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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
151 to 175 of 193 Research Studies DisplayedMcHugh JP, Foster A, Mor V JP, Foster A, Mor V
Reducing hospital readmissions through preferred networks of skilled nursing facilities.
This study used a concurrent mixed-methods approach to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal skilled nursing facilities (SNF) networks.
AHRQ-funded; HS023961.
Citation: McHugh JP, Foster A, Mor V JP, Foster A, Mor V .
Reducing hospital readmissions through preferred networks of skilled nursing facilities.
Health Aff 2017 Sep;36(9):1591-98. doi: 10.1377/hlthaff.2017.0211..
Keywords: Care Coordination, Hospital Readmissions, Hospitals, Nursing Homes, Transitions of Care
Acher AW, Campbell-Flohr SA, Brenny-Fitzpatrick M
Improving patient-centered transitional care after complex abdominal surgery.
Poor-quality transitions of care from hospital to home contribute to high rates of readmission after complex abdominal surgery. The Coordinated Transitional Care (C-TraC) program improved readmission rates in medical patients, but evidence-based surgical transitional care protocols are still lacking. This pilot study evaluated the feasibility and preliminary effectiveness of an adapted surgical C-TraC protocol. The investigators concluded that a phone-based transitional care protocol for surgical patients is feasible, with <1% refusals and 95% engagement.
patients is feasible, with <1% refusals and 95% engagement.
AHRQ-funded; HS022446.
AHRQ-funded; HS022446.
Citation: Acher AW, Campbell-Flohr SA, Brenny-Fitzpatrick M .
Improving patient-centered transitional care after complex abdominal surgery.
J Am Coll Surg 2017 Aug;225(2):259-65. doi: 10.1016/j.jamcollsurg.2017.04.008..
Keywords: Patient-Centered Healthcare, Quality of Care, Quality Improvement, Surgery, Transitions of Care
Clark B, Baron K, Tynan-McKiernan K
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative study.
The purpose of this paper was to understand the perspectives of clinicians working at skilled nursing facilities (SNFs) regarding factors contributing to readmissions. SNF clinicians identified a broad range of factors that contributed to readmissions. The investigators suggest that addressing these factors may mitigate patients' risk of readmission from SNFs to acute care hospitals.
AHRQ-funded; HS023554.
Citation: Clark B, Baron K, Tynan-McKiernan K .
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative study.
J Hosp Med 2017 Aug;12(8):632-38. doi: 10.12788/jhm.2785..
Keywords: Hospital Readmissions, Nursing Homes, Quality Improvement, Transitions of Care
Berry J, Wilson K, Dumas H
Use of post-acute facility care in children hospitalized with acute respiratory illness.
In this retrospective analysis, the investigators assessed which children hospitalized with respiratory illness (RI) were the most likely to use post-acute facility care (PAC) for recovery. The investigators found that children with RI who were most likely to use PAC had a high prevalence of multiple chronic conditions, multiple medications, and medical technology.
AHRQ-funded; HS023092.
Citation: Berry J, Wilson K, Dumas H .
Use of post-acute facility care in children hospitalized with acute respiratory illness.
J Hosp Med 2017 Aug;12(8):626-31. doi: 10.12788/jhm.2780..
Keywords: Children/Adolescents, Hospitalization, Respiratory Conditions, Transitions of Care
Hewner S, Casucci S, Sullivan S
Integrating social determinants of health into primary care clinical and informational workflow during care transitions.
Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. This paper describes the coordinating transitions intervention which uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach.
AHRQ-funded; HS022575.
Citation: Hewner S, Casucci S, Sullivan S .
Integrating social determinants of health into primary care clinical and informational workflow during care transitions.
eGEMS 2017 Jul 4;5(2):2. doi: 10.13063/2327-9214.1282..
Keywords: Care Coordination, Chronic Conditions, Patient-Centered Healthcare, Social Determinants of Health, Transitions of Care
Wang SY, Aldridge MD, Gross CP
End-of-life care transition patterns of Medicare beneficiaries.
The researchers characterized the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132). They found that 218,731 had four or more transitions within the last 6 months of life. Women, blacks, individuals younger than 85, and individuals without dementia were more likely to have four or more transitions.
AHRQ-funded; HS023900.
Citation: Wang SY, Aldridge MD, Gross CP .
End-of-life care transition patterns of Medicare beneficiaries.
J Am Geriatr Soc 2017 Jul;65(7):1406-13. doi: 10.1111/jgs.14891.
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Keywords: Elderly, Medicare, Palliative Care, Transitions of Care
Sauser Zachrison K, Schwamm LH
Implementation of rapid treatment and interfacility transport for patients with suspected stroke by large-vessel occlusion: in one door and out the other.
This editorial discusses an article in this same issue of JAMA Neurology (McTaggart et al) that describes the results of the implementation of a standard protocol for patients with suspected emergent large-vessel occlusion (ELVO), and the protocol’s impact on both the process of care and patient outcomes. The editorial concludes that the McTaggart article challenges the medical community to develop an interdisciplinary, team-based, protocol-based approach to patients with potential ELVOs, and that work across the disciplines is needed to achieve an acceptable false-positive rate for the system.
AHRQ-funded; HS024561.
Citation: Sauser Zachrison K, Schwamm LH .
Implementation of rapid treatment and interfacility transport for patients with suspected stroke by large-vessel occlusion: in one door and out the other.
JAMA Neurol 2017 Jul;74(7):765-66. doi: 10.1001/jamaneurol.2017.0324..
Keywords: Brain Injury, Health Services Research (HSR), Healthcare Delivery, Stroke, Transitions of Care, Trauma
Jones CD, Bowles KH, Richard A
High-value home health care for patients with heart failure: an opportunity to optimize transitions from hospital to home.
Providing home health nursing and therapy could promote recovery in vulnerable HF patients with post-hospital syndrome and potentially reduce readmissions. The authors argue that understanding the characteristics of effective post-acute HHC for patients with HF will inform best practices, optimal outcomes for cost, and ultimately high-value care.
AHRQ-funded; HS024569.
Citation: Jones CD, Bowles KH, Richard A .
High-value home health care for patients with heart failure: an opportunity to optimize transitions from hospital to home.
Circ Cardiovasc Qual Outcomes 2017 May;10(5). doi: 10.1161/circoutcomes.117.003676.
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Keywords: Home Healthcare, Heart Disease and Health, Transitions of Care, Care Coordination, Medicare
Fernandes-Taylor S, Gunter RL, Bennett KM
Feasibility of implementing a patient-centered postoperative wound monitoring program using smartphone images: a pilot protocol.
The researchers propose a protocol of postoperative wound monitoring using smartphone digital images. Their study will help establish the feasibility of such a program, both for patients and for the clinical care team. The feasibility trial will confirm whether patients and their caregivers can learn to use a postdischarge wound monitoring smartphone app and will assess patient and provider satisfaction.
AHRQ-funded; HS023395.
Citation: Fernandes-Taylor S, Gunter RL, Bennett KM .
Feasibility of implementing a patient-centered postoperative wound monitoring program using smartphone images: a pilot protocol.
JMIR Res Protoc 2017 Feb 22;6(2):e26. doi: 10.2196/resprot.6819.
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Keywords: Telehealth, Health Information Technology (HIT), Surgery, Injuries and Wounds, Transitions of Care
Lindquist LA, Miller RK, Saltsman WS
SGIM-AMDA-AGS consensus best practice recommendations for transitioning patients' healthcare from skilled nursing facilities to the community.
The authors assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish.
AHRQ-funded; HS022916.
Citation: Lindquist LA, Miller RK, Saltsman WS .
SGIM-AMDA-AGS consensus best practice recommendations for transitioning patients' healthcare from skilled nursing facilities to the community.
J Gen Intern Med 2017 Feb;32(2):199-203. doi: 10.1007/s11606-016-3850-8.
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Keywords: Quality of Care, Long-Term Care, Nursing Homes, Primary Care, Transitions of Care
Natafgi N, Zhu X, Baloh J
Critical access hospital use of TeamSTEPPS to implement shift-change handoff communication.
Implementation of handoff as part of TeamSTEPPS initiatives for improving shift-change communication is examined via qualitative analysis of on-site interviews and process observations in 8 critical access hospitals. Comparing implementation attributes and handoff performance across hospitals shows that the purpose of implementation did not differentiate between high and low performance, but facilitators and barriers did.
AHRQ-funded; HS018396.
Citation: Natafgi N, Zhu X, Baloh J .
Critical access hospital use of TeamSTEPPS to implement shift-change handoff communication.
J Nurs Care Qual 2017 Jan/Mar;32(1):77-86. doi: 10.1097/ncq.0000000000000203.
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Keywords: Communication, Patient Safety, Quality Improvement, TeamSTEPPS, Transitions of Care
Broecker M, Ponto K, Tredinnick R
SafeHOME: promoting safe transitions to the home.
This paper introduces the SafeHome Simulator system, a set of immersive Virtual Reality Training tools and display systems to train patients in safe discharge procedures in captured environments of their actual houses. The aim is to lower patient readmission by significantly improving discharge planning and training. The SafeHOME Simulator is a project currently under review.
AHRQ-funded; HS022548.
Citation: Broecker M, Ponto K, Tredinnick R .
SafeHOME: promoting safe transitions to the home.
Stud Health Technol Inform 2016;220:51-4.
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Keywords: Transitions of Care, Health Information Technology (HIT), Patient Safety, Patient Self-Management, Hospital Discharge
Werner NE, Gurses AP, Leff B
Improving care transitions across healthcare settings through a human factors approach.
This article describes how a systems' approach known as Human Factors and Ergonomics can complement and further strengthen efforts to improve care transitions.
AHRQ-funded; HS022916.
Citation: Werner NE, Gurses AP, Leff B .
Improving care transitions across healthcare settings through a human factors approach.
J Healthc Qual 2016 Nov/Dec;38(6):328-43. doi: 10.1097/jhq.0000000000000025.
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Keywords: Healthcare Delivery, Provider, Hospital Discharge, Patient Safety, Transitions of Care
Johnson SA, Shi J, Groner JI
Inter-facility transfer of pediatric burn patients from U.S. Emergency Departments.
This study described the epidemiology of pediatric burn patients seen in U.S. emergency departments (EDs) in order to determine factors associated with inter-facility transfer. It concluded that over 90 percent of pediatric burn ED patients meet ABA burn referral criteria but are not transferred from low volume hospitals.
AHRQ-funded; HS022277.
Citation: Johnson SA, Shi J, Groner JI .
Inter-facility transfer of pediatric burn patients from U.S. Emergency Departments.
Burns 2016 Nov;42(7):1413-22. doi: 10.1016/j.burns.2016.06.024.
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Keywords: Healthcare Cost and Utilization Project (HCUP), Transitions of Care, Children/Adolescents, Emergency Medical Services (EMS), Guidelines
Harrod M, Montoya A, Mody L
Challenges for nurses caring for individuals with peripherally inserted central catheters in skilled nursing facilities.
The researchers sought to understand the perceived preparedness of frontline nurses (registered nurses (RNs), licensed practical nurses (LPNs)), unit nurse managers, and skilled nursing facility (SNF) administrators in providing care for residents with peripherally inserted central catheters (PICCs) in SNFs. They noted differences between resident self-reported PICC concerns (quality of life) and those described by frontline nurses.
AHRQ-funded; HS019979; HS022835.
Citation: Harrod M, Montoya A, Mody L .
Challenges for nurses caring for individuals with peripherally inserted central catheters in skilled nursing facilities.
J Am Geriatr Soc 2016 Oct;64(10):2059-64. doi: 10.1111/jgs.14341.
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Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Communication, Nursing, Quality of Life, Transitions of Care
Jones CE, Hollis RH, Wahl TS
Transitional care interventions and hospital readmissions in surgical populations: a systematic review.
The researchers performed a systematic review of transitional care interventions and their effect on hospital readmissions after surgery. Discharge planning programs reduced readmissions by 11.5 percent , 12.5 percent, and 23 percent . Patient education interventions reduced readmissions by 14 percent and 23.5 percent . Primary care follow-up reduced readmissions by 8.3 percent for patients after high-risk surgeries . Home visits reduced readmissions by 7.7 percent and 4 percent, respectively.
AHRQ-funded; HS013852.
Citation: Jones CE, Hollis RH, Wahl TS .
Transitional care interventions and hospital readmissions in surgical populations: a systematic review.
Am J Surg 2016 Aug;212(2):327-35. doi: 10.1016/j.amjsurg.2016.04.004.
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Keywords: Education: Patient and Caregiver, Hospital Discharge, Hospital Readmissions, Transitions of Care
Donovan JL, Kanaan AO, Gurwitz JH
A pilot health information technology-based effort to increase the quality of transitions from skilled nursing facility to home: compelling evidence of high rate of adverse outcomes.
The authors investigated whether or not patients transferred from skilled nursing facilities to home may be at risk for adverse outcomes. They tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days. They concluded that older adults discharged from skilled nursing facilities are at high risk of adverse outcomes immediately following discharge.
AHRQ-funded; HS017817.
Citation: Donovan JL, Kanaan AO, Gurwitz JH .
A pilot health information technology-based effort to increase the quality of transitions from skilled nursing facility to home: compelling evidence of high rate of adverse outcomes.
J Am Med Dir Assoc 2016 Apr;17(4):312-7. doi: 10.1016/j.jamda.2015.11.008.
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Keywords: Health Information Technology (HIT), Transitions of Care, Adverse Events, Elderly, Hospital Readmissions
Leyenaar JK, Lagu T, Lindenauer PK
Direct admission to the hospital: an alternative approach to hospitalization.
The authors discussed the role of hospital medicine in the changing epidemiology of hospital admissions, the potential risks and benefits of direct admission to the hospital, and the need for research to evaluate the safety and effectiveness of this admission approach. They proposed that transitions of care research and quality improvement be expanded to address transitions into the hospital.
AHRQ-funded; HS024133.
Citation: Leyenaar JK, Lagu T, Lindenauer PK .
Direct admission to the hospital: an alternative approach to hospitalization.
J Hosp Med 2016 Apr;11(4):303-5. doi: 10.1002/jhm.2512.
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Keywords: Emergency Department, Emergency Medical Services (EMS), Hospitalization, Transitions of Care
Vora AN, Peterson ED, Hellkamp AS
Care transitions after acute myocardial infarction for transferred-in versus direct-arrival patients.
Many patients in the United States require transfer from one hospital to another for acute myocardial infarction (MI) care. How well these transferred-in patients are transitioned back to their local community is unknown. This study found that transferred-in patients with acute MI are less likely to have outpatient clinic follow-up within 30 days and more likely to be readmitted within the first 30 days post discharge compared with direct-arrival patients.
AHRQ-funded; HS021092.
Citation: Vora AN, Peterson ED, Hellkamp AS .
Care transitions after acute myocardial infarction for transferred-in versus direct-arrival patients.
Circ Cardiovasc Qual Outcomes 2016 Mar;9(2):109-16. doi: 10.1161/circoutcomes.115.002108.
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Keywords: Transitions of Care, Hospital Readmissions, Cardiovascular Conditions, Patient-Centered Outcomes Research, Hospital Discharge
Dharmarajan K, Chaudhry SI
New approaches to reduce readmissions in patients with heart failure.
The authors discuss a study by Ong and colleagues that presents the results of Better Effectiveness After Transition–Heart Failure (BEATHF), a randomized clinical trial of a combined telemonitoring and care transitions intervention to prevent readmission in patients with heart failure. The BEAT-HF intervention did not lower readmissions after hospitalization for heart failure.
AHRQ-funded; HS023554.
Citation: Dharmarajan K, Chaudhry SI .
New approaches to reduce readmissions in patients with heart failure.
JAMA Intern Med 2016 Mar;176(3):318-20. doi: 10.1001/jamainternmed.2015.7993.
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Keywords: Heart Disease and Health, Hospital Discharge, Hospital Readmissions, Quality of Life, Transitions of Care
Kansagara D, Chiovaro JC, Kagen D
So many options, where do we start? An overview of the care transitions literature.
The purpose of this paper is to summarize the health and utilization effects of transitional care interventions, and to identify common themes about intervention types, patient populations, or settings that modify these effects. The authors found evidence that enhanced discharge planning and hospital-at-home interventions reduced readmissions. They further found that transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations.
AHRQ-funded; HS022981.
Citation: Kansagara D, Chiovaro JC, Kagen D .
So many options, where do we start? An overview of the care transitions literature.
J Hosp Med 2016 Mar;11(3):221-30. doi: 10.1002/jhm.2502.
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Keywords: Caregiving, Hospital Discharge, Hospital Readmissions, Transitions of Care
Acher AW, LeCaire TJ, Hundt AS
Using human factors and systems engineering to evaluate readmission after complex surgery.
The study objective was to use a human factors and systems engineering approach to understand contributors to surgical readmissions from a patient and provider perspective. Patients and clinician providers identified a number of factors during the transition of care that may have contributed to readmission, including poor patient and caregiver understanding; inadequate discharge preparation for home care; insufficient educational process and materials.
AHRQ-funded; HS022446.
Citation: Acher AW, LeCaire TJ, Hundt AS .
Using human factors and systems engineering to evaluate readmission after complex surgery.
J Am Coll Surg 2015 Oct;221(4):810-20. doi: 10.1016/j.jamcollsurg.2015.06.014..
Keywords: Surgery, Hospital Readmissions, Hospital Discharge, Transitions of Care, Electronic Health Records (EHRs)
Sawicki GS, Garvey KC, Toomey SL
Development and validation of the adolescent assessment of preparation for transition: a novel patient experience measure.
The authors developed an adolescent-reported measure of the quality of health care transition (HCT) preparation received from pediatric health care providers. They found that the Adolescent Assessment of Preparation for Transition (ADAPT) is a reliable, validated instrument measuring the quality of HCT preparation experiences reported by adolescents with chronic disease.
AHRQ-funded; HS020513.
Citation: Sawicki GS, Garvey KC, Toomey SL .
Development and validation of the adolescent assessment of preparation for transition: a novel patient experience measure.
J Adolesc Health 2015 Sep;57(3):282-7. doi: 10.1016/j.jadohealth.2015.06.004.
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Keywords: Children/Adolescents, Chronic Conditions, Patient Experience, Quality of Care, Transitions of Care
Gupta K, Mueller SK
Interhospital transfers: the need for standards.
Patient transfers from one hospital to another are common and occur for a multitude of reasons with varied outcomes. The authors discuss interhospital transfers and difficulties encountered by the providers who care for these patients. They recommend further research to identify more clearly which patients are most likely to benefit from transfer and why.
AHRQ-funded; HS023331.
Citation: Gupta K, Mueller SK .
Interhospital transfers: the need for standards.
J Hosp Med 2015 Jun;10(6):415-7. doi: 10.1002/jhm.2320.
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Keywords: Case Study, Shared Decision Making, Elderly, Patient Safety, Transitions of Care
Marcum ZA, Hardy SE
Medication management skills in older skilled nursing facility residents transitioning home.
The objective of this pilot study was to describe potential medication management deficiencies of older SNF residents transitioning home. It found that medication management deficiencies were found to be common in a high-risk group of elderly adults making this important transition.
AHRQ-funded; HS020831.
Citation: Marcum ZA, Hardy SE .
Medication management skills in older skilled nursing facility residents transitioning home.
J Am Geriatr Soc 2015 Jun;63(6):1266-8. doi: 10.1111/jgs.13469..
Keywords: Patient Safety, Nursing Homes, Elderly, Medication, Transitions of Care