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INTRODUCTION - Hospital readmissions within 30 days are a healthcare quality problem associated with increased costs and poor health outcomes. Identifying interventions to improve patients' successful transition from inpatient to outpatient care is a continued challenge.
METHODS AND ANALYSIS - This is a single-centre pragmatic randomised and controlled clinical trial examining the effectiveness of a discharge follow-up phone call to reduce 30-day inpatient readmissions. Our primary endpoint is inpatient readmission within 30 days of hospital discharge censored for death analysed with an intention-to-treat approach. Secondary endpoints included observation status readmission within 30 days, time to readmission, all-cause emergency department revisits within 30 days, patient satisfaction (measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems scores) and 30-day mortality. Exploratory endpoints include the need for assistance with discharge plan implementation among those randomised to the intervention arm and reached by the study nurse, and the number of call attempts to achieve successful intervention delivery. Consistent with the Learning Healthcare System model for clinical research, timeliness is a critical quality for studies to most effectively inform hospital clinical practice. We are challenged to apply pragmatic design elements in order to maintain a high-quality practicable study providing timely results. This type of prospective pragmatic trial empowers the advancement of hospital-wide evidence-based practice directly affecting patients.
ETHICS AND DISSEMINATION - Study results will inform the structure, objective and function of future iterations of the hospital's discharge follow-up phone call programme and be submitted for publication in the literature.
TRIAL REGISTRATION NUMBER - NCT03050918; Pre-results.
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BACKGROUND - Patient portal adoption has rapidly increased over the last decade. Most patient portal research has been done in primary care or medical specialties, and few studies have examined their use in surgical patients or for recruiting research subjects. No known studies have compared portal messaging with other approaches of recruitment.
OBJECTIVES - This case report describes our experience with patient portal versus telephone recruitment for a study involving long-term follow up of surgical patients.
METHODS - Participants were recruited for a study of recurrence after ventral hernia repair through telephone calls and patient portal messaging based on registration status with the portal. Potential subjects who did not have a portal account or whose portal messages were returned after 5 days were called. The proportion of participants enrolled with each method was determined and demographics of eligible patients, portal users, and participants were compared.
RESULTS - 1359 patients were eligible for the hernia study, and enrollment was 35% (n=465). Most participants were recruited by telephone (84%, n=391); 16% (n=74) were recruited through portal messaging. Forty-four percent of eligible participants had a registered portal account, and 14% of users responded to the recruitment message. Portal users were younger than non-users (55 vs. 58 years, p<0.001); participants recruited through the portal versus telephone were also younger (54 vs. 59 years, p=0.001). Differences in the sex and racial distributions between users and non-users and between portal and telephone recruits were not significant.
CONCLUSIONS - Portal versus telephone recruitment for a surgical research study demonstrated modest portal recruitment rates and similar demographics between recruitment methods. Published studies of portal-only recruitment in primary care or medical-specialty patient populations have demonstrated higher enrollment rates, but this case study demonstrates that portal recruitment for research studies in the surgical population is feasible, and it offers convenience to patients and researchers.
BACKGROUND - Early-stage diagnosis of colorectal cancer is associated with high survival rates; screening prevalence, however, remains suboptimal.
PURPOSE - This study seeks to test the hypothesis that participants receiving telephone-based tailored education or motivational interviewing had higher colorectal cancer screening completion rates compared to usual care.
METHODS - Primary care patients not adherent with colorectal cancer screening and with no personal or family history of cancer (n = 515) were assigned by block randomization to control (n = 169), tailored education (n = 168), or motivational interview (n = 178). The response rate was 70%; attrition was 24%.
RESULTS - Highest screening occurred in the tailored education group (23.8%, p < .02); participants had 2.2 times the odds of completing a post-intervention colorectal cancer screening than did the control group (AOR = 2.2, CI = 1.2-4.0). Motivational interviewing was not associated with significant increase in post-intervention screening.
CONCLUSIONS - Tailored education showed promise as a feasible strategy to increase colorectal cancer screening.
PURPOSE - Patients receiving cancer-related thoracotomy are highly symptomatic in the first weeks after surgery. This study examined whether at-home symptom monitoring plus feedback to clinicians about severe symptoms contributes to more effective postoperative symptom control.
PATIENTS AND METHODS - We enrolled 100 patients receiving thoracotomy for lung cancer or lung metastasis in a two-arm randomized controlled trial; 79 patients completed the study. After hospital discharge, patients rated symptoms twice weekly for 4 weeks via automated telephone calls. For intervention group patients, an e-mail alert was forwarded to the patient's clinical team for response if any of a subset of symptoms (pain, disturbed sleep, distress, shortness of breath, or constipation) reached a predetermined severity threshold. No alerts were generated for controls. Group differences in symptom threshold events were examined by generalized estimating equation modeling.
RESULTS - The intervention group experienced greater reduction in symptom threshold events than did controls (19% v 8%, respectively) and a more rapid decline in symptom threshold events. The difference in average reduction in symptom interference between groups was -0.36 (SE, 0.078; P = .02). Clinicians responded to 84% of e-mail alerts. Both groups reported equally high satisfaction with the automated system and with postoperative symptom control.
CONCLUSION - Frequent symptom monitoring with alerts to clinicians when symptoms became moderate or severe reduced symptom severity during the 4 weeks after thoracic surgery. Methods of automated symptom monitoring and triage may improve symptom control after major cancer surgery. These results should be confirmed in a larger study.
UNLABELLED - Development and pilot testing of a disease management program for low literacy patients with heart failure.
BACKGROUND - Randomized trials have shown that disease management programs can reduce hospitalizations and improve symptoms for patients with congestive heart failure. We sought to create and pilot test such a program for patients with low literacy skills.
METHODS - We used focus groups and individual cognitive response interviews (CRIs) to develop an educational booklet for low literacy patients with heart failure. We incorporated the booklet into a disease management intervention that also included an initial individualized 1-h educational session and scheduled supportive phone calls that were tapered over 6 weeks. We then conducted a 3-month before-after study on patients with low literacy skills (<9th grade literacy level) in a university internal medicine clinic to test the acceptability and efficacy of our program. Outcomes of interest included heart failure-related knowledge, self-care behavior and heart failure-related symptoms measured on the Minnesota Living with Heart Failure (MLwHF) scale.
RESULTS - Twenty-five patients were enrolled and 23 (92%) completed 3-month follow-up. Mean age was 60 years (range 35-74), 60% were men, 60% were African-American, and 74% had household income under $15,000 per year. The median reading level was fifth grade with 32% reading at or below the third grade level. Mean knowledge score at baseline was 67% and did not improve after the intervention. The proportion of patients reporting weighing themselves daily increased from 32% at baseline to 100% at 12 weeks. Mean improvement on the MLwHF scale was 9.9 points over the 3-month trial (95% CI: 0.5, 19.2), which corresponds to an improvement in one class on the New York Heart Association heart failure scale.
CONCLUSION - A heart failure disease management program designed specifically for patients with low literacy skills is acceptable and is associated with improvement in self-care behavior and heart failure related symptoms.
Low-income women have a high mortality from breast cancer. Yet, they participate in breast cancer early detection screening programs less than women in the general population. An intervention study to improve screening mammography rates of low-income women participating in Tennessee's TennCare program (state Medicaid and Medicare program) revealed significant barriers to reaching these women. Intervention methods included mail, telephone calls, and home visits. Results indicate that only 38 percent of the women could be contacted for a baseline survey. Reasons for noncontact included absence from home (39 percent), having moved (22 percent), refusal to participate (17 percent), having no physical domicile (15 percent), language barriers (4 percent), and miscellaneous other factors (4 percent). Women with telephones tended to have a relatively higher economic status and were more successfully reached than women without telephones. These findings provide useful insights for future program planning and research design.
The question of when to survey patients is the subject of ongoing debate because of the rising interest in monitoring quality from the consumer's perspective. This study of 772 randomly assigned patients from 17 hospitals compared results from predischarge in-person interviews (HI) and postdischarge telephone interviews (PHTI) for differences in participation rates, respondents' characteristics, and reports of quality most affected by nursing. The methods were equally costly. The results suggest that hospital interviews may enhance response rates of some vulnerable patient groups without jeopardizing the results.
As part of a study of patient-centered care outcomes that requires the ability to be interviewed by telephone after hospitalization, 4,600 adult patients on 118 medical-surgical units in 17 midwestern hospitals selected by stratified random sampling were identified as potential subjects. This article describes response-rate differences and reasons for nonparticipation by gender, age, ethnicity, and race. Issues related to understanding and reporting response rates, reducing losses due to ineligibility, dealing with refusals, and tailoring survey approaches to special populations are discussed.