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AMBULATORY CARE: How time of day affects quality of care and what to do about decision fatigue

Quality of care deteriorates over the course of the day due to the combination of shared cognitive biases, hurried visits, and mounting decision fatigue…”

Studies show that the quality of outpatient care decreases over the course of the clinic day. Patients seen later in the day are likely to have fewer appropriate services ordered and, also, more low-value inappropriate services ordered. A difference in diagnostic accuracy has also been found based on time of day. How to counteract this time-of-day trend by incorporating alerts into the electronic health record, by using social norm interventions, by optimizing use of telehealth and mail, and by changing payment models are discussed.

Source: Allison H. Oakes, and Mitesh S. Patel. “Time to Address Disparities in Care by Appointment Time.” Healthcare 9(1), (Mar. 2021). https://www.sciencedirect.com/science/article/pii/S2213076420301068

BCBS Association: The Health of America Report Understanding Health Conditions Across the U.S.

In partnership with Moody’s Analytics, the Blue Cross Blue Shield Association has published a report on understanding health conditions across the U.S. The report sets out to address these questions:

  • Why are some communities healthier than others?
  • Which factors are most important in keeping a population healthy: economics, healthy behaviors, or access to quality care?
  • How does the importance of these factors change when measuring different health conditions?

The report analyzes and scores the impact of population demographics, socio-economic factors, healthy behaviors, and access to care and other health care considerations for each of the following conditions:

  • Substance abuse
  • Depression
  • Hypertension
  • High cholesterol
  • Coronary artery disease
  • Chronic obstructive pulmonary disease (COPD)
  • Hyperactivity
  • Breast cancer
  • Lung cancer

Source: Blue Cross Blue Shield Association: Health of America Report-Understanding Health Conditions across the U.S. December, 2017. https://www.bcbs.com/sites/default/files/file-attachments/health-of-america-report/BCBS.HealthOfAmericaReport.Moodys_02.pdf.

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Top 10 Patient Safety Concerns for Healthcare Organizations for 2016

The ECRI Institute has released its annual ranking of the top patient safety concerns for healthcare organizations. Based on a review of its patient safety organization [PSO] database of reported safety events, its PSO members’ root cause analyses and research requests, and a vote by an expert panel, these are currently the top issues:

  1. Health IT configurations and organizational workflow that do not support each other
  2. Patient identification errors
  3. Inadequate management of behavioral health issues in non-behavioral-health settings
  4. Inadequate cleaning and disinfection of flexible endoscopes
  5. Inadequate test-result reporting and follow-up
  6. Inadequate monitoring for respiratory depression in patients prescribed opioids
  7. Medication errors related to pounds and kilograms
  8. Unintentionally retained objects despite correct count
  9. Inadequate antimicrobial stewardship
  10. Failure to embrace a culture of safety

Source: Top 10 patient safety concerns for healthcare organizations 2016: executive brief. ECRI Institute, April 2016. www.ecri.org/patientsafetytop10 [free registration required]

Posted by AHA Resource Center (312) 422-2050 rc@aha.org

Top 10 Issues Facing Community Hospital CEOs

Last month the American College of Healthcare Executives released the results of its annual CEO survey on the top concerns confronting community hospitals. The most pressing concerns of the CEOs in 2015 were:

  1. Financial challenges
  2. Patient safety and quality
  3. Governmental mandates
  4. Personnel shortages
  5. Patient satisfaction
  6. Physician-hospital relations
  7. Access to care
  8. Population health management
  9. Technology
  10. Reorganization [mergers, acquisitions, restructuring, partnerships]

Financial challenges has remained the top concern when compared to 2013 and 2014 surveys. Transition from volume to value, Medicaid reimbursement, bad debt, and increasing costs were among the financial challenges most often mentioned. Engaging physicians in improving the culture of safety/quality and in reducing clinically unnecessary tests and procedures were top concerns related to patient safety and quality.

Access to care and reorganization were new to the top 10 list in 2015, and personnel shortages rose to 4th place on the list, up from the 10th spot in 2014.

Source: Top issues confronting hospitals in 2015. American College of Healthcare Executives, Feb. 2, 1016. http://ache.org/pubs/research/ceoissues.cfm [press release: http://ache.org/pubs/Releases/2016/top-issues-confronting-hospitals-2015.cfm]

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Patient and Family Engagement Resource Compendium

A new resource compendium links users to key resources on patient and family engagement. The resources, each briefly described, are grouped into these categories:

  • Leadership
  • Organizational assessments
  • Patient and family advisory council/committee: resources for hospitals
  • Partnering to improve the quality of care
  • Engaging patients and families during the hospital stay
  • Health literacy: resources for providers
  • Health literacy: resources to help patients communicate with providers and manage medications
  • Health literacy: resources to help patients prevent adverse events in the hospital
  • Shared decision making
  • Engaging to reduce disparities

The compendium also explains how the resources can help in getting started with a new program or initiative, and it ends with a general bibliography of additional article references.

Patient and family engagement resource compendium. Health Research & Education Trust, Dec. 2015. http://www.hret-hen.org/topics/pfe/20160104-PFEcompendium.pdf

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Unplanned Revisits Following Ambulatory Surgery

The outpatient counterpart for hospital inpatient readmissions is revisits. Even though two-thirds of surgeries  are done on an outpatient revisit, less quality of care data has been available for unplanned revisits following outpatient surgery than for unplanned readmissions after an inpatient operation. Here are some initial benchmarks from one research team that looked at ambulatory surgeries performed in hospital-owned settings that had low surgical risk:

  • All-cause revisits within 30 days of ambulatory surgery: 95 per 1000 operations
  • Most revisits were to emergency departments: 59 per 1000 operations
  • Revisits to inpatient surgery setting: 27 per 1000 operations
  • Two-thirds of the revisits [65 per 1000 operations] were for complications related to the procedure, while the remaining revisits were attributed to unrelated conditions.

The authors indicate more research is needed to determine which of the ambulatory surgery complication revisits may be preventable.


Steiner CA and others. Return to acute care following ambulatory surgery. JAMA 314(13):1397-1399, Oct. 6, 2015. http://jama.jamanetwork.com/article.aspx?articleid=2449176

AHRQ study: ambulatory ‘revisits’ occur frequently, often due to complications. AHRQ Electronic Newsletter, no. 497, Dec. 8, 2015, p. 3. http://content.govdelivery.com/accounts/USAHRQ/bulletins/129ba69

Posted by AHA Resource Center (312) 422-2050 rc@aha.org

All-Cause Readmissions by Payer and Age, 2009-2013

A new report from the Agency for Healthcare Research and Quality examines all-cause readmission rates and costs for 2009-13. Here are some of the findings:

  • The overall readmission rate for all payers combined stayed about the same 14.0 per 100 readmission for all five years.
  • However, readmission rates for Medicare patients aged 65 and over [which have the highest readmission rates] declined 6.1%, from 17.3 per 100 admissions in 2009 to 16.2 in 2013.
  • For the uninsured, the readmission rate increased by 8.9% over five years, up to 11.1% per 100 admissions in 2013.
  • The average cost of a readmission was more than the average cost of an index admission for every payer category. For all payers combined, the readmission cost was about $3000 higher than the admission.

Additional data is provided for all-cause readmission rates, readmission numbers, and readmission costs by payer, patient age, and maternal status.

Source: Barrett ML and others. All-cause readmissions by payer and age, 2009-2013. HCUP Statistical Brief [Agency for Healthcare Research and Quality], no. 199, Dec. 2015. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb199-Readmissions-Payer-Age.pdf

Posted by AHA Resource Center (312) 422-2050 rc@aha.org

Back to the Future: Volume as a Quality Metric

At one time, volume was the major measure of quality because other measures were lacking. Now volume is getting renewed attention, and it seems common sense if practice makes perfect. While it’s not quite that straight forward, as Dr. Ashish K. Jha, discusses in a JAMA Forum article, volume does indeed matter but other factors can impact outcomes as well.

Quality leaders from 3 major academic health systems — Dartmouth-Hitchcock Medical Center, The Johns Hopkins Hospital and Health System, and the University of Michigan Health System — have begun a Take the Volume Pledge campaign to define a minimum annual volume threshold for hospitals and surgeons for surgeries.

Recommended volumes for 10 surgical procedures are being proposed by the group:

proposed ann surg vol jun15

Dr Jha mentions 2 issues for setting surgical volume standards: what to do about new surgeons, and the argument that setting  thresholds may be self-serving for high-volume surgeons or hospitals.


Jha AK. JAMA Forum: Back to the future: volume as a quality metric. JAMA News, June 10, 2015. http://newsatjama.jama.com/2015/06/10/jama-forum-back-to-the-future-volume-as-a-quality-metric

Sternberg S. Low volume hospitals – what to ask. US News & World Reports, May 18, 2015. http://www.usnews.com/news/articles/2015/05/18/low-volume-hospitals-what-to-ask


Clark C Limits urged on surgeries by low-volume providers. HealthLeaders Media, May 20, 2015.

Sternberg S. Hospitals move to limit low-volume surgeries. US News & World Reports, May 19, 2015. http://www.usnews.com/news/articles/2015/05/19/hospitals-move-to-limit-low-volume-surgeries

Sternberg S and Dougherty G. Risks are high at low-volume hospitals. US News & World Reports, May 18, 2015. http://www.usnews.com/news/articles/2015/05/18/risks-are-high-at-low-volume-hospitals

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Hospital Readmissions for Psychiatric Conditions

The Agency for Healthcare Research and Quality has released two new reports focused on psychiatric readmissions.

The first is a statistical brief looking at readmission rates for psychiatric conditions. It indicates the 30-day readmission rate for schizophrenia in 2012 was 15.7%, while it was 9% for primary diagnoses involving mood disorders. This compares to a 3.8% readmission rate for all other non-mental health/substance abuse conditions.

The second report comes from AHRQ’s Effective Health Care Program. It identifies and evaluates the research on strategies to reduce hospital readmissions for psychiatric conditions. It found availability and implementation of strategies varied widely and concluded more research is needed to determine which are most effective, especially in settings with varying resources.

Psychiatric readmissions are probably undercounted, according to the report. More research on ways to accurately measure the most meaningful outcomes for psychiatric conditions is also needed.

In 2012, nearly one quarter of U.S. adults experienced some form of mental or substance abuse disorder.


Heslin KC and Weiss AJ. Hospital readmissions involving psychiatric disorders, 2012. HCUP (Healthcare Cost and Utilization Project) Statistical Brief, no. 189, May 2015. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb189-Hospital-Readmissions-Psychiatric-Disorders-2012.pdf

Gaynes BN and others. Management strategies to reduce psychiatric readmissions. Effective Health Care Program Technical Brief no. 21,  May 21, 2015. http://www.effectivehealthcare.ahrq.gov/ehc/products/596/2082/psychiatric-readmissions-report-150521.pdf

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

Delirium May Be Under-Recognized Side Effect of Hospitalization

Patient delirium as a side effect of hospitalization has been in the news recently. It’s estimated to affect 7 million hospitalized patients each year, and while it can occur at any age, it generally affects the older population. Delirium costs the nation $143 billion annually, primarily due to longer hospital stays and follow-up nursing home care.

Delirium occurs suddenly and may fluctuate during the day. It differs from dementia that develops slowly and is progressive. Symptoms can range from agitation and combativeness to lethargy and inattention, and they may be under-diagnosed as delirium. The American Delirium Society estimates as many as 60% of delirium patients are undiagnosed.

Intensive care patients that are heavily sedated and on ventilators may be especially prone to delirium [also called ICU psychosis at one time], as many as 85% of them according to some studies. There are other diverse and multi-faceted delirium triggers as well, including large doses of anti-anxiety drugs and narcotics and the busy and noisy hospital environment itself.

As many as 40% of delirium cases may be preventable, according to some researchers. Delirium may lead to greater risk of falls, increased probability of developing dementia, and an accelerated death rate.

What are hospitals doing to prevent delirium?

  • Using medications more carefully, especially tranquilizers
  • Weaning ICU patients off ventilators sooner
  • Limiting use of restraints
  • Getting patients out of bed sooner
  • Softening the environment by shutting off room lights and minimizing noise.
  • Preserving sleep cycles
  • Ensuring patients have their eyeglasses and hearing aids to prevent disorientation
  • Keeping patients engaged with daily visitor programs
  • Using cognitive and other therapeutic activities

The Hospital Elder Life Program [HELP] has been implemented in 200 hospitals to prevent delirium development, with significant success.

Source: Boodman SG. For many patients, delirium is a surprising side effect of being the the hospital. Kaiser Health News, June 2, 2015. http://khn.org/news/for-many-patients-delirium-is-a-surprising-side-effect-of-being-in-the-hospital/


American Delirium Society: http://www.americandeliriumsociety.org/

Hospital Elder Life Program: http://www.hospitalelderlifeprogram and its delirium bibliography at http://www.hospitalelderlifeprogram.org/for-clinicians/bibliography/

Leslie DL and Inouye SK. The importance of delirium: economic and societal costs. Journal of the American Geriatrics Association 59(Supplement):S241-S243, Nov. 2011. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415302/

MacLullich AM and others. New horizons in the pathogenesis, assessment and management of delirium. Age and Ageing 42(6):667-674, Nov. 2013. http://ageing.oxfordjournals.org/content/42/6/667.long

Popeo DM. Delirium in older adults. Mt Sinai Journal of Medicine 78(4):571–582, July 2011. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136888/

Fong TG and others. Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews Neurology 5(4):210–220, April 2009. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/

Posted by AHA Resource Center (312) 422-2050, rc@aha.org