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Hospital Readmissions in End of Life
The need to improve end‐of‐life care is well recognized. Its quality is often poor, and its cost is enormous, with 30% of the Medicare expenditures used for medical treatments of the 6% of beneficiaries who die each year.[1, 2] Repeated hospitalizations are frequent toward the end of life,[3] where each admission should be viewed as an opportunity to initiate advance care planning to improve end‐of‐life care and possibly reduce future unnecessary readmissions.[4, 5] Identified problems include undertreatment of pain, lack of awareness of patient wishes or advance directives, and unwanted overtreatment.
To improve quality and reduce unnecessary hospital use near the end of life, there is an urgent need to help healthcare providers to better identify the most vulnerable and at‐risk patients to provide them with care coordination and supportive care services. We aimed to identify the risk factors for having a 30‐day potentially avoidable readmission (PAR) due to end‐of‐life care issues.
METHODS
Study Design and Population
A nested case‐control study was designed where potentially avoidable end‐of‐life readmissions were compared to nonreadmitted controls. We collected data on all consecutive adult patient admissions to any medical services of the Brigham and Women's Hospital with a discharge date between July 1, 2009 and June 30, 2010. Brigham and Women's Hospital is a 780‐bed academic medical center in Boston, Massachusetts. To avoid observation stays, only admissions with a length of stay of more than 1 day were included. We excluded patients who died before discharge, were transferred to another acute care hospital, and those who left against medical advice. We also excluded patients with no available data on medication treatment at discharge. The protocol was approved by the institutional review board of Brigham and Women's Hospital/Partners Healthcare.
Study Outcome
The study outcome was any 30‐day PAR due to end‐of‐life issues. To determine this outcome, first we identified all 30‐day readmissions to any service of 3 hospitals within the Partners network in Boston that followed the index hospitalization (prior studies have shown that these hospitals capture approximately 80% of readmissions after a Brigham and Women's Hospital medical hospitalization).[6, 7] These readmissions were subsequently differentiated as potentially avoidable or not using a validated algorithm (SQLape; SQLape, Corseaux, Switzerland).[8, 9] This algorithm uses administrative data and International Classification of Diseases, 9th Revision, Clinical Modification codes from the index and repeat hospitalization. Readmissions were considered potentially avoidable if they were: (1) readmissions related to previously known conditions during the index hospitalization, or (2) complications of treatment (eg, deep vein thrombosis, drug‐induced disorders). Conversely, readmissions were considered unavoidable if they were: (1) foreseen (such as readmissions for transplantation, delivery, chemo‐ or radiotherapy, and other specific surgical procedures), (2) follow‐up and rehabilitation treatments, or (3) readmissions for a new condition unknown during the preceding hospitalization. The algorithm has both a sensitivity and specificity of 96% compared with medical record review using the same criteria. Finally, a random sample of the 30‐day PARs was reviewed independently by 9 trained senior resident physicians to identify those due to end‐of‐life issues, defined by the following 2 criteria: (1) patient has a terminal clinical condition, such as malignancy, end stage renal disease, end stage congestive heart failure, or other condition with a life expectancy of 6 months or less; and (2) the readmission is part of the terminal disease process that was not adequately addressed during the index hospitalization. Examples of factors that were used when identifying cases included lack of healthcare proxy and lack of documentation of why end‐of‐life discussions did not take place during the index hospitalization. Training of adjudicators included a didactic session and review of standardized cases.
Risk Factors
We collected candidate risk factors based on a priori knowledge and according to the medical literature,[10, 11, 12] including demographic information, previous healthcare utilization, and index hospitalization characteristics from administrative data sources; procedures and chronic medical conditions from billing data; last laboratory values and medication information prior to discharge from the electronic medical record (Table 1). When laboratory values were missing (<1%), values were considered as normal.
| Characteristics | No 30‐Day Readmission, n=7,974 | 30‐Day PAR due to End of Life, n=80 | P Value |
|---|---|---|---|
| |||
| Age, y, mean (SD) | 61.5 (16.6) | 60.8 (11.9) | 0.69 |
| Male sex, n (%) | 3875 (48.6) | 37 (46.3) | 0.69 |
| Ethnicity, n (%) | 0.05 | ||
| Non‐Hispanic white* | 5772 (72.4) | 69 (86.3) | |
| Non‐Hispanic black | 1281 (16.1) | 4 (5.0) | |
| Hispanic | 666 (8.4) | 5 (6.3) | |
| Other | 255 (3.2) | 2 (2.5) | |
| Language, n (%) | 0.99 | ||
| English* | 7254 (91.0) | 73 (91.3) | |
| Spanish | 415 (5.2) | 4 (5.0) | |
| Other | 305 (3.8) | 3 (3.8) | |
| Marital status, n (%) | 0.37 | ||
| Currently married or partner* | 4107 (51.35) | 46 (57.5) | |
| Single/never married | 1967 (24.7) | 14 (17.5) | |
| Separated/divorced/widowed/no answer | 1900 (23.8) | 20 (25.0) | |
| Source of index admission, n (%) | 0.10 | ||
| Direct from home/outpatient clinic | 2456 (30.8) | 33 (41.3) | |
| Emergency department* | 4222 (53.0) | 34 (42.5) | |
| Nursing home/rehabilitation/other hospital | 1296 (16.3) | 13 (16.3) | |
| Length of stay of the index admission, median (IQR) | 4 (27) | 5.5 (38] | 0.13 |
| No. of hospital admissions in the past year, median (IQR) | 1 (02) | 2 (03) | <0.001 |
| Any procedure during the hospital stay, n (%) | 4809 (60.3) | 57 (71.3) | 0.05 |
| Identified caregiver at discharge | 7300 (91.6) | 76 (95.0) | 0.27 |
| No. of medications at discharge, mean (SD) | 10.6 (5.1) | 13.0 (5.0) | <0.001 |
| No. of opiate medication at discharge | <0.001 | ||
| 0 | 5297 (66.4) | 21 (26.3) | |
| 1 | 2677 (33.2) | 59 (73.8) | |
| Elixhauser, median (IQR) | 8 (215) | 23 (1442) | <0.001 |
| Selected comorbidities, n (%) | |||
| Diabetes mellitus | 1971 (24.7) | 20 (25.0) | 0.96 |
| Heart failure | 1756 (22.0) | 11 (13.8) | 0.10 |
| Atrial fibrillation | 1439 (18.1) | 10 (12.5) | 0.20 |
| COPD | 816 (10.2) | 7 (8.8) | 0.66 |
| Neoplasm | 2705 (33.9) | 69 (86.3) | <0.001 |
| Stroke | 294 (3.7) | 2 (2.5) | 0.57 |
| ESRD | 1258 (15.8) | 6 (7.5) | 0.04 |
| Liver disease | 328 (4.1) | 2 (2.5) | 0.47 |
Statistical Analysis
We first conducted a bivariate analysis on all collected potential risk factors, comparing admissions followed by a 30‐day PAR due to end‐of‐life care issues with admissions not followed by any 30‐day readmission, using the Pearson [2] test for categorical variables and Student t test for continuous variables. Then, we performed a multivariable logistic regression restricted to the variables that were found significantly associated with the outcome in the bivariate analysis. Age and Elixhauser comorbidity index were forced into the model as important potential confounders. Because a patient could have several outcomes over the study period, we used general estimating equations to cluster at the patient level. All tests were conducted as 2‐sided at a 0.05 level of significance. Analyses were performed using the SAS system for Windows, version 9.3 (SAS Institute Inc., Cary, NC).
RESULTS
From the total of 12,383 patients who were discharged from the medical services of the Brigham and Women's Hospital during the study period, 2108 (17.0%) were excluded because of: (1) death before discharge, (2) transfer to another acute care hospital, (3) discharge against medical advice, or (4) missing data (Figure 1). Among the 10,275 eligible admissions, 22.3% (n=2301) were followed by a 30‐day readmission. Of these, 826 (8.0% of all admissions) were identified as potentially avoidable. Among a random sample of 534 PARs, 80 (15.0%) were related to end‐of‐life care issues (cases). Of note, only 16 (20%) of these patients received palliative care consultation during the index hospitalization. A total of 7974 discharges were not followed by any 30‐day readmission (controls).
Baseline characteristics are presented in Table 1. Among the combined cohort of cases plus controls, the patient's mean age at inclusion was 61.3 years, and about half were male. In bivariate analysis, demographics such as age and sex were similar between cases and controls. Cases had more hospitalizations in the previous year, a higher number of medications at discharge, and a higher Elixhauser comorbidity index. When looking at diseases more specifically, neoplasm was significantly associated with potentially avoidable 30‐day readmission due to end‐of‐life care issues. In contrast, end‐stage renal disease was associated with a significantly lower risk of 30‐day PAR due to end‐of‐life care issues.
In multivariate analysis, 4 factors remained significantly associated with 30‐day PAR due to end‐of‐life care issues (Table 2). Neoplasm was the strongest risk factor, with an odds ratio of 5.6 (95% confidence interval: 2.8511.0), followed by opiate medication use, Elixhauser score, and number of admissions in the previous 12 months.
| Variable | Odds Ratio (95% CI) |
|---|---|
| |
| Age, per 10 years | 1.04 (0.911.19) |
| No. of admissions in the previous 12 months, per admission | 1.10 (1.021.20)a |
| Total no. of medications at discharge, per medication | 1.04 (1.001.10) |
| Neoplasm | 5.60 (2.8511.0)a |
| Endstage renal disease | 0.60 (0.251.42) |
| Opiate medication at discharge | 2.29 (1.294.07)a |
| Elixhauser, per 5 unit increase | 1.16 (1.101.22)a |
The model, including all 4 variables, had an excellent discrimination power, with a C statistic of 0.85. Without the Elixhauser score, the C statistic remained very high, with a value of 0.82.
DISCUSSION
In a large medical population, potentially avoidable readmissions due to end‐of‐life care issues were not uncommon: 15% of all potentially avoidable readmissions (1.2% of all discharges). We identified 4 main risk factors for having a 30‐day potentially avoidable readmission due to end‐of‐life care issues: neoplasm, opiate use, Elixhauser comorbidity index, and number of admissions in the previous year. In a model that includes these 4 variables, the discrimination was very high with a C statistic of 0.85.
This study extends prior work indicating some risk factors for the need for palliative care. Neoplasm has been logically identified as a criterion for palliative care assessment at the time of admission.[13] Patients with neoplasm are not only at overall high risk for readmission,[14, 15, 16] but they obviously represent a fragile population whose condition is often terminal. Our results suggest that still more attention may be necessary to reduce the risk of readmission due to end‐of‐life care issues in this population (for example, only 20% of cases in our study received palliative care consultation during the index hospitalization). The overall comorbidity measured by the Elixhauser index was not surprisingly a significant risk factor. It probably accounts for the burden of comorbidities, but also for other advanced diseases besides neoplasm, like heart failure, chronic obstructive pulmonary disease, and others that may also be terminal. The number of previous hospital admissions in the past year is also an important risk factor, not only for the general population,[10, 11, 14, 17, 18] but also for patients with more advanced conditions,[19, 20, 21, 22] where admissions become more frequent as the disease progresses toward end stage. Opioid use was the final statistically significant risk factor, specific for this population, likely as a proxy for disease severity and progression toward terminal illness, especially in combination with the other risk factors such as cancer. Age was not a significant factor in either bivariate or multivariate analysis. Previous studies on the risk factors for readmission among patients receiving palliative care also failed to show age as a significant factor.[23, 24] Both of these studies looked at readmissions among patients who were already receiving palliative care. Our study asks a fundamentally different (and in many ways a more practical) question: who among a large population of medical patients might benefit from receiving input from palliative care in the first place. The number of medications at discharge was no longer significant in the multivariate analysis, likely due to its collinearity with the Elixhauser comorbidity index. An increased number of medications might be associated with a higher risk of adverse drug events and readmission, but they would not be necessarily considered to be end‐of‐life readmissions. Taken together, the 4 variables provide a very promising prediction model with high discrimination. To our knowledge, there is no previous existing list of risk factors for 30‐day potentially avoidable readmission due to end‐of‐life care issues, and no existing model to help prioritize palliative care to the most high‐risk patients. It is worth noting that the Elixhauser score might be difficult to calculate before the discharge of the patient (although hospitals with electronic capture of medical problem lists might be able to approximate it). However, even without the Elixhauser score, the C statistic remained very high at 0.82.
Our study has several limitations. Although we looked at readmissions at 2 other affiliated hospitals, some patients might have been readmitted to other acute care facilities outside our network. However, we would not expect the risk factors in these patients to be so different. The identification of end‐of‐life care issues by medical record review is based on a subjective judgment, although strict criteria were used. Furthermore, differentiation between potentially avoidable readmission and unavoidable readmission cannot be perfect. We used clear and logical criteria that were previously validated and allow large database management. Also, we did not analyze a comprehensive list of potential risk factors. It is probable that functional or cognitive status, for example, could also be important risk factors. We purposely chose a set of variables that could be easily obtained from administrative data sources. The small number of cases may have led to limited statistical power to identify less strongly associated risk factors. Last, the results may not be completely generalizable to small or community hospitals, in particular those that may care for less severely ill cancer patients.
Our findings have important implications. End‐of‐life care issues are not infrequent causes of readmission. Our study's findings could help prioritize palliative care resources to those patients at higher risk to improve the quality of end‐of‐life care. The risk factors identified in this study could be used informally by physicians at the bedside to identify such patients. In addition, a hospital could use these factors to provide a second‐level screen, beyond clinician recognition, to assist palliative care teams to identify patients who may not have otherwise been referred. This screen could be automated, for example, by using a list of medical problems from an electronic medical record to approximate an Elixhauser comorbidity score, or even leaving comorbidities out and simply relying on the other 3 easily identifiable risk factors. Such efforts could have a substantial effect on improving care near the end of life and potentially reducing unnecessary hospitalizations.
Acknowledgements
The authors thank Yves Eggli for having screened the database for potentially avoidable readmission using the algorithm SQLape.
Disclosures: Dr. Donz was supported by the Swiss National Science Foundation and the Swiss Foundation for MedicalBiological Scholarships. The Swiss Science National Foundation and the Swiss Foundation for MedicalBiological Scholarships had no role in the design and conduct of this study, the analysis or interpretation of the data, or the preparation of this manuscript. Dr. Schnipper is a consultant to QuantiaMD, for which he has helped create online educational materials for both providers and patients regarding patient safety, including medication safety during transitions in care. The findings of this study are not a part of those materials. Dr. Schnipper has received grant funding from Sanofi‐Aventis for an investigator‐initiated study to design and evaluate an intensive discharge and follow‐up intervention in patients with diabetes. The funder had had no role in the design of the study.
- , , , . Medicare beneficiaries' costs of care in the last year of life. Health Aff (Millwood). 2001;20(4):188–195.
- , , . Quality of End‐of‐Life Cancer Care for Medicare Beneficiaries: Regional and Hospital‐Specific Analyses. Lebanon, NH: The Dartmouth Institute for Health Policy and Clinical Practice; 2010.
- , , . Repeated hospitalizations predict mortality in the community population with heart failure. Am Heart J. 2007;154(2):260–266.
- . Perspectives on care at the close of life. Initiating end‐of‐life discussions with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284(19):2502–2507.
- , , , . Advance care planning as a process: structuring the discussions in practice. J Am Geriatr Soc. 1995;43(4):440–446.
- , , , et al. Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) study. Circ Cardiovasc Qual Outcomes. 2010;3(2):212–219.
- , , , et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1–10.
- , , , , , . Measuring potentially avoidable hospital readmissions. J Clin Epidemiol. 2002;55(6):573–587.
- , , , , , . Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Med Care. 2006;44(11):972–981.
- , , , et al. Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med. 2010;25(3):211–219.
- , , , , , . Screening elders for risk of hospital admission. J Am Geriatr Soc. 1993;41(8):811–817.
- , , , , . Risk factors for 30‐day hospital readmission in patients ≥65 years of age. Proc (Bayl Univ Med Cent). 2008;21(4):363–372.
- , . Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17–23.
- , , , . Potentially avoidable 30‐day hospital readmissions in medical patients: derivation and validation of a prediction model. JAMA Intern Med. 2013;173(8):632–638.
- , , , . Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6(2):54–60.
- , , . Patient and disease profile of emergency medical readmissions to an Irish teaching hospital. Postgrad Med J. 2004;80(946):470–474.
- , , , . Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39(5):1449–1465.
- , . Factors predicting readmission of older general medicine patients. J Gen Intern Med. 1991;6(5):389–393.
- , , , , . Differences in health care utilization at the end of life among patients with chronic obstructive pulmonary disease and patients with lung cancer. Arch Intern Med. 2006;166(3):326–331.
- , , , , . Frequent hospital readmissions for acute exacerbation of COPD and their associated factors. Respirology. 2006;11(2):188–195.
- , , , et al. Consensus statement: Palliative and supportive care in advanced heart failure. J Card Fail. 2004;10(3):200–209.
- , , , , . Unplanned discharges from a surgical intensive care unit: readmissions and mortality. J Crit Care. 2010;25(3):375–381.
- , , , , . Evaluating causes for unplanned hospital readmissions of palliative care patients. Am J Hosp Palliat Care. 2010;27(8):526–531.
- , , . 30‐day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356–1361.
The need to improve end‐of‐life care is well recognized. Its quality is often poor, and its cost is enormous, with 30% of the Medicare expenditures used for medical treatments of the 6% of beneficiaries who die each year.[1, 2] Repeated hospitalizations are frequent toward the end of life,[3] where each admission should be viewed as an opportunity to initiate advance care planning to improve end‐of‐life care and possibly reduce future unnecessary readmissions.[4, 5] Identified problems include undertreatment of pain, lack of awareness of patient wishes or advance directives, and unwanted overtreatment.
To improve quality and reduce unnecessary hospital use near the end of life, there is an urgent need to help healthcare providers to better identify the most vulnerable and at‐risk patients to provide them with care coordination and supportive care services. We aimed to identify the risk factors for having a 30‐day potentially avoidable readmission (PAR) due to end‐of‐life care issues.
METHODS
Study Design and Population
A nested case‐control study was designed where potentially avoidable end‐of‐life readmissions were compared to nonreadmitted controls. We collected data on all consecutive adult patient admissions to any medical services of the Brigham and Women's Hospital with a discharge date between July 1, 2009 and June 30, 2010. Brigham and Women's Hospital is a 780‐bed academic medical center in Boston, Massachusetts. To avoid observation stays, only admissions with a length of stay of more than 1 day were included. We excluded patients who died before discharge, were transferred to another acute care hospital, and those who left against medical advice. We also excluded patients with no available data on medication treatment at discharge. The protocol was approved by the institutional review board of Brigham and Women's Hospital/Partners Healthcare.
Study Outcome
The study outcome was any 30‐day PAR due to end‐of‐life issues. To determine this outcome, first we identified all 30‐day readmissions to any service of 3 hospitals within the Partners network in Boston that followed the index hospitalization (prior studies have shown that these hospitals capture approximately 80% of readmissions after a Brigham and Women's Hospital medical hospitalization).[6, 7] These readmissions were subsequently differentiated as potentially avoidable or not using a validated algorithm (SQLape; SQLape, Corseaux, Switzerland).[8, 9] This algorithm uses administrative data and International Classification of Diseases, 9th Revision, Clinical Modification codes from the index and repeat hospitalization. Readmissions were considered potentially avoidable if they were: (1) readmissions related to previously known conditions during the index hospitalization, or (2) complications of treatment (eg, deep vein thrombosis, drug‐induced disorders). Conversely, readmissions were considered unavoidable if they were: (1) foreseen (such as readmissions for transplantation, delivery, chemo‐ or radiotherapy, and other specific surgical procedures), (2) follow‐up and rehabilitation treatments, or (3) readmissions for a new condition unknown during the preceding hospitalization. The algorithm has both a sensitivity and specificity of 96% compared with medical record review using the same criteria. Finally, a random sample of the 30‐day PARs was reviewed independently by 9 trained senior resident physicians to identify those due to end‐of‐life issues, defined by the following 2 criteria: (1) patient has a terminal clinical condition, such as malignancy, end stage renal disease, end stage congestive heart failure, or other condition with a life expectancy of 6 months or less; and (2) the readmission is part of the terminal disease process that was not adequately addressed during the index hospitalization. Examples of factors that were used when identifying cases included lack of healthcare proxy and lack of documentation of why end‐of‐life discussions did not take place during the index hospitalization. Training of adjudicators included a didactic session and review of standardized cases.
Risk Factors
We collected candidate risk factors based on a priori knowledge and according to the medical literature,[10, 11, 12] including demographic information, previous healthcare utilization, and index hospitalization characteristics from administrative data sources; procedures and chronic medical conditions from billing data; last laboratory values and medication information prior to discharge from the electronic medical record (Table 1). When laboratory values were missing (<1%), values were considered as normal.
| Characteristics | No 30‐Day Readmission, n=7,974 | 30‐Day PAR due to End of Life, n=80 | P Value |
|---|---|---|---|
| |||
| Age, y, mean (SD) | 61.5 (16.6) | 60.8 (11.9) | 0.69 |
| Male sex, n (%) | 3875 (48.6) | 37 (46.3) | 0.69 |
| Ethnicity, n (%) | 0.05 | ||
| Non‐Hispanic white* | 5772 (72.4) | 69 (86.3) | |
| Non‐Hispanic black | 1281 (16.1) | 4 (5.0) | |
| Hispanic | 666 (8.4) | 5 (6.3) | |
| Other | 255 (3.2) | 2 (2.5) | |
| Language, n (%) | 0.99 | ||
| English* | 7254 (91.0) | 73 (91.3) | |
| Spanish | 415 (5.2) | 4 (5.0) | |
| Other | 305 (3.8) | 3 (3.8) | |
| Marital status, n (%) | 0.37 | ||
| Currently married or partner* | 4107 (51.35) | 46 (57.5) | |
| Single/never married | 1967 (24.7) | 14 (17.5) | |
| Separated/divorced/widowed/no answer | 1900 (23.8) | 20 (25.0) | |
| Source of index admission, n (%) | 0.10 | ||
| Direct from home/outpatient clinic | 2456 (30.8) | 33 (41.3) | |
| Emergency department* | 4222 (53.0) | 34 (42.5) | |
| Nursing home/rehabilitation/other hospital | 1296 (16.3) | 13 (16.3) | |
| Length of stay of the index admission, median (IQR) | 4 (27) | 5.5 (38] | 0.13 |
| No. of hospital admissions in the past year, median (IQR) | 1 (02) | 2 (03) | <0.001 |
| Any procedure during the hospital stay, n (%) | 4809 (60.3) | 57 (71.3) | 0.05 |
| Identified caregiver at discharge | 7300 (91.6) | 76 (95.0) | 0.27 |
| No. of medications at discharge, mean (SD) | 10.6 (5.1) | 13.0 (5.0) | <0.001 |
| No. of opiate medication at discharge | <0.001 | ||
| 0 | 5297 (66.4) | 21 (26.3) | |
| 1 | 2677 (33.2) | 59 (73.8) | |
| Elixhauser, median (IQR) | 8 (215) | 23 (1442) | <0.001 |
| Selected comorbidities, n (%) | |||
| Diabetes mellitus | 1971 (24.7) | 20 (25.0) | 0.96 |
| Heart failure | 1756 (22.0) | 11 (13.8) | 0.10 |
| Atrial fibrillation | 1439 (18.1) | 10 (12.5) | 0.20 |
| COPD | 816 (10.2) | 7 (8.8) | 0.66 |
| Neoplasm | 2705 (33.9) | 69 (86.3) | <0.001 |
| Stroke | 294 (3.7) | 2 (2.5) | 0.57 |
| ESRD | 1258 (15.8) | 6 (7.5) | 0.04 |
| Liver disease | 328 (4.1) | 2 (2.5) | 0.47 |
Statistical Analysis
We first conducted a bivariate analysis on all collected potential risk factors, comparing admissions followed by a 30‐day PAR due to end‐of‐life care issues with admissions not followed by any 30‐day readmission, using the Pearson [2] test for categorical variables and Student t test for continuous variables. Then, we performed a multivariable logistic regression restricted to the variables that were found significantly associated with the outcome in the bivariate analysis. Age and Elixhauser comorbidity index were forced into the model as important potential confounders. Because a patient could have several outcomes over the study period, we used general estimating equations to cluster at the patient level. All tests were conducted as 2‐sided at a 0.05 level of significance. Analyses were performed using the SAS system for Windows, version 9.3 (SAS Institute Inc., Cary, NC).
RESULTS
From the total of 12,383 patients who were discharged from the medical services of the Brigham and Women's Hospital during the study period, 2108 (17.0%) were excluded because of: (1) death before discharge, (2) transfer to another acute care hospital, (3) discharge against medical advice, or (4) missing data (Figure 1). Among the 10,275 eligible admissions, 22.3% (n=2301) were followed by a 30‐day readmission. Of these, 826 (8.0% of all admissions) were identified as potentially avoidable. Among a random sample of 534 PARs, 80 (15.0%) were related to end‐of‐life care issues (cases). Of note, only 16 (20%) of these patients received palliative care consultation during the index hospitalization. A total of 7974 discharges were not followed by any 30‐day readmission (controls).
Baseline characteristics are presented in Table 1. Among the combined cohort of cases plus controls, the patient's mean age at inclusion was 61.3 years, and about half were male. In bivariate analysis, demographics such as age and sex were similar between cases and controls. Cases had more hospitalizations in the previous year, a higher number of medications at discharge, and a higher Elixhauser comorbidity index. When looking at diseases more specifically, neoplasm was significantly associated with potentially avoidable 30‐day readmission due to end‐of‐life care issues. In contrast, end‐stage renal disease was associated with a significantly lower risk of 30‐day PAR due to end‐of‐life care issues.
In multivariate analysis, 4 factors remained significantly associated with 30‐day PAR due to end‐of‐life care issues (Table 2). Neoplasm was the strongest risk factor, with an odds ratio of 5.6 (95% confidence interval: 2.8511.0), followed by opiate medication use, Elixhauser score, and number of admissions in the previous 12 months.
| Variable | Odds Ratio (95% CI) |
|---|---|
| |
| Age, per 10 years | 1.04 (0.911.19) |
| No. of admissions in the previous 12 months, per admission | 1.10 (1.021.20)a |
| Total no. of medications at discharge, per medication | 1.04 (1.001.10) |
| Neoplasm | 5.60 (2.8511.0)a |
| Endstage renal disease | 0.60 (0.251.42) |
| Opiate medication at discharge | 2.29 (1.294.07)a |
| Elixhauser, per 5 unit increase | 1.16 (1.101.22)a |
The model, including all 4 variables, had an excellent discrimination power, with a C statistic of 0.85. Without the Elixhauser score, the C statistic remained very high, with a value of 0.82.
DISCUSSION
In a large medical population, potentially avoidable readmissions due to end‐of‐life care issues were not uncommon: 15% of all potentially avoidable readmissions (1.2% of all discharges). We identified 4 main risk factors for having a 30‐day potentially avoidable readmission due to end‐of‐life care issues: neoplasm, opiate use, Elixhauser comorbidity index, and number of admissions in the previous year. In a model that includes these 4 variables, the discrimination was very high with a C statistic of 0.85.
This study extends prior work indicating some risk factors for the need for palliative care. Neoplasm has been logically identified as a criterion for palliative care assessment at the time of admission.[13] Patients with neoplasm are not only at overall high risk for readmission,[14, 15, 16] but they obviously represent a fragile population whose condition is often terminal. Our results suggest that still more attention may be necessary to reduce the risk of readmission due to end‐of‐life care issues in this population (for example, only 20% of cases in our study received palliative care consultation during the index hospitalization). The overall comorbidity measured by the Elixhauser index was not surprisingly a significant risk factor. It probably accounts for the burden of comorbidities, but also for other advanced diseases besides neoplasm, like heart failure, chronic obstructive pulmonary disease, and others that may also be terminal. The number of previous hospital admissions in the past year is also an important risk factor, not only for the general population,[10, 11, 14, 17, 18] but also for patients with more advanced conditions,[19, 20, 21, 22] where admissions become more frequent as the disease progresses toward end stage. Opioid use was the final statistically significant risk factor, specific for this population, likely as a proxy for disease severity and progression toward terminal illness, especially in combination with the other risk factors such as cancer. Age was not a significant factor in either bivariate or multivariate analysis. Previous studies on the risk factors for readmission among patients receiving palliative care also failed to show age as a significant factor.[23, 24] Both of these studies looked at readmissions among patients who were already receiving palliative care. Our study asks a fundamentally different (and in many ways a more practical) question: who among a large population of medical patients might benefit from receiving input from palliative care in the first place. The number of medications at discharge was no longer significant in the multivariate analysis, likely due to its collinearity with the Elixhauser comorbidity index. An increased number of medications might be associated with a higher risk of adverse drug events and readmission, but they would not be necessarily considered to be end‐of‐life readmissions. Taken together, the 4 variables provide a very promising prediction model with high discrimination. To our knowledge, there is no previous existing list of risk factors for 30‐day potentially avoidable readmission due to end‐of‐life care issues, and no existing model to help prioritize palliative care to the most high‐risk patients. It is worth noting that the Elixhauser score might be difficult to calculate before the discharge of the patient (although hospitals with electronic capture of medical problem lists might be able to approximate it). However, even without the Elixhauser score, the C statistic remained very high at 0.82.
Our study has several limitations. Although we looked at readmissions at 2 other affiliated hospitals, some patients might have been readmitted to other acute care facilities outside our network. However, we would not expect the risk factors in these patients to be so different. The identification of end‐of‐life care issues by medical record review is based on a subjective judgment, although strict criteria were used. Furthermore, differentiation between potentially avoidable readmission and unavoidable readmission cannot be perfect. We used clear and logical criteria that were previously validated and allow large database management. Also, we did not analyze a comprehensive list of potential risk factors. It is probable that functional or cognitive status, for example, could also be important risk factors. We purposely chose a set of variables that could be easily obtained from administrative data sources. The small number of cases may have led to limited statistical power to identify less strongly associated risk factors. Last, the results may not be completely generalizable to small or community hospitals, in particular those that may care for less severely ill cancer patients.
Our findings have important implications. End‐of‐life care issues are not infrequent causes of readmission. Our study's findings could help prioritize palliative care resources to those patients at higher risk to improve the quality of end‐of‐life care. The risk factors identified in this study could be used informally by physicians at the bedside to identify such patients. In addition, a hospital could use these factors to provide a second‐level screen, beyond clinician recognition, to assist palliative care teams to identify patients who may not have otherwise been referred. This screen could be automated, for example, by using a list of medical problems from an electronic medical record to approximate an Elixhauser comorbidity score, or even leaving comorbidities out and simply relying on the other 3 easily identifiable risk factors. Such efforts could have a substantial effect on improving care near the end of life and potentially reducing unnecessary hospitalizations.
Acknowledgements
The authors thank Yves Eggli for having screened the database for potentially avoidable readmission using the algorithm SQLape.
Disclosures: Dr. Donz was supported by the Swiss National Science Foundation and the Swiss Foundation for MedicalBiological Scholarships. The Swiss Science National Foundation and the Swiss Foundation for MedicalBiological Scholarships had no role in the design and conduct of this study, the analysis or interpretation of the data, or the preparation of this manuscript. Dr. Schnipper is a consultant to QuantiaMD, for which he has helped create online educational materials for both providers and patients regarding patient safety, including medication safety during transitions in care. The findings of this study are not a part of those materials. Dr. Schnipper has received grant funding from Sanofi‐Aventis for an investigator‐initiated study to design and evaluate an intensive discharge and follow‐up intervention in patients with diabetes. The funder had had no role in the design of the study.
The need to improve end‐of‐life care is well recognized. Its quality is often poor, and its cost is enormous, with 30% of the Medicare expenditures used for medical treatments of the 6% of beneficiaries who die each year.[1, 2] Repeated hospitalizations are frequent toward the end of life,[3] where each admission should be viewed as an opportunity to initiate advance care planning to improve end‐of‐life care and possibly reduce future unnecessary readmissions.[4, 5] Identified problems include undertreatment of pain, lack of awareness of patient wishes or advance directives, and unwanted overtreatment.
To improve quality and reduce unnecessary hospital use near the end of life, there is an urgent need to help healthcare providers to better identify the most vulnerable and at‐risk patients to provide them with care coordination and supportive care services. We aimed to identify the risk factors for having a 30‐day potentially avoidable readmission (PAR) due to end‐of‐life care issues.
METHODS
Study Design and Population
A nested case‐control study was designed where potentially avoidable end‐of‐life readmissions were compared to nonreadmitted controls. We collected data on all consecutive adult patient admissions to any medical services of the Brigham and Women's Hospital with a discharge date between July 1, 2009 and June 30, 2010. Brigham and Women's Hospital is a 780‐bed academic medical center in Boston, Massachusetts. To avoid observation stays, only admissions with a length of stay of more than 1 day were included. We excluded patients who died before discharge, were transferred to another acute care hospital, and those who left against medical advice. We also excluded patients with no available data on medication treatment at discharge. The protocol was approved by the institutional review board of Brigham and Women's Hospital/Partners Healthcare.
Study Outcome
The study outcome was any 30‐day PAR due to end‐of‐life issues. To determine this outcome, first we identified all 30‐day readmissions to any service of 3 hospitals within the Partners network in Boston that followed the index hospitalization (prior studies have shown that these hospitals capture approximately 80% of readmissions after a Brigham and Women's Hospital medical hospitalization).[6, 7] These readmissions were subsequently differentiated as potentially avoidable or not using a validated algorithm (SQLape; SQLape, Corseaux, Switzerland).[8, 9] This algorithm uses administrative data and International Classification of Diseases, 9th Revision, Clinical Modification codes from the index and repeat hospitalization. Readmissions were considered potentially avoidable if they were: (1) readmissions related to previously known conditions during the index hospitalization, or (2) complications of treatment (eg, deep vein thrombosis, drug‐induced disorders). Conversely, readmissions were considered unavoidable if they were: (1) foreseen (such as readmissions for transplantation, delivery, chemo‐ or radiotherapy, and other specific surgical procedures), (2) follow‐up and rehabilitation treatments, or (3) readmissions for a new condition unknown during the preceding hospitalization. The algorithm has both a sensitivity and specificity of 96% compared with medical record review using the same criteria. Finally, a random sample of the 30‐day PARs was reviewed independently by 9 trained senior resident physicians to identify those due to end‐of‐life issues, defined by the following 2 criteria: (1) patient has a terminal clinical condition, such as malignancy, end stage renal disease, end stage congestive heart failure, or other condition with a life expectancy of 6 months or less; and (2) the readmission is part of the terminal disease process that was not adequately addressed during the index hospitalization. Examples of factors that were used when identifying cases included lack of healthcare proxy and lack of documentation of why end‐of‐life discussions did not take place during the index hospitalization. Training of adjudicators included a didactic session and review of standardized cases.
Risk Factors
We collected candidate risk factors based on a priori knowledge and according to the medical literature,[10, 11, 12] including demographic information, previous healthcare utilization, and index hospitalization characteristics from administrative data sources; procedures and chronic medical conditions from billing data; last laboratory values and medication information prior to discharge from the electronic medical record (Table 1). When laboratory values were missing (<1%), values were considered as normal.
| Characteristics | No 30‐Day Readmission, n=7,974 | 30‐Day PAR due to End of Life, n=80 | P Value |
|---|---|---|---|
| |||
| Age, y, mean (SD) | 61.5 (16.6) | 60.8 (11.9) | 0.69 |
| Male sex, n (%) | 3875 (48.6) | 37 (46.3) | 0.69 |
| Ethnicity, n (%) | 0.05 | ||
| Non‐Hispanic white* | 5772 (72.4) | 69 (86.3) | |
| Non‐Hispanic black | 1281 (16.1) | 4 (5.0) | |
| Hispanic | 666 (8.4) | 5 (6.3) | |
| Other | 255 (3.2) | 2 (2.5) | |
| Language, n (%) | 0.99 | ||
| English* | 7254 (91.0) | 73 (91.3) | |
| Spanish | 415 (5.2) | 4 (5.0) | |
| Other | 305 (3.8) | 3 (3.8) | |
| Marital status, n (%) | 0.37 | ||
| Currently married or partner* | 4107 (51.35) | 46 (57.5) | |
| Single/never married | 1967 (24.7) | 14 (17.5) | |
| Separated/divorced/widowed/no answer | 1900 (23.8) | 20 (25.0) | |
| Source of index admission, n (%) | 0.10 | ||
| Direct from home/outpatient clinic | 2456 (30.8) | 33 (41.3) | |
| Emergency department* | 4222 (53.0) | 34 (42.5) | |
| Nursing home/rehabilitation/other hospital | 1296 (16.3) | 13 (16.3) | |
| Length of stay of the index admission, median (IQR) | 4 (27) | 5.5 (38] | 0.13 |
| No. of hospital admissions in the past year, median (IQR) | 1 (02) | 2 (03) | <0.001 |
| Any procedure during the hospital stay, n (%) | 4809 (60.3) | 57 (71.3) | 0.05 |
| Identified caregiver at discharge | 7300 (91.6) | 76 (95.0) | 0.27 |
| No. of medications at discharge, mean (SD) | 10.6 (5.1) | 13.0 (5.0) | <0.001 |
| No. of opiate medication at discharge | <0.001 | ||
| 0 | 5297 (66.4) | 21 (26.3) | |
| 1 | 2677 (33.2) | 59 (73.8) | |
| Elixhauser, median (IQR) | 8 (215) | 23 (1442) | <0.001 |
| Selected comorbidities, n (%) | |||
| Diabetes mellitus | 1971 (24.7) | 20 (25.0) | 0.96 |
| Heart failure | 1756 (22.0) | 11 (13.8) | 0.10 |
| Atrial fibrillation | 1439 (18.1) | 10 (12.5) | 0.20 |
| COPD | 816 (10.2) | 7 (8.8) | 0.66 |
| Neoplasm | 2705 (33.9) | 69 (86.3) | <0.001 |
| Stroke | 294 (3.7) | 2 (2.5) | 0.57 |
| ESRD | 1258 (15.8) | 6 (7.5) | 0.04 |
| Liver disease | 328 (4.1) | 2 (2.5) | 0.47 |
Statistical Analysis
We first conducted a bivariate analysis on all collected potential risk factors, comparing admissions followed by a 30‐day PAR due to end‐of‐life care issues with admissions not followed by any 30‐day readmission, using the Pearson [2] test for categorical variables and Student t test for continuous variables. Then, we performed a multivariable logistic regression restricted to the variables that were found significantly associated with the outcome in the bivariate analysis. Age and Elixhauser comorbidity index were forced into the model as important potential confounders. Because a patient could have several outcomes over the study period, we used general estimating equations to cluster at the patient level. All tests were conducted as 2‐sided at a 0.05 level of significance. Analyses were performed using the SAS system for Windows, version 9.3 (SAS Institute Inc., Cary, NC).
RESULTS
From the total of 12,383 patients who were discharged from the medical services of the Brigham and Women's Hospital during the study period, 2108 (17.0%) were excluded because of: (1) death before discharge, (2) transfer to another acute care hospital, (3) discharge against medical advice, or (4) missing data (Figure 1). Among the 10,275 eligible admissions, 22.3% (n=2301) were followed by a 30‐day readmission. Of these, 826 (8.0% of all admissions) were identified as potentially avoidable. Among a random sample of 534 PARs, 80 (15.0%) were related to end‐of‐life care issues (cases). Of note, only 16 (20%) of these patients received palliative care consultation during the index hospitalization. A total of 7974 discharges were not followed by any 30‐day readmission (controls).
Baseline characteristics are presented in Table 1. Among the combined cohort of cases plus controls, the patient's mean age at inclusion was 61.3 years, and about half were male. In bivariate analysis, demographics such as age and sex were similar between cases and controls. Cases had more hospitalizations in the previous year, a higher number of medications at discharge, and a higher Elixhauser comorbidity index. When looking at diseases more specifically, neoplasm was significantly associated with potentially avoidable 30‐day readmission due to end‐of‐life care issues. In contrast, end‐stage renal disease was associated with a significantly lower risk of 30‐day PAR due to end‐of‐life care issues.
In multivariate analysis, 4 factors remained significantly associated with 30‐day PAR due to end‐of‐life care issues (Table 2). Neoplasm was the strongest risk factor, with an odds ratio of 5.6 (95% confidence interval: 2.8511.0), followed by opiate medication use, Elixhauser score, and number of admissions in the previous 12 months.
| Variable | Odds Ratio (95% CI) |
|---|---|
| |
| Age, per 10 years | 1.04 (0.911.19) |
| No. of admissions in the previous 12 months, per admission | 1.10 (1.021.20)a |
| Total no. of medications at discharge, per medication | 1.04 (1.001.10) |
| Neoplasm | 5.60 (2.8511.0)a |
| Endstage renal disease | 0.60 (0.251.42) |
| Opiate medication at discharge | 2.29 (1.294.07)a |
| Elixhauser, per 5 unit increase | 1.16 (1.101.22)a |
The model, including all 4 variables, had an excellent discrimination power, with a C statistic of 0.85. Without the Elixhauser score, the C statistic remained very high, with a value of 0.82.
DISCUSSION
In a large medical population, potentially avoidable readmissions due to end‐of‐life care issues were not uncommon: 15% of all potentially avoidable readmissions (1.2% of all discharges). We identified 4 main risk factors for having a 30‐day potentially avoidable readmission due to end‐of‐life care issues: neoplasm, opiate use, Elixhauser comorbidity index, and number of admissions in the previous year. In a model that includes these 4 variables, the discrimination was very high with a C statistic of 0.85.
This study extends prior work indicating some risk factors for the need for palliative care. Neoplasm has been logically identified as a criterion for palliative care assessment at the time of admission.[13] Patients with neoplasm are not only at overall high risk for readmission,[14, 15, 16] but they obviously represent a fragile population whose condition is often terminal. Our results suggest that still more attention may be necessary to reduce the risk of readmission due to end‐of‐life care issues in this population (for example, only 20% of cases in our study received palliative care consultation during the index hospitalization). The overall comorbidity measured by the Elixhauser index was not surprisingly a significant risk factor. It probably accounts for the burden of comorbidities, but also for other advanced diseases besides neoplasm, like heart failure, chronic obstructive pulmonary disease, and others that may also be terminal. The number of previous hospital admissions in the past year is also an important risk factor, not only for the general population,[10, 11, 14, 17, 18] but also for patients with more advanced conditions,[19, 20, 21, 22] where admissions become more frequent as the disease progresses toward end stage. Opioid use was the final statistically significant risk factor, specific for this population, likely as a proxy for disease severity and progression toward terminal illness, especially in combination with the other risk factors such as cancer. Age was not a significant factor in either bivariate or multivariate analysis. Previous studies on the risk factors for readmission among patients receiving palliative care also failed to show age as a significant factor.[23, 24] Both of these studies looked at readmissions among patients who were already receiving palliative care. Our study asks a fundamentally different (and in many ways a more practical) question: who among a large population of medical patients might benefit from receiving input from palliative care in the first place. The number of medications at discharge was no longer significant in the multivariate analysis, likely due to its collinearity with the Elixhauser comorbidity index. An increased number of medications might be associated with a higher risk of adverse drug events and readmission, but they would not be necessarily considered to be end‐of‐life readmissions. Taken together, the 4 variables provide a very promising prediction model with high discrimination. To our knowledge, there is no previous existing list of risk factors for 30‐day potentially avoidable readmission due to end‐of‐life care issues, and no existing model to help prioritize palliative care to the most high‐risk patients. It is worth noting that the Elixhauser score might be difficult to calculate before the discharge of the patient (although hospitals with electronic capture of medical problem lists might be able to approximate it). However, even without the Elixhauser score, the C statistic remained very high at 0.82.
Our study has several limitations. Although we looked at readmissions at 2 other affiliated hospitals, some patients might have been readmitted to other acute care facilities outside our network. However, we would not expect the risk factors in these patients to be so different. The identification of end‐of‐life care issues by medical record review is based on a subjective judgment, although strict criteria were used. Furthermore, differentiation between potentially avoidable readmission and unavoidable readmission cannot be perfect. We used clear and logical criteria that were previously validated and allow large database management. Also, we did not analyze a comprehensive list of potential risk factors. It is probable that functional or cognitive status, for example, could also be important risk factors. We purposely chose a set of variables that could be easily obtained from administrative data sources. The small number of cases may have led to limited statistical power to identify less strongly associated risk factors. Last, the results may not be completely generalizable to small or community hospitals, in particular those that may care for less severely ill cancer patients.
Our findings have important implications. End‐of‐life care issues are not infrequent causes of readmission. Our study's findings could help prioritize palliative care resources to those patients at higher risk to improve the quality of end‐of‐life care. The risk factors identified in this study could be used informally by physicians at the bedside to identify such patients. In addition, a hospital could use these factors to provide a second‐level screen, beyond clinician recognition, to assist palliative care teams to identify patients who may not have otherwise been referred. This screen could be automated, for example, by using a list of medical problems from an electronic medical record to approximate an Elixhauser comorbidity score, or even leaving comorbidities out and simply relying on the other 3 easily identifiable risk factors. Such efforts could have a substantial effect on improving care near the end of life and potentially reducing unnecessary hospitalizations.
Acknowledgements
The authors thank Yves Eggli for having screened the database for potentially avoidable readmission using the algorithm SQLape.
Disclosures: Dr. Donz was supported by the Swiss National Science Foundation and the Swiss Foundation for MedicalBiological Scholarships. The Swiss Science National Foundation and the Swiss Foundation for MedicalBiological Scholarships had no role in the design and conduct of this study, the analysis or interpretation of the data, or the preparation of this manuscript. Dr. Schnipper is a consultant to QuantiaMD, for which he has helped create online educational materials for both providers and patients regarding patient safety, including medication safety during transitions in care. The findings of this study are not a part of those materials. Dr. Schnipper has received grant funding from Sanofi‐Aventis for an investigator‐initiated study to design and evaluate an intensive discharge and follow‐up intervention in patients with diabetes. The funder had had no role in the design of the study.
- , , , . Medicare beneficiaries' costs of care in the last year of life. Health Aff (Millwood). 2001;20(4):188–195.
- , , . Quality of End‐of‐Life Cancer Care for Medicare Beneficiaries: Regional and Hospital‐Specific Analyses. Lebanon, NH: The Dartmouth Institute for Health Policy and Clinical Practice; 2010.
- , , . Repeated hospitalizations predict mortality in the community population with heart failure. Am Heart J. 2007;154(2):260–266.
- . Perspectives on care at the close of life. Initiating end‐of‐life discussions with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284(19):2502–2507.
- , , , . Advance care planning as a process: structuring the discussions in practice. J Am Geriatr Soc. 1995;43(4):440–446.
- , , , et al. Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) study. Circ Cardiovasc Qual Outcomes. 2010;3(2):212–219.
- , , , et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1–10.
- , , , , , . Measuring potentially avoidable hospital readmissions. J Clin Epidemiol. 2002;55(6):573–587.
- , , , , , . Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Med Care. 2006;44(11):972–981.
- , , , et al. Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med. 2010;25(3):211–219.
- , , , , , . Screening elders for risk of hospital admission. J Am Geriatr Soc. 1993;41(8):811–817.
- , , , , . Risk factors for 30‐day hospital readmission in patients ≥65 years of age. Proc (Bayl Univ Med Cent). 2008;21(4):363–372.
- , . Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17–23.
- , , , . Potentially avoidable 30‐day hospital readmissions in medical patients: derivation and validation of a prediction model. JAMA Intern Med. 2013;173(8):632–638.
- , , , . Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6(2):54–60.
- , , . Patient and disease profile of emergency medical readmissions to an Irish teaching hospital. Postgrad Med J. 2004;80(946):470–474.
- , , , . Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39(5):1449–1465.
- , . Factors predicting readmission of older general medicine patients. J Gen Intern Med. 1991;6(5):389–393.
- , , , , . Differences in health care utilization at the end of life among patients with chronic obstructive pulmonary disease and patients with lung cancer. Arch Intern Med. 2006;166(3):326–331.
- , , , , . Frequent hospital readmissions for acute exacerbation of COPD and their associated factors. Respirology. 2006;11(2):188–195.
- , , , et al. Consensus statement: Palliative and supportive care in advanced heart failure. J Card Fail. 2004;10(3):200–209.
- , , , , . Unplanned discharges from a surgical intensive care unit: readmissions and mortality. J Crit Care. 2010;25(3):375–381.
- , , , , . Evaluating causes for unplanned hospital readmissions of palliative care patients. Am J Hosp Palliat Care. 2010;27(8):526–531.
- , , . 30‐day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356–1361.
- , , , . Medicare beneficiaries' costs of care in the last year of life. Health Aff (Millwood). 2001;20(4):188–195.
- , , . Quality of End‐of‐Life Cancer Care for Medicare Beneficiaries: Regional and Hospital‐Specific Analyses. Lebanon, NH: The Dartmouth Institute for Health Policy and Clinical Practice; 2010.
- , , . Repeated hospitalizations predict mortality in the community population with heart failure. Am Heart J. 2007;154(2):260–266.
- . Perspectives on care at the close of life. Initiating end‐of‐life discussions with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284(19):2502–2507.
- , , , . Advance care planning as a process: structuring the discussions in practice. J Am Geriatr Soc. 1995;43(4):440–446.
- , , , et al. Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) study. Circ Cardiovasc Qual Outcomes. 2010;3(2):212–219.
- , , , et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1–10.
- , , , , , . Measuring potentially avoidable hospital readmissions. J Clin Epidemiol. 2002;55(6):573–587.
- , , , , , . Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Med Care. 2006;44(11):972–981.
- , , , et al. Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med. 2010;25(3):211–219.
- , , , , , . Screening elders for risk of hospital admission. J Am Geriatr Soc. 1993;41(8):811–817.
- , , , , . Risk factors for 30‐day hospital readmission in patients ≥65 years of age. Proc (Bayl Univ Med Cent). 2008;21(4):363–372.
- , . Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17–23.
- , , , . Potentially avoidable 30‐day hospital readmissions in medical patients: derivation and validation of a prediction model. JAMA Intern Med. 2013;173(8):632–638.
- , , , . Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011;6(2):54–60.
- , , . Patient and disease profile of emergency medical readmissions to an Irish teaching hospital. Postgrad Med J. 2004;80(946):470–474.
- , , , . Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39(5):1449–1465.
- , . Factors predicting readmission of older general medicine patients. J Gen Intern Med. 1991;6(5):389–393.
- , , , , . Differences in health care utilization at the end of life among patients with chronic obstructive pulmonary disease and patients with lung cancer. Arch Intern Med. 2006;166(3):326–331.
- , , , , . Frequent hospital readmissions for acute exacerbation of COPD and their associated factors. Respirology. 2006;11(2):188–195.
- , , , et al. Consensus statement: Palliative and supportive care in advanced heart failure. J Card Fail. 2004;10(3):200–209.
- , , , , . Unplanned discharges from a surgical intensive care unit: readmissions and mortality. J Crit Care. 2010;25(3):375–381.
- , , , , . Evaluating causes for unplanned hospital readmissions of palliative care patients. Am J Hosp Palliat Care. 2010;27(8):526–531.
- , , . 30‐day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356–1361.
© 2014 Society of Hospital Medicine
On the Go Education: Mobile software in cardiothoracic training
In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.
In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.
"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.
He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."
In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.
iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.
Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.
CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.
CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.
SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.
TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.
NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.
CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.
EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.
Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.
This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.
What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.
If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.
Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.
In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.
In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.
"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.
He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."
In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.
iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.
Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.
CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.
CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.
SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.
TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.
NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.
CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.
EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.
Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.
This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.
What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.
If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.
Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.
In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.
In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.
"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.
He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."
In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.
iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.
Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.
CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.
CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.
SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.
TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.
NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.
CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.
EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.
Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.
This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.
What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.
If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.
Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.
Reconsidering comfort care
Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.
When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).
Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.
As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.
In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.
As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.
With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.
Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.
Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.
When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).
Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.
As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.
In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.
As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.
With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.
Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.
Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.
When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).
Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.
As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.
In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.
As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.
With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.
Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.
Peptides
Peptides have recently generated interest as biologically active compounds incorporated into cosmeceutical products intended to treat aging skin. Peptides are composed of chains of amino acids, which are derived from DNA transcription. In typical cellular settings, peptides communicate or signal between DNA and the cellular network. Consequently, they are thought to be capable of being used or exploited to direct cells to maintain youthful behavior, yielding a stable, nonaging manifestation. In addition, peptides can be rendered by protein degradation, thus forming an essential feedback inhibition and upregulation loop (Facial Plast. Surg. 2009;25:285-9). Downregulation of metalloproteinases (MMPs), notably collagenase, by peptides is a good example, as well as a window into why peptides have sparked interest within antiaging research (Dermatol. Surg. 2005;31[7 Pt 2]:832-6, discussion 836).
Researchers at the University of Tennessee, Memphis, performed some of the seminal work that has paved the way for understanding how to harness the activity of natural peptides by showing that the production of the extracellular matrix in fibroblasts is fostered by a pentapeptide subfragment of propeptide of type I collagen (J. Biol. Chem. 1993;268:9941-4).
But the foundational work setting the stage for development of cosmeceutical peptides has been in the research for ameliorating wounds, which dates back several decades and can be traced to the use of yeast extracts for wound care in the 1930s, later leading to the extraction of a usable protein fraction (Dermatol. Ther. 2007;20:343-9; Clin. Ther. 1991;13:430-4). Signal peptides, enzyme-inhibitor peptides, neurotransmitter-inhibitor peptides (or neuropeptides), and carrier peptides are the four primary classes of topical or cosmeceutical peptides. This column will offer a brief summary of each and acknowledge additional recent research. Future columns may address each of these peptide categories pertinent to antiaging cosmeceuticals.
Signal peptides
Specific bioactive amino acid chains have been discovered in recent years that promote human skin dermal fibroblast growth in vitro and in vivo, and reduce the length and depth of wrinkles (Dermatol. Ther. 2007;20:343-9). The most popular signal peptide is the lysine-threonine-threonine-lysine-serine (KTTKS) located on type 1 procollagen. To enhance epidermal delivery, it has been linked to palmitic acid, thus the marketed version (Matrixyl) is a palmitoyl pentapeptide, which has been shown to augment the synthesis of collagen by fibroblasts and yield reductions in fine lines and wrinkles, according to quantitative analysis and self-reports (J. Biol. Chem. 1993;268:9941-4; Int. J. Cosmet. Sci. 2005;27:155-60).
New signal peptides are expected to be stronger and better targeted than those presently marketed (Facial Plast. Surg. 2009;25:285-9). Signal peptides promote the synthesis of matrix proteins, collagen in particular, which leads to firmer, younger looking skin, and also augments levels of elastin, proteoglycans, glycosaminoglycans, and fibronectin (Int. J. Cosmet. Sci. 2009;31:327-45).
Enzyme-inhibitor peptides
These peptides suppress enzymatic activity either directly or indirectly. Enzyme-inhibiting peptides extracted from soybeans have been incorporated into antiaging, moisturizing, and cleansing products as well as hair care formulations (Int. J. Cosmet. Sci. 2009;31:327-45). In a small study in 10 white females, a 2% soya biopeptide performed better than did placebo in collagen and glycosaminoglycan promotion (Int. J. Cosmet. Sci. 1999;21:299-311).
More recently, a rice peptide derived from germinated black rice, which has been used in traditional Asian medicines, was found to block MMP activity and dose-dependently stimulate hyaluronan synthase 2 gene expression (a twofold increase) in human keratinocytes (J. Microbiol. Biotechnol. 2007;17:271-9). Such peptides are found in antiaging and hair products.
In addition, antioxidant activity, a high affinity to chelate with copper, and the capacity to suppress tyrosinase activity and keratinocyte apoptosis have been displayed by the enzyme-inhibiting peptide sericin, derived from the silkworm Bombyx mori (Int. J. Cosmet. Sci. 2009;31:327-45). Sericin also has been shown to facilitate the intrinsic moisturization of skin by restoring amino acids and imparting an occlusive effect (J. Cosmet. Dermatol. 2005;4:250-7).
Neuropeptides
Neuropeptides are known to mediate skin inflammation and, thus, contribute as an underlying aspect of reactive skin conditions (Eur. J. Dermatol. 2010;20:731-7). Also known as neurotransmitter-affecting peptides, these compounds are included in cosmeceuticals to mimic the action of botulinum toxin A. Essentially, they inhibit acetylcholine release at the neuromuscular junction.
The best known of these is acetyl hexapeptide-3, marketed as Argireline. Attached to acetic acid residue, this synthetic peptide, based on the N-terminal end of the synaptosomal-associated protein (SNAP)–25 that blocks soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) complex development and catecholamine release (Int. J. Cosmet. Sci. 2009;31:327-45), is thought to suppress the release of neurotransmitters, easing facial tension, and thus reducing wrinkles. Evidence of its effectiveness has appeared largely in proprietary studies. Much more research is necessary to establish the suitability of this form of peptide for topical antiaging applications.
Carrier peptides
Carrier peptides stabilize and transport trace elements essential for healing wounds and enzymatic processes (Dermatol. Ther. 2007;20:343-9). Although it also confers signal peptide effects, glycyl-L-histidyl-L-lysine (GHK), a naturally occurring tripeptide initially isolated from human plasma (Nat. New Biol. 1973;243:85-7), is known mainly as a carrier peptide. It is typically linked with copper, given its high affinity for it, and several studies have shown that copper peptide molecules using GHK (glycyl-L-histidyl-L-lysine-Cu2+ or GHK-Cu) deliver varied restorative effects, including the improvement in the appearance of fine lines and wrinkles (Dermatol. Ther. 2007;20:343-9). This tripeptide complex has been used for many years to accelerate wound healing and is found in several moisturizers. Significantly, the GHK-Cu complex also has been shown to stimulate collagen synthesis (FEBS Lett. 1988;238:343-6) and to augment sulfated proteoglycans levels in fibroblast cultures as well as experimental animal wound models (J. Clin. Invest. 1993;92:2368-76). GHK-Cu also influences tissue remodeling by raising the levels of MMP-2 and tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) (Life Sci. 2000;67:2257-65). More research is necessary to ascertain the efficacy of copper peptide as an antiaging agent.
Recent general research findings
A double-blind clinical study in 2004 of 20 healthy women volunteers between 40 and 62 years of age revealed that a gel formula containing 3% of a collagen-like hexapeptide significantly reduced the total surface of wrinkles as well as the number and average depth of wrinkles (Int. J. Tissue React. 2004;26:105-11).
In 2005, a literature review of studies published on the effects and practical applications of peptides as topical agents for skin improvement showed that peptide cosmeceuticals seem to exhibit the potential to blunt the visual effects of aging on the skin, and that formulations must be stable, absorbed into the skin, and biologically active (Dermatol. Surg. 2005;31[7 Pt 2]:832-6, discussion 836).
In 2007, investigators reported on the development of a new hand care formulation derived from wool peptides. The keratin fraction from wool was shown through long-term in vivo studies to enhance cutaneous hydration, water-holding capacity, and elasticity in volunteers with dry skin. In addition, the researchers found that the keratin peptide preparation blunted some of the adverse effects due to surfactant exposure (J. Cosmet. Sci. 2007;58:99-107).
That same year, researchers reported that they prepared two stable cosmetic formulations, an emulsion with an external aqueous phase for normal-to-dry skin and a gel for oily skin, with acetyl hexapeptide-8 (Argireline) as the active ingredient (J. Cosmet. Sci. 2007;58:157-71).
Previously, Argireline was shown in healthy women volunteers, in a skin topography analysis of an oil/water (O/W) emulsion containing 10% of the hexapeptide, to have decreased wrinkle depth up to 30% after 30 days of treatment. Researchers determined that the synthetic hexapeptide significantly suppresses neurotransmitter release comparably to botulinum toxin A, with fewer side effects but lower efficacy. They also noted that Argireline displayed no in vivo oral toxicity and evoked no irritation at high doses, suggesting that the peptide is a topical nontoxic antiwrinkle alternative to botulinum toxins (Int. J. Cosmet. Sci. 2002;24:303-10).
In 2008, investigators tested a hydrolyzed keratin peptide derived from wool on skin in two different formulations. Long-term in vivo studies yielded significant differences between the control and treated sites, with the treated areas exhibiting an increase in hydration and elasticity because of keratin peptide application. The investigators also noted measurements showing that the keratin formulations supported skin barrier integrity, enhancing its water-holding capacity. In particular, the formulation combining keratin peptide with internal wool lipids in a liposome suspension showed promising effects that they deemed appropriate for new cosmetic products (Skin Res. Technol. 2008;14:243-8).
Conclusion
Peptide cosmeceuticals represent a new and popular choice for consumers shopping for antiaging products. Are they worthy options? As always, the capacity of topical products to penetrate the skin and exert a biologic impact is of great significance. Some products appear to exert antiaging effects, but most evidence of effectiveness has emerged from in vitro studies or small in vivo investigations. More research, in the form of large randomized controlled trials, is necessary to establish the effectiveness of these intriguing products. As it is, though, numerous products are on the market and this area of research and product development shows promise.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
Peptides have recently generated interest as biologically active compounds incorporated into cosmeceutical products intended to treat aging skin. Peptides are composed of chains of amino acids, which are derived from DNA transcription. In typical cellular settings, peptides communicate or signal between DNA and the cellular network. Consequently, they are thought to be capable of being used or exploited to direct cells to maintain youthful behavior, yielding a stable, nonaging manifestation. In addition, peptides can be rendered by protein degradation, thus forming an essential feedback inhibition and upregulation loop (Facial Plast. Surg. 2009;25:285-9). Downregulation of metalloproteinases (MMPs), notably collagenase, by peptides is a good example, as well as a window into why peptides have sparked interest within antiaging research (Dermatol. Surg. 2005;31[7 Pt 2]:832-6, discussion 836).
Researchers at the University of Tennessee, Memphis, performed some of the seminal work that has paved the way for understanding how to harness the activity of natural peptides by showing that the production of the extracellular matrix in fibroblasts is fostered by a pentapeptide subfragment of propeptide of type I collagen (J. Biol. Chem. 1993;268:9941-4).
But the foundational work setting the stage for development of cosmeceutical peptides has been in the research for ameliorating wounds, which dates back several decades and can be traced to the use of yeast extracts for wound care in the 1930s, later leading to the extraction of a usable protein fraction (Dermatol. Ther. 2007;20:343-9; Clin. Ther. 1991;13:430-4). Signal peptides, enzyme-inhibitor peptides, neurotransmitter-inhibitor peptides (or neuropeptides), and carrier peptides are the four primary classes of topical or cosmeceutical peptides. This column will offer a brief summary of each and acknowledge additional recent research. Future columns may address each of these peptide categories pertinent to antiaging cosmeceuticals.
Signal peptides
Specific bioactive amino acid chains have been discovered in recent years that promote human skin dermal fibroblast growth in vitro and in vivo, and reduce the length and depth of wrinkles (Dermatol. Ther. 2007;20:343-9). The most popular signal peptide is the lysine-threonine-threonine-lysine-serine (KTTKS) located on type 1 procollagen. To enhance epidermal delivery, it has been linked to palmitic acid, thus the marketed version (Matrixyl) is a palmitoyl pentapeptide, which has been shown to augment the synthesis of collagen by fibroblasts and yield reductions in fine lines and wrinkles, according to quantitative analysis and self-reports (J. Biol. Chem. 1993;268:9941-4; Int. J. Cosmet. Sci. 2005;27:155-60).
New signal peptides are expected to be stronger and better targeted than those presently marketed (Facial Plast. Surg. 2009;25:285-9). Signal peptides promote the synthesis of matrix proteins, collagen in particular, which leads to firmer, younger looking skin, and also augments levels of elastin, proteoglycans, glycosaminoglycans, and fibronectin (Int. J. Cosmet. Sci. 2009;31:327-45).
Enzyme-inhibitor peptides
These peptides suppress enzymatic activity either directly or indirectly. Enzyme-inhibiting peptides extracted from soybeans have been incorporated into antiaging, moisturizing, and cleansing products as well as hair care formulations (Int. J. Cosmet. Sci. 2009;31:327-45). In a small study in 10 white females, a 2% soya biopeptide performed better than did placebo in collagen and glycosaminoglycan promotion (Int. J. Cosmet. Sci. 1999;21:299-311).
More recently, a rice peptide derived from germinated black rice, which has been used in traditional Asian medicines, was found to block MMP activity and dose-dependently stimulate hyaluronan synthase 2 gene expression (a twofold increase) in human keratinocytes (J. Microbiol. Biotechnol. 2007;17:271-9). Such peptides are found in antiaging and hair products.
In addition, antioxidant activity, a high affinity to chelate with copper, and the capacity to suppress tyrosinase activity and keratinocyte apoptosis have been displayed by the enzyme-inhibiting peptide sericin, derived from the silkworm Bombyx mori (Int. J. Cosmet. Sci. 2009;31:327-45). Sericin also has been shown to facilitate the intrinsic moisturization of skin by restoring amino acids and imparting an occlusive effect (J. Cosmet. Dermatol. 2005;4:250-7).
Neuropeptides
Neuropeptides are known to mediate skin inflammation and, thus, contribute as an underlying aspect of reactive skin conditions (Eur. J. Dermatol. 2010;20:731-7). Also known as neurotransmitter-affecting peptides, these compounds are included in cosmeceuticals to mimic the action of botulinum toxin A. Essentially, they inhibit acetylcholine release at the neuromuscular junction.
The best known of these is acetyl hexapeptide-3, marketed as Argireline. Attached to acetic acid residue, this synthetic peptide, based on the N-terminal end of the synaptosomal-associated protein (SNAP)–25 that blocks soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) complex development and catecholamine release (Int. J. Cosmet. Sci. 2009;31:327-45), is thought to suppress the release of neurotransmitters, easing facial tension, and thus reducing wrinkles. Evidence of its effectiveness has appeared largely in proprietary studies. Much more research is necessary to establish the suitability of this form of peptide for topical antiaging applications.
Carrier peptides
Carrier peptides stabilize and transport trace elements essential for healing wounds and enzymatic processes (Dermatol. Ther. 2007;20:343-9). Although it also confers signal peptide effects, glycyl-L-histidyl-L-lysine (GHK), a naturally occurring tripeptide initially isolated from human plasma (Nat. New Biol. 1973;243:85-7), is known mainly as a carrier peptide. It is typically linked with copper, given its high affinity for it, and several studies have shown that copper peptide molecules using GHK (glycyl-L-histidyl-L-lysine-Cu2+ or GHK-Cu) deliver varied restorative effects, including the improvement in the appearance of fine lines and wrinkles (Dermatol. Ther. 2007;20:343-9). This tripeptide complex has been used for many years to accelerate wound healing and is found in several moisturizers. Significantly, the GHK-Cu complex also has been shown to stimulate collagen synthesis (FEBS Lett. 1988;238:343-6) and to augment sulfated proteoglycans levels in fibroblast cultures as well as experimental animal wound models (J. Clin. Invest. 1993;92:2368-76). GHK-Cu also influences tissue remodeling by raising the levels of MMP-2 and tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) (Life Sci. 2000;67:2257-65). More research is necessary to ascertain the efficacy of copper peptide as an antiaging agent.
Recent general research findings
A double-blind clinical study in 2004 of 20 healthy women volunteers between 40 and 62 years of age revealed that a gel formula containing 3% of a collagen-like hexapeptide significantly reduced the total surface of wrinkles as well as the number and average depth of wrinkles (Int. J. Tissue React. 2004;26:105-11).
In 2005, a literature review of studies published on the effects and practical applications of peptides as topical agents for skin improvement showed that peptide cosmeceuticals seem to exhibit the potential to blunt the visual effects of aging on the skin, and that formulations must be stable, absorbed into the skin, and biologically active (Dermatol. Surg. 2005;31[7 Pt 2]:832-6, discussion 836).
In 2007, investigators reported on the development of a new hand care formulation derived from wool peptides. The keratin fraction from wool was shown through long-term in vivo studies to enhance cutaneous hydration, water-holding capacity, and elasticity in volunteers with dry skin. In addition, the researchers found that the keratin peptide preparation blunted some of the adverse effects due to surfactant exposure (J. Cosmet. Sci. 2007;58:99-107).
That same year, researchers reported that they prepared two stable cosmetic formulations, an emulsion with an external aqueous phase for normal-to-dry skin and a gel for oily skin, with acetyl hexapeptide-8 (Argireline) as the active ingredient (J. Cosmet. Sci. 2007;58:157-71).
Previously, Argireline was shown in healthy women volunteers, in a skin topography analysis of an oil/water (O/W) emulsion containing 10% of the hexapeptide, to have decreased wrinkle depth up to 30% after 30 days of treatment. Researchers determined that the synthetic hexapeptide significantly suppresses neurotransmitter release comparably to botulinum toxin A, with fewer side effects but lower efficacy. They also noted that Argireline displayed no in vivo oral toxicity and evoked no irritation at high doses, suggesting that the peptide is a topical nontoxic antiwrinkle alternative to botulinum toxins (Int. J. Cosmet. Sci. 2002;24:303-10).
In 2008, investigators tested a hydrolyzed keratin peptide derived from wool on skin in two different formulations. Long-term in vivo studies yielded significant differences between the control and treated sites, with the treated areas exhibiting an increase in hydration and elasticity because of keratin peptide application. The investigators also noted measurements showing that the keratin formulations supported skin barrier integrity, enhancing its water-holding capacity. In particular, the formulation combining keratin peptide with internal wool lipids in a liposome suspension showed promising effects that they deemed appropriate for new cosmetic products (Skin Res. Technol. 2008;14:243-8).
Conclusion
Peptide cosmeceuticals represent a new and popular choice for consumers shopping for antiaging products. Are they worthy options? As always, the capacity of topical products to penetrate the skin and exert a biologic impact is of great significance. Some products appear to exert antiaging effects, but most evidence of effectiveness has emerged from in vitro studies or small in vivo investigations. More research, in the form of large randomized controlled trials, is necessary to establish the effectiveness of these intriguing products. As it is, though, numerous products are on the market and this area of research and product development shows promise.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
Peptides have recently generated interest as biologically active compounds incorporated into cosmeceutical products intended to treat aging skin. Peptides are composed of chains of amino acids, which are derived from DNA transcription. In typical cellular settings, peptides communicate or signal between DNA and the cellular network. Consequently, they are thought to be capable of being used or exploited to direct cells to maintain youthful behavior, yielding a stable, nonaging manifestation. In addition, peptides can be rendered by protein degradation, thus forming an essential feedback inhibition and upregulation loop (Facial Plast. Surg. 2009;25:285-9). Downregulation of metalloproteinases (MMPs), notably collagenase, by peptides is a good example, as well as a window into why peptides have sparked interest within antiaging research (Dermatol. Surg. 2005;31[7 Pt 2]:832-6, discussion 836).
Researchers at the University of Tennessee, Memphis, performed some of the seminal work that has paved the way for understanding how to harness the activity of natural peptides by showing that the production of the extracellular matrix in fibroblasts is fostered by a pentapeptide subfragment of propeptide of type I collagen (J. Biol. Chem. 1993;268:9941-4).
But the foundational work setting the stage for development of cosmeceutical peptides has been in the research for ameliorating wounds, which dates back several decades and can be traced to the use of yeast extracts for wound care in the 1930s, later leading to the extraction of a usable protein fraction (Dermatol. Ther. 2007;20:343-9; Clin. Ther. 1991;13:430-4). Signal peptides, enzyme-inhibitor peptides, neurotransmitter-inhibitor peptides (or neuropeptides), and carrier peptides are the four primary classes of topical or cosmeceutical peptides. This column will offer a brief summary of each and acknowledge additional recent research. Future columns may address each of these peptide categories pertinent to antiaging cosmeceuticals.
Signal peptides
Specific bioactive amino acid chains have been discovered in recent years that promote human skin dermal fibroblast growth in vitro and in vivo, and reduce the length and depth of wrinkles (Dermatol. Ther. 2007;20:343-9). The most popular signal peptide is the lysine-threonine-threonine-lysine-serine (KTTKS) located on type 1 procollagen. To enhance epidermal delivery, it has been linked to palmitic acid, thus the marketed version (Matrixyl) is a palmitoyl pentapeptide, which has been shown to augment the synthesis of collagen by fibroblasts and yield reductions in fine lines and wrinkles, according to quantitative analysis and self-reports (J. Biol. Chem. 1993;268:9941-4; Int. J. Cosmet. Sci. 2005;27:155-60).
New signal peptides are expected to be stronger and better targeted than those presently marketed (Facial Plast. Surg. 2009;25:285-9). Signal peptides promote the synthesis of matrix proteins, collagen in particular, which leads to firmer, younger looking skin, and also augments levels of elastin, proteoglycans, glycosaminoglycans, and fibronectin (Int. J. Cosmet. Sci. 2009;31:327-45).
Enzyme-inhibitor peptides
These peptides suppress enzymatic activity either directly or indirectly. Enzyme-inhibiting peptides extracted from soybeans have been incorporated into antiaging, moisturizing, and cleansing products as well as hair care formulations (Int. J. Cosmet. Sci. 2009;31:327-45). In a small study in 10 white females, a 2% soya biopeptide performed better than did placebo in collagen and glycosaminoglycan promotion (Int. J. Cosmet. Sci. 1999;21:299-311).
More recently, a rice peptide derived from germinated black rice, which has been used in traditional Asian medicines, was found to block MMP activity and dose-dependently stimulate hyaluronan synthase 2 gene expression (a twofold increase) in human keratinocytes (J. Microbiol. Biotechnol. 2007;17:271-9). Such peptides are found in antiaging and hair products.
In addition, antioxidant activity, a high affinity to chelate with copper, and the capacity to suppress tyrosinase activity and keratinocyte apoptosis have been displayed by the enzyme-inhibiting peptide sericin, derived from the silkworm Bombyx mori (Int. J. Cosmet. Sci. 2009;31:327-45). Sericin also has been shown to facilitate the intrinsic moisturization of skin by restoring amino acids and imparting an occlusive effect (J. Cosmet. Dermatol. 2005;4:250-7).
Neuropeptides
Neuropeptides are known to mediate skin inflammation and, thus, contribute as an underlying aspect of reactive skin conditions (Eur. J. Dermatol. 2010;20:731-7). Also known as neurotransmitter-affecting peptides, these compounds are included in cosmeceuticals to mimic the action of botulinum toxin A. Essentially, they inhibit acetylcholine release at the neuromuscular junction.
The best known of these is acetyl hexapeptide-3, marketed as Argireline. Attached to acetic acid residue, this synthetic peptide, based on the N-terminal end of the synaptosomal-associated protein (SNAP)–25 that blocks soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) complex development and catecholamine release (Int. J. Cosmet. Sci. 2009;31:327-45), is thought to suppress the release of neurotransmitters, easing facial tension, and thus reducing wrinkles. Evidence of its effectiveness has appeared largely in proprietary studies. Much more research is necessary to establish the suitability of this form of peptide for topical antiaging applications.
Carrier peptides
Carrier peptides stabilize and transport trace elements essential for healing wounds and enzymatic processes (Dermatol. Ther. 2007;20:343-9). Although it also confers signal peptide effects, glycyl-L-histidyl-L-lysine (GHK), a naturally occurring tripeptide initially isolated from human plasma (Nat. New Biol. 1973;243:85-7), is known mainly as a carrier peptide. It is typically linked with copper, given its high affinity for it, and several studies have shown that copper peptide molecules using GHK (glycyl-L-histidyl-L-lysine-Cu2+ or GHK-Cu) deliver varied restorative effects, including the improvement in the appearance of fine lines and wrinkles (Dermatol. Ther. 2007;20:343-9). This tripeptide complex has been used for many years to accelerate wound healing and is found in several moisturizers. Significantly, the GHK-Cu complex also has been shown to stimulate collagen synthesis (FEBS Lett. 1988;238:343-6) and to augment sulfated proteoglycans levels in fibroblast cultures as well as experimental animal wound models (J. Clin. Invest. 1993;92:2368-76). GHK-Cu also influences tissue remodeling by raising the levels of MMP-2 and tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) (Life Sci. 2000;67:2257-65). More research is necessary to ascertain the efficacy of copper peptide as an antiaging agent.
Recent general research findings
A double-blind clinical study in 2004 of 20 healthy women volunteers between 40 and 62 years of age revealed that a gel formula containing 3% of a collagen-like hexapeptide significantly reduced the total surface of wrinkles as well as the number and average depth of wrinkles (Int. J. Tissue React. 2004;26:105-11).
In 2005, a literature review of studies published on the effects and practical applications of peptides as topical agents for skin improvement showed that peptide cosmeceuticals seem to exhibit the potential to blunt the visual effects of aging on the skin, and that formulations must be stable, absorbed into the skin, and biologically active (Dermatol. Surg. 2005;31[7 Pt 2]:832-6, discussion 836).
In 2007, investigators reported on the development of a new hand care formulation derived from wool peptides. The keratin fraction from wool was shown through long-term in vivo studies to enhance cutaneous hydration, water-holding capacity, and elasticity in volunteers with dry skin. In addition, the researchers found that the keratin peptide preparation blunted some of the adverse effects due to surfactant exposure (J. Cosmet. Sci. 2007;58:99-107).
That same year, researchers reported that they prepared two stable cosmetic formulations, an emulsion with an external aqueous phase for normal-to-dry skin and a gel for oily skin, with acetyl hexapeptide-8 (Argireline) as the active ingredient (J. Cosmet. Sci. 2007;58:157-71).
Previously, Argireline was shown in healthy women volunteers, in a skin topography analysis of an oil/water (O/W) emulsion containing 10% of the hexapeptide, to have decreased wrinkle depth up to 30% after 30 days of treatment. Researchers determined that the synthetic hexapeptide significantly suppresses neurotransmitter release comparably to botulinum toxin A, with fewer side effects but lower efficacy. They also noted that Argireline displayed no in vivo oral toxicity and evoked no irritation at high doses, suggesting that the peptide is a topical nontoxic antiwrinkle alternative to botulinum toxins (Int. J. Cosmet. Sci. 2002;24:303-10).
In 2008, investigators tested a hydrolyzed keratin peptide derived from wool on skin in two different formulations. Long-term in vivo studies yielded significant differences between the control and treated sites, with the treated areas exhibiting an increase in hydration and elasticity because of keratin peptide application. The investigators also noted measurements showing that the keratin formulations supported skin barrier integrity, enhancing its water-holding capacity. In particular, the formulation combining keratin peptide with internal wool lipids in a liposome suspension showed promising effects that they deemed appropriate for new cosmetic products (Skin Res. Technol. 2008;14:243-8).
Conclusion
Peptide cosmeceuticals represent a new and popular choice for consumers shopping for antiaging products. Are they worthy options? As always, the capacity of topical products to penetrate the skin and exert a biologic impact is of great significance. Some products appear to exert antiaging effects, but most evidence of effectiveness has emerged from in vitro studies or small in vivo investigations. More research, in the form of large randomized controlled trials, is necessary to establish the effectiveness of these intriguing products. As it is, though, numerous products are on the market and this area of research and product development shows promise.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
FDA approves ibrutinib for previously treated CLL
Credit: Rhoda Baer
The US Food and Drug Administration (FDA) has expanded the indication for the Bruton’s tyrosine kinase inhibitor ibrutinib (Imbruvica).
Last November, the drug gained accelerated approval as a “breakthrough therapy” for patients with mantle cell lymphoma who had received at least 1 prior therapy.
Now, ibrutinib has been granted accelerated approval to treat patients with chronic lymphocytic leukemia (CLL) who have received at least 1 prior therapy.
The accelerated approval process allows the FDA to approve a drug based on a surrogate or intermediate endpoint that is reasonably likely to predict clinical benefit. Both approvals of ibrutinib are based on observed benefits in overall response rates.
Ibrutinib also received priority review and orphan-product designation for CLL.
Trial results
The accelerated approval of ibrutinib is based on results of a phase 1b/2 study, which included 48 patients with relapsed or refractory CLL. The patients had been diagnosed an average of 6.7 years prior to study enrollment and had received 4 prior therapies.
All patients received 420 mg of ibrutinib orally until disease progression or the development of unacceptable toxicity.
The overall response rate was 58.3%, and all of these were partial responses. The median duration of response was not reached (range, 5.6 months to more than 24.2 months).
Study investigators have not established whether ibrutinib confers improvements in survival or disease-related symptoms.
The median treatment duration was 15.6 months. Ten percent of patients (n=5) discontinued treatment due to adverse events. Three of these patients developed infections, and 2 had subdural hematomas. Thirteen percent of patients experienced adverse events that led to dose reductions.
The most commonly occurring adverse events (all grades and grade 3/4, respectively) included thrombocytopenia (71%, 10%), diarrhea (63%, 4%), bruising (54%, 2%), neutropenia (54%, 27%), anemia (44%, 0%), upper respiratory tract infection (48%, 26%), fatigue (31%, 4%), musculoskeletal pain (27%, 6%), rash (27%, 0%), pyrexia (25%, 2%), constipation (23%, 2%), peripheral edema (23%, 0%), arthralgia (23%, 0%), nausea (21%, 2%), stomatitis (21%, 0%), sinusitis (21%, 6%), and dizziness (21%, 0%).
Ibrutinib is being developed and commercialized by Pharmacyclics and Janssen Biotech, Inc. For full prescribing information, visit http://www.imbruvica.com/downloads/Prescribing_Information.pdf. 
Credit: Rhoda Baer
The US Food and Drug Administration (FDA) has expanded the indication for the Bruton’s tyrosine kinase inhibitor ibrutinib (Imbruvica).
Last November, the drug gained accelerated approval as a “breakthrough therapy” for patients with mantle cell lymphoma who had received at least 1 prior therapy.
Now, ibrutinib has been granted accelerated approval to treat patients with chronic lymphocytic leukemia (CLL) who have received at least 1 prior therapy.
The accelerated approval process allows the FDA to approve a drug based on a surrogate or intermediate endpoint that is reasonably likely to predict clinical benefit. Both approvals of ibrutinib are based on observed benefits in overall response rates.
Ibrutinib also received priority review and orphan-product designation for CLL.
Trial results
The accelerated approval of ibrutinib is based on results of a phase 1b/2 study, which included 48 patients with relapsed or refractory CLL. The patients had been diagnosed an average of 6.7 years prior to study enrollment and had received 4 prior therapies.
All patients received 420 mg of ibrutinib orally until disease progression or the development of unacceptable toxicity.
The overall response rate was 58.3%, and all of these were partial responses. The median duration of response was not reached (range, 5.6 months to more than 24.2 months).
Study investigators have not established whether ibrutinib confers improvements in survival or disease-related symptoms.
The median treatment duration was 15.6 months. Ten percent of patients (n=5) discontinued treatment due to adverse events. Three of these patients developed infections, and 2 had subdural hematomas. Thirteen percent of patients experienced adverse events that led to dose reductions.
The most commonly occurring adverse events (all grades and grade 3/4, respectively) included thrombocytopenia (71%, 10%), diarrhea (63%, 4%), bruising (54%, 2%), neutropenia (54%, 27%), anemia (44%, 0%), upper respiratory tract infection (48%, 26%), fatigue (31%, 4%), musculoskeletal pain (27%, 6%), rash (27%, 0%), pyrexia (25%, 2%), constipation (23%, 2%), peripheral edema (23%, 0%), arthralgia (23%, 0%), nausea (21%, 2%), stomatitis (21%, 0%), sinusitis (21%, 6%), and dizziness (21%, 0%).
Ibrutinib is being developed and commercialized by Pharmacyclics and Janssen Biotech, Inc. For full prescribing information, visit http://www.imbruvica.com/downloads/Prescribing_Information.pdf.
Credit: Rhoda Baer
The US Food and Drug Administration (FDA) has expanded the indication for the Bruton’s tyrosine kinase inhibitor ibrutinib (Imbruvica).
Last November, the drug gained accelerated approval as a “breakthrough therapy” for patients with mantle cell lymphoma who had received at least 1 prior therapy.
Now, ibrutinib has been granted accelerated approval to treat patients with chronic lymphocytic leukemia (CLL) who have received at least 1 prior therapy.
The accelerated approval process allows the FDA to approve a drug based on a surrogate or intermediate endpoint that is reasonably likely to predict clinical benefit. Both approvals of ibrutinib are based on observed benefits in overall response rates.
Ibrutinib also received priority review and orphan-product designation for CLL.
Trial results
The accelerated approval of ibrutinib is based on results of a phase 1b/2 study, which included 48 patients with relapsed or refractory CLL. The patients had been diagnosed an average of 6.7 years prior to study enrollment and had received 4 prior therapies.
All patients received 420 mg of ibrutinib orally until disease progression or the development of unacceptable toxicity.
The overall response rate was 58.3%, and all of these were partial responses. The median duration of response was not reached (range, 5.6 months to more than 24.2 months).
Study investigators have not established whether ibrutinib confers improvements in survival or disease-related symptoms.
The median treatment duration was 15.6 months. Ten percent of patients (n=5) discontinued treatment due to adverse events. Three of these patients developed infections, and 2 had subdural hematomas. Thirteen percent of patients experienced adverse events that led to dose reductions.
The most commonly occurring adverse events (all grades and grade 3/4, respectively) included thrombocytopenia (71%, 10%), diarrhea (63%, 4%), bruising (54%, 2%), neutropenia (54%, 27%), anemia (44%, 0%), upper respiratory tract infection (48%, 26%), fatigue (31%, 4%), musculoskeletal pain (27%, 6%), rash (27%, 0%), pyrexia (25%, 2%), constipation (23%, 2%), peripheral edema (23%, 0%), arthralgia (23%, 0%), nausea (21%, 2%), stomatitis (21%, 0%), sinusitis (21%, 6%), and dizziness (21%, 0%).
Ibrutinib is being developed and commercialized by Pharmacyclics and Janssen Biotech, Inc. For full prescribing information, visit http://www.imbruvica.com/downloads/Prescribing_Information.pdf.
New insight into megakaryocytic leukemias
Researchers have linked a mutation causing Down syndrome-associated leukemias to developmental abnormalities in megakaryocytes.
Experiments showed that the leukemia-associated GATA1 mutant, GATA1s, interferes with the enzyme calpain 2, which acts as an initial trigger for a chain of reactions that determines the size and shape of megakaryocytes.
This interference hinders the normal process of cellular enlargement and platelet production.
“It’s like there’s a long pipeline and there’s a clog,” explained study author Adam N. Goldfarb, MD, of the University of Virginia School of Medicine in Charlottesville.
“We think it’s this pipeline that’s getting clogged in this disease and other diseases.”
Dr Goldfarb and his colleagues explained this discovery in Developmental Cell.
The researchers found that leukemia cells with the GATA1s mutation display a critical deficiency of calpain 2. And the enzyme’s absence leaves them stuck in an early stage of development, contributing to the development of Down syndrome-associated leukemias.
That could be the case in other forms of leukemia as well, Dr Goldfarb noted.
“These leukemias in Down syndrome aren’t that common,” he said, “but this finding has implications for other leukemias in that it lets us understand basic growth and development patterns.”
The team discovered that restoring calpain 2 expression in affected cells fixed the problem and allowed normal megakaryocyte development to resume.
As such, the researchers speculate that calpain deficiency could be a key defect in Down syndrome-associated leukemias, which provides a potential target for therapeutic development.
The findings might also help us find a way to mimic the natural process that allows a subset of Down syndrome-associated leukemias to disappear spontaneously.
Researchers have linked a mutation causing Down syndrome-associated leukemias to developmental abnormalities in megakaryocytes.
Experiments showed that the leukemia-associated GATA1 mutant, GATA1s, interferes with the enzyme calpain 2, which acts as an initial trigger for a chain of reactions that determines the size and shape of megakaryocytes.
This interference hinders the normal process of cellular enlargement and platelet production.
“It’s like there’s a long pipeline and there’s a clog,” explained study author Adam N. Goldfarb, MD, of the University of Virginia School of Medicine in Charlottesville.
“We think it’s this pipeline that’s getting clogged in this disease and other diseases.”
Dr Goldfarb and his colleagues explained this discovery in Developmental Cell.
The researchers found that leukemia cells with the GATA1s mutation display a critical deficiency of calpain 2. And the enzyme’s absence leaves them stuck in an early stage of development, contributing to the development of Down syndrome-associated leukemias.
That could be the case in other forms of leukemia as well, Dr Goldfarb noted.
“These leukemias in Down syndrome aren’t that common,” he said, “but this finding has implications for other leukemias in that it lets us understand basic growth and development patterns.”
The team discovered that restoring calpain 2 expression in affected cells fixed the problem and allowed normal megakaryocyte development to resume.
As such, the researchers speculate that calpain deficiency could be a key defect in Down syndrome-associated leukemias, which provides a potential target for therapeutic development.
The findings might also help us find a way to mimic the natural process that allows a subset of Down syndrome-associated leukemias to disappear spontaneously.
Researchers have linked a mutation causing Down syndrome-associated leukemias to developmental abnormalities in megakaryocytes.
Experiments showed that the leukemia-associated GATA1 mutant, GATA1s, interferes with the enzyme calpain 2, which acts as an initial trigger for a chain of reactions that determines the size and shape of megakaryocytes.
This interference hinders the normal process of cellular enlargement and platelet production.
“It’s like there’s a long pipeline and there’s a clog,” explained study author Adam N. Goldfarb, MD, of the University of Virginia School of Medicine in Charlottesville.
“We think it’s this pipeline that’s getting clogged in this disease and other diseases.”
Dr Goldfarb and his colleagues explained this discovery in Developmental Cell.
The researchers found that leukemia cells with the GATA1s mutation display a critical deficiency of calpain 2. And the enzyme’s absence leaves them stuck in an early stage of development, contributing to the development of Down syndrome-associated leukemias.
That could be the case in other forms of leukemia as well, Dr Goldfarb noted.
“These leukemias in Down syndrome aren’t that common,” he said, “but this finding has implications for other leukemias in that it lets us understand basic growth and development patterns.”
The team discovered that restoring calpain 2 expression in affected cells fixed the problem and allowed normal megakaryocyte development to resume.
As such, the researchers speculate that calpain deficiency could be a key defect in Down syndrome-associated leukemias, which provides a potential target for therapeutic development.
The findings might also help us find a way to mimic the natural process that allows a subset of Down syndrome-associated leukemias to disappear spontaneously.
Study shows parents well-adjusted after child’s SCT
Credit: George Hodan
Although they initially show signs of psychological distress, parents of children undergoing stem cell transplant (SCT) are as resilient as the children themselves, new research suggests.
Investigators evaluated psychological adjustment in 171 children undergoing SCT and their parents.
Results in the children, which were previously reported in Pediatrics, suggested they were well-adjusted after SCT, whether or not they had received therapy to promote psychological well-being.
Results in the parents, which are now available in Biology of Blood and Marrow Transplantation, are similar.
“The aim of the study was to examine an intervention to promote positive adjustment of patients and their parents,” said study author Jennifer Lindwall, PhD, of St Jude Children’s Research Hospital and Children’s Hospital of Colorado.
The 171 parent/child pairs were randomized to receive a child-targeted intervention, a child and parent intervention, or standard care. The child intervention consisted of massage and humor therapy, and the parent intervention included massage and relaxation/imagery training.
The investigators measured psychological distress and positive affect from the time of admission for a child’s SCT until 6 weeks after the procedure.
The team also measured depression, post-traumatic stress disorder (PTSD), and benefit-finding (potential positive outcomes that result from enduring a difficult experience) at the time of admission and 24 weeks after.
There were no significant differences among the 3 groups with regard to measures of parental distress. And distress decreased significantly from baseline to week 6.
Improvements also occurred over time with regard to positive affect. However, parents in the child/parent-intervention group and child-only-intervention group experienced significant benefits over the standard-care group.
On the other hand, there were no significant differences among the 3 groups with regard to depression, PTSD, and benefit-finding.
Parents from all groups experienced significant decreases in depression and PTSD from baseline to the 24-week mark. And they showed significant increases in benefit-finding.
“In many respects, a parent’s distress parallels the child’s distress,” Dr Lindwall said. “As things get better for the child, they get better for the parent as well.”
Dr Lindwall noted that, although this study suggests resiliency is the norm, there are parents who remain distressed as a result of their child’s illness.
“Our challenge now is to predict which parents are at the highest risk for difficulties,” she said, “and to design interventions that can help these parents cope during their child’s medical challenges.”
Credit: George Hodan
Although they initially show signs of psychological distress, parents of children undergoing stem cell transplant (SCT) are as resilient as the children themselves, new research suggests.
Investigators evaluated psychological adjustment in 171 children undergoing SCT and their parents.
Results in the children, which were previously reported in Pediatrics, suggested they were well-adjusted after SCT, whether or not they had received therapy to promote psychological well-being.
Results in the parents, which are now available in Biology of Blood and Marrow Transplantation, are similar.
“The aim of the study was to examine an intervention to promote positive adjustment of patients and their parents,” said study author Jennifer Lindwall, PhD, of St Jude Children’s Research Hospital and Children’s Hospital of Colorado.
The 171 parent/child pairs were randomized to receive a child-targeted intervention, a child and parent intervention, or standard care. The child intervention consisted of massage and humor therapy, and the parent intervention included massage and relaxation/imagery training.
The investigators measured psychological distress and positive affect from the time of admission for a child’s SCT until 6 weeks after the procedure.
The team also measured depression, post-traumatic stress disorder (PTSD), and benefit-finding (potential positive outcomes that result from enduring a difficult experience) at the time of admission and 24 weeks after.
There were no significant differences among the 3 groups with regard to measures of parental distress. And distress decreased significantly from baseline to week 6.
Improvements also occurred over time with regard to positive affect. However, parents in the child/parent-intervention group and child-only-intervention group experienced significant benefits over the standard-care group.
On the other hand, there were no significant differences among the 3 groups with regard to depression, PTSD, and benefit-finding.
Parents from all groups experienced significant decreases in depression and PTSD from baseline to the 24-week mark. And they showed significant increases in benefit-finding.
“In many respects, a parent’s distress parallels the child’s distress,” Dr Lindwall said. “As things get better for the child, they get better for the parent as well.”
Dr Lindwall noted that, although this study suggests resiliency is the norm, there are parents who remain distressed as a result of their child’s illness.
“Our challenge now is to predict which parents are at the highest risk for difficulties,” she said, “and to design interventions that can help these parents cope during their child’s medical challenges.”
Credit: George Hodan
Although they initially show signs of psychological distress, parents of children undergoing stem cell transplant (SCT) are as resilient as the children themselves, new research suggests.
Investigators evaluated psychological adjustment in 171 children undergoing SCT and their parents.
Results in the children, which were previously reported in Pediatrics, suggested they were well-adjusted after SCT, whether or not they had received therapy to promote psychological well-being.
Results in the parents, which are now available in Biology of Blood and Marrow Transplantation, are similar.
“The aim of the study was to examine an intervention to promote positive adjustment of patients and their parents,” said study author Jennifer Lindwall, PhD, of St Jude Children’s Research Hospital and Children’s Hospital of Colorado.
The 171 parent/child pairs were randomized to receive a child-targeted intervention, a child and parent intervention, or standard care. The child intervention consisted of massage and humor therapy, and the parent intervention included massage and relaxation/imagery training.
The investigators measured psychological distress and positive affect from the time of admission for a child’s SCT until 6 weeks after the procedure.
The team also measured depression, post-traumatic stress disorder (PTSD), and benefit-finding (potential positive outcomes that result from enduring a difficult experience) at the time of admission and 24 weeks after.
There were no significant differences among the 3 groups with regard to measures of parental distress. And distress decreased significantly from baseline to week 6.
Improvements also occurred over time with regard to positive affect. However, parents in the child/parent-intervention group and child-only-intervention group experienced significant benefits over the standard-care group.
On the other hand, there were no significant differences among the 3 groups with regard to depression, PTSD, and benefit-finding.
Parents from all groups experienced significant decreases in depression and PTSD from baseline to the 24-week mark. And they showed significant increases in benefit-finding.
“In many respects, a parent’s distress parallels the child’s distress,” Dr Lindwall said. “As things get better for the child, they get better for the parent as well.”
Dr Lindwall noted that, although this study suggests resiliency is the norm, there are parents who remain distressed as a result of their child’s illness.
“Our challenge now is to predict which parents are at the highest risk for difficulties,” she said, “and to design interventions that can help these parents cope during their child’s medical challenges.”
Mutant HSCs appear to drive AML
A new study has shown that hematopoietic stem cells (HSCs) can acquire mutations in DNMT3A, and this may be the first step in initiating acute myeloid leukemia (AML).
These HSCs also appear to be a means of treatment resistance and may trigger relapse in patients with AML, investigators reported in Nature.
“Our discovery lays the groundwork to detect and target the pre-leukemic stem cell and thereby potentially stop the disease at a very early stage, when it may be more amenable to treatment,” said study author John Dick, PhD, of the University of Toronto in Ontario, Canada.
“Now, we have a potential tool for earlier diagnosis that may allow early intervention before the development of full AML. We can also monitor remission and initiate therapy to target the pre-leukemic stem cell to prevent relapse.”
Dr Dick and his colleagues analyzed 71 samples from AML patients and discovered that 17 of them (24%) carried mutations in DNMT3A. Fifteen of those samples (88%) also had mutated NPM1.
Both mutations were present in patients’ blasts. But 12 patients (70.5%) had T cells that contained DNMT3A mutations but no NPM1 mutations. FLT3-ITD mutations were also present in blasts but not T cells in 2 patients.
These results suggest DNMT3A mutations arise earlier than NPM1 and FLT3-ITD mutations, the researchers said.
To determine the origin of mutated DNMT3A, they analyzed hematopoietic stem and progenitor cell populations from 11 patients with DNMT3A and NPM1 mutations.
While both types of mutations were present in CD33+ blasts, mutant DNMT3A was present without mutant NPM1 across the spectrum of mature and progenitor cell populations.
Experiments in mice revealed that DNMT3A-mutant HSCs had a multilineage repopulation advantage over non-mutant HSCs. This, the investigators said, establishes the mutant cells as pre-leukemic HSCs.
The team also found the pre-leukemic HSCs in samples taken from AML patients in remission, which showed that the cells survived chemotherapy.
The researchers therefore concluded that DNMT3A mutations arise early in AML evolution and lead to a clonally expanded pool of pre-leukemic HSCs from which AML develops.
“By peering into the ‘black box’ of how cancer develops during the months and years prior to when it is first diagnosed, we have demonstrated a unique finding,” Dr Dick said. “People tend to think relapse after remission means chemotherapy didn’t kill all the cancer cells.”
“Our study suggests that, in some cases, the chemotherapy does, in fact, eradicate AML. What it does not touch are the pre-leukemic stem cells that can trigger another round of AML development and, ultimately, disease relapse.”
Dr Dick believes this finding could spawn accelerated drug development to specifically target DNMT3A. The discovery should also provide impetus for researchers to look for pre-cancerous cells in AML patients with other mutations.
A new study has shown that hematopoietic stem cells (HSCs) can acquire mutations in DNMT3A, and this may be the first step in initiating acute myeloid leukemia (AML).
These HSCs also appear to be a means of treatment resistance and may trigger relapse in patients with AML, investigators reported in Nature.
“Our discovery lays the groundwork to detect and target the pre-leukemic stem cell and thereby potentially stop the disease at a very early stage, when it may be more amenable to treatment,” said study author John Dick, PhD, of the University of Toronto in Ontario, Canada.
“Now, we have a potential tool for earlier diagnosis that may allow early intervention before the development of full AML. We can also monitor remission and initiate therapy to target the pre-leukemic stem cell to prevent relapse.”
Dr Dick and his colleagues analyzed 71 samples from AML patients and discovered that 17 of them (24%) carried mutations in DNMT3A. Fifteen of those samples (88%) also had mutated NPM1.
Both mutations were present in patients’ blasts. But 12 patients (70.5%) had T cells that contained DNMT3A mutations but no NPM1 mutations. FLT3-ITD mutations were also present in blasts but not T cells in 2 patients.
These results suggest DNMT3A mutations arise earlier than NPM1 and FLT3-ITD mutations, the researchers said.
To determine the origin of mutated DNMT3A, they analyzed hematopoietic stem and progenitor cell populations from 11 patients with DNMT3A and NPM1 mutations.
While both types of mutations were present in CD33+ blasts, mutant DNMT3A was present without mutant NPM1 across the spectrum of mature and progenitor cell populations.
Experiments in mice revealed that DNMT3A-mutant HSCs had a multilineage repopulation advantage over non-mutant HSCs. This, the investigators said, establishes the mutant cells as pre-leukemic HSCs.
The team also found the pre-leukemic HSCs in samples taken from AML patients in remission, which showed that the cells survived chemotherapy.
The researchers therefore concluded that DNMT3A mutations arise early in AML evolution and lead to a clonally expanded pool of pre-leukemic HSCs from which AML develops.
“By peering into the ‘black box’ of how cancer develops during the months and years prior to when it is first diagnosed, we have demonstrated a unique finding,” Dr Dick said. “People tend to think relapse after remission means chemotherapy didn’t kill all the cancer cells.”
“Our study suggests that, in some cases, the chemotherapy does, in fact, eradicate AML. What it does not touch are the pre-leukemic stem cells that can trigger another round of AML development and, ultimately, disease relapse.”
Dr Dick believes this finding could spawn accelerated drug development to specifically target DNMT3A. The discovery should also provide impetus for researchers to look for pre-cancerous cells in AML patients with other mutations.
A new study has shown that hematopoietic stem cells (HSCs) can acquire mutations in DNMT3A, and this may be the first step in initiating acute myeloid leukemia (AML).
These HSCs also appear to be a means of treatment resistance and may trigger relapse in patients with AML, investigators reported in Nature.
“Our discovery lays the groundwork to detect and target the pre-leukemic stem cell and thereby potentially stop the disease at a very early stage, when it may be more amenable to treatment,” said study author John Dick, PhD, of the University of Toronto in Ontario, Canada.
“Now, we have a potential tool for earlier diagnosis that may allow early intervention before the development of full AML. We can also monitor remission and initiate therapy to target the pre-leukemic stem cell to prevent relapse.”
Dr Dick and his colleagues analyzed 71 samples from AML patients and discovered that 17 of them (24%) carried mutations in DNMT3A. Fifteen of those samples (88%) also had mutated NPM1.
Both mutations were present in patients’ blasts. But 12 patients (70.5%) had T cells that contained DNMT3A mutations but no NPM1 mutations. FLT3-ITD mutations were also present in blasts but not T cells in 2 patients.
These results suggest DNMT3A mutations arise earlier than NPM1 and FLT3-ITD mutations, the researchers said.
To determine the origin of mutated DNMT3A, they analyzed hematopoietic stem and progenitor cell populations from 11 patients with DNMT3A and NPM1 mutations.
While both types of mutations were present in CD33+ blasts, mutant DNMT3A was present without mutant NPM1 across the spectrum of mature and progenitor cell populations.
Experiments in mice revealed that DNMT3A-mutant HSCs had a multilineage repopulation advantage over non-mutant HSCs. This, the investigators said, establishes the mutant cells as pre-leukemic HSCs.
The team also found the pre-leukemic HSCs in samples taken from AML patients in remission, which showed that the cells survived chemotherapy.
The researchers therefore concluded that DNMT3A mutations arise early in AML evolution and lead to a clonally expanded pool of pre-leukemic HSCs from which AML develops.
“By peering into the ‘black box’ of how cancer develops during the months and years prior to when it is first diagnosed, we have demonstrated a unique finding,” Dr Dick said. “People tend to think relapse after remission means chemotherapy didn’t kill all the cancer cells.”
“Our study suggests that, in some cases, the chemotherapy does, in fact, eradicate AML. What it does not touch are the pre-leukemic stem cells that can trigger another round of AML development and, ultimately, disease relapse.”
Dr Dick believes this finding could spawn accelerated drug development to specifically target DNMT3A. The discovery should also provide impetus for researchers to look for pre-cancerous cells in AML patients with other mutations.
Progress on Reducing Readmissions
The Hospital Readmission Reduction Program (HRRP)[1] contained within the Affordable Care Act focused national and local attention on hospital resources and efforts to reduce hospital readmissions. Driven by the Centers for Medicare and Medicaid Services' (CMS) desire to pay for value instead of volume, the response of hospitals and health systems appears to be yielding change across the United States.[2] A number of recent publications in the Journal of Hospital Medicine (JHM) exemplify the keen interest in reducing readmissions, while providing guidance regarding interventions and where we might target future research. Evidence from an exemplary systematic review of the pediatric literature confirms some experience in adults regarding effective interventionsall studies were multifacetedand highlights the importance of identifying a single healthcare provider or centrally coordinated hub to assume responsibility for extended care transition and follow‐up.[3] Notably, studies of pediatric patients and their families document the effectiveness of enhanced inpatient education and engagement while in the hospital.[3] Unfortunately, a study among adults at a top‐ranked academic institution indicates poor communication among nurses and physicians regarding patient discharge education.[4] Efforts to improve nursephysician communication by redesigning the hospitalist model of care delivery at a Veterans Affairs (VA) institution appeared to enhance perceptions of communication among the care team members and reduced length of stay, but disappointingly there was no reduction in readmission rates.[5] Studies such as this are essential in identifying which specific interventions may actually change outcomes such as readmission rates.
In 1984, a diminutive elderly woman provocatively squawked Where's the beef?, launching a highly successful advertising campaign for Wendy's hamburger chain.[6] This catchphrase may aptly describe Bradley and colleague's survey study of the State Action on Avoidable Rehospitalization (STAAR) and Hospital‐to‐Home (H2H) campaigns.[7] Auerbach and colleagues eloquently stated in a 2007 New England Journal of Medicine perspective[8] how they had witnessed recent initiatives that emphasize dissemination of innovative but unproven strategies, an approach that runs counter to the principle of following the evidence[9] in selecting interventions that meet quality and safety goals.[10] I firmly agree with this assessment, and 6 years later believe we should be more thoughtful about potentially repeating implementation of unproven strategies.
Do we know if the interventions recommended by H2H and STAAR are what hospital care teams should be attempting? Even the authors mention that definitive evidence on their effectiveness is lacking. The H2H and STAAR programs certainly encourage some theoretically laudable activitiesmedication reconciliation by nurses, alerting outpatient physicians within 48 hours of patient discharge, and providing skilled nursing facilities the direct contact number of the inpatient treating physician for patients transferred. However, do these efforts actually improve patient outcomes? Before embarking on state or national campaigns to improve care, we should consider carefully what are the best evidence‐based interventions. Remarkably, some prior evidence indicates that direct communication between the hospital‐based physician and primary care provider (PCP) may not actually impact patient outcomes.[11] Newer research published in JHM confirms my belief that the PCP needs to be engaged by hospitalists during a hospitalization. Lindquist's research group at Northwestern nicely demonstrated how communication between a patient's PCP and the admitting hospitalist, complemented by contact between the PCP and patient within 24 hours postdischarge, reduced the probability of a medication discrepancy by 70%.[12] Although no evaluation of the effect on readmissions was reported, this study may provide information on causality related to the importance of PCP involvement in the care of hospitalized patients.
Numerous publications now document research on successfully implemented programs that lowered hospital readmissions, and are cited by CMS as evidence‐based interventions.[13] Projects Re‐Engineered Discharge (RED)[14] and Better Outcomes by Optimizing Safe Transitions[15] target the hospital discharge process, and both appear to lower hospital readmission rates. The Care Transitions Intervention (CTI),[16] Transitional Care Model (TCM),[17] and the Guided Care model[18] all leverage nurse practitioners or nurses to protect elderly patients during what can be a perilous care transition from hospital to home. CTI and TCM have been further validated in effectiveness studies.[19, 20] Two recent systematic reviews provide further insight into the complexity of efforts to reduce 30‐day rehospitalizations, but unfortunately do not reveal a desired silver bullet. The first focused exclusively on interventions to reduce 30‐day rehospitalization, and concluded that no single intervention was successful alone, but identified interventions bridging the hospital‐to‐home transition (eg, CTI), and a bundle of interventions such as Project RED as showing efficacy.[21] The second review more broadly sought to evaluate the effectiveness of hospital‐initiated strategies to prevent postdischarge adverse events (AEs) such as readmissions and emergency department visits,[22] stating Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. The researchers' sobering conclusion stated that strategies to improve patient safety at hospital discharge remain unclear.
With rising federal penalties for higher‐than‐expected readmission rates, many hospital leaders eagerly join collaboratives aiming to reduce hospital readmissions. H2H appears to be among the largest, reporting >600 hospital participants, and STAAR has been active since 2009, with a recently published qualitative study identifying gaps in evidence for effective interventions, and deficits in quality improvement capabilities among some organizations as implementation challenges.[23] Notably, the survey by Bradley and colleagues documented that just half of the hospitals had a quality improvement (QI) team focused on reducing readmissions. Although laudable in their goals, H2H and STAAR may represent expensive commitments of staff and time to efforts that may not improve outcomes. Importantly, recently published research evaluating QI studies showed concerning results among patients with chronic obstructive pulmonary disease (COPD). A randomized controlled trial (RCT) conducted at 6 Glasgow hospitals evaluated supported self‐management (home visits by nurses and thorough education) by patients with moderate to severe COPD, but documented no changes in hospitalization or mortality.[24]Another RCT at 20 sites evaluated a comprehensive care management program to prevent hospitalizations among 960 VA patients with COPD.[25] It had to be stopped early due to elevated all‐cause mortality in the intervention group, and there was no difference in hospitalization rates.
Moving forward, QI efforts to reduce hospital readmissions should utilize proven interventions unless they are part of a rigorous trial. The emerging field of implementation science (the scientific study of methods to promote the systematic uptake of research findings and other evidence‐based practices into routine practice, and hence, to improve the quality and effectiveness of health services[26]) needs to be applied to additional research in this area.[27] Another consideration would be for CMS and funders such as the Commonwealth Foundation or The Robert Wood Johnson Foundation to encourage and fund merging of current initiatives to move away from competition and provide clarity to community hospitals. Regardless, such collaboration should still undertake formal evaluation to discern best approaches to implementation. I applaud the authors for recognizing that Input from hospitalists who are often critical links among inpatient and outpatient care and between patients and their families is strongly needed to ensure hospitals focus on what strategies are most effective for successful transitions from hospital to home. Yet, I wonder why neither of the large STAAR and H2H initiatives actively partnered with hospitalists and their specialty society (Society of Hospital Medicine) directly in the leadership of these initiatives? On the other hand, why not ask medical societies engaged in delivery of primary care (eg, American Academy for Family Practice, American College of Physicians, or Society of General Internal Medicine), especially to elderly patients (American Geriatric Society), to contribute directly? Involvement on an advisory board is likely not sufficient. Prior efforts document the willingness of these organizations to collaborate and achieve consensus on principles for transitions of care.[28] As powerfully articulated 6 years ago, [W]e must pursue the solutions to quality and safety problems in a way that does not blind us to harms, squander scarce resources, or delude us about the effectiveness of our efforts.[8]
Acknowledgments
Disclosure: Dr. Williams is principal investigator for Project BOOST (
- Centers for Medicare and Medicaid Services. Readmissions reduction program. Available at: http://www.cms.gov/Medicare/Medicare‐Fee‐for‐service‐Payment/AcuteInpatientPPS/Readmissions‐Reduction‐Program.html. Accessed December 30, 2013.
- , , , , , . Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2):E1–E12.
- , , , . Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med. doi: 10.1002/jhm.2134.
- , , . Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices. J Hosp Med. 2013;8:36–41.
- , , , et al. An academic hospitalist model to improve healthcare work communication and learner education: results from a quasi‐experimental study at a Veterans Affairs medical center. J Hosp Med. 2013;8:702–710.
- Wikipedia website. Where's the beef? Available at: http://en.wikipedia.org/wiki/Where's_the_beef%3F. Accessed November 4, 2013.
- , , , , , . Quality collaboratives and campaigns to reduce readmissions: what strategies are hospitals using? J Hosp Med. 2013;8(11):601–608.
- , , . The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608–613.
- , , , . Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;353(13):1405–1409.
- , , . Clinical Improvement Action Guide. Oak Brook, IL: Joint Commission Resources; 1998.
- , , , et al. Association of communication between hospital‐based physicians and primary care providers with patient outcomes. J Gen Int Med. 2009;24(3):381–386.
- , , , , . Primary care physician communication a hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8:672–677.
- Centers for Medicare 150(3):178–187.
- , , , et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421–427.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828.
- , , , et al. Comprehensive discharge planning and home follow‐up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–620.
- , , , et al. The effect of guided care teams on the use of health services: results from a cluster‐randomized controlled trial. Arch Intern Med. 2011;171(5):460–466.
- , , , et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med. 2011;171(14):1238–1243.
- , , , , , . The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171(14):1232–1237.
- , , , , . Interventions to reduce 30‐day rehospitalization: a systematic review. Ann Int Med. 2011;155(8):520–528.
- , , , , , . Hospital‐initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Int Med. 2013;158(5 pt 2):433–440.
- , , , , , . Turning readmission reduction policies into results: some lessons from a multistate initiative to reduce readmissions. Popul Health Manag. 2013;16(4):255–260.
- , , , et al. Glasgow supported self‐management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ. 2013;344:e1060.
- , , , et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized controlled trial. Ann Int Med. 2012;156(10):673–683.
- , . Welcome to implementation science. Implement Sci. 2006;1:1.
- , . Moving comparative effectiveness research into practice: implementation science and the role of academic medicine. Health Aff (Millwood). 2010;29(10):1901–1905.
- , , , et al.; American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. Transitions of care consensus policy statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Int Med. 2009;24(8):971–976.
The Hospital Readmission Reduction Program (HRRP)[1] contained within the Affordable Care Act focused national and local attention on hospital resources and efforts to reduce hospital readmissions. Driven by the Centers for Medicare and Medicaid Services' (CMS) desire to pay for value instead of volume, the response of hospitals and health systems appears to be yielding change across the United States.[2] A number of recent publications in the Journal of Hospital Medicine (JHM) exemplify the keen interest in reducing readmissions, while providing guidance regarding interventions and where we might target future research. Evidence from an exemplary systematic review of the pediatric literature confirms some experience in adults regarding effective interventionsall studies were multifacetedand highlights the importance of identifying a single healthcare provider or centrally coordinated hub to assume responsibility for extended care transition and follow‐up.[3] Notably, studies of pediatric patients and their families document the effectiveness of enhanced inpatient education and engagement while in the hospital.[3] Unfortunately, a study among adults at a top‐ranked academic institution indicates poor communication among nurses and physicians regarding patient discharge education.[4] Efforts to improve nursephysician communication by redesigning the hospitalist model of care delivery at a Veterans Affairs (VA) institution appeared to enhance perceptions of communication among the care team members and reduced length of stay, but disappointingly there was no reduction in readmission rates.[5] Studies such as this are essential in identifying which specific interventions may actually change outcomes such as readmission rates.
In 1984, a diminutive elderly woman provocatively squawked Where's the beef?, launching a highly successful advertising campaign for Wendy's hamburger chain.[6] This catchphrase may aptly describe Bradley and colleague's survey study of the State Action on Avoidable Rehospitalization (STAAR) and Hospital‐to‐Home (H2H) campaigns.[7] Auerbach and colleagues eloquently stated in a 2007 New England Journal of Medicine perspective[8] how they had witnessed recent initiatives that emphasize dissemination of innovative but unproven strategies, an approach that runs counter to the principle of following the evidence[9] in selecting interventions that meet quality and safety goals.[10] I firmly agree with this assessment, and 6 years later believe we should be more thoughtful about potentially repeating implementation of unproven strategies.
Do we know if the interventions recommended by H2H and STAAR are what hospital care teams should be attempting? Even the authors mention that definitive evidence on their effectiveness is lacking. The H2H and STAAR programs certainly encourage some theoretically laudable activitiesmedication reconciliation by nurses, alerting outpatient physicians within 48 hours of patient discharge, and providing skilled nursing facilities the direct contact number of the inpatient treating physician for patients transferred. However, do these efforts actually improve patient outcomes? Before embarking on state or national campaigns to improve care, we should consider carefully what are the best evidence‐based interventions. Remarkably, some prior evidence indicates that direct communication between the hospital‐based physician and primary care provider (PCP) may not actually impact patient outcomes.[11] Newer research published in JHM confirms my belief that the PCP needs to be engaged by hospitalists during a hospitalization. Lindquist's research group at Northwestern nicely demonstrated how communication between a patient's PCP and the admitting hospitalist, complemented by contact between the PCP and patient within 24 hours postdischarge, reduced the probability of a medication discrepancy by 70%.[12] Although no evaluation of the effect on readmissions was reported, this study may provide information on causality related to the importance of PCP involvement in the care of hospitalized patients.
Numerous publications now document research on successfully implemented programs that lowered hospital readmissions, and are cited by CMS as evidence‐based interventions.[13] Projects Re‐Engineered Discharge (RED)[14] and Better Outcomes by Optimizing Safe Transitions[15] target the hospital discharge process, and both appear to lower hospital readmission rates. The Care Transitions Intervention (CTI),[16] Transitional Care Model (TCM),[17] and the Guided Care model[18] all leverage nurse practitioners or nurses to protect elderly patients during what can be a perilous care transition from hospital to home. CTI and TCM have been further validated in effectiveness studies.[19, 20] Two recent systematic reviews provide further insight into the complexity of efforts to reduce 30‐day rehospitalizations, but unfortunately do not reveal a desired silver bullet. The first focused exclusively on interventions to reduce 30‐day rehospitalization, and concluded that no single intervention was successful alone, but identified interventions bridging the hospital‐to‐home transition (eg, CTI), and a bundle of interventions such as Project RED as showing efficacy.[21] The second review more broadly sought to evaluate the effectiveness of hospital‐initiated strategies to prevent postdischarge adverse events (AEs) such as readmissions and emergency department visits,[22] stating Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. The researchers' sobering conclusion stated that strategies to improve patient safety at hospital discharge remain unclear.
With rising federal penalties for higher‐than‐expected readmission rates, many hospital leaders eagerly join collaboratives aiming to reduce hospital readmissions. H2H appears to be among the largest, reporting >600 hospital participants, and STAAR has been active since 2009, with a recently published qualitative study identifying gaps in evidence for effective interventions, and deficits in quality improvement capabilities among some organizations as implementation challenges.[23] Notably, the survey by Bradley and colleagues documented that just half of the hospitals had a quality improvement (QI) team focused on reducing readmissions. Although laudable in their goals, H2H and STAAR may represent expensive commitments of staff and time to efforts that may not improve outcomes. Importantly, recently published research evaluating QI studies showed concerning results among patients with chronic obstructive pulmonary disease (COPD). A randomized controlled trial (RCT) conducted at 6 Glasgow hospitals evaluated supported self‐management (home visits by nurses and thorough education) by patients with moderate to severe COPD, but documented no changes in hospitalization or mortality.[24]Another RCT at 20 sites evaluated a comprehensive care management program to prevent hospitalizations among 960 VA patients with COPD.[25] It had to be stopped early due to elevated all‐cause mortality in the intervention group, and there was no difference in hospitalization rates.
Moving forward, QI efforts to reduce hospital readmissions should utilize proven interventions unless they are part of a rigorous trial. The emerging field of implementation science (the scientific study of methods to promote the systematic uptake of research findings and other evidence‐based practices into routine practice, and hence, to improve the quality and effectiveness of health services[26]) needs to be applied to additional research in this area.[27] Another consideration would be for CMS and funders such as the Commonwealth Foundation or The Robert Wood Johnson Foundation to encourage and fund merging of current initiatives to move away from competition and provide clarity to community hospitals. Regardless, such collaboration should still undertake formal evaluation to discern best approaches to implementation. I applaud the authors for recognizing that Input from hospitalists who are often critical links among inpatient and outpatient care and between patients and their families is strongly needed to ensure hospitals focus on what strategies are most effective for successful transitions from hospital to home. Yet, I wonder why neither of the large STAAR and H2H initiatives actively partnered with hospitalists and their specialty society (Society of Hospital Medicine) directly in the leadership of these initiatives? On the other hand, why not ask medical societies engaged in delivery of primary care (eg, American Academy for Family Practice, American College of Physicians, or Society of General Internal Medicine), especially to elderly patients (American Geriatric Society), to contribute directly? Involvement on an advisory board is likely not sufficient. Prior efforts document the willingness of these organizations to collaborate and achieve consensus on principles for transitions of care.[28] As powerfully articulated 6 years ago, [W]e must pursue the solutions to quality and safety problems in a way that does not blind us to harms, squander scarce resources, or delude us about the effectiveness of our efforts.[8]
Acknowledgments
Disclosure: Dr. Williams is principal investigator for Project BOOST (
The Hospital Readmission Reduction Program (HRRP)[1] contained within the Affordable Care Act focused national and local attention on hospital resources and efforts to reduce hospital readmissions. Driven by the Centers for Medicare and Medicaid Services' (CMS) desire to pay for value instead of volume, the response of hospitals and health systems appears to be yielding change across the United States.[2] A number of recent publications in the Journal of Hospital Medicine (JHM) exemplify the keen interest in reducing readmissions, while providing guidance regarding interventions and where we might target future research. Evidence from an exemplary systematic review of the pediatric literature confirms some experience in adults regarding effective interventionsall studies were multifacetedand highlights the importance of identifying a single healthcare provider or centrally coordinated hub to assume responsibility for extended care transition and follow‐up.[3] Notably, studies of pediatric patients and their families document the effectiveness of enhanced inpatient education and engagement while in the hospital.[3] Unfortunately, a study among adults at a top‐ranked academic institution indicates poor communication among nurses and physicians regarding patient discharge education.[4] Efforts to improve nursephysician communication by redesigning the hospitalist model of care delivery at a Veterans Affairs (VA) institution appeared to enhance perceptions of communication among the care team members and reduced length of stay, but disappointingly there was no reduction in readmission rates.[5] Studies such as this are essential in identifying which specific interventions may actually change outcomes such as readmission rates.
In 1984, a diminutive elderly woman provocatively squawked Where's the beef?, launching a highly successful advertising campaign for Wendy's hamburger chain.[6] This catchphrase may aptly describe Bradley and colleague's survey study of the State Action on Avoidable Rehospitalization (STAAR) and Hospital‐to‐Home (H2H) campaigns.[7] Auerbach and colleagues eloquently stated in a 2007 New England Journal of Medicine perspective[8] how they had witnessed recent initiatives that emphasize dissemination of innovative but unproven strategies, an approach that runs counter to the principle of following the evidence[9] in selecting interventions that meet quality and safety goals.[10] I firmly agree with this assessment, and 6 years later believe we should be more thoughtful about potentially repeating implementation of unproven strategies.
Do we know if the interventions recommended by H2H and STAAR are what hospital care teams should be attempting? Even the authors mention that definitive evidence on their effectiveness is lacking. The H2H and STAAR programs certainly encourage some theoretically laudable activitiesmedication reconciliation by nurses, alerting outpatient physicians within 48 hours of patient discharge, and providing skilled nursing facilities the direct contact number of the inpatient treating physician for patients transferred. However, do these efforts actually improve patient outcomes? Before embarking on state or national campaigns to improve care, we should consider carefully what are the best evidence‐based interventions. Remarkably, some prior evidence indicates that direct communication between the hospital‐based physician and primary care provider (PCP) may not actually impact patient outcomes.[11] Newer research published in JHM confirms my belief that the PCP needs to be engaged by hospitalists during a hospitalization. Lindquist's research group at Northwestern nicely demonstrated how communication between a patient's PCP and the admitting hospitalist, complemented by contact between the PCP and patient within 24 hours postdischarge, reduced the probability of a medication discrepancy by 70%.[12] Although no evaluation of the effect on readmissions was reported, this study may provide information on causality related to the importance of PCP involvement in the care of hospitalized patients.
Numerous publications now document research on successfully implemented programs that lowered hospital readmissions, and are cited by CMS as evidence‐based interventions.[13] Projects Re‐Engineered Discharge (RED)[14] and Better Outcomes by Optimizing Safe Transitions[15] target the hospital discharge process, and both appear to lower hospital readmission rates. The Care Transitions Intervention (CTI),[16] Transitional Care Model (TCM),[17] and the Guided Care model[18] all leverage nurse practitioners or nurses to protect elderly patients during what can be a perilous care transition from hospital to home. CTI and TCM have been further validated in effectiveness studies.[19, 20] Two recent systematic reviews provide further insight into the complexity of efforts to reduce 30‐day rehospitalizations, but unfortunately do not reveal a desired silver bullet. The first focused exclusively on interventions to reduce 30‐day rehospitalization, and concluded that no single intervention was successful alone, but identified interventions bridging the hospital‐to‐home transition (eg, CTI), and a bundle of interventions such as Project RED as showing efficacy.[21] The second review more broadly sought to evaluate the effectiveness of hospital‐initiated strategies to prevent postdischarge adverse events (AEs) such as readmissions and emergency department visits,[22] stating Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. The researchers' sobering conclusion stated that strategies to improve patient safety at hospital discharge remain unclear.
With rising federal penalties for higher‐than‐expected readmission rates, many hospital leaders eagerly join collaboratives aiming to reduce hospital readmissions. H2H appears to be among the largest, reporting >600 hospital participants, and STAAR has been active since 2009, with a recently published qualitative study identifying gaps in evidence for effective interventions, and deficits in quality improvement capabilities among some organizations as implementation challenges.[23] Notably, the survey by Bradley and colleagues documented that just half of the hospitals had a quality improvement (QI) team focused on reducing readmissions. Although laudable in their goals, H2H and STAAR may represent expensive commitments of staff and time to efforts that may not improve outcomes. Importantly, recently published research evaluating QI studies showed concerning results among patients with chronic obstructive pulmonary disease (COPD). A randomized controlled trial (RCT) conducted at 6 Glasgow hospitals evaluated supported self‐management (home visits by nurses and thorough education) by patients with moderate to severe COPD, but documented no changes in hospitalization or mortality.[24]Another RCT at 20 sites evaluated a comprehensive care management program to prevent hospitalizations among 960 VA patients with COPD.[25] It had to be stopped early due to elevated all‐cause mortality in the intervention group, and there was no difference in hospitalization rates.
Moving forward, QI efforts to reduce hospital readmissions should utilize proven interventions unless they are part of a rigorous trial. The emerging field of implementation science (the scientific study of methods to promote the systematic uptake of research findings and other evidence‐based practices into routine practice, and hence, to improve the quality and effectiveness of health services[26]) needs to be applied to additional research in this area.[27] Another consideration would be for CMS and funders such as the Commonwealth Foundation or The Robert Wood Johnson Foundation to encourage and fund merging of current initiatives to move away from competition and provide clarity to community hospitals. Regardless, such collaboration should still undertake formal evaluation to discern best approaches to implementation. I applaud the authors for recognizing that Input from hospitalists who are often critical links among inpatient and outpatient care and between patients and their families is strongly needed to ensure hospitals focus on what strategies are most effective for successful transitions from hospital to home. Yet, I wonder why neither of the large STAAR and H2H initiatives actively partnered with hospitalists and their specialty society (Society of Hospital Medicine) directly in the leadership of these initiatives? On the other hand, why not ask medical societies engaged in delivery of primary care (eg, American Academy for Family Practice, American College of Physicians, or Society of General Internal Medicine), especially to elderly patients (American Geriatric Society), to contribute directly? Involvement on an advisory board is likely not sufficient. Prior efforts document the willingness of these organizations to collaborate and achieve consensus on principles for transitions of care.[28] As powerfully articulated 6 years ago, [W]e must pursue the solutions to quality and safety problems in a way that does not blind us to harms, squander scarce resources, or delude us about the effectiveness of our efforts.[8]
Acknowledgments
Disclosure: Dr. Williams is principal investigator for Project BOOST (
- Centers for Medicare and Medicaid Services. Readmissions reduction program. Available at: http://www.cms.gov/Medicare/Medicare‐Fee‐for‐service‐Payment/AcuteInpatientPPS/Readmissions‐Reduction‐Program.html. Accessed December 30, 2013.
- , , , , , . Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2):E1–E12.
- , , , . Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med. doi: 10.1002/jhm.2134.
- , , . Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices. J Hosp Med. 2013;8:36–41.
- , , , et al. An academic hospitalist model to improve healthcare work communication and learner education: results from a quasi‐experimental study at a Veterans Affairs medical center. J Hosp Med. 2013;8:702–710.
- Wikipedia website. Where's the beef? Available at: http://en.wikipedia.org/wiki/Where's_the_beef%3F. Accessed November 4, 2013.
- , , , , , . Quality collaboratives and campaigns to reduce readmissions: what strategies are hospitals using? J Hosp Med. 2013;8(11):601–608.
- , , . The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608–613.
- , , , . Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;353(13):1405–1409.
- , , . Clinical Improvement Action Guide. Oak Brook, IL: Joint Commission Resources; 1998.
- , , , et al. Association of communication between hospital‐based physicians and primary care providers with patient outcomes. J Gen Int Med. 2009;24(3):381–386.
- , , , , . Primary care physician communication a hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8:672–677.
- Centers for Medicare 150(3):178–187.
- , , , et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421–427.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828.
- , , , et al. Comprehensive discharge planning and home follow‐up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–620.
- , , , et al. The effect of guided care teams on the use of health services: results from a cluster‐randomized controlled trial. Arch Intern Med. 2011;171(5):460–466.
- , , , et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med. 2011;171(14):1238–1243.
- , , , , , . The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171(14):1232–1237.
- , , , , . Interventions to reduce 30‐day rehospitalization: a systematic review. Ann Int Med. 2011;155(8):520–528.
- , , , , , . Hospital‐initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Int Med. 2013;158(5 pt 2):433–440.
- , , , , , . Turning readmission reduction policies into results: some lessons from a multistate initiative to reduce readmissions. Popul Health Manag. 2013;16(4):255–260.
- , , , et al. Glasgow supported self‐management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ. 2013;344:e1060.
- , , , et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized controlled trial. Ann Int Med. 2012;156(10):673–683.
- , . Welcome to implementation science. Implement Sci. 2006;1:1.
- , . Moving comparative effectiveness research into practice: implementation science and the role of academic medicine. Health Aff (Millwood). 2010;29(10):1901–1905.
- , , , et al.; American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. Transitions of care consensus policy statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Int Med. 2009;24(8):971–976.
- Centers for Medicare and Medicaid Services. Readmissions reduction program. Available at: http://www.cms.gov/Medicare/Medicare‐Fee‐for‐service‐Payment/AcuteInpatientPPS/Readmissions‐Reduction‐Program.html. Accessed December 30, 2013.
- , , , , , . Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2):E1–E12.
- , , , . Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med. doi: 10.1002/jhm.2134.
- , , . Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices. J Hosp Med. 2013;8:36–41.
- , , , et al. An academic hospitalist model to improve healthcare work communication and learner education: results from a quasi‐experimental study at a Veterans Affairs medical center. J Hosp Med. 2013;8:702–710.
- Wikipedia website. Where's the beef? Available at: http://en.wikipedia.org/wiki/Where's_the_beef%3F. Accessed November 4, 2013.
- , , , , , . Quality collaboratives and campaigns to reduce readmissions: what strategies are hospitals using? J Hosp Med. 2013;8(11):601–608.
- , , . The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608–613.
- , , , . Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;353(13):1405–1409.
- , , . Clinical Improvement Action Guide. Oak Brook, IL: Joint Commission Resources; 1998.
- , , , et al. Association of communication between hospital‐based physicians and primary care providers with patient outcomes. J Gen Int Med. 2009;24(3):381–386.
- , , , , . Primary care physician communication a hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8:672–677.
- Centers for Medicare 150(3):178–187.
- , , , et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421–427.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828.
- , , , et al. Comprehensive discharge planning and home follow‐up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–620.
- , , , et al. The effect of guided care teams on the use of health services: results from a cluster‐randomized controlled trial. Arch Intern Med. 2011;171(5):460–466.
- , , , et al. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Arch Intern Med. 2011;171(14):1238–1243.
- , , , , , . The care transitions intervention: translating from efficacy to effectiveness. Arch Intern Med. 2011;171(14):1232–1237.
- , , , , . Interventions to reduce 30‐day rehospitalization: a systematic review. Ann Int Med. 2011;155(8):520–528.
- , , , , , . Hospital‐initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Int Med. 2013;158(5 pt 2):433–440.
- , , , , , . Turning readmission reduction policies into results: some lessons from a multistate initiative to reduce readmissions. Popul Health Manag. 2013;16(4):255–260.
- , , , et al. Glasgow supported self‐management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial. BMJ. 2013;344:e1060.
- , , , et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized controlled trial. Ann Int Med. 2012;156(10):673–683.
- , . Welcome to implementation science. Implement Sci. 2006;1:1.
- , . Moving comparative effectiveness research into practice: implementation science and the role of academic medicine. Health Aff (Millwood). 2010;29(10):1901–1905.
- , , , et al.; American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. Transitions of care consensus policy statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Int Med. 2009;24(8):971–976.
Tablet Computers to Engage Patients
BACKGROUND
Many hospitals have initiated intense efforts to improve transitions of care[1] such as discharge coordinators or transition coaches,[2, 3] but use of mobile devices as approaches to add or extend the value of human interventions have been understudied.[4] Additionally, many hospitalized patients experience substantial inactive time between provider visits, tests, and treatments. This time could be used to engage patients in their care through interactive health education modules and by learning to use their PHR to manage medications and postdischarge appointments.
Greater understanding of the advantages and limitations of mobile devices may be important for improving transitions of care and may help leverage existing hospital personnel resources. However, prior studies have focused on healthcare provider uses of tablet computers for medical education,[5] to collect clinical registration data,[6] or to do clinical work (eg, check labs, write notes)[7, 8, 9] primarily in outpatient settings; few studies have focused on patient uses for this technology in hospital settings.[10, 11] To address these knowledge gaps, we conducted a pilot project to explore inpatient satisfaction with bedside tablets and barriers to usability. Additionally, we evaluated use of these devices to deliver 2 specific Web‐based programs: (1) an interactive video to improve inpatient education about hospital safety, and (2) PHR access to promote inpatient engagement in discharge planning.
METHODS
Study Design, Patient Selection, and Devices/Programs
We conducted a prospective study of tablet computers to engage patients in their care and discharge planning through Web‐based interactive health education modules and use of PHRs. We used 2 tablets, distributed daily by research assistants (RAs) to eligible patients after morning rounds. Inclusion criteria for patients were ability to speak English and admission to the medical (hospitalist) service at University of California San Francisco (UCSF) Medical Center. Exclusion criteria were intensive care unit admission, contact isolation, or inability to complete the consent process due to altered mental status or cognitive impairment.
RAs screened patients for inclusion/exclusion via the electronic medical record and then approached them after rounds for enrollment (11:00 am1:00 pm). RAs then performed a tiered orientation tailored to individual patient experience and needs. First, they delivered a brief tutorial focused on the tablet itself and its basic functions (touchscreen, keypad, and Internet browser use). Second, RAs showed patients how to access the online educational health module and how to navigate content within the module. RAs next explained what the PHR is and demonstrated how to login, how to navigate tabs within the PHR, and how to perform basic tasks (view/refill medications, view/modify appointments, and view/send messages to providers). The RAs left devices with patients for 3 to 5 hours and returned to collect them and perform debriefing interviews. After each device was returned, RAs cleaned devices with disinfectant wipes available in patient rooms and checked for physical damage or software malfunctions (eg, unable to turn on or unlock). Finally, RAs used the reset function to erase any personal data or setting modifications made by patients and docked the devices overnight to resynchronize the original settings and recharge the batteries.
We used the 16 gigabyte Apple iPad2 (Apple Inc., Cupertino, CA) without any enclosures, cases, or security devices. Our educational health module was Patient Safety in the Hospital, which was professionally developed by Emmi Solutions (
Survey Instruments and Data Collection
We developed pre‐ and postintervention surveys to characterize patients' demographics, device ownership, and health‐related Internet activities in the last year based on questions used in the Centers for Disease Control and Prevention National Health Interview Study (
Analyses
We used frequency analysis to describe patient demographics, ability to complete online health educational modules, and utilization of their PHR. We performed bivariate analyses (Fisher exact test) to assess correlations between demographics (age, device ownership, Internet use) and key pilot program performance measures (orientation time 15 minutes, online health module completion, and completion of 1 essential function in the PHR). All analyses were performed in SAS 9.2 (SAS Institute Inc., Cary, NC). The institutional review board of record for UCSF approved this study.
RESULTS
As shown in Table 1, we enrolled 30 patients. Most participants (60%) were aged 40 years or older, and most (87%) owned a mobile device; 70% owned a laptop and 60% owned a smartphone, but few (22%) owned a computer tablet. Most participants accessed the Internet daily, but fewer reported Internet use for health tasks; about half (52%) communicated with a provider, but few refilled a prescription (27%) or scheduled an appointment (21%) online over the last year.
| Characteristic | No. (%) |
|---|---|
| Age, y | |
| 1839 | 11 (38%) |
| 4049 | 5 (18%) |
| 5059 | 4 (14%) |
| 6069 | 5 (18%) |
| 7079 | 3 (10%) |
| Gender, female | 17 (60%) |
| Device ownership | |
| Desktop computer | 12 (44%) |
| Laptop computer | 19 (70%) |
| Smart phone | 17 (60%) |
| Tablet computer | 6 (22%) |
| Any mobile device (laptop, smartphone, or tablet) | 26 (87%) |
| Internet use | |
| Daily | 21 (72%) |
| Several times a week | 3 (10%) |
| Once a week or less | 5 (18%) |
| Prestudy online health tasks | |
| Looked up health information | 21 (72%) |
| Communicated with provider | 15 (52%) |
| Refilled prescription | 8 (27%) |
| Scheduled medical appointment | 6 (21%) |
Nearly all participants (90%) were satisfied or very satisfied with their experience using the tablet in the hospital (Figure 1). Most (87%) required 30 minutes or less for basic orientation, and 70% required only 15 minutes or less. Most participants (83%) were able to independently complete an interactive health education module on hospital safety and were highly satisfied with the module. Despite the fact that 73% of participants were first‐time users of our PHR, the majority were able to login and independently access their medication list, verify scheduled appointments, or send a secure message to their primary care provider.
Participants aged 50 years or older were less likely to complete orientation in 15 minutes or less compared to those under 50 years old (25% vs 79%, P=0.025); however, age was not a significant factor in ability to complete the online health educational module or perform at least 1 essential PHR function. Other demographic features, such as device ownership and daily Internet use, did not correlate with shorter orientation time, educational module completion, or PHR use (data available on request).
Participants also made suggestions for improvement during the debrief interviews. Several suggested applications for entertainment (gaming, magazines, or music) and 2 suggested that all patients should be introduced to their PHR during hospitalization (data available on request). No device software malfunction (eg, device freezes, Internet connection failures), hardware issues (eg, damage from falls, wetness, or repeated disinfectant exposure), or theft or misappropriation were reported by patients or observed by the RAs to date.
DISCUSSION
Our pilot study suggests that tablet‐based access to educational modules and PHRs can increase inpatient engagement in care with high satisfaction and minimal time for orientation. Surprisingly, even older patients and those who might be considered less tech savvy in terms of Internet use and device ownership were equally able to utilize our tablet interventions. Furthermore, we did not experience any hardware issues in the harsh physical environment of inpatient wards. These preliminary findings suggest the potential utility of tablets for clinically meaningful tasks by inpatients with a low rate of technical issues.
From a technical standpoint, our experience suggests several next steps. First, although orientation time was minimal, it might be even less if patients used their own mobile devices because most patients already owned one. This bring your own device (BYOD) approach could also promote postdischarge patient engagement. Second, the flexibility of a BYOD approach raises the question of whether to also allow patients a choice of application‐based versus browser‐based platforms for specific programs such as the PHR and educational video we used. Indeed, although we used a browser‐based approach, several other teams have developed patient‐facing engagement applications (or apps) for mobile devices,[4, 12] and hospitalists could prescribe apps at discharge as a more providers are now doing in outpatient settings.[13] Of course, maximizing flexibility for BYOD and Web‐based versus app‐based approaches would likely increase patient engagement but would come at the cost of more time and effort for hospital providers to vet apps/websites and educate patients about their use. Third, regardless of the devices and programs used, broader engagement of patients, nurses, hospitalists, and other providers will be needed in the future to identify key areas for development to avoid overburdening patients and providers.
From a quality‐improvement perspective, recent literature has considered broad clinical uses for tablets by hospital providers,[14, 15] but our experience suggests more specific opportunities to improve transitions of care though direct patient engagement. Tablets and other mobile devices may help improve discharge education for patients taking high‐risk medications such as warfarin or insulin using interactive educational modules similar to the hospital safety modules we used. Additionally, clinical staff, such as nurses and pharmacists, can be trained to deliver mobile device interventions such as education on high‐risk medications.[16] Ultimately, scale up for our intervention will require that mobile devices and content eventually improve and replace current practices by hospital staff (especially nurses) in a way that streamlines, rather than compounds, current workflow. This could increase efficiency in these discharge tasks and extend contributions of these providers to high‐quality transitions.
Our study has several limitations. First, although this is a pilot study with only 30 patients, it adds needed scale to much smaller (N=58) published feasibility studies of tablet computer use by inpatients.[11, 12] Beyond more robust feasibility testing, our study adds new data about mobile device use for specific clinical tasks in the hospital such as patient education and PHR use. Second, we did not track postdischarge outcomes to test the effects of our intervention on transition care quality; this will be a focus of our future research. Third, we used existing platforms for interactive educational modules and PHR access at our site; participant satisfaction in our study may not generalize to other platforms. Furthermore, most PHR platforms (including ours) are not optimally configured to engage patients during transitions of care, but we plan to integrate existing functions (such as ability to refill medications or change appointments) into discharge education and planning. Finally, we have not engaged caregivers as surrogates for cognitively impaired patients or adapted our platform for non‐English speakers; these are areas for development in our ongoing work. Overall, our pilot results help set the stage to deploy mobile devices for better patient monitoring, engagement, and quality of care in the inpatient setting.[17]
In conclusion, our pilot project demonstrates that tablet computers can be used to improve inpatient education and patient engagement in discharge planning. Inpatients are highly satisfied with the use of tablets to complete health education modules and access their PHR, with minimal time required for patient training and device management by hospital staff. Tablets and other mobile devices have significant potential to improve patients' education and engagement in their hospital care.
Acknowledgements
The authors thank the UCSF mHealth group and Center for Digital Health Innovation for advice and for providing tablet computers for this pilot project.
Disclosures: This article was presented as a finalist in the Research, Innovations, and Clinical Vignettes competition (Innovations category) at the 2013 Annual Meeting of the Society for Hospital Medicine. Dr. Auerbach was supported by grant K24HL098372 (NHLBI). Dr. Greysen was supported by a career development award (KL‐2) from the UCSF Clinical Translational Sciences Institute. The authors have declared they have no financial, personal, or other conflicts of interest relevant to this study.
- , . Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306(16):1794–1795.
- , , , et al. A reengineered hospital discharge program to decrease re‐hospitalization. Ann Intern Med. 2009;150:178–187.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–1828.
- Project RED. Meet Louise…and virtual patient advocates. Available at: http://www.bu.edu/fammed/projectred/publications/VirtualPatientAdvocateWebsiteInfo2.pdf. Accessed July 12, 2013.
- , , , . Use of handheld computers in medical education. A systematic review. J Gen Intern Med. 2006;21(5):531–537.
- , , , . Ongoing evaluation of ease‐of‐use and usefulness of wireless tablet computers within an ambulatory care unit. Stud Health Tech Inform. 2009;143:459–464.
- . Use of a tablet personal computer to enhance patient care on multidisciplinary rounds. Am J Health Syst Pharm. 2009;66(21):1909–1911.
- , . Experiences incorporating Tablet PCs into clinical pharmacists' workflow. J Healthc Inf Manag. 2005;19(4):32–37.
- , , . The impact of mobile handheld technology on hospital physicians' work practices and patient care: a systematic review. J Am Med Inform Assoc. 2009;16(6):792–801.
- , , , et al. An investigation of the efficacy of electronic consenting interfaces of research permissions management system in a hospital setting. Int J Med Inform. 2013;82(9):854–863.
- , , , et al. A tablet computer application for patients to participate in their hospital care. AMIA Annu Symp Proc. 2011;2011:1428–1435.
- , , , et al. Building and testing a patient‐centric electronic bedside communication center. J Gerontol Nurs. 2013;39(1):15–19.
- . How apps are changing family medicine. J Fam Pract. 2013Jul;62(7):362–367.
- . The iPad: gadget or medical godsend? Ann Emerg Med. 2010;56(1):A21–A22.
- , , , et al. How might the iPad change healthcare? J R Soc Med. 2012;105(6):233–241.
- . Keeping the patient focus: using tablet technology to enhance education and practice. J Contin Educ Nurs. 2012;43(6):249–250.
- , , , et al. Advancing the science of mHealth. J Health Commun. 2012;17(suppl 1):5–10.
BACKGROUND
Many hospitals have initiated intense efforts to improve transitions of care[1] such as discharge coordinators or transition coaches,[2, 3] but use of mobile devices as approaches to add or extend the value of human interventions have been understudied.[4] Additionally, many hospitalized patients experience substantial inactive time between provider visits, tests, and treatments. This time could be used to engage patients in their care through interactive health education modules and by learning to use their PHR to manage medications and postdischarge appointments.
Greater understanding of the advantages and limitations of mobile devices may be important for improving transitions of care and may help leverage existing hospital personnel resources. However, prior studies have focused on healthcare provider uses of tablet computers for medical education,[5] to collect clinical registration data,[6] or to do clinical work (eg, check labs, write notes)[7, 8, 9] primarily in outpatient settings; few studies have focused on patient uses for this technology in hospital settings.[10, 11] To address these knowledge gaps, we conducted a pilot project to explore inpatient satisfaction with bedside tablets and barriers to usability. Additionally, we evaluated use of these devices to deliver 2 specific Web‐based programs: (1) an interactive video to improve inpatient education about hospital safety, and (2) PHR access to promote inpatient engagement in discharge planning.
METHODS
Study Design, Patient Selection, and Devices/Programs
We conducted a prospective study of tablet computers to engage patients in their care and discharge planning through Web‐based interactive health education modules and use of PHRs. We used 2 tablets, distributed daily by research assistants (RAs) to eligible patients after morning rounds. Inclusion criteria for patients were ability to speak English and admission to the medical (hospitalist) service at University of California San Francisco (UCSF) Medical Center. Exclusion criteria were intensive care unit admission, contact isolation, or inability to complete the consent process due to altered mental status or cognitive impairment.
RAs screened patients for inclusion/exclusion via the electronic medical record and then approached them after rounds for enrollment (11:00 am1:00 pm). RAs then performed a tiered orientation tailored to individual patient experience and needs. First, they delivered a brief tutorial focused on the tablet itself and its basic functions (touchscreen, keypad, and Internet browser use). Second, RAs showed patients how to access the online educational health module and how to navigate content within the module. RAs next explained what the PHR is and demonstrated how to login, how to navigate tabs within the PHR, and how to perform basic tasks (view/refill medications, view/modify appointments, and view/send messages to providers). The RAs left devices with patients for 3 to 5 hours and returned to collect them and perform debriefing interviews. After each device was returned, RAs cleaned devices with disinfectant wipes available in patient rooms and checked for physical damage or software malfunctions (eg, unable to turn on or unlock). Finally, RAs used the reset function to erase any personal data or setting modifications made by patients and docked the devices overnight to resynchronize the original settings and recharge the batteries.
We used the 16 gigabyte Apple iPad2 (Apple Inc., Cupertino, CA) without any enclosures, cases, or security devices. Our educational health module was Patient Safety in the Hospital, which was professionally developed by Emmi Solutions (
Survey Instruments and Data Collection
We developed pre‐ and postintervention surveys to characterize patients' demographics, device ownership, and health‐related Internet activities in the last year based on questions used in the Centers for Disease Control and Prevention National Health Interview Study (
Analyses
We used frequency analysis to describe patient demographics, ability to complete online health educational modules, and utilization of their PHR. We performed bivariate analyses (Fisher exact test) to assess correlations between demographics (age, device ownership, Internet use) and key pilot program performance measures (orientation time 15 minutes, online health module completion, and completion of 1 essential function in the PHR). All analyses were performed in SAS 9.2 (SAS Institute Inc., Cary, NC). The institutional review board of record for UCSF approved this study.
RESULTS
As shown in Table 1, we enrolled 30 patients. Most participants (60%) were aged 40 years or older, and most (87%) owned a mobile device; 70% owned a laptop and 60% owned a smartphone, but few (22%) owned a computer tablet. Most participants accessed the Internet daily, but fewer reported Internet use for health tasks; about half (52%) communicated with a provider, but few refilled a prescription (27%) or scheduled an appointment (21%) online over the last year.
| Characteristic | No. (%) |
|---|---|
| Age, y | |
| 1839 | 11 (38%) |
| 4049 | 5 (18%) |
| 5059 | 4 (14%) |
| 6069 | 5 (18%) |
| 7079 | 3 (10%) |
| Gender, female | 17 (60%) |
| Device ownership | |
| Desktop computer | 12 (44%) |
| Laptop computer | 19 (70%) |
| Smart phone | 17 (60%) |
| Tablet computer | 6 (22%) |
| Any mobile device (laptop, smartphone, or tablet) | 26 (87%) |
| Internet use | |
| Daily | 21 (72%) |
| Several times a week | 3 (10%) |
| Once a week or less | 5 (18%) |
| Prestudy online health tasks | |
| Looked up health information | 21 (72%) |
| Communicated with provider | 15 (52%) |
| Refilled prescription | 8 (27%) |
| Scheduled medical appointment | 6 (21%) |
Nearly all participants (90%) were satisfied or very satisfied with their experience using the tablet in the hospital (Figure 1). Most (87%) required 30 minutes or less for basic orientation, and 70% required only 15 minutes or less. Most participants (83%) were able to independently complete an interactive health education module on hospital safety and were highly satisfied with the module. Despite the fact that 73% of participants were first‐time users of our PHR, the majority were able to login and independently access their medication list, verify scheduled appointments, or send a secure message to their primary care provider.
Participants aged 50 years or older were less likely to complete orientation in 15 minutes or less compared to those under 50 years old (25% vs 79%, P=0.025); however, age was not a significant factor in ability to complete the online health educational module or perform at least 1 essential PHR function. Other demographic features, such as device ownership and daily Internet use, did not correlate with shorter orientation time, educational module completion, or PHR use (data available on request).
Participants also made suggestions for improvement during the debrief interviews. Several suggested applications for entertainment (gaming, magazines, or music) and 2 suggested that all patients should be introduced to their PHR during hospitalization (data available on request). No device software malfunction (eg, device freezes, Internet connection failures), hardware issues (eg, damage from falls, wetness, or repeated disinfectant exposure), or theft or misappropriation were reported by patients or observed by the RAs to date.
DISCUSSION
Our pilot study suggests that tablet‐based access to educational modules and PHRs can increase inpatient engagement in care with high satisfaction and minimal time for orientation. Surprisingly, even older patients and those who might be considered less tech savvy in terms of Internet use and device ownership were equally able to utilize our tablet interventions. Furthermore, we did not experience any hardware issues in the harsh physical environment of inpatient wards. These preliminary findings suggest the potential utility of tablets for clinically meaningful tasks by inpatients with a low rate of technical issues.
From a technical standpoint, our experience suggests several next steps. First, although orientation time was minimal, it might be even less if patients used their own mobile devices because most patients already owned one. This bring your own device (BYOD) approach could also promote postdischarge patient engagement. Second, the flexibility of a BYOD approach raises the question of whether to also allow patients a choice of application‐based versus browser‐based platforms for specific programs such as the PHR and educational video we used. Indeed, although we used a browser‐based approach, several other teams have developed patient‐facing engagement applications (or apps) for mobile devices,[4, 12] and hospitalists could prescribe apps at discharge as a more providers are now doing in outpatient settings.[13] Of course, maximizing flexibility for BYOD and Web‐based versus app‐based approaches would likely increase patient engagement but would come at the cost of more time and effort for hospital providers to vet apps/websites and educate patients about their use. Third, regardless of the devices and programs used, broader engagement of patients, nurses, hospitalists, and other providers will be needed in the future to identify key areas for development to avoid overburdening patients and providers.
From a quality‐improvement perspective, recent literature has considered broad clinical uses for tablets by hospital providers,[14, 15] but our experience suggests more specific opportunities to improve transitions of care though direct patient engagement. Tablets and other mobile devices may help improve discharge education for patients taking high‐risk medications such as warfarin or insulin using interactive educational modules similar to the hospital safety modules we used. Additionally, clinical staff, such as nurses and pharmacists, can be trained to deliver mobile device interventions such as education on high‐risk medications.[16] Ultimately, scale up for our intervention will require that mobile devices and content eventually improve and replace current practices by hospital staff (especially nurses) in a way that streamlines, rather than compounds, current workflow. This could increase efficiency in these discharge tasks and extend contributions of these providers to high‐quality transitions.
Our study has several limitations. First, although this is a pilot study with only 30 patients, it adds needed scale to much smaller (N=58) published feasibility studies of tablet computer use by inpatients.[11, 12] Beyond more robust feasibility testing, our study adds new data about mobile device use for specific clinical tasks in the hospital such as patient education and PHR use. Second, we did not track postdischarge outcomes to test the effects of our intervention on transition care quality; this will be a focus of our future research. Third, we used existing platforms for interactive educational modules and PHR access at our site; participant satisfaction in our study may not generalize to other platforms. Furthermore, most PHR platforms (including ours) are not optimally configured to engage patients during transitions of care, but we plan to integrate existing functions (such as ability to refill medications or change appointments) into discharge education and planning. Finally, we have not engaged caregivers as surrogates for cognitively impaired patients or adapted our platform for non‐English speakers; these are areas for development in our ongoing work. Overall, our pilot results help set the stage to deploy mobile devices for better patient monitoring, engagement, and quality of care in the inpatient setting.[17]
In conclusion, our pilot project demonstrates that tablet computers can be used to improve inpatient education and patient engagement in discharge planning. Inpatients are highly satisfied with the use of tablets to complete health education modules and access their PHR, with minimal time required for patient training and device management by hospital staff. Tablets and other mobile devices have significant potential to improve patients' education and engagement in their hospital care.
Acknowledgements
The authors thank the UCSF mHealth group and Center for Digital Health Innovation for advice and for providing tablet computers for this pilot project.
Disclosures: This article was presented as a finalist in the Research, Innovations, and Clinical Vignettes competition (Innovations category) at the 2013 Annual Meeting of the Society for Hospital Medicine. Dr. Auerbach was supported by grant K24HL098372 (NHLBI). Dr. Greysen was supported by a career development award (KL‐2) from the UCSF Clinical Translational Sciences Institute. The authors have declared they have no financial, personal, or other conflicts of interest relevant to this study.
BACKGROUND
Many hospitals have initiated intense efforts to improve transitions of care[1] such as discharge coordinators or transition coaches,[2, 3] but use of mobile devices as approaches to add or extend the value of human interventions have been understudied.[4] Additionally, many hospitalized patients experience substantial inactive time between provider visits, tests, and treatments. This time could be used to engage patients in their care through interactive health education modules and by learning to use their PHR to manage medications and postdischarge appointments.
Greater understanding of the advantages and limitations of mobile devices may be important for improving transitions of care and may help leverage existing hospital personnel resources. However, prior studies have focused on healthcare provider uses of tablet computers for medical education,[5] to collect clinical registration data,[6] or to do clinical work (eg, check labs, write notes)[7, 8, 9] primarily in outpatient settings; few studies have focused on patient uses for this technology in hospital settings.[10, 11] To address these knowledge gaps, we conducted a pilot project to explore inpatient satisfaction with bedside tablets and barriers to usability. Additionally, we evaluated use of these devices to deliver 2 specific Web‐based programs: (1) an interactive video to improve inpatient education about hospital safety, and (2) PHR access to promote inpatient engagement in discharge planning.
METHODS
Study Design, Patient Selection, and Devices/Programs
We conducted a prospective study of tablet computers to engage patients in their care and discharge planning through Web‐based interactive health education modules and use of PHRs. We used 2 tablets, distributed daily by research assistants (RAs) to eligible patients after morning rounds. Inclusion criteria for patients were ability to speak English and admission to the medical (hospitalist) service at University of California San Francisco (UCSF) Medical Center. Exclusion criteria were intensive care unit admission, contact isolation, or inability to complete the consent process due to altered mental status or cognitive impairment.
RAs screened patients for inclusion/exclusion via the electronic medical record and then approached them after rounds for enrollment (11:00 am1:00 pm). RAs then performed a tiered orientation tailored to individual patient experience and needs. First, they delivered a brief tutorial focused on the tablet itself and its basic functions (touchscreen, keypad, and Internet browser use). Second, RAs showed patients how to access the online educational health module and how to navigate content within the module. RAs next explained what the PHR is and demonstrated how to login, how to navigate tabs within the PHR, and how to perform basic tasks (view/refill medications, view/modify appointments, and view/send messages to providers). The RAs left devices with patients for 3 to 5 hours and returned to collect them and perform debriefing interviews. After each device was returned, RAs cleaned devices with disinfectant wipes available in patient rooms and checked for physical damage or software malfunctions (eg, unable to turn on or unlock). Finally, RAs used the reset function to erase any personal data or setting modifications made by patients and docked the devices overnight to resynchronize the original settings and recharge the batteries.
We used the 16 gigabyte Apple iPad2 (Apple Inc., Cupertino, CA) without any enclosures, cases, or security devices. Our educational health module was Patient Safety in the Hospital, which was professionally developed by Emmi Solutions (
Survey Instruments and Data Collection
We developed pre‐ and postintervention surveys to characterize patients' demographics, device ownership, and health‐related Internet activities in the last year based on questions used in the Centers for Disease Control and Prevention National Health Interview Study (
Analyses
We used frequency analysis to describe patient demographics, ability to complete online health educational modules, and utilization of their PHR. We performed bivariate analyses (Fisher exact test) to assess correlations between demographics (age, device ownership, Internet use) and key pilot program performance measures (orientation time 15 minutes, online health module completion, and completion of 1 essential function in the PHR). All analyses were performed in SAS 9.2 (SAS Institute Inc., Cary, NC). The institutional review board of record for UCSF approved this study.
RESULTS
As shown in Table 1, we enrolled 30 patients. Most participants (60%) were aged 40 years or older, and most (87%) owned a mobile device; 70% owned a laptop and 60% owned a smartphone, but few (22%) owned a computer tablet. Most participants accessed the Internet daily, but fewer reported Internet use for health tasks; about half (52%) communicated with a provider, but few refilled a prescription (27%) or scheduled an appointment (21%) online over the last year.
| Characteristic | No. (%) |
|---|---|
| Age, y | |
| 1839 | 11 (38%) |
| 4049 | 5 (18%) |
| 5059 | 4 (14%) |
| 6069 | 5 (18%) |
| 7079 | 3 (10%) |
| Gender, female | 17 (60%) |
| Device ownership | |
| Desktop computer | 12 (44%) |
| Laptop computer | 19 (70%) |
| Smart phone | 17 (60%) |
| Tablet computer | 6 (22%) |
| Any mobile device (laptop, smartphone, or tablet) | 26 (87%) |
| Internet use | |
| Daily | 21 (72%) |
| Several times a week | 3 (10%) |
| Once a week or less | 5 (18%) |
| Prestudy online health tasks | |
| Looked up health information | 21 (72%) |
| Communicated with provider | 15 (52%) |
| Refilled prescription | 8 (27%) |
| Scheduled medical appointment | 6 (21%) |
Nearly all participants (90%) were satisfied or very satisfied with their experience using the tablet in the hospital (Figure 1). Most (87%) required 30 minutes or less for basic orientation, and 70% required only 15 minutes or less. Most participants (83%) were able to independently complete an interactive health education module on hospital safety and were highly satisfied with the module. Despite the fact that 73% of participants were first‐time users of our PHR, the majority were able to login and independently access their medication list, verify scheduled appointments, or send a secure message to their primary care provider.
Participants aged 50 years or older were less likely to complete orientation in 15 minutes or less compared to those under 50 years old (25% vs 79%, P=0.025); however, age was not a significant factor in ability to complete the online health educational module or perform at least 1 essential PHR function. Other demographic features, such as device ownership and daily Internet use, did not correlate with shorter orientation time, educational module completion, or PHR use (data available on request).
Participants also made suggestions for improvement during the debrief interviews. Several suggested applications for entertainment (gaming, magazines, or music) and 2 suggested that all patients should be introduced to their PHR during hospitalization (data available on request). No device software malfunction (eg, device freezes, Internet connection failures), hardware issues (eg, damage from falls, wetness, or repeated disinfectant exposure), or theft or misappropriation were reported by patients or observed by the RAs to date.
DISCUSSION
Our pilot study suggests that tablet‐based access to educational modules and PHRs can increase inpatient engagement in care with high satisfaction and minimal time for orientation. Surprisingly, even older patients and those who might be considered less tech savvy in terms of Internet use and device ownership were equally able to utilize our tablet interventions. Furthermore, we did not experience any hardware issues in the harsh physical environment of inpatient wards. These preliminary findings suggest the potential utility of tablets for clinically meaningful tasks by inpatients with a low rate of technical issues.
From a technical standpoint, our experience suggests several next steps. First, although orientation time was minimal, it might be even less if patients used their own mobile devices because most patients already owned one. This bring your own device (BYOD) approach could also promote postdischarge patient engagement. Second, the flexibility of a BYOD approach raises the question of whether to also allow patients a choice of application‐based versus browser‐based platforms for specific programs such as the PHR and educational video we used. Indeed, although we used a browser‐based approach, several other teams have developed patient‐facing engagement applications (or apps) for mobile devices,[4, 12] and hospitalists could prescribe apps at discharge as a more providers are now doing in outpatient settings.[13] Of course, maximizing flexibility for BYOD and Web‐based versus app‐based approaches would likely increase patient engagement but would come at the cost of more time and effort for hospital providers to vet apps/websites and educate patients about their use. Third, regardless of the devices and programs used, broader engagement of patients, nurses, hospitalists, and other providers will be needed in the future to identify key areas for development to avoid overburdening patients and providers.
From a quality‐improvement perspective, recent literature has considered broad clinical uses for tablets by hospital providers,[14, 15] but our experience suggests more specific opportunities to improve transitions of care though direct patient engagement. Tablets and other mobile devices may help improve discharge education for patients taking high‐risk medications such as warfarin or insulin using interactive educational modules similar to the hospital safety modules we used. Additionally, clinical staff, such as nurses and pharmacists, can be trained to deliver mobile device interventions such as education on high‐risk medications.[16] Ultimately, scale up for our intervention will require that mobile devices and content eventually improve and replace current practices by hospital staff (especially nurses) in a way that streamlines, rather than compounds, current workflow. This could increase efficiency in these discharge tasks and extend contributions of these providers to high‐quality transitions.
Our study has several limitations. First, although this is a pilot study with only 30 patients, it adds needed scale to much smaller (N=58) published feasibility studies of tablet computer use by inpatients.[11, 12] Beyond more robust feasibility testing, our study adds new data about mobile device use for specific clinical tasks in the hospital such as patient education and PHR use. Second, we did not track postdischarge outcomes to test the effects of our intervention on transition care quality; this will be a focus of our future research. Third, we used existing platforms for interactive educational modules and PHR access at our site; participant satisfaction in our study may not generalize to other platforms. Furthermore, most PHR platforms (including ours) are not optimally configured to engage patients during transitions of care, but we plan to integrate existing functions (such as ability to refill medications or change appointments) into discharge education and planning. Finally, we have not engaged caregivers as surrogates for cognitively impaired patients or adapted our platform for non‐English speakers; these are areas for development in our ongoing work. Overall, our pilot results help set the stage to deploy mobile devices for better patient monitoring, engagement, and quality of care in the inpatient setting.[17]
In conclusion, our pilot project demonstrates that tablet computers can be used to improve inpatient education and patient engagement in discharge planning. Inpatients are highly satisfied with the use of tablets to complete health education modules and access their PHR, with minimal time required for patient training and device management by hospital staff. Tablets and other mobile devices have significant potential to improve patients' education and engagement in their hospital care.
Acknowledgements
The authors thank the UCSF mHealth group and Center for Digital Health Innovation for advice and for providing tablet computers for this pilot project.
Disclosures: This article was presented as a finalist in the Research, Innovations, and Clinical Vignettes competition (Innovations category) at the 2013 Annual Meeting of the Society for Hospital Medicine. Dr. Auerbach was supported by grant K24HL098372 (NHLBI). Dr. Greysen was supported by a career development award (KL‐2) from the UCSF Clinical Translational Sciences Institute. The authors have declared they have no financial, personal, or other conflicts of interest relevant to this study.
- , . Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306(16):1794–1795.
- , , , et al. A reengineered hospital discharge program to decrease re‐hospitalization. Ann Intern Med. 2009;150:178–187.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–1828.
- Project RED. Meet Louise…and virtual patient advocates. Available at: http://www.bu.edu/fammed/projectred/publications/VirtualPatientAdvocateWebsiteInfo2.pdf. Accessed July 12, 2013.
- , , , . Use of handheld computers in medical education. A systematic review. J Gen Intern Med. 2006;21(5):531–537.
- , , , . Ongoing evaluation of ease‐of‐use and usefulness of wireless tablet computers within an ambulatory care unit. Stud Health Tech Inform. 2009;143:459–464.
- . Use of a tablet personal computer to enhance patient care on multidisciplinary rounds. Am J Health Syst Pharm. 2009;66(21):1909–1911.
- , . Experiences incorporating Tablet PCs into clinical pharmacists' workflow. J Healthc Inf Manag. 2005;19(4):32–37.
- , , . The impact of mobile handheld technology on hospital physicians' work practices and patient care: a systematic review. J Am Med Inform Assoc. 2009;16(6):792–801.
- , , , et al. An investigation of the efficacy of electronic consenting interfaces of research permissions management system in a hospital setting. Int J Med Inform. 2013;82(9):854–863.
- , , , et al. A tablet computer application for patients to participate in their hospital care. AMIA Annu Symp Proc. 2011;2011:1428–1435.
- , , , et al. Building and testing a patient‐centric electronic bedside communication center. J Gerontol Nurs. 2013;39(1):15–19.
- . How apps are changing family medicine. J Fam Pract. 2013Jul;62(7):362–367.
- . The iPad: gadget or medical godsend? Ann Emerg Med. 2010;56(1):A21–A22.
- , , , et al. How might the iPad change healthcare? J R Soc Med. 2012;105(6):233–241.
- . Keeping the patient focus: using tablet technology to enhance education and practice. J Contin Educ Nurs. 2012;43(6):249–250.
- , , , et al. Advancing the science of mHealth. J Health Commun. 2012;17(suppl 1):5–10.
- , . Hospital readmissions and the Affordable Care Act: paying for coordinated quality care. JAMA. 2011;306(16):1794–1795.
- , , , et al. A reengineered hospital discharge program to decrease re‐hospitalization. Ann Intern Med. 2009;150:178–187.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–1828.
- Project RED. Meet Louise…and virtual patient advocates. Available at: http://www.bu.edu/fammed/projectred/publications/VirtualPatientAdvocateWebsiteInfo2.pdf. Accessed July 12, 2013.
- , , , . Use of handheld computers in medical education. A systematic review. J Gen Intern Med. 2006;21(5):531–537.
- , , , . Ongoing evaluation of ease‐of‐use and usefulness of wireless tablet computers within an ambulatory care unit. Stud Health Tech Inform. 2009;143:459–464.
- . Use of a tablet personal computer to enhance patient care on multidisciplinary rounds. Am J Health Syst Pharm. 2009;66(21):1909–1911.
- , . Experiences incorporating Tablet PCs into clinical pharmacists' workflow. J Healthc Inf Manag. 2005;19(4):32–37.
- , , . The impact of mobile handheld technology on hospital physicians' work practices and patient care: a systematic review. J Am Med Inform Assoc. 2009;16(6):792–801.
- , , , et al. An investigation of the efficacy of electronic consenting interfaces of research permissions management system in a hospital setting. Int J Med Inform. 2013;82(9):854–863.
- , , , et al. A tablet computer application for patients to participate in their hospital care. AMIA Annu Symp Proc. 2011;2011:1428–1435.
- , , , et al. Building and testing a patient‐centric electronic bedside communication center. J Gerontol Nurs. 2013;39(1):15–19.
- . How apps are changing family medicine. J Fam Pract. 2013Jul;62(7):362–367.
- . The iPad: gadget or medical godsend? Ann Emerg Med. 2010;56(1):A21–A22.
- , , , et al. How might the iPad change healthcare? J R Soc Med. 2012;105(6):233–241.
- . Keeping the patient focus: using tablet technology to enhance education and practice. J Contin Educ Nurs. 2012;43(6):249–250.
- , , , et al. Advancing the science of mHealth. J Health Commun. 2012;17(suppl 1):5–10.
