LeRoi S. Hicks, M.D., MPH

Hugh R. Sharp, Jr. Chair, Department of Medicine; Service Line Leader, Acute Medicine

Publications

Predictors and Outcomes of Patient Knowledge of Plan of Care in Hospital Medicine: A Quality Improvement Study
Predictors and Outcomes of Patient Knowledge of Plan of Care in Hospital Medicine: A Quality Improvement Study
Bhamidipati VS, Hicks LS, Caplan R, Ingraham B, Rn PM, Robinson EJ

Jt Comm J Qual Patient Saf 2021 03;47(3):176-184

PMID: 33454235

Abstract

BACKGROUND">Patient understanding of plan of care is associated with positive outcomes in ambulatory settings. In hospital medicine settings, patient-physician agreement on plan of care (concordance) has been limited and difficult to improve. This study examined the impact of adding a hospitalist to interdisciplinary rounds (IDR) on physician-patient-nurse concordance and the relationship between concordance and outcomes.</Abstr: Patient understanding of plan of care is associated with positive outcomes in ambulatory settings. In hospital medicine settings, patient-physician agreement on plan of care (concordance) has been limited and difficult to improve. This study examined the impact of adding a hospitalist to interdisciplinary rounds (IDR) on physician-patient-nurse concordance and the relationship between concordance and outcomes.

METHODS">IDR were conducted by core teams made up of unit-based nurses, a case manager, and a pharmacist. Over time, with cohorting, hospitalists were included in IDR (hospitalist IDR) for some patients assigned to unit-based hospitalists. In developing hospitalist IDR, the researchers emphasized using an IDR checklist, including a patient communication plan. Patient-nurse-physician interviews were used to assess concordance in the domains of diagnosis, tests and procedures, and expected discharge date. Using two-hospitalist review, agreement was rated as none, partial, or complete, and a total concordance score was calculated for each patient in both IDR groups. Multivariate analysis was used to examine the relationship between concordance, IDR type, patient factors, and utilization outcomes.</Abstr: IDR were conducted by core teams made up of unit-based nurses, a case manager, and a pharmacist. Over time, with cohorting, hospitalists were included in IDR (hospitalist IDR) for some patients assigned to unit-based hospitalists. In developing hospitalist IDR, the researchers emphasized using an IDR checklist, including a patient communication plan. Patient-nurse-physician interviews were used to assess concordance in the domains of diagnosis, tests and procedures, and expected discharge date. Using two-hospitalist review, agreement was rated as none, partial, or complete, and a total concordance score was calculated for each patient in both IDR groups. Multivariate analysis was used to examine the relationship between concordance, IDR type, patient factors, and utilization outcomes.

RESULTS">For 658 patients, the mean concordance score was 11.71 out of a possible 18. There was no difference in concordance between hospitalist and core IDR groups (11.68 vs. 11.84, p = 0.7). Higher total concordance score was associated with lower lengths of stay (p < 0.001) and readmission rates (p = 0.001). Total concordance had a negative association with patient age (p = 0.04).</Abstr: For 658 patients, the mean concordance score was 11.71 out of a possible 18. There was no difference in concordance between hospitalist and core IDR groups (11.68 vs. 11.84, p = 0.7). Higher total concordance score was associated with lower lengths of stay (p < 0.001) and readmission rates (p = 0.001). Total concordance had a negative association with patient age (p = 0.04).

CONCLUSION">Concordance did not change with IDR type. Higher concordance appears to be related to positive utilization outcomes. Future studies are needed to evaluate potential interventions to improve concordance.Copyright © 2020 The Joint Commission. Published by Elsevier Inc. All rights reserved.</CopyrightInfo: Concordance did not change with IDR type. Higher concordance appears to be related to positive utilization outcomes. Future studies are needed to evaluate potential interventions to improve concordance.

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Frequency of Sale and Reasons for Purchase of Over-the-Counter Insulin in the United States
Frequency of Sale and Reasons for Purchase of Over-the-Counter Insulin in the United States
Goldstein JN, Patel RM, Bland K, Hicks LS

JAMA Intern Med 2019 05;179(5):722-723

PMID: 30776058

Abstract

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Impact of care coordination based on insurance and zip code
Impact of care coordination based on insurance and zip code
Goldstein JN, Shinwari M, Kolm P, Elliott DJ, Weintraub WS, Hicks LS

Am J Manag Care 2019 06;25(6):e173-e178

PMID: 31211549

Abstract

OBJECTIVES: To examine whether a care transitions program, Bridges, differentially reduced rehospitalizations among patients who underwent percutaneous coronary intervention (PCI) based on insurance status and zip code poverty level.
STUDY DESIGN: Retrospective observational cohort.
METHODS: We examined data from a single health system in Delaware, collected as part of a care transitions program for patients who underwent PCI from 2012 to 2015 compared with an unmatched historical control cohort from 2010 to 2011. Socioeconomic status was assessed by insurance status and zip code-level poverty data. Patients were divided into tertiles based on the proportion of their zip code of residence living under 100% of the federal poverty level. Rehospitalization rates were analyzed by negative binomial regression and included interaction terms to examine differential effects of Bridges by insurance and poverty level.
RESULTS: There were 4638 patients representing 5710 hospitalizations: 3212 in the historical control and 2498 in the Bridges cohort. Among patients with Medicaid who received the Bridges intervention, those living in the wealthiest zip codes were 15.5% less likely to be rehospitalized than patients with Medicare and 9.4% less likely than patients with commercial insurance (P = .04). However, patients with Medicaid who lived in the poorest zip codes and those with dual Medicare/Medicaid status had higher rates of rehospitalization post intervention.
CONCLUSIONS: The Bridges intervention was associated with improved rehospitalization rates for Medicaid patients compared with those with Medicare or commercial insurance within Delaware's wealthier communities. Care transitions programs may differentially affect Medicaid patients based on the wealth of the communities in which they reside.
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"Implications of cost-sharing for observation care among Medicare beneficiaries: a pilot survey"
"Implications of cost-sharing for observation care among Medicare beneficiaries: a pilot survey"
Goldstein JN, Schwartz JS, McGraw P, Hicks LS

BMC Health Serv Res 2019 Mar;19(1):149

PMID: 30845953

Abstract

BACKGROUND: Medicare beneficiaries hospitalized under observation status have significant cost-sharing responsibilities under Medicare Part B. Prior work has demonstrated an association between increased cost-sharing and health care rationing among low-income Medicare beneficiaries. The objective of this study was to explore the potential impact of observation cost-sharing on future medical decision making of Medicare beneficiaries.
METHODS: Single-center pilot cohort study. A convenience sample of Medicare beneficiaries hospitalized under observation status care was surveyed.
RESULTS: Out of 144 respondents, low-income beneficiaries were more likely to be concerned about the cost of their observation stay than higher-income respondents (70.7% vs29.3%, p = 0.015). If hospitalized under observation status again, there was a trend among low-income beneficiaries to request completion of their workup outside of the hospital (56.3% vs 43.8%), and to consider leaving against medical advice (AMA) (100% vs 0%), though these trends were not statistically significant (p = 0.30).
CONCLUSION: The results of this pilot study suggest that low-income Medicare beneficiaries hospitalized under observation status have greater concerns about their cost-sharing obligations than their higher income peers. Cost-sharing for observation care may have unintended consequences on utilization for low-income beneficiaries. Future studies should examine this potential relationship on a larger scale.
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The Unmet Need for Postacute Rehabilitation Among Medicare Observation Patients: A Single-Center Study
The Unmet Need for Postacute Rehabilitation Among Medicare Observation Patients: A Single-Center Study
Goldstein JN, Schwartz JS, McGraw P, Banks TL, Hicks LS

J Hosp Med 2017 03;12(3):168-172

PMID: 28272593

Abstract

BACKGROUND: Medicare beneficiaries admitted under observation status must pay for postacute inpatient rehabilitation (PAIR) services, out of pocket, at potentially prohibitive costs.
OBJECTIVE: To determine if there is an unmet need for PAIR among Medicare observation patients and if this care is associated with longer hospital stay and increased rehospitalization.
DESIGN/SETTING: Observational study using electronic medical record and administrative data from a regional health system.
PATIENTS: 1323 community-dwelling Medicare patients admitted under observation status.
MEASUREMENTS: Summary statistics were calculated for demographic and administrative variables. Physical therapy (PT) and case management recommendations for a representative sample of 386 medical records were reviewed regarding need for PAIR services. Linear regression was used to measure the association between PT recommendation and hospital length of stay, adjusting for ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis, age, sex, and provider. Chi-square test was used to determine the association between PT recommendation and 30-day hospital revisit.
RESULTS: Of the 1323 study patients, 11 (0.83%) were discharged to PAIR facilities. However, 17 (4.4%) of the 386 patients whose charts were reviewed received a recommendation for this care. Adjusted mean hospital stay was longer (P ⟨ 0.001) for patients recommended for rehabilitation (75.9 h) than for patients with no PT needs (46.8 h). In addition, the 30-day hospital revisit rate was higher (P = 0.037) for the patients who had been recommended for rehabilitation (52.9%, 9/17) than for those who had not (25.4%, 30/118).
CONCLUSIONS: Medicare observation patients' potential need for PAIR services is 5- to 6-fold higher than their use of these services. Observation patients recommended for this care may have worse outcomes. Journal of Hospital Medicine 2017;12:168-172.
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Observation Status, Poverty, and High Financial Liability Among Medicare Beneficiaries
Observation Status, Poverty, and High Financial Liability Among Medicare Beneficiaries
Goldstein JN, Zhang Z, Schwartz JS, Hicks LS

Am. J. Med. 2018 Jan;131(1):101.e9-101.e15

PMID: 28774801

Abstract

BACKGROUND: Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries.
METHODS: We performed a retrospective, observational analysis of Medicare Part B claims and US Census Bureau data from 2013. Medicare beneficiaries with Part A and B coverage for the full calendar year, with 1 or more observation stay(s), were included in the study. Beneficiaries were divided into quartiles representing poverty level. The associations between poverty quartile and high use of observation care and between poverty quartile and high financial liability for observation care were evaluated.
RESULTS: After multivariate adjustment, the risk of high use was higher for beneficiaries in the poor (Quartile 3) and poorest (Quartile 4) quartiles compared with those in the wealthiest quartile (Quartile 1) (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.13-1.31; AOR, 1.24; 95% CI, 1.16-1.33). The risk of high financial liability was higher in every poverty quartile compared with the wealthiest and peaked in Quartile 3, which represented the poor but not the poorest beneficiaries (AOR, 1.17; 95% CI, 1.10-1.24).
CONCLUSIONS: Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability.
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Is the Care Transitions Measure Associated with Readmission Risk? Analysis from a Single Academic Center
Is the Care Transitions Measure Associated with Readmission Risk? Analysis from a Single Academic Center
Goldstein JN, Hicks LS, Kolm P, Weintraub WS, Elliott DJ

J Gen Intern Med 2016 07;31(7):732-8

PMID: 26868279

Abstract

BACKGROUND: It is widely hypothesized that improvement in transitions of care will reduce unplanned hospital readmissions. However, the association between the Care Transitions Measure, the national quality metric for transitions of care and readmission risk, has not been established.
OBJECTIVE: We aimed to determine the association between the Care Transition Measure and readmission.
DESIGN: This was a single-center, prospective cohort study.
PARTICIPANTS: Convenience sample of 2,963 patients enrolled in the "Bridging the Divides" program, a longitudinal care management program for patients with coronary revascularization, from 2013 to 2014. Of these, 1594 (54 %) patients completed a post-discharge Care Transition Measure questionnaire.
INTERVENTION: Care Transition Measure scores were collected by trained research staff blinded to study hypothesis, by telephone, within 30 days of discharge. Higher Care Transition Measure scores reflect a higher quality transition of care.
MAIN MEASURES: 30-day readmission was measured.
KEY RESULTS: Of the1594 patients that completed the Care Transition Measure survey, 1216 (76 %) received percutaneous coronary intervention and 378 (24 %) received coronary artery bypass grafting. Mean Care Transition Measure scores were significantly lower among patients who had a prior admission (77.2 vs. 82.1, p < 0.001) and those with ≥ 5 comorbidities (77 vs. 82.6 vs. 81.6, p < 0.001). Mean scores were significantly lower among patients who were readmitted within the percutaneous coronary intervention subgroup (73 vs. 80.9, p < 0.001) and the total study population (74.6 vs. 81.1, p < 0.001) compared to those who were not readmitted. This was not the case in the coronary artery bypass grafting subgroup (78.5 vs. 81.7, p = 0.29). After multivariable adjustment, every ten-point increase in the Care Transition Measure score was associated with a 14 % reduction in readmission risk (adjusted odds ratio 0.86, 95 % CI 0.78-0.95).
CONCLUSIONS: The Care Transition Measure is strongly associated with readmissions, which strengthens its validity. However, its association with patient variables linked with readmission and its inconsistent association with readmission across clinical groups raises concerns that scores may be influenced by patient characteristics.
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