Unplanned readmissions following surgery are associated with increased morbidity and mortality. Health systems are focusing more heavily on readmissions as some Affordable Care Act provisions withhold reimbursement for unplanned readmissions. Given that these provisions will begin to impact surgery reimbursements by 2015, this provides a critical window to identify and address factors influencing unplanned surgery readmissions. In this study, we focus on colorectal surgery as it occurs frequently within the VA, is associated with high readmission rates (13-16%), and has significant cost implications ($18,000 per readmission). No interventions specifically target this population at or immediately following discharge to reduce unplanned readmissions. Evidence-based interventions have demonstrated reductions in readmissions, e.g., Project Re-Engineered Discharge (RED), by standardizing the hospital discharge process to improve care transitions for patients with medical illnesses. In addition to standardization, we have adapted this evidence based intervention to the context of a VA surgical service (RED-S) using empiric evidence and expert consensus.
The specific objective of this study is to evaluate the feasibility and formative implementation of the Re-Engineered Discharge-Surgery (RED-S) intervention. The specific aims of this Rapid Response Proposal include, aim 1: to assess acceptability and feasibility of RED-S components using cognitive interviews with Veterans, their caregivers and clinicians in a high-volume VA surgical service; and aim 2: to conduct a formative evaluation of the implementation of RED-S with a pilot sample of Veterans and their clinicians following colorectal surgery.
To achieve these objectives, we conducted a mixed-methods formative evaluation, culminating in the adaptation and pilot testing of acceptability and feasibility of RED-S among Veterans being discharged following colorectal surgery. Our prior work refined the evidence-based Project RED intervention for the context of VA operative care line services, including adaptations for patient-reported symptoms and experts' recommendations for health-coaching instructions to avoid unplanned readmissions following colorectal surgery. In aim 1, we completed adaptation and elicited acceptability of this adapted RED-S intervention using cognitive interviews with Veterans following colorectal surgery and their caregivers and clinicians. 11 Clinicians and staff completed the formative evaluation interviews including the Organizational Readiness for Change Assessment (ORCA) to provide perceptions of evidence, context and facilitation of the intervention. 12 Patients and their caregivers completed cognitive interviews about the After Hospital Care Plan that was given to patients at discharge.
In aim 2, we conducted a feasibility pilot of Project RED-S using implementation-focused formative evaluation consisting of surveys and interviews with a sample of Veterans following colorectal surgery. Of the 44 patients we consented for Aim 2, 26 completed surgery and 21 (81%) of those completed our 30 day follow-up surveys. The results of this study will inform larger implementation studies of RED-S.
In aim 1, cognitive interviews with Veterans revealed that the After Hospital Care Plan has positive features such as its layout, color, personalization, assistance in self-care, readability/ understanding of content, and provider contact information. Suggested areas for improvement include clarity, layout, and providing additional information in certain content areas. Formative evaluation interviews with staff and providers revealed potential barriers and facilitators to RED-S acceptance and implementation. The results of the ORCA survey demonstrated that frontline staff and clinical administrators are in agreement regarding strength of evidence and feasibility of the program. Front line staff and administrators deviated in perceptions of organizational context to support implementation, scoring lower than administrators in several subscales of context, including senior leadership culture (p=0.001), leadership feedback and data transparency (p=0.002), and resources to support change (p=<0.001). Qualitative themes suggested implementation barriers such as lack of communication and lack of clear expectations from administrators, and added workload on frontline staff were barriers to implementation. Themes also suggested positive organizational characteristics that are likely to improve effectiveness of implementation, including shared focus on patient-centered care and commitment to patient care innovation.
In aim 2, post-discharge interviews with veterans highlighted improvements in the discharge processes, and improved clinical quality of care using the Care Transitions Measure (CTM3).
Compared with Veterans discharge prior to RED-S implementation, Veterans in the pilot were more likely to endorse the statements, "Staff took my preferences and those of my family or caregiver into account" (94.4% vs 48%; p<.05); "I had a good understanding of the purposes for my medications" (100% vs 58.2%; p<.05) "at discharge I had a good understanding of things I am responsible for in managing my health" (89.5% vs 69.2%; p=.10).
Preliminary data indicates that four out of the 26 patients that consented were readmitted to the hospital within 30 days of their discharge. This rate is consistent with the hospital average and not a reduction from pre-implementation rates. However, our formative evaluation indicated barriers to implementation with moderate uptake of intervention components during the pilot (only 47% of Veterans received RED-S after hospital care plans and only 18% received pharmacist-directed medication reconciliation). As RED-S is more consistently implemented and used by hospital staff, we anticipate better overall readmission outcomes.
The anticipated impact of a fully implemented RED-S includes improved discharge processes with greater reliability of intervention components (medication reconciliation, patient education with teach-back of warning signs, following appointment set, and follow-up call made), which result in reductions in unplanned hospital readmissions for colorectal surgery patients and improved long-term health outcomes.
- Naik AD, Horstman MJ, Li LT, Paasche-Orlow MK, Campbell B, Mills WL, Herman LI, Anaya DA, Trautner BW, Berger DH. User-centered design of discharge warnings tool for colorectal surgery patients. Journal of the American Medical Informatics Association : JAMIA. 2017 Sep 1; 24(5):975-980.
- Horstman MJ, Mills WL, Herman LI, Cai C, Shelton G, Qdaisat T, Berger DH, Naik AD. Patient experience with discharge instructions in postdischarge recovery: a qualitative study. BMJ open. 2017 Feb 22; 7(2):e014842.
- Li LT, Mills WL, Gutierrez AM, Herman LI, Berger DH, Naik AD. A patient-centered early warning system to prevent readmission after colorectal surgery: a national consensus using the Delphi method. Journal of the American College of Surgeons. 2013 Feb 1; 216(2):210-6.e6.
- Horstman MJ, Mills WL, Herman LI, Cai C, Shelton G, Qdaisat T, Berger DH, Naik AD. Patient Experience with Discharge Instructions in Post-Discharge Recovery. Poster session presented at: National Society of Hospital Medicine Annual Conference; 2016 Mar 7; San Diego, CA.
- Robinson C, Shelton G, Trautner B, Li LT, Berger DH, Anaya D, Awad S, Naik AD. The implementation of a comprehensive discharge pathway for colorectal surgery patients (Project RED-Surgery). Poster session presented at: Association of VA Surgeons Annual Meeting; 2015 May 3; Miami, FL.
- Trautner B, Campbell B, Herman LI, Poppelaars V, Berger DH, Anaya D, Awad S, Naik AD. Developing patient-centric discharge instructions to prevent readmissions after colorectal surgery. Poster session presented at: American Surgical Association Annual Meeting; 2015 Feb 3; Las Vegas, NV.
- Shelton G, Naik AD, Penner M, Floyd K, Harmon A, Crowley Q, McMaster-Baxter N, Hostman M, Cowart J, Trautner B. Project RED: Quality Improvement (QU) with Exploratory and Prescriptive Benefits. Poster session presented at: Baylor College of Medicine Quality and Safety Annual Conference; 2014 May 15; Houston, TX.
- Shelton G, Naik AD. Known Enemy to the Kidney. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.
- Shelton G, Naik AD. Project RED: Quality Improvement (QUI) with Exploratory and Prescriptive Benefits. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.
- Campbell B, Naik AD. Designing and after hospital care plan for the colorectal surgery patient. Poster session presented at: Human Factors and Ergonomics Society Annual Symposium on Human Factors and Ergonomics in Health Care; 2014 Mar 18; Chicago, IL.
- Li LT, Gutierrez AM, Mills WL, Herman LI, Berger DH, Naik AD. Developing a patient-centered early warning system to prevent readmission after colorectal surgery: A national consensus using the Delphi method. Poster session presented at: American Geriatrics Society Annual Meeting; 2013 May 3; Grapevine, TX.
- Li LT, Gutierrez AM, Mills WL, Herman LI, Berger DH, Naik AD. A Patient-Centered Early Warning System to Prevent Readmission after Colorectal Surgery: A National Consensus Using the Delphi Method. Paper presented at: Academic Surgical Annual Congress; 2013 Feb 3; New Orleans, LA.
Treatment - Implementation