The new era of comparative effectiveness research will require prospective documentation of patient outcomes as well as the outcomes. In the past, innovations by Weill Cornell faculty have improved outcomes, but we have often not systematically documented the improvements. Thus, we lose the advantage of proving the value that we add.
Most of the previous analyses have focused on inpatients and specifically on resource utilization according to discharge DRG. This data does not capture the picture of the patient from the prospective perspective of the clinician. Until the analytic perspective matches the actual clinical situation, it will be difficult to plan approaches that can result in tangible improvements.
We need to begin large scale efforts to prospectively evaluate the characteristics of patients at risk for adverse outcomes and interventions to improve outcomes. Clearly, collection of clinical data must be integrated into the process of care and not performed as a separate step or it will be impossibly expensive.
We know how to integrate the data acquisition into the clinical care process without adding significant burden to the practitioners. Our team will work with faculty who want to identify predictive models from effectiveness data and lay the foundation to test new interventions. In addition we need to collect data on patient-reported quality of life and function by having patients themselves enter the data on touch screen computers, or web based databases. Our Informatics group will create the real time informatics tools to enable collaborating investigators to capture data critical to documenting outcomes.
1. A test of real time prognostic Data: Can It improve outcomes and reduce total costs of hospitalization Funding: NYPH (Mary Charlson, MD; Carla Boutin-Foster MD, MS, Janey Peterson EdD, James Hollenberg, MD)
We propose to build upon the successes of our previous projects and to implement a new and ongoing system for directing resources to hospital inpatients. This approach utilizes clinical judgment and prognostic data available at the time of admission to direct resources to patients. During hospitalization, the team plays a critical role in capturing data on all aspects of care and in developing analytic tools to influence care in real time.
Studies were performed and validated during a four month period which demonstrated that physicians' estimates of illness severity, stability and functional status at the time of admission predicted outcomes (mortality, morbidity) and resource utilization among hospitalized patients.
All patients admitted to Internal Medicine, who met eligibility criteria, were approached by a research assistant within 24 hours of admission. Patients were interviewed using a computerized standardized questionnaire, which had been previously tested for reliability and validated. Based on their response to the questionnaire items, separate scores were automatically generated for each of the 4 disciplines involved in the study: social work, physical therapy, occupational therapy, and psychiatry. Through an independent process, patients were then randomized to either an intervention group or a usual care group. Patients who were randomized to the intervention group and who additionally had scores on the questionnaire, which indicated the need for evaluation by one of the 4 disciplines, were evaluated by that discipline. The intervention team consisted of trained social workers, physical and occupational therapists, and the psychiatric consultation liaison team. Patients were assessed on a daily basis until discharge from the hospital for primary outcomes: a decrease in falls, worsening pressure ulcers, aspiration pneumonia, and length of stay. 444 patients who were moderately ill with fair to poor function were enrolled in the Signout study from April, 2000 through September, 2000 with half assigned to the control group and half to the Signout intervention. Length of stay did not differ. Importantly, iatrogenic complications (falls, decubitus ulcers and aspiration pneumonia) were 50% less in the intervention group
2. Implementation of Signout on 10N (PI: Mary Charlson, MD, Janey Peterson, EdD, Carla Boutin Foster, MD, MS, James Hollenberg, MS, NYPH)
Based upon the success of the Signout clinical trial, the decision was made to test Signout as a new methodology for care for all general medicine patients by introducing it to a single medicine floor. During a three month period from February through April, 2002, the Signout approach was implemented as part of usual care for non-CSS patients on 10N. All general medicine patients were screened and a multidisciplinary team shared information. There was a length of stay reduction of 1.7 days among general medicine patients on 10N following implementation of this strategy. There was a 50% reduction in falls. We learned the importance of developing clinical effectiveness approaches must be in real time and not based solely upon retrospective data.
Division of Clinical Epidemiology and Evaluative Sciences Research
Mary E. Charlson, MD, Chief
Suzan Toro, Administrator
338 East 66th Street
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