharged home or to assisted living, were clinic employees, retirees or dependents of clinic employees, were hospitalized longer than 6 months prior to study entry, lived further than 60 miles from the town of Rochester, could not travel, or did not sign research consent.

There were 975 patients who met inclusion criteria. The institution’s survey research center randomly selected 300 eligible patients and contacted them by letter after discharge. The letter was followed up with a telephone call and verbal consent was obtained if the patient expressed interest in participation. Of the 17 patients who gave consent, 12 patients participated in focus group interviews.

E-Board Development

Prior focus group discussions facilitated by our institution’s marketing department (Mr. Kent Seltman, personal communication) explored patients’ perceptions of the discharge process from the institution’s primary hospital. The opportunities for improvement that surfaced during these focus groups included identifying the date of discharge, communication about the time of discharge, and discharging the patient at the identified time, not several hours later. The study group leveraged software available at our institution to create a bedside e-Board that could possibly mitigate these issues by improving communication about discharge. The software tools were loaded onto a tablet computer for patients to use as a resource during their admission. These tools included:

1. A photo display of the patient’s nurse and physician, with estimated time of bedside rounds
2. A display of the day and time of anticipated discharge. Providing anticipated day and time of discharge has been found to be an achievable goal for internal medicine and surgical services [7].
3. A medication display, named the “Durable Display at Discharge,” previously found to improve patient understanding of prescribed medications [8]
4. A display of a mobility tool, I-MOVE, designed to screen for debility that could prevent patients’ return to independent living [6].

Focus Groups

Facilitated interviews were conducted on 2 consecutive days in March 2014. Participants were divided into a focus group of 5 to 6 participants if they were functionally independent, or dyads of patient and care partner if they were functionally dependent. Interviews were both video- and audiotaped.

A trained facilitator led 1.5-hour sessions with each focus group. The sessions began with introductions and guidelines by which the focus groups were conducted, including explanations of the video and audio recording equipment, and a request for participants to speak one person at a time to facilitate recording. Discussions were carried out in 2 parts, guided by a facilitator script ( available from the authors). First, participants were asked to share their experiences regarding planning for discharge and the information they received leading up to their planned day and time of hospital discharge. Second, participants were shown a prototype of the e-Board. Participants were asked to reflect as to whether they had received similar information when they had been hospitalized, whether that information was helpful or useful, what information they did not receive that would have been helpful, how information was given, and whether information displayed via an e-Board would be better or worse than the ways they received information while in the hospital.

Data Analysis

Three teams, each comprised of 2 reviewers, met to analyze the video and audio recordings of each focus group. Unfortunately, the video files from the dyad interviews were not recoverable after the recorded sessions, and thus those groups were excluded from the study. Reviewers met prior to analyzing the focus group video and audio recordings to review the qualitative analysis protocol developed by the research team [9] (protocol available froom the authors). The teams then independently reviewed the video recordings and transcripts of the focus groups. The reviewer teams observed the focus group recordings and identified (1) themes regarding perceptions of the bedside e-Board and (2) experiences and perceptions around discharge. The protocol helped reviewer teams create a classification structure by identifying the key themes, which were then combined to create categories. The reviewer teams then compared their classification structures and by incorporating the most frequently identified categories, built a relational model of discharge perceptions.

Results

Eleven patients participated in 2 focus groups, one group of 5 patients and the other of 6 patients. Patient participants included 6 females and 5 males ranging in age from 22 to 84 years.

Using the qualitative analysis protocol, review teams grouped key themes from the focus group discussions about discharge into 4 categories. The categories, with themes listed below and representative patient comments in the Table, were

1.  Coordination and timing of discharge

• Giving patients the opportunity to prepare for discussion with clinician teams
•  Communicating the specific time of discharge
• Internal collaboration of inter-professional teams
• Preparing for transition out of the hospital

  2.  Communication

• Patient inclusion in care discussions
• Discharge summary delay and/or completeness
• Education at the time of discharge

  3. Ramifications of the unexpected and unknown

• Increased stress and frustration due to inability to plan, fear of the unknown, and lack of information

  4. Interpersonal interactions

• Both favorable and unfavorable interactions caused an emotional response that impacts perceptions of hospitalization and discharge

The reviewers also analyzed patients’ comments regarding the bedside e-Board. The medication display (“Durable Display at Discharge,” Figure 1) was universally considered to be the most relevant and best-liked of the 4 elements tested. The visual display of medications and their purpose were commonly referenced as the most positive aspects of the display, and patients and caregivers were readily able to generate multiple potential uses for the display. Several mentioned that the information on the medication display were so desirable and necessary that if not supplied by the hospital, they hand-crafted such reminder displays at home.

It was difficult for patients to see how the I-MOVE assessment (Figure 2) would apply to their discharge planning. They perceived I-MOVE as a tool for clinicians. One exception was a patient who had on a previous admission undergone heart surgery. She explained to the other patients that in such debilitated conditions, mobility independence assessments were important and commonly done.

Patients voiced some skepticism and concerns regarding the e-Board, including expense, privacy, security, and cleanliness. One patient observed the tablet was “more current than a printed piece of paper. It’s more up to date.” Other patients, however, questioned the process required to update information and wondered how much electronic displays added compared to the dry-erase board already in each patient’s room with which they were more familiar. They also voiced concern that the tablet would replace face-to-face interactions with their care teams. A patient shared that, “if we don’t have the conversation and we just get it through this, then I would hate that…you want to be able to give your input.”

Discussion

In this study, we used available software to create a bedside e-Board that addressed opportunities for patient-centered improvement in our institution’s discharge process. Patients felt that 3 of 4 software tools on the tablet could enhance the discharge experience. Additionally, we explored patients’ expectations and perceptions of our hospital discharge process.

Key information to inform our current discharge process was divulged by our patients during focus groups. Patients conveyed that the only time that matters to them is the time they get to walk out the door of the hospital, and that general statements (eg, “You’ll probably be going home today.”) create anxiety and dissatisfaction. Since family and care partners need to manage hospital discharge in combination with regular activities of daily life (eg, work schedules, child care), un-communicated changes to the discharge time are very difficult to accommodate and should be discussed in advance. Further, acknowledging the disruption of hospital admission to patients’, their families’, and care partners’ daily lives, as well as being mindful of the impact of interpersonal interactions with patients, remind clinicians of the impact hospitalization has on patients.

Focus group discussions revealed that an ideal patient-centered discharge process would include active patient participation, clear communication regarding the discharge process, especially changes in the specific discharge date and time, and education regarding discharge summary instructions. Further, patients voiced that the unexpected nature of admissions can be very disruptive to patients’ lives and that interpersonal interactions during admission cause emotional responses in patients that influence their perceptions of hospitalization.

Comments regarding poor coordination and communication of internal processes, opportunities to improve collaboration within and across care teams, and need to improve communication with patients regarding timing of discharge and plan of care are consistent with recent studies that used focus groups to explore patient perceptions and expectations around discharge [3,4]. The ramifications of unexpected admissions and the emotional responses patients expressed regarding interpersonal interactions during admission have not been reported by others conducting patient focus groups.

The unexpected nature of many admissions, and the uncertainty of the day-to-day activities during hospitalization, caused patients anxiety and stress. These emotions perhaps heightened their response and memories of both favorable and unfavorable interpersonal interactions. These memories left lasting impressions on patients and care teams may help alleviate anxiety and stress by providing consistency and routine such as rounding at the same time daily, and communicating this time with patients. In this regard, the e-Board was helpful in communicating the patients’ care team and their planned rounding time.

Regarding the ability of e-tools to facilitate information sharing and planning for discharge, patients felt that the display of medications would have been most beneficial when thinking about post-discharge care. They perceived a display of discharge date and time estimate display as very useful to coordinate the activities around physically leaving the hospital, but based on their experiences did not find anticipated discharge times to be believable.

Patients’ perceptions of the tool were assessed after a recent hospitalization, and our data would have been strengthened had patients and their care partners used the e-Board during the actual admission. On the other hand, post-discharge, patients had time to reflect on opportunities for improving their recent admission and had insight into gaps in their discharge that the tool could potentially fill. Because we were unable to access video recordings from our dyad groups, which led us to exclude these participants, we lost care partners’ perceptions of the e-Board and discharge process. Care partners likely have different perceptions of discharge processes compared to patients, and their insight would have augmented our findings.

Several patients observed that the e-Board presented much of the same information that was filled out by care teams on the in-room dry erase boards and questioned whether the tablet was needed. These observations provide future opportunity for studies comparing display of discharge information on in-room dry-erase boards to an electronic tablet display. E-tools have shown some benefit when used for patient self-monitoring [10], to increase patient engagement [11,12], or to improve patient education [12]. Computer tablets may be most useful when used in these manners, compared to information display.

Focus groups provide patient-provided information that is readily actionable, and this work presents patient insight into discharge processes elicited through focus groups. Patients discussed their perceptions of an e-tool that might address patient-identified opportunities to improve the discharge process. Future work in this area will explore e-tools, and how best to leverage their functionality to design a patient-centered discharge process.

Acknowledgments: Our thanks to Mr. Thomas J. (Tripp) Welch for the original suggestion of this study design, and to Ms. Heidi Miller and Ms. Lizann Williams for their invaluable contributions to this work. A special thanks to our exceptional colleagues of the Mayo Clinic Department of Medicine Clinical Research Office Clinical Trials Unit for their efforts in executing this study, and to the study participants who participated in this research, without whom this project would not have been possible.

Corresponding author: Deanne Kashiwagi, MD, MS, 200 First Street SW, Rochester, MN 55902, [email protected].

Financial disclosures: None.