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March 2022 symbicort online usa Alert -- Tell your State Senator and Assemblyperson and Gov. Hochul to expand income limits for MSPs - Support Senate Bill S8228/A9245 - see more here!. Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs symbicort online usa. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below. Those in QMB receive additional subsidies for Medicare costs.

See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH symbicort online usa State law. N.Y. Soc. Serv. L.

Â§ 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging Note. Some consumers may be eligible for the Medicare Insurance Premium Payment (MIPP) Program, instead of MSP. See this article for more info. TOPICS COVERED IN THIS ARTICLE 1.

No Asset Limit 1A. Summary Chart of MSP Programs with current income limits 2. Income Limits &. Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?.

4. FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &. Applications for People who Have Medicare WHO IS AUTOMATICALLY ENROLLED IN AN MSP Applying for MSP Directly with Local Medicaid Program - including those who already have Medicaid through local Medicaid program but need MSP, and those newly applying for MSP Enrolling in an MSP if you have Medicaid and Just Became Eligible for Medicare MIPPA - SSA Notifies Social Security recipients that they may be eligible for MSP based on their income.

6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP.

1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2021) Single Couple Single Couple Single Couple $1,133 $1,526 $1,359 $1,831 $1,529 $2,060 Federal Poverty Level 100% FPL 100 â 120% FPL 120 â 135% FPL Benefits Pays Monthly Part B premium?. YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See âPart A Buy-Inâ YES YES Pays Part A &. B deductibles &.

Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR Â§360-7.8(b)(5) Yes â Retroactive to 3rd month before month of application, if eligible in prior months Yes â may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See GIS 07 MA 027.

Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down. 2.

INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). The figures in the chart are based on a document issued by HRA in March 2022 (Box 7) based on the 2022 FPL. See 2021 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y.

Soc. Serv. L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded.

The most common income disregards, also known as deductions, include. (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted).

* Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart. As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher.

The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the âSSI-related category.â Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP.

EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit.

In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO. DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?.

Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). In NYC, if you have a Medicaid case with HRA, instead of submitting an MSP application, you only need to complete and submit MAP-751W (check off "Medicare Savings Program Evaluation") and fax to (917) 639-0837. (The MAP-751W is also posted in languages other than English in this link.

(Updated 4/14/2021.)) 3. The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits.

Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The programâs benefits will begin the month after the month in which your client is found eligible. ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center).

2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3.

Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only. QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage.

Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both. It is their choice. DOH MRG p. 19.

In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1. Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable.

They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason.

Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application.

The State implementing procedures are in DOH 2010 ADM-03. Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center.

If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP.

AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3. No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs.

In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4.

SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?.

And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the householdâs benefit until the next recertification. New Yorkâs SNAP policy per administrative directive 02 ADM-07 is to âfreezeâ the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the householdâs request, but NYS never decreases a householdâs medical expense deduction until the next recertification.

Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website.

Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply. The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP.

See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York Stateâs Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid.

(NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP. Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason.

SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1.

APPLYING FOR MSP DIRECTLY WITH LOCAL MEDICAID OFFICE Client already has Medicaid with Local District/HRA but not MSP. They should NOT have to submit an MSP application because the local district is required to review all Medicaid recipients for MSP eligibility and enroll them. (NYS DOH 2000-ADM-7 and GIS 05 MA 033). But if a Medicaid recipient does not have MSP, contact the Local Medicaid office and request that they be enrolled. In NYC - Use Form 751W and check the box on page 2 requesting evaluation for Medicare Savings Program.

Fax it to the Undercare Division at 1-917-639-0837 or email it to undercareproviderrelations@hra.nyc.gov. Use by secure email. If enrolling in the MSP will cause a Spenddown (because income will increase by the amount of the Part B premium, include a completed and signed "Choice Notice" (MAP-3054a)(3/19/2019)(You must adapt this notice - generally check box 3B on page 2 to select enrollment in MSP while keeping Medicaid.) If do not have Medicaid -- must apply for an MSP through their local social services district. (See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare.

If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available). Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &.

Back), and proof of residency/address. See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1.

Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare" The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare - See article about the Medicare Insurance Payment Program (MIPP).

IF CLIENT HAD MEDICAID THROUGH LOCAL DISTRICT - see here, same procedure for any Medicaid recipient who needs MSP. MIPPA - Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. Â· Beneficiary has Extra Help (LIS), but not MSP Â· Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium.

See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment. The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as.

SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the âRemarksâ section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st).

7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health â that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiaryâs Social Security check. SSA also refunds any amounts owed to the recipient. (Note.

This process can take awhile!. !. !. ) CMS âdeemsâ the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). âCan the MSP be retroactive like Medicaid, back to 3 months before the application?.

âThe answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility â Benefits begin the month after the month of the MSP application. 18 NYCRR Â§ 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year. No retroactive eligibility to the previous year.

7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance. However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid.

Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider. But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance. Click here for an article that explains all of these rules. This article was authored by the Empire Justice Center.Maximizing health coverage for DAP clients.

Before and after winning the case Outline prepared by Geoffrey Hale and Cathy Roberts - updated August 2012 This outline is intended to assist Disability Advocacy Program (DAP) advocates maximize health insurance coverage for clients they are representing on Social Security/SSI disability determinations. We begin with a discussion of coverage options available while your clientâs DAP case is pending and then outline the effect winning the DAP case can have on your clientâs access to health care coverage. How your client is affected will vary depending on the source and amount of disability income he or she receives after the successful appeal. I. BACKGROUND.

Public health coverage for your clients will primarily be provided by Medicaid and Medicare. The two programs are structured differently and have different eligibility criteria, but in order to provide the most complete coverage possible for your clients, they must work effectively together. Understanding their interactions is essential to ensuring benefits for your client. Here is a brief overview of the programs we will cover. A.

Medicaid. Medicaid is the public insurance program jointly funded by the federal, state and local governments for people of limited means. For federal Medicaid law, see 42 U.S.C. Â§ 1396 et seq., 42 C.F.R. Â§ 430 et seq.

Regular Medicaid is described in New Yorkâs State Plan and codified at N.Y. Soc. Serv. L. Â§Â§ 122, 131, 363- 369-1.

18 N.Y.C.R.R. Â§ 360, 505. New York also offers several additional programs to provide health care benefits to those whose income might be too high for Regular Medicaid. i. Family Health Plus (FHPlus) is an extension of New Yorkâs Medicaid program that provides health coverage for adults who are over-income for regular Medicaid.

FHPlus is described in New Yorkâs 1115 waiver and codified at N.Y. Soc. Serv. L. Â§369-ee.

ii. Child Health Plus (CHPlus) is a sliding scale premium program for children who are over-income for regular Medicaid. CHPlus is codified at N.Y. Pub. Health L.

Â§2510 et seq. b. Medicare. Medicare is the federal health insurance program providing coverage for the elderly, disabled, and people with end-stage renal disease. Medicare is codified under title XVIII of the Social Security Law, see 42 U.S.C.

Â§ 1395 et seq., 42 C.F.R. Â§ 400 et seq. Medicare is divided into four parts. i. Part A covers hospital, skilled nursing facility, home health, and hospice care, with some deductibles and coinsurance.

Most people are eligible for Part A at no cost. See 42 U.S.C. Â§ 1395c, 42 C.F.R. Pt. 406.

ii. Part B provides medical insurance for doctorâs visits and other outpatient medical services. Medicare Part B has significant cost-sharing components. There are monthly premiums (the standard premium in 2012 is $99.90. In addition, there is a $135 annual deductible (which will increase to $155 in 2010) as well as 20% co-insurance for most covered out-patient services.

See 42 U.S.C. Â§ 1395k, 42 C.F.R. Pt. 407. iii.

Part C, also called Medicare Advantage, provides traditional Medicare coverage (Parts A and B) through private managed care insurers. See 42 U.S.C. Â§ 1395w, 42 C.F.R. Pt. 422.

Premium amounts for Medicare Advantage plans vary. Some Medicare Advantage plans include prescription drug coverage. iv. Part D is an optional prescription drug benefit available to anyone with Medicare Parts A and B. See 42 U.S.C.

Â§ 1395w, 42 C.F.R. Â§ 423.30(a)(1)(i) and (ii). Unlike Parts A and B, Part D benefits are provided directly through private plans offered by insurance companies. In order to receive prescription drug coverage, a Medicare beneficiary must join a Part D Plan or participate in a Medicare Advantage plan that provides prescription drug coverage. C.

Medicare Savings Programs (MSPs). Funded by the State Medicaid program, MSPs help eligible individuals meet some or all of their cost-sharing obligations under Medicare. See N.Y. Soc. Serv.

L. Â§ 367-a(3)(a), (b), and (d). There are three separate MSPs, each with different eligibility requirements and providing different benefits. i. Qualified Medicare Beneficiary (QMB).

The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. ii. Special Low-Income Medicare Beneficiary (SLMB).

For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. iii. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, but not otherwise Medicaid eligible, the QI-1 program covers Medicare Part B premiums. D.

Medicare Part D Low Income Subsidy (LIS or âExtra Helpâ). LIS is a federal subsidy administered by CMS that helps Medicare beneficiaries with limited income and/or resources pay for some or most of the costs of Medicare prescription drug coverage. See 42 C.F.R. Â§ 423.773. Some of the costs covered in full or in part by LIS include the monthly premiums, annual deductible, co-payments, and the coverage gap.

Individuals eligible for Medicaid, SSI, or MSP are deemed eligible for full LIS benefitsSee 42 C.F.R. Â§ 423.773(c). LIS applications are treated as (âdeemedâ) applications for MSP benefits, See the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, Pub. Law 110-275. II.

WHILE THE DAP APPEAL IS PENDING Does your client have health insurance?. If not, why isnât s/he getting Medicaid, Family Health Plus or Child Health Plus?. There have been many recent changes which expand eligibility and streamline the application process. All/most of your DAP clients should qualify. Significant changes to Medicaid include.

Elimination of the resource test for certain categories of Medicaid applicants/recipients and all applicants to the Family Health Plus program. N.Y. Soc. Serv. L.

Â§369-ee (2), as amended by L. 2009, c. 58, pt. C, Â§ 59-d. As of October 1, 2009, a resource test is no longer required for these categories.

Elimination of the fingerprinting requirement. N.Y. Soc. Serv. L.

Â§369-ee, as amended by L. 2009, c. 58, pt. C, Â§ 62. Elimination of the waiting period for CHPlus.

N.Y. Pub. Health L. Â§2511, as amended by L. 2008, c.

58. Elimination of the face-to-face interview requirement for Medicaid, effective April 1, 2010. N.Y. Soc. Serv.

L. Â§366-a (1), as amended by L. 2009, c. 58, pt. C, Â§ 60.

Higher income levels for Single Adults and Childless Couples. N.Y. Soc. Serv. L.

Â§366(1)(a)(1),(8) as amended by L. 2008, c. 58. See also. GIS 08 MA/022.

Higher income levels for Medicaidâs Medically Needy program. N.Y. Soc. Serv. L.

Â§366(2)(a)(7) as amended by L. 2008, c. 58. See also. GIS 08 MA/022 More detailed information on recent changes to Medicaid is available at.

III. AFTER CLIENT IS AWARDED DAP BENEFITS a. Medicaid eligibility. Clients receiving even $1.00 of SSI should qualify for Medicaid automatically. The process for qualifying will differ, however, depending on the source of payment.

1. Clients Receiving SSI Only. i. These clients are eligible for full Medicaid without a spend-down. See N.Y.

Medicaid coverage is automatic. No separate application/ recertification required. iii. Most SSI-only recipients are required to participate in Medicaid managed care. See N.Y.

Concurrent (SSI/SSD) cases. Eligible for full Medicaid since receiving SSI. See N.Y. Soc. Serv.

They can still qualify for Medicaid but may have a spend-down. Federal Law allows states to use a âspend-downâ to extend Medicaid to âmedically needyâ persons in the federal mandatory categories (children, caretakers, elderly and disabled people) whose income or resources are above the eligibility level for regular Medicaid. See 42 U.S.C. Â§ 1396 (a) (10) (ii) (XIII). ii.

Under spend-down, applicants in New Yorkâs Medically Needy program can qualify for Medicaid once their income/resources, minus incurred medical expenses, fall below the specified level. For an explanation of spend-down, see 96 ADM 15. B. Family Health Plus Until your client qualifies for Medicare, those over-income for Medicaid may qualify for Family Health Plus without needing to satisfy a spend-down. It covers adults without children with income up to 100% of the FPL and adults with children up to 150% of the FPL.[1] The eligibility tests are the same as for regular Medicaid with two additional requirements.

Applicants must be between the ages of 19 and 64 and they generally must be uninsured. See N.Y. Soc. Serv. L.

Â§ 369-ee et. Seq. Once your client begins to receive Medicare, he or she will not be eligible for FHP, because FHP is generally only available to those without insurance. For more information on FHP see our article on Family Health Plus. IV.

LOOMING ISSUES - MEDICARE ELIGIBILITY (WHETHER YOU LIKE IT OR NOT) a. SSI-only cases Clients receiving only SSI arenât eligible for Medicare until they turn 65, unless they also have End Stage Renal Disease. B. Concurrent (SSD and SSI) cases 1. Medicare eligibility kicks in beginning with 25th month of SSD receipt.

See 42 U.S.C. Â§ 426(f). Exception. In 2000, Congress eliminated the 24-month waiting period for people diagnosed with ALS (Lou Gehrigâs Disease.) See 42 U.S.C. Â§ 426 (h) 2.

Enrollment in Medicare is a condition of eligibility for Medicaid coverage. These clients cannot decline Medicare coverage. (05 OMM/ADM 5. Medicaid Reference Guide p. 344.1) 3.

Medicare coverage is not free. Although most individuals receive Part A without any premium, Part B has monthly premiums and significant cost-sharing components. 4. Medicaid and/or the Medicare Savings Program (MSP) should pick up most of Medicareâs cost sharing. Most SSI beneficiaries are eligible not only for full Medicaid, but also for the most comprehensive MSP, the Qualified Medicare Beneficiary (QMB) program.

I. Parts A &. B (hospital and outpatient/doctors visits). A. Medicaid will pick up premiums, deductibles, co-pays.

For those not enrolled in an MSP, SSA normally deducts the Part B premium directly from the monthly check. However, SSI recipients are supposed to be enrolled automatically in QMB, and Medicaid is responsible for covering the premiums. Part B premiums should never be deducted from these clientsâ checks.[1] Medicaid and QMB-only recipients should NEVER be billed directly for Part A or B services. Even non-Medicaid providers are supposed to be able to bill Medicaid directly for services.[2] Clients are only responsible for Medicaid co-pay amount. See 42 U.S.C.

Â§ 1396a (n) ii. Part D (prescription drugs). a. Clients enrolled in Medicaid and/or MSP are deemed eligible for Low Income Subsidy (LIS aka Extra Help). See 42 C.F.R.

Â§ 423.773(c). SSA POMS SI Â§ 01715.005A.5. New York State If client doesnât enroll in Part D plan on his/her own, s/he will be automatically assigned to a benchmark[3] plan. See 42 C.F.R. Â§ 423.34 (d).

LIS will pick up most of cost-sharing.[3] Because your clients are eligible for full LIS, they should have NO deductible and NO premium if they are in a benchmark plan, and will not be subject to the coverage gap (aka âdonut holeâ). See 42 C.F.R. Â§Â§ 423.780 and 423.782. The full LIS beneficiary will also have co-pays limited to either $1.10 or $3.30 (2010 amounts). See 42 C.F.R.

Â§ 423.104 (d) (5) (A). Other important points to remember. - Medicaid co-pay rules do not apply to Part D drugs. - Your clientâs plan may not cover all his/her drugs. - You can help your clients find the plan that best suits their needs.

To figure out what the best Part D plans are best for your particular client, go to www.medicare.gov. Click on âformulary finderâ and plug in your clientâs medication list. You can enroll in a Part D plan through www.medicare.gov, or by contacting the plan directly. Â Your clients can switch plans at any time during the year. Iii.

Part C (âMedicare Advantageâ). a. Medicare Advantage plans provide traditional Medicare coverage (Parts A and B) through private managed care insurers. See 42 U.S.C. Â§ 1395w, 42 C.F.R.

Pt. 422. Medicare Advantage participation is voluntary. For those clients enrolled in Medicare Advantage Plans, the QMB cost sharing obligations are the same as they are under traditional Medicare. Medicaid must cover any premiums required by the plan, up to the Part B premium amount.

Medicaid must also cover any co-payments and co-insurance under the plan. As with traditional Medicare, both providers and plans are prohibited from billing the beneficiary directly for these co-payments. C. SSD only individuals. 1.

Same Medicare eligibility criteria (24 month waiting period, except for persons w/ ALS). I. During the 24 month waiting period, explore eligibility for Medicaid or Family Health Plus. 2. Once Medicare eligibility begins.

ii. Parts A &. B. SSA will automatically enroll your client. Part B premiums will be deducted from monthly Social Security benefits.

(Part A will be free â no monthly premium) Clients have the right to decline ongoing Part B coverage, BUT this is almost never a good idea, and can cause all sorts of headaches if client ever wants to enroll in Part B in the future. (late enrollment penalty and canât enroll outside of annual enrollment period, unless person is eligible for Medicare Savings Program â see more below) Clients can decline âretroâ Part B coverage with no penalty on the Medicare side â just make sure they donât actually need the coverage. Risky to decline if they had other coverage during the retro period â their other coverage may require that Medicare be utilized if available. Part A and Part B also have deductibles and co-pays. Medicaid and/or the MSPs can help cover this cost sharing.

iii. Part D. Client must affirmatively enroll in Part D, unless they receive LIS. See 42 U.S.C. Â§ 1395w-101 (b) (2), 42 C.F.R.

Â§ 423.38 (a). Enrollment is done through individual private plans. LIS recipients will be auto-assigned to a Part D benchmark plan if they have not selected a plan on their own. Client can decline Part D coverage with no penalty if s/he has âcomparable coverage.â 42 C.F.R. Â§ 423.34 (d) (3) (i).

If no comparable coverage, person faces possible late enrollment penalty &. Limited enrollment periods. 42 C.F.R. Â§ 423.46. However, clients receiving LIS do not incur any late enrollment penalty.

42 C.F.R. Â§ 423.780 (e). Part D has a substantial cost-sharing component â deductibles, premiums and co-pays which vary from plan to plan. There is also the coverage gap, also known as âdonut hole,â which can leave beneficiaries picking up 100% of the cost of their drugs until/unless a catastrophic spending limit is reached. The LIS program can help with Part D cost-sharing.

Use Medicareâs website to figure out what plan is best for your client. (Go to www.medicare.gov , click on âformulary finderâ and plug in your clientâs medication list. ) You can also enroll in a Part D plan directly through www.medicare.gov. Iii. Help with Medicare cost-sharing a.

Medicaid â After eligibility for Medicare starts, client may still be eligible for Medicaid, with or without a spend-down. There are lots of ways to help clients meet their spend-down â including - Medicare cost sharing amounts (deductibles, premiums, co-pays) - over the counter medications if prescribed by a doctor. - expenses paid by state-funded programs like EPIC and ADAP. - medical bills of personâs spouse or child. - health insurance premiums.

- joining a pooled Supplemental Needs Trust (SNT). B. Medicare Savings Program (MSP) â If client is not eligible for Medicaid, explore eligibility for Medicare Savings Program (MSP). MSP pays for Part B premiums and gets you into the Part D LIS. There are no asset limits in the Medicare Savings Program.

One of the MSPs (QMB), also covers all cost sharing for Parts A &. B. If your client is eligible for Medicaid AND MSP, enrolling in MSP may subject him/her to, or increase a spend-down, because Medicaid and the various MSPs have different income eligibility levels. It is the clientâs choice as to whether or not to be enrolled into MSP. C.

Part D Low Income Subsidy (LIS) â If your client is not eligible for MSP or Medicaid, s/he may still be eligible for Part D Low Income Subsidy. Applications for LIS are also be treated as applications for MSP, unless the client affirmatively indicates that s/he does not want to apply for MSP. d. Medicare supplemental insurance (Medigap) -- Medigap is supplemental private insurance coverage that covers all or some of the deductibles and coinsurance for Medicare Parts A and B. Medigap is not available to people enrolled in Part C.

E. Medicare Advantage â Medicare Advantage plans âpackageâ Medicare (Part A and B) benefits, with or without Part D coverage, through a private health insurance plan. The cost-sharing structure (deductible, premium, co-pays) varies from plan to plan. For a list of Medicare Advantage plans in your area, go to www.medicare.gov â click on âfind health plans.â f. NY Prescription Saver Card -- NYP$ is a state-sponsored pharmacy discount card that can lower the cost of prescriptions by as much as 60 percent on generics and 30 percent on brand name drugs.

Can be used during the Part D âdonut holeâ (coverage gap) g. For clients living with HIV. ADAP [AIDS Drug Assistance Program] ADAP provides free medications for the treatment of HIV/AIDS and opportunistic s. ADAP can be used to help meet a Medicaid spenddown and get into the Part D Low Income subsidy. For more information about ADAP, go to V.

GETTING MEDICAID IN THE DISABLED CATEGORY AFTER AN SSI/SSDI DENIAL What if your client's application for SSI or SSDI is denied based on SSA's finding that they were not "disabled?. " Obviously, you have your appeals work cut out for you, but in the meantime, what can they do about health insurance?. It is still possible to have Medicaid make a separate disability determination that is not controlled by the unfavorable SSA determination in certain situations. Specifically, an applicant is entitled to a new disability determination where he/she. alleges a different or additional disabling condition than that considered by SSA in making its determination.

Or alleges less than 12 months after the most recent unfavorable SSA disability determination that his/her condition has changed or deteriorated, alleges a new period of disability which meets the duration requirement, and SSA has refused to reopen or reconsider the allegations, or the individual is now ineligible for SSA benefits for a non-medical reason. Or alleges more than 12 months after the most recent unfavorable SSA disability determination that his/her condition has changed or deteriorated since the SSA determination and alleges a new period of disability which meets the duration requirement, and has not applied to SSA regarding these allegations. See GIS 10-MA-014 and 08 OHIP/INF-03.[4] [1] Potential wrinkle â for some clients Medicaid is not automatically pick up cost-sharing. In Monroe County we have had several cases where SSA began deducting Medicare Part B premiums from the checks of clients who were receiving SSI and Medicaid and then qualified for Medicare. The process should be automatic.

Please contact Geoffrey Hale in our Rochester office if you encounter any cases like this. [2]Under terms established to provide benefits for QMBs, a provider agreement necessary for reimbursement âmay be executed through the submission of a claim to the Medicaid agency requesting Medicaid payment for Medicare deductibles and coinsurance for QMBs.â CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), available at. http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?. ItemID=CMS021927. [3]Benchmark plans are free if you are an LIS recipient.

The amount of the benchmark changes from year to year. In 2013, a Part D plan in New York State is considered benchmark if it provides basic Part D coverage and its monthly premium is $43.22 or less. [4] These citations courtesy of Jim Murphy at Legal Services of Central New York. This site provides general information only. This is not legal advice.

You can only obtain legal advice from a lawyer. In addition, your use of this site does not create an attorney-client relationship. To contact a lawyer, visit http://lawhelp.org/ny. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law. However, we do not guarantee the accuracy of this information..

Symbicort drug card

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AbstractThe objective of this study was Where to get kamagra to determining the frequency of different sub-types of pathogenic CDH1 germline mutations in symbicort drug card healthy and asymptomatic individuals from families with the hereditary diffuse gastric cancer (HDGC) syndrome. Relevant literature dating from 1998 to 2019 was systematically searched for data on CDH1 germline mutations. The collected variants were classified according to their subtype into the following symbicort drug card classes. Missense, non-sense, splicing, insertions and deletions.

The Ï2 test was used to estimate if the difference observed between patients with gastric cancer (GC) and unaffected symbicort drug card individuals was statistically significant. CDH1 genetic screening data were retrieved for 224 patients with GC and 289 healthy individuals. Among the subjects that had tested CDH1 positive, symbicort drug card splicing mutations were found in 30.4% of the healthy individuals and in 15.2% of the patients with GC (p=0.0076). Missense mutations were also found to occur in healthy subjects with higher frequency (22.2%) than in GC-affected individuals (18.3%), but the difference was not significant in this case.

In families meeting the clinical criteria for the HDGC syndrome, CDH1 splicing and missense germline symbicort drug card mutations have been reported to occur with higher frequency in healthy subjects than in patients with cancer. This preliminary observation suggests that not all pathogenic CDH1 germline mutations confer the same risk of developing GC.gastroenterology.

AbstractThe objective symbicort online usa Where to get kamagra of this study was to determining the frequency of different sub-types of pathogenic CDH1 germline mutations in healthy and asymptomatic individuals from families with the hereditary diffuse gastric cancer (HDGC) syndrome. Relevant literature dating from 1998 to 2019 was systematically searched for data on CDH1 germline mutations. The collected symbicort online usa variants were classified according to their subtype into the following classes.

Missense, non-sense, splicing, insertions and deletions. The Ï2 test was used to estimate if the difference symbicort online usa observed between patients with gastric cancer (GC) and unaffected individuals was statistically significant. CDH1 genetic screening data were retrieved for 224 patients with GC and 289 healthy individuals.

Among the subjects that had tested CDH1 positive, splicing mutations were found in 30.4% of the healthy individuals and in 15.2% of the patients with symbicort online usa GC (p=0.0076). Missense mutations were also found to occur in healthy subjects with higher frequency (22.2%) than in GC-affected individuals (18.3%), but the difference was not significant in this case. In families meeting the clinical criteria for the HDGC syndrome, CDH1 splicing and missense germline mutations have been reported to occur with higher frequency in healthy subjects than in patients with symbicort online usa cancer.

This preliminary observation suggests that not all pathogenic CDH1 germline mutations confer the same risk of developing GC.gastroenterology.

What may interact with Symbicort?

Before using Budesonide+Formoterol tell your doctor about all other medicines you use, especially:

antibiotics such as azithromycin, clarithromycin, erythromycin, or telithromycin;
antifungal medication such as ketoconazole, or itraconazole;
a diuretic;
a MAO inhibitor such as furazolidone, isocarboxazid, phenelzine, rasagiline, selegiline, or tranylcypromine;
an antidepressant such as amitriptyline, doxepin nortriptyline, and others; or
a beta-blocker such as atenolol, carvedilol, labetalol, metoprolol, nadolol, propranolol, sotalol, and others.

Symbicort 80mg

A 2870âg male infant symbicort 80mg was born at 36+1 weeksâ gestation by cesarean section due to mild polyhydramnios and a non-reassuring cardiotocography. An uasound at 31 weeks demonstrated transient hyperechogenic fetal bowel (HFB).At birth, the Apgar scores were 9 and 10. The abdominal examination was unremarkable.He spontaneously symbicort 80mg passed meconium. After 20âhours, he developed left hemiabdominal distension with visible dilated bowel loop sign (figure 1) and bile-stained vomiting.Figure 1 âBowel loop signâ on abdominal wall due to a segmental intestinal dilatation.Abdominal radiography â¦.

A 2870âg male infant was symbicort online usa born at 36+1 weeksâ gestation by cesarean section due to Lasix 40mg price mild polyhydramnios and a non-reassuring cardiotocography. An uasound at 31 weeks demonstrated transient hyperechogenic fetal bowel (HFB).At birth, the Apgar scores were 9 and 10. The abdominal symbicort online usa examination was unremarkable.He spontaneously passed meconium. After 20âhours, he developed left hemiabdominal distension with visible dilated bowel loop sign (figure 1) and bile-stained vomiting.Figure 1 âBowel loop signâ on abdominal wall due to a segmental intestinal dilatation.Abdominal radiography â¦.

How long does symbicort inhaler last

The potential impact of how long does symbicort inhaler last patient education on improving outcomes in patients with cardiovascular disease (CVD) has received http://2017.swissbiotechday.ch/kamagra-wholesale/ little attention. In a randomised clinical trial, McIntyre and colleagues1 found that waiting room video-based education about CVD risk reduction resulted in more patients being motivated to implement heart healthy behaviours (29.6% vs 18.7%, relative risk 1.63, 95% CI 1.04 to 2.55) and higher levels of satisfaction with the clinic visit. Participants who were also randomised to receive education about cardio-pulmonary resuscitation how long does symbicort inhaler last (CPR) reported greater confidence in performing CPR.

Overall, at baseline 16% of patients reported optimal CVD risk factors which increased to 25% at 30 days but there was no difference in improvement between the intervention group and usual care (figure 1).Informational graphic summary of the While Youâre Waiting study." data-icon-position data-hide-link-title="0">Figure 1 Informational graphic summary of the While Youâre Waiting study.In an editorial, White2 comments that âHealth literacy is an underused resource for improving cardiac outcomes with patients being better able to understand their disease, understand modifications in their lifestyles required for prevention such as nutrition and exercise and understand the need for medications that may improve adherence. Patients may therefore be better able how long does symbicort inhaler last to maintain their own health and well-being. Waiting room computer tablets have the potential to improve outcomes.â Clearly, additional research is needed on the optimal educational materials and presentation formats to improve cardiovascular outcomes, hopefully with close collaboration between patients and healthcare providers.Also in this issue of Heart, Imberti and colleagues3 present data from a systematic review and meta-analysis to support catheter ablation (CA) as first-line treatment in patients with paroxysmal atrial fibrillation (AF).

In 1212 patients with paroxysmal AF combined from six studies, those treated with CA had how long does symbicort inhaler last a 36% relative risk reduction for recurrent arrhythmias compared with those treated with medications, with symptomatic recurrent arrhythmias in 20% vs 37% and lower rates of healthcare utilisation (figure 2).Forest plots showing the comparative efficacy and safety of catheter ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation. (A) Risk of atrial arrhythmia recurrence. (B) Risk of serious how long does symbicort inhaler last adverse events.

(C) Risk of symptomatic arrhythmia recurrence. (D) Risk of healthcare how long does symbicort inhaler last resources use. CI, confidence interval.

Cryo, cryoballoon how long does symbicort inhaler last ablation. M-H, Mantel-Haenszel. RFA, radiofrequency how long does symbicort inhaler last ablation.

RR, risk ratio." data-icon-position data-hide-link-title="0">Figure 2 Forest plots showing the comparative efficacy and safety of catheter ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation. (A) Risk of atrial arrhythmia recurrence how long does symbicort inhaler last. (B) Risk of serious adverse events.

(C) Risk of symptomatic arrhythmia how long does symbicort inhaler last recurrence. (D) Risk of healthcare resources use. CI, confidence how long does symbicort inhaler last interval.

Cryo, cryoballoon ablation. M-H, Mantel-Haenszel. RFA, radiofrequency how long does symbicort inhaler last ablation.

RR, risk ratio.Blaauw, Mulder and Rienstra4 concur with the conclusion that CA is more effective than anti-arrhythmic medication for reducing recurrent AF but urge caution in widespread adoption of this approach because âquestions remain regarding timing of CA, selection of patients, quality of life outcomes, balancing procedural complications and AAD side effects, and instituting risk factor management as background therapy.â They urge âShared decision-making focusing on individualised timing and balancing benefitsârisks is the preferred approach to assess first-line treatment with CA. As CA is rapidly evolving, with novel single-shot devices and promising energy sources (eg, pulsed field ablation), it is foreseen that CA keeps moving towards the frontline how long does symbicort inhaler last of AF management.âIn an elegant study using cardiac MRI combined with statistical machine learning methods, Schuwerk and colleagues5 demonstrate overall normal biventricular and biatrial function in patients with an arterial switch operation for transposition of the great arteries (TGA). Only right ventricular longitudinal strain and left atrial function were impaired at a median of 16 years after surgery.Going forward, Ostenfeld and Carlsson6 suggest that âRemaining questions in this patient group are if the ventricular and atrial function parameters have any prognostic information when all four chambers are examined.

Furthermore, assessment of fibrosis and perfusion related to heart function how long does symbicort inhaler last in patients with TGA and arterial switch operation would be of interest in the future.â A review article by Gaur and colleague7 discusses overall management consideration in adults with surgically modified TGA, including both those with an atrial and those with an arterial switch procedure (figure 3).Schematic of (A) d-transposition of the great arteries, (B) d-TGA following ASR and (C) D-TGA following ASO. ASO, arterial switch operation. ASR, atrial switch repair." data-icon-position data-hide-link-title="0">Figure 3 Schematic of (A) d-transposition of the how long does symbicort inhaler last great arteries, (B) d-TGA following ASR and (C) D-TGA following ASO.

ASO, arterial switch operation. ASR, atrial switch repair.The Education in Heart article8 in this issue addresses management of how long does symbicort inhaler last ventricular tachycardia storm including diagnostic criteria, initial management and a multidisciplinary team approach to long-term care.The Cardiology in Focus article9 in this issue provides information about the need for and training of cardiologists in global health. As Akhter and colleagues note.

ÂIn the ecosystem of global cardiovascular healthcare, cardiologists are a part of a multidisciplinary, multisector response in which global how long does symbicort inhaler last cooperation can support better health outcomes.â (figure 4).Global cardiovascular healthcare. IT, information technology." data-icon-position data-hide-link-title="0">Figure 4 Global cardiovascular healthcare. IT, information technology.Ethics statementsPatient consent for publicationNot applicable.Atrial fibrillation (AF) is the most how long does symbicort inhaler last common arrhythmia and is associated with increased risk of thromboembolic events, heart failure and mortality.1 In addition, many patients have symptomatic episodes of AF and quality of life is impaired.

In this group of patients, rhythm control management is the preferred therapy of choice. Anti-arrhythmic drugs (AADs) how long does symbicort inhaler last have long been the most often used treatment modality for symptomatic AF. The last decades, catheter ablation (CA) has emerged as an alternative treatment option, especially in patients with failed AAD treatment.2 Studies comparing CA and AADs demonstrated superiority of CA in patients with previous failed AAD treatment.3 Recently, numerous studies comparing CA and AAD as first-line treatment for symptomatic AF have been reported.Imberti et al reported a systematic review and meta-analysis of six randomised clinical trials (RCTs) comparing these two treatment arms in patients with predominantly paroxysmal AF who had no prior treatment with AADs, that is, first-line treatment with CA or AADs.4 Pooled data from six RCTs showed that CA is more effective than AADs in reducing AF recurrences.

In addition, how long does symbicort inhaler last side effects were numerically non-significantly different between the two treatment arms. Other factors favouring CA as the preferred treatment were a reduced healthcare utilisation and a lower treatment crossover rate in the CA patients. The strength of the current meta-analysis is that it included medium-to-large-sized RCT using contemporary ablation techniques.The authors should how long does symbicort inhaler last be congratulated for their important contribution in this rapidly evolving field of CA.

The main findings further strengthen the arguments of those supporting first-line treatment of AF with CA. However, â¦.

The potential impact of patient education on improving outcomes symbicort online usa in patients with cardiovascular disease (CVD) http://2017.swissbiotechday.ch/kamagra-wholesale/ has received little attention. In a randomised clinical trial, McIntyre and colleagues1 found that waiting room video-based education about CVD risk reduction resulted in more patients being motivated to implement heart healthy behaviours (29.6% vs 18.7%, relative risk 1.63, 95% CI 1.04 to 2.55) and higher levels of satisfaction with the clinic visit. Participants who were symbicort online usa also randomised to receive education about cardio-pulmonary resuscitation (CPR) reported greater confidence in performing CPR. Overall, at baseline 16% of patients reported optimal CVD risk factors which increased to 25% at 30 days but there was no difference in improvement between the intervention group and usual care (figure 1).Informational graphic summary of the While Youâre Waiting study." data-icon-position data-hide-link-title="0">Figure 1 Informational graphic summary of the While Youâre Waiting study.In an editorial, White2 comments that âHealth literacy is an underused resource for improving cardiac outcomes with patients being better able to understand their disease, understand modifications in their lifestyles required for prevention such as nutrition and exercise and understand the need for medications that may improve adherence.

Patients may therefore be symbicort online usa better able to maintain their own health and well-being. Waiting room computer tablets have the potential to improve outcomes.â Clearly, additional research is needed on the optimal educational materials and presentation formats to improve cardiovascular outcomes, hopefully with close collaboration between patients and healthcare providers.Also in this issue of Heart, Imberti and colleagues3 present data from a systematic review and meta-analysis to support catheter ablation (CA) as first-line treatment in patients with paroxysmal atrial fibrillation (AF). In 1212 patients with paroxysmal AF combined from six studies, those treated with CA had a 36% relative risk reduction for recurrent arrhythmias symbicort online usa compared with those treated with medications, with symptomatic recurrent arrhythmias in 20% vs 37% and lower rates of healthcare utilisation (figure 2).Forest plots showing the comparative efficacy and safety of catheter ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation. (A) Risk of atrial arrhythmia recurrence.

(B) Risk symbicort online usa of serious adverse events. (C) Risk of symptomatic arrhythmia recurrence. (D) Risk of symbicort online usa healthcare resources use. CI, confidence interval.

Cryo, cryoballoon ablation symbicort online usa. M-H, Mantel-Haenszel. RFA, radiofrequency ablation symbicort online usa. RR, risk ratio." data-icon-position data-hide-link-title="0">Figure 2 Forest plots showing the comparative efficacy and safety of catheter ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation.

(A) Risk of atrial symbicort online usa arrhythmia recurrence. (B) Risk of serious adverse events. (C) Risk of symbicort online usa symptomatic arrhythmia recurrence. (D) Risk of healthcare resources use.

CI, confidence symbicort online usa interval. Cryo, cryoballoon ablation. M-H, Mantel-Haenszel. RFA, radiofrequency ablation symbicort online usa.

RR, risk ratio.Blaauw, Mulder and Rienstra4 concur with the conclusion that CA is more effective than anti-arrhythmic medication for reducing recurrent AF but urge caution in widespread adoption of this approach because âquestions remain regarding timing of CA, selection of patients, quality of life outcomes, balancing procedural complications and AAD side effects, and instituting risk factor management as background therapy.â They urge âShared decision-making focusing on individualised timing and balancing benefitsârisks is the preferred approach to assess first-line treatment with CA. As CA is rapidly evolving, with novel single-shot devices and symbicort online usa promising energy sources (eg, pulsed field ablation), it is foreseen that CA keeps moving towards the frontline of AF management.âIn an elegant study using cardiac MRI combined with statistical machine learning methods, Schuwerk and colleagues5 demonstrate overall normal biventricular and biatrial function in patients with an arterial switch operation for transposition of the great arteries (TGA). Only right ventricular longitudinal strain and left atrial function were impaired at a median of 16 years after surgery.Going forward, Ostenfeld and Carlsson6 suggest that âRemaining questions in this patient group are if the ventricular and atrial function parameters have any prognostic information when all four chambers are examined. Furthermore, assessment of fibrosis and perfusion related to heart function in patients with TGA and arterial symbicort online usa switch operation would be of interest in the future.â A review article by Gaur and colleague7 discusses overall management consideration in adults with surgically modified TGA, including both those with an atrial and those with an arterial switch procedure (figure 3).Schematic of (A) d-transposition of the great arteries, (B) d-TGA following ASR and (C) D-TGA following ASO.

ASO, arterial switch operation. ASR, atrial switch repair." data-icon-position data-hide-link-title="0">Figure 3 Schematic of (A) d-transposition of the great symbicort online usa arteries, (B) d-TGA following ASR and (C) D-TGA following ASO. ASO, arterial switch operation. ASR, atrial switch repair.The Education in Heart article8 in this issue addresses management of ventricular tachycardia storm including diagnostic criteria, initial management and a multidisciplinary team approach to long-term care.The Cardiology in Focus article9 symbicort online usa in this issue provides information about the need for and training of cardiologists in global health.

As Akhter and colleagues note. ÂIn the ecosystem of global cardiovascular healthcare, cardiologists are a symbicort online usa part of a multidisciplinary, multisector response in which global cooperation can support better health outcomes.â (figure 4).Global cardiovascular healthcare. IT, information technology." data-icon-position data-hide-link-title="0">Figure 4 Global cardiovascular healthcare. IT, information technology.Ethics statementsPatient consent for publicationNot applicable.Atrial fibrillation (AF) is the most common arrhythmia and is associated with symbicort online usa increased risk of thromboembolic events, heart failure and mortality.1 In addition, many patients have symptomatic episodes of AF and quality of life is impaired.

In this group of patients, rhythm control management is the preferred therapy of choice. Anti-arrhythmic drugs (AADs) have long been the symbicort online usa most often used treatment modality for symptomatic AF. The last decades, catheter ablation (CA) has emerged as an alternative treatment option, especially in patients with failed AAD treatment.2 Studies comparing CA and AADs demonstrated superiority of CA in patients with previous failed AAD treatment.3 Recently, numerous studies comparing CA and AAD as first-line treatment for symptomatic AF have been reported.Imberti et al reported a systematic review and meta-analysis of six randomised clinical trials (RCTs) comparing these two treatment arms in patients with predominantly paroxysmal AF who had no prior treatment with AADs, that is, first-line treatment with CA or AADs.4 Pooled data from six RCTs showed that CA is more effective than AADs in reducing AF recurrences. In addition, symbicort online usa side effects were numerically non-significantly different between the two treatment arms.

Other factors favouring CA as the preferred treatment were a reduced healthcare utilisation and a lower treatment crossover rate in the CA patients. The strength of the current meta-analysis is that it included medium-to-large-sized RCT using contemporary ablation techniques.The authors should be congratulated for symbicort online usa their important contribution in this rapidly evolving field of CA. The main findings further strengthen the arguments of those supporting first-line treatment of AF with CA. However, â¦.

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CMS is developing a streamlined, automated process to standardize emergency waiver requests based on lessons learned during the anti inflammatory drugs symbicort, according to a proposed information collection on Tuesday.The agency http://keim-farben.de/discount-levitra-coupon/ said the new system would be based mainly on the volume of requests medicine similar to symbicort to ensure facilities receive a quick response. CMS will medicine similar to symbicort collect relevant information from healthcare providers and suppliers to decide whether to approve their waiver request. The new waiver request form was approved on an emergency basis Oct. 15. "Prior to this request, CMS did not have a standard process or (White House budget office) approval for providers/suppliers impacted to submit 1135 waiver/flexibility requests or inquiries, as these were generally seen on a smaller scale (natural disasters) prior to the anti inflammatory drugs public health emergency," CMS wrote.Comments on the information collection are due in December.Under the old system, providers and suppliers would email a summary of their request to each CMS locationâpreviously known as CMS regional offices.The agency also plans to create a streamlined, automated system to gather information from providers about how their operations have been affected by an emergency or disaster.

CMS currently relies on State Survey Agencies to collect that information.Under the new process, the agency would directly collect the information through a "public-facing web form." CMS would use the information to triage, respond to and report requests or inquiries for Medicare, Medicaid and Children's Health Insurance Program beneficiaries. It plans to add a second form to collect information about healthcare facilities' operational status to help providers deliver critical care during emergencies.HHS can waive or change certain Medicare, Medicaid or CHIP requirements during a disaster or emergency to ensure enough healthcare items or services are available to beneficiaries. The agency can suspend or change conditions of participation, program participation and preapproval requirements, Stark self-referral sanctions and performance deadlines, among other things. Providers can get reimbursed and avoid penalties for delivering those items and services during the emergency if they do it in good faith..

CMS is developing a streamlined, automated process to standardize emergency waiver requests based on lessons learned during the anti inflammatory drugs symbicort, according to a proposed information collection on Tuesday.The agency said the new system would be based mainly on the volume of requests to ensure symbicort online usa facilities receive a quick response. CMS will collect relevant information from healthcare providers and suppliers symbicort online usa to decide whether to approve their waiver request. The new waiver request form was approved on an emergency basis Oct. 15. "Prior to this request, CMS did not have a standard process or (White House budget office) approval for providers/suppliers impacted to submit 1135 waiver/flexibility requests or inquiries, as these were generally seen on a smaller scale (natural disasters) prior to the anti inflammatory drugs public health emergency," CMS wrote.Comments on the information collection are due in December.Under the old system, providers and suppliers would email a summary of their request to each CMS locationâpreviously known as CMS regional offices.The agency also plans to create a streamlined, automated system to gather information from providers about how their operations have been affected by an emergency or disaster.

Symbicort 2020 coupon

In this symbicort 2020 coupon issue of BMJ Quality and Safety, Jorro-BarÃ³n and colleagues1 report the findings of a stepped-wedge cluster randomised trial (SW-CRT) to evaluate the implementation of the I-PASS handover system among six paediatric intensive care units (PICUs) at five Argentinian hospitals between July 2018 and May 2019. According to the authors, prior to the intervention there were complaints that handovers were ââ¦lengthy, disorganized, â¦participants experienced problems with interruptions, distractions, and â¦ senior professionals had problems accepting dissentâ.Adverse events were assessed by two independent symbicort 2020 coupon reviewers using the Global Assessment of Pediatric Patient Safety instrument. Study results demonstrated significantly improved handover compliance in the intervention group, validating Kirkpatrick Level 3 (behavioural change)2 effectiveness of the training initiative.

Notably, however, on the primary outcome there were no differences between control and intervention groups regarding preventable adverse events symbicort 2020 coupon per 1000 days of hospitalisation (control 60.4 (37.5â97.4) vs intervention 60.4 (33.2â109.9), p=0.998, risk ratio. 1.0 (0.74â1.34)). Regarding balancing measures, there was no observed difference in the symbicort 2020 coupon âfull-shiftâ handover duration (control 35.7 min (29.6â41.8).

Intervention 34.7 min (26.5â42.1), p=0.490), although more time was spent on individual patient handovers in the intervention period (7.29 min (5.77â8.81). Control 5.96 symbicort 2020 coupon min (4.69â7.23). P=0.001).

From the provider perspective, preintervention and postintervention Agency for Healthcare Research and Quality (AHRQ) safety culture surveys did not show significant differences in their responses to communication-focused questions before and after the intervention.Thus, consistent with all previous studies, I-PASS was implemented successfully and handover quality improved. However, is the lack of association of I-PASS implementation with clinical outcomes and adverse events in this study a concern?. To answer this question, it is necessary to review the origins of I-PASS more than a decade ago and its continually expanding evidence base.Healthcare has a handover problemHandovers are among the most vulnerable reoccurring processes in healthcare.

In the AHRQ safety culture survey,3 the handovers and transitions of care domain is consistently among the lowest scoring, and handover and communication issues are among the most common cause of Joint Commission Sentinel Events and the subject of Joint Commission Sentinel Event Alert Issue 58.4 A study by CRICO Strategies found that communication issues were a factor in 30% of 23â658 malpractice claims filed from 2009 to 2013, accounting for $1.7 billion in incurred losses.5 The importance of handovers and care transitions for trainees is specifically discussed in a Clinical Learning Environment Review Issue Brief published by the Accreditation Council for Graduate Medical Education (ACGME),6 and Section VI.E.3 (Transitions of Care) of the ACGME Common Program Requirements (Residency) addresses the requirement for residents to be taught and to use structured handovers.7Both the numbers of handovers and handover-related problems have increased in contemporary practice because of greater patient complexity and the expanding number and types of providers involved in a typical patientâs care. Further, in teaching institutions, resident work-hour restrictions have resulted in the need for complex coverage schemes. Off-hours care is often provided by âcross-coveringâ, âfloatâ or âmoonlightingâ practitioners who are responsible for numerous unfamiliar patients during their shifts, thus imposing an even greater need for effective handovers.

The net effect of all these changes may be inconsistent, fragmented care resulting from suboptimal handovers from one provider, service or hospital to another, with resulting medical errors (often of omission) and adverse events.Structured, standardised handoversThese serious vulnerabilities have led to pleas for more consistent, structured and standardised handovers.8â11 In addition to their use in routine shift-to-shift provider sign-off, these may be of particular value in the high-risk transfers of critically ill patients, such as from operating rooms to postoperative care units and ICUs12â16. Admissions to a surgery unit17. Management of trauma patients18â20.

ICU to general ward transfers21 22. Night and weekend coverage of large services, many of whose patients are unfamiliar to the physician receiving the handover23â28. And end-of-rotation resident transitions.29â31Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes.32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites.

A basic, common framework that could be customised to individual use cases would clearly be preferable.The I-PASS systemResponding to these concerns, the I-PASS Study Group was initiated in 2009 and the I-PASS Institute in 2016. Although numerous other systems are available, since its pilot studies a decade ago,34 35 I-PASS has emerged as the dominant system in healthcare for structured, standardised handovers. This system is specifically designed for healthcare applications.

It is based on adult educational principles and simple to use. It has been extensively validated in the peer-reviewed literature encompassing studies at multiple institutions in the USA and internationally34â40. And extensive training materials are available to assist programmes in implementation.39 41â45 Ideally, this system is implemented hospital-wide, which addresses the issue of cross-unit and cross-service transfers.I-PASS includes five major elements regarded as important for every handoverâillness severity, patient summary, action list, situation awareness/contingency planning and synthesis by receiver.

The first three of these elements are often included in non-structured handovers, although not necessarily in a specific sequence or format. The last two I-PASS elementsâsituational awareness/contingency planning and synthesisâhave not historically been included in typical handover practice. The former assures that any anticipated problems are conveyed from the handover giver to the incoming provider and that appropriate responses to these issues are discussed.

However, other than in I-PASS, it is quite uncommon in healthcare, with the potential exception of confirming verbal or telephonic orders.I-PASS validationIn an initial study of I-PASS handover implementation by residents on two general inpatient paediatric units at Boston Childrenâs Hospital,34 written handovers were more comprehensive and had fewer omissions of key data, and mean time spent on verbal handover sessions did not change significantly (32.3 min vs 33.2 min). Medical errors and adverse events were ascertained prospectively by research nurse reviewers and independent physician investigators. Following I-PASS implementation, preventable adverse events decreased from 3.3 (95% CI 1.7 to 4.8) to 1.5 (95% CI 0.51 to 2.4) per 100 admissions (p=0.04), and medical error rates decreased significantly from 33.8 per 100 admissions (95% CI 27.3 to 40.3) to 18.3 per 100 admissions (95% CI 14.7 to 21.9.

P<0.001). A commentary by Horwitz46 noted that this was ââ¦by far the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations and is the first to demonstrate an associated significant decrease in medical errors on a large scaleâ, while also noting limitations including its uncontrolled, âbefore and afterâ design, confounding by secular changes, Hawthorne effects and inability to blind the nurses collecting adverse event data.The more expansive, landmark I-PASS study was conducted by Starmer and colleagues37 among nine paediatric hospitals and 10â740 patient admissions between January 2011 and May 2013. Handover quality was evaluated, and medical errors and adverse events were ascertained by active surveillance, including on-site nurse review of medical records, orders, formal incident reports, nursing reports and daily medical error reports from residents.

Independent physician investigators classified occurrences as adverse events, near misses or exclusions, and they subclassified adverse events as preventable or non-preventable. Results revealed a 23% reduction in medical errors from the preintervention to the postintervention period (24.5 vs 18.8 per 100 admissions, p<0.001) and a 30% reduction in preventable adverse events (4.7 vs 3.3 events per 100 admissions, p<0.001). Inclusion of prespecified elements in written and verbal handovers increased significantly, and there was no significant change in handover time per patient (2.4 vs 2.5âmin.

P=0.55).Subsequent investigations in other institutions have replicated many of the findings of the original I-PASS studies, with higher postintervention inclusion rates of critical handover elements. Fewer mistakes or omissions. Greater provider satisfaction with handover organisation and information conveyed.

Unchanged or shorter handoff times. And decreased handover interruptions (probably reflecting greater attention to the importance of the handover process).36 40 47â50 In a mentored implementation study conducted in 2015â2016 among 16 hospitals (five community hospitals, 11 academic centres and multiple specialties), handover quality improved, and there was a provider-reported 27% reduction in adverse events.38 Among nurses at Boston Childrenâs Hospital, I-PASS implementation was associated with significant decreases in handover-related care failures.40In recognition of its achievements in improving healthcare quality, the I-PASS Study Group was awarded the 2016 John M Eisenberg Award for Patient Safety and Quality by the National Quality Forum and the Joint Commission.The challenge of linking handovers to clinical outcomes and eventsAlthough investigations from many centres, including the report of Jorro-BarrÃ³n and colleagues,1 have now confirmed that I-PASS can be readily assimilated and used by clinicians, most of these have either not rigorously assessed adverse events, medical errors and other clinical outcomes (Kirkpatrick Level 4 evaluation) or have failed to demonstrate significant postintervention improvements in these clinical outcomes. Why is this, and should current or potential I-PASS users be concerned?.

With regard to the first question, there are practical considerations that complicate the rigorous study of clinical outcome improvements associated with I-PASS (or any other handover system). Notwithstanding the importance of effective communications, these are only one of many provider processes and hospital systems, not to mention the overall hospital quality and safety culture, that impact a patientâs clinical outcome. In most hospitals, a diverse portfolio of quality and safety improvement initiatives are always being conducted.

Disentangling and isolating the effects of any one specific intervention, such as I-PASS handovers, is challenging if not impossible. At a minimum, it requires real-time, prospective monitoring by trained nurse or physician reviewers as in the original I-PASS studies, a research design which realistically is unlikely to be reproduced. Ideally, the study design would also include blinding of the study period (control or intervention) and blinding of observers, the former of which is virtually impossible for this type of intervention.Further, if other provider processes and hospital systems are functioning at a high level, they may partially offset the impact of suboptimal communications and make it even more challenging to demonstrate significant improvements.

The current study of Jorro-BarÃ³n and colleagues,1 which uses PICUs as the unit of analysis, illustrates this concept. PICUs are typically among the most compulsive, detail-oriented units in any hospital, even if they may have nominally ânon-standardizedâ handovers.Study design. The SW-CRTIn an attempt to address the limitations of some previous studies, Parent and colleagues51 studied eight medical and surgical ICUs across two academic tertiary teaching hospitals using an SW-CRT design.

Clinician self-assessment of having been inadequately prepared for their shift because of a poor-quality handoff decreased from 35 of 343 handoffs (10.2%) in the control arm to 53 of 740 handoffs (7.2%) postintervention (OR 0.19. 95% CI 0.03 to 0.74. P=0.03).

ÂLast-minuteâ, early morning order writing decreased, and handover duration increased but not significantly (+5.5âmin. 95% CI 0.34 to 9.39. P=0.30).

As in the current study of Jorro-BarÃ³n and colleagues,1 who also employed an SW-CRT, there were no associated changes in clinical outcomes such as ICU length of stay, duration of mechanical ventilation or necessity for reintubation. The authors comment that given high baseline quality of care in these ICUs, it was not surprising that there were no changes in outcomes.An SW-CRT is generally considered a rigorous study design as it includes cluster randomisation. However, though novel and increasingly popular, this approach is complex and may sometimes add confusion rather than clarity.52â57 Its major appeal is that all clusters will at some point, in a random and sequential fashion, transition from control to intervention condition.

For an intervention that is perceived by participants as having more potential for good than harm, this may enhance cluster recruitment. It may also make it possible to conduct a randomised study in scenarios where pragmatic considerations, such as the inability to conduct interventions simultaneously across numerous clusters, may make a parallel randomised study (or any study) infeasible.However, as acknowledged even by its proponents, the added practical and statistical complexity of SW-CRTs often makes them more challenging to properly implement, and compared with traditional parallel cluster randomised trials they may be more prone to biases.53â57 A Consolidated Standards of Reporting Trials extension has been specifically developed in response to these concerns.55 Unique design and analytical considerations include the number of clusters, sequences and periods. Clusters per sequence.

And cluster-period sizes.55 56 Concerns include recruitment and selection biases. Proper accounting for secular trends in outcomes (ie, because of the sequential rather than simultaneous nature of the SW-CRT design, observations from the intervention condition occur on average at a later calendar time, so that the intervention effect may be confounded by an underlying time trend). Accounting for repeated measures on participants and clusters in sample size calculations and analyses (ie, data are not independent).

Possible time-varying treatment effects. And the potential for within-cluster contamination of observations obtained under the control or intervention condition.52â56Regarding contamination, a secular trend may be responsible if, for example, institutional activities focused on improving patient outcomes include a general emphasis on communications. There might also be more direct contamination of the intervention among clusters waiting to be crossed over, as described in the context of the Matching Michigan programme.58 Participating in a trial and awareness of being observed may change the behaviour of participants.

Finally, because of sometimes prolonged PICU length of stay and regularly scheduled resident rotations on and off a unit or service, some patients and providers might overlap the transition from control to intervention state and contribute observations to both, while others will be limited to one or the other. This possibility is not clearly defined by the authors of the current study, but seems unlikely to have had a major statistical effect.Do we need more evidence?. From an implementation science perspective, handovers are a deeply flawed healthcare process with the demonstrated potential to harm patients.

A new toolâI-PASSâhas been developed which can be easily and economically taught and subsequently applied by virtually any provider, and many resources are available to assist in implementation.45 It has few, if any, unintended negative consequences to patients or providers and has been associated in at least two extensive and well-conducted (although non-randomised) trials with dramatic reductions in medical errors and adverse events. Notably, these were conducted at a time when there was much less emphasis on and awareness of handover systems, including I-PASS. Thus, there was much greater separation between control and intervention states than would be possible today.Returning to the question posed at the beginning of this commentary, is the inability to demonstrate a favourable impact on clinical outcomes in studies other than those of the developers34 35 a reason to question the value of I-PASS?.

For the reasons discussed above, I think not. In his classic 2008 article,60 âThe Science of Improvementâ, Dr Don Berwick recounts the transformational development of sophisticated statistical analyses in healthcare, of which the randomised clinical trial is the paradigm. While in many instances randomised controlled trials have been invaluable in scientifically affirming or rejecting the utility of specific treatments or interventions, their limitations are more obvious in interventions involving complex social and behavioural change.

Berwick illustrates this challenge with the example of hospital rapid response teams, whose benefit was challenged by the results of a large cluster randomised trial. His comments regarding that conflict are equally applicable to the current challenge of demonstrating the impact of standardised handovers on clinical outcomes:These critics refused to accept as evidence the large, positive, accumulating experience of many hospitals that were adapting rapid response for their own use, such as childrenâs hospitals. How can accumulating local reports of effectiveness of improvement interventions, such as rapid response systems, be reconciled with contrary findings from formal trials with their own varying imperfections?.

Leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.Having personally observed the value of I-PASS, as well as the devastating consequences of inadequate handovers, I vote with Dr Berwick.

The evidence for effectiveness is overwhelming and the need for action is urgentâall that is lacking is the will to implement.Ethics statementsPatient consent for publicationNot required.Palliative care is associated with improved patient-centred and caregiver-centred outcomes, higher-quality end-of-life care, and decreased healthcare use among patients with serious illness.1â3 The Centre to Advance Palliative Care has established a set of recommended clinical criteria (or âtriggersâ), including a projected survival of less than 1âyear,4 to help clinicians identify patients likely to benefit from palliative care. Nevertheless, referrals often occur within the last 3 months of life5 due in part to clinician overestimation of prognosis.6 A growing number of automated predictive models leverage vast data in the electronic medical record (EMR) to accurately predict short-term mortality risk in real time and can be paired with systems to prompt clinicians to refer to palliative care.7â12 These models hold great promise to overcome the many clinician-level and system-level barriers to improving access to timely palliative care. First, mortality risk prediction algorithms have been shown to outperform clinician prognostic assessment, and clinicianâmachine collaboration may even outperform both.13 Second, algorithm-based ânudgesâ that systematically provide prognostic information could address many cognitive biases, including status quo bias and optimism bias,14 15 that make clinicians less apt to identify patients who may benefit from palliative care.

Indeed, such models have been shown to improve the frequency of palliative care delivery and patient outcomes in the hospital and clinic settings.9 16 17 With that said, successful implementation of automated prognostic models into routine clinical care at scale requires clinician and patient engagement and support.In this issue of BMJ Quality &. Safety, Saunders and colleagues report on the acceptability of using the EMR-based Modified Hospitalised-Patient One-Year Mortality Risk (mHOMR) score to alert clinicians to individual patients with a >21%ârisk of dying within 12 months. The goal of the clinician notification of an elevated risk score was to prompt clinicians to consider palliative care referral.18 In a previously reported feasibility study among 400 hospitalised patients, use of the mHOMR alert was associated with increased rates of goals of care discussions and palliative care consultation in comparison to the preimplementation baseline (34% vs 18%, respectively).19 In the present study, the authors conducted qualitative interviews pre-mHOMR and post-mHOMR implementation among 64 stakeholders, including patients identified at high risk by the mHOMR algorithm, their caregivers, staff and physicians.

Thirty-five (55%) participants agreed that the mHOMR tool was acceptable. 14 (22%) were unsure or did not agree. And 15 (23%) did not respond.

The authors concluded that clinicians and patients found the automated prognostic trigger to be an acceptable addition to usual clinical care.Saunders et alâs work adds to our understanding of critical perceptions regarding end usersâ acceptability of automated prognostic triggers in routine clinical care. The findings from this study align with prior evidence suggesting that clinicians recognise the value of automated, algorithm-based approaches to improve serious illness care. For example, in a qualitative study of clinicians by Hallen et al, prognostic models confirmed cliniciansâ gestalt and served as a tool to help communicate prognosis to patients.20 Clinicians described prognostic models as a tool to facilitate interclinician disagreements, mitigate medicolegal risk, and overcome the tendency to ignore or overestimate prognosis.20 Clinicians also reported that EMR-generated lists of high-risk patients improved their ability to identify potential palliative care beneficiaries in a mixed-methods study by Mason et al.21 In a single-centre pilot study, we similarly found that most clinicians believed that using an EMR-based prognostic model to encourage inpatient palliative care consultation was acceptable.9 However, in the Saunders et al study, as in prior similar work, clinicians highlighted the importance of delivering notifications without causing excess provider workload, redundancy or alert fatigue.16 18 21 Clinicians also raised concerns regarding the accuracy of the prognostic information and the potential for negative effects on patients due to common misperceptions about palliative care being equivalent to hospice.18 20 21 Ultimately, Saunders et alâs work complements and builds on existing literature, demonstrating a general perception that integration of automated prognostic models into routine clinical care could be beneficial and acceptable.Important gaps remain in this literature which were not addressed by the Saunders et al study.

For example, there is a need to capture more diverse clinician and patient perspectives, and there was no information provided about the sociodemographic or clinical characteristics of the study participants. Additionally, important themes found in prior studies were not identified in this study. For example, two prior studies of cliniciansâ perspectives on automated prognostic triggers for palliative care revealed concerns that prognosis alone may not be a sufficient surrogate indicator of actual palliative care need, or may inadvertently engender clinician overconfidence in an individual patientâs prognosis.9 21 The brevity of the interviews in Saunders et alâs study (mean.

12âmin) could suggest all relevant themes may not have emerged in the data analysis. Additionally, while the inclusion of patient and caregiver perceptions is an important addition, limited information is provided about their perspectives and whether certain themes differed among the stakeholders. In the study from Mason et al, themes unique to patients and caregivers were identified, such as hesitancy due to a lack of understanding of palliative care, a preference to âfocus on the presentâ, and a worry that a clinician would not have the time to adequately address advanced care planning or palliative care during their visit.21 Healthcare systems should therefore be prepared to consider their unique workflows, patients and staff prior to implementing one of these programmes.Achieving stakeholder acceptability prior to widespread implementation is essential.

An intervention should ideally undergo multiple cycles of optimisation with ongoing appraisal of patient and clinician perspectives prior to wide-scale implementation.22 23 Additionally, it is unclear whether cliniciansâ acceptability of the intervention in one setting will generalise to other inpatient health settings. For instance, Saunders et al found that some providers were leery about the use of mHOMR due the need to balance the patientâs acute needs that brought them to the hospital with their long-term priorities that may be better served in the outpatient setting.18 Clinical workflows, patient acuity and patientâprovider relationships are markedly different between the inpatient and outpatient settings, suggesting Saunders et alâs findings cannot be extrapolated to outpatient care. This is particularly relevant as many âoff-the-shelfâ prognostic algorithms are now commercially available that, while accurate, may not be as familiar or acceptable to clinicians as a homegrown model.

For example, Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) is a framework that measures the impact of a programme based on five factors. Reach, effectiveness, adoption, implementation and maintenance.27 Due to their pragmatic approach, hybrid trials frequently include heterogenous samples and clinical settings that optimise external validity and generalisability.26 28 They can be designed to primarily test the effects of a clinical interventions while observing and gathering information on implementation outcomes (type I), for equal evaluation of both the clinical intervention and implementation strategies (type II), or to primarily assess implementation outcomes while collecting effectiveness data (type III).26 29 For example, Beidas et al used a type I hybrid effectivenessâimplementation trial design to test the effectiveness of an exercise intervention for breast cancer. This study not only evaluated the effectiveness of the intervention but also identified multiple significant implementation barriers such as cost, referral logistics and patient selection challenges which informed their subsequent dissemination efforts.30 Prospective, randomised, hybrid effectivenessâimplementation designs focusing on other key implementation outcomes are a logical and necessary next step in advancing the field.

In total, the work by Saunders et al demonstrates the potential acceptability of an automated prognostic model to improve the timeliness of palliative care, setting the stage for further work to optimise and implement these programmes into real-world clinical care.Ethics statementsPatient consent for publicationNot required..

In this issue of BMJ Quality and Safety, Jorro-BarÃ³n and colleagues1 report the findings of a stepped-wedge cluster randomised trial (SW-CRT) to evaluate symbicort online usa the implementation of the I-PASS handover system among six paediatric intensive care units (PICUs) at five Argentinian hospitals between July 2018 and May 2019. According to the authors, prior to the intervention there were complaints that handovers were ââ¦lengthy, disorganized, â¦participants symbicort online usa experienced problems with interruptions, distractions, and â¦ senior professionals had problems accepting dissentâ.Adverse events were assessed by two independent reviewers using the Global Assessment of Pediatric Patient Safety instrument. Study results demonstrated significantly improved handover compliance in the intervention group, validating Kirkpatrick Level 3 (behavioural change)2 effectiveness of the training initiative. Notably, however, on the primary outcome there were no differences between control and intervention groups regarding preventable adverse symbicort online usa events per 1000 days of hospitalisation (control 60.4 (37.5â97.4) vs intervention 60.4 (33.2â109.9), p=0.998, risk ratio. 1.0 (0.74â1.34)).

Regarding balancing measures, there was no observed difference in the âfull-shiftâ handover duration (control 35.7 min symbicort online usa (29.6â41.8). Intervention 34.7 min (26.5â42.1), p=0.490), although more time was spent on individual patient handovers in the intervention period (7.29 min (5.77â8.81). Control 5.96 symbicort online usa min (4.69â7.23). P=0.001). From the provider perspective, preintervention and postintervention Agency for Healthcare Research and Quality (AHRQ) safety culture surveys did not show significant differences in their responses to communication-focused questions before and after the intervention.Thus, consistent with all previous studies, I-PASS was implemented successfully and handover quality improved.

However, is the lack of association of I-PASS implementation with clinical outcomes and adverse events in this study a concern?. To answer this question, it is necessary to review the origins of I-PASS more than a decade ago and its continually expanding evidence base.Healthcare has a handover problemHandovers are among the most vulnerable reoccurring processes in healthcare. In the AHRQ safety culture survey,3 the handovers and transitions of care domain is consistently among the lowest scoring, and handover and communication issues are among the most common cause of Joint Commission Sentinel Events and the subject of Joint Commission Sentinel Event Alert Issue 58.4 A study by CRICO Strategies found that communication issues were a factor in 30% of 23â658 malpractice claims filed from 2009 to 2013, accounting for $1.7 billion in incurred losses.5 The importance of handovers and care transitions for trainees is specifically discussed in a Clinical Learning Environment Review Issue Brief published by the Accreditation Council for Graduate Medical Education (ACGME),6 and Section VI.E.3 (Transitions of Care) of the ACGME Common Program Requirements (Residency) addresses the requirement for residents to be taught and to use structured handovers.7Both the numbers of handovers and handover-related problems have increased in contemporary practice because of greater patient complexity and the expanding number and types of providers involved in a typical patientâs care. Further, in teaching institutions, resident work-hour restrictions have resulted in the need for complex coverage schemes. Off-hours care is often provided by âcross-coveringâ, âfloatâ or âmoonlightingâ practitioners who are responsible for numerous unfamiliar patients during their shifts, thus imposing an even greater need for effective handovers.

And end-of-rotation resident transitions.29â31Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes.32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites. A basic, common framework that could be customised to individual use cases would clearly be preferable.The I-PASS systemResponding to these concerns, the I-PASS Study Group was initiated in 2009 and the I-PASS Institute in 2016. Although numerous other systems are available, since its pilot studies a decade ago,34 35 I-PASS has emerged as the dominant system in healthcare for structured, standardised handovers. This system is specifically designed for healthcare applications. It is based on adult educational principles and simple to use.

It has been extensively validated in the peer-reviewed literature encompassing studies at multiple institutions in the USA and internationally34â40. And extensive training materials are available to assist programmes in implementation.39 41â45 Ideally, this system is implemented hospital-wide, which addresses the issue of cross-unit and cross-service transfers.I-PASS includes five major elements regarded as important for every handoverâillness severity, patient summary, action list, situation awareness/contingency planning and synthesis by receiver. The first three of these elements are often included in non-structured handovers, although not necessarily in a specific sequence or format. The last two I-PASS elementsâsituational awareness/contingency planning and synthesisâhave not historically been included in typical handover practice. The former assures that any anticipated problems are conveyed from the handover giver to the incoming provider and that appropriate responses to these issues are discussed.

Synthesis is closed-loop communication, with brief read-back of the handover information by the receiver to assure their accurate comprehension, followed by an opportunity for questions and discussion. This read-back of mission-critical communications is standard operating practice in other high-reliability settings such as aviation, the military and nuclear power. It is essential to establishing a shared mental model of the current state and any potential concerns. However, other than in I-PASS, it is quite uncommon in healthcare, with the potential exception of confirming verbal or telephonic orders.I-PASS validationIn an initial study of I-PASS handover implementation by residents on two general inpatient paediatric units at Boston Childrenâs Hospital,34 written handovers were more comprehensive and had fewer omissions of key data, and mean time spent on verbal handover sessions did not change significantly (32.3 min vs 33.2 min). Medical errors and adverse events were ascertained prospectively by research nurse reviewers and independent physician investigators.

Following I-PASS implementation, preventable adverse events decreased from 3.3 (95% CI 1.7 to 4.8) to 1.5 (95% CI 0.51 to 2.4) per 100 admissions (p=0.04), and medical error rates decreased significantly from 33.8 per 100 admissions (95% CI 27.3 to 40.3) to 18.3 per 100 admissions (95% CI 14.7 to 21.9. P<0.001). A commentary by Horwitz46 noted that this was ââ¦by far the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations and is the first to demonstrate an associated significant decrease in medical errors on a large scaleâ, while also noting limitations including its uncontrolled, âbefore and afterâ design, confounding by secular changes, Hawthorne effects and inability to blind the nurses collecting adverse event data.The more expansive, landmark I-PASS study was conducted by Starmer and colleagues37 among nine paediatric hospitals and 10â740 patient admissions between January 2011 and May 2013. Handover quality was evaluated, and medical errors and adverse events were ascertained by active surveillance, including on-site nurse review of medical records, orders, formal incident reports, nursing reports and daily medical error reports from residents. Independent physician investigators classified occurrences as adverse events, near misses or exclusions, and they subclassified adverse events as preventable or non-preventable.

Results revealed a 23% reduction in medical errors from the preintervention to the postintervention period (24.5 vs 18.8 per 100 admissions, p<0.001) and a 30% reduction in preventable adverse events (4.7 vs 3.3 events per 100 admissions, p<0.001). Inclusion of prespecified elements in written and verbal handovers increased significantly, and there was no significant change in handover time per patient (2.4 vs 2.5âmin. P=0.55).Subsequent investigations in other institutions have replicated many of the findings of the original I-PASS studies, with higher postintervention inclusion rates of critical handover elements. Fewer mistakes or omissions. Greater provider satisfaction with handover organisation and information conveyed.

In most hospitals, a diverse portfolio of quality and safety improvement initiatives are always being conducted. Disentangling and isolating the effects of any one specific intervention, such as I-PASS handovers, is challenging if not impossible. At a minimum, it requires real-time, prospective monitoring by trained nurse or physician reviewers as in the original I-PASS studies, a research design which realistically is unlikely to be reproduced. Ideally, the study design would also include blinding of the study period (control or intervention) and blinding of observers, the former of which is virtually impossible for this type of intervention.Further, if other provider processes and hospital systems are functioning at a high level, they may partially offset the impact of suboptimal communications and make it even more challenging to demonstrate significant improvements. The current study of Jorro-BarÃ³n and colleagues,1 which uses PICUs as the unit of analysis, illustrates this concept.

PICUs are typically among the most compulsive, detail-oriented units in any hospital, even if they may have nominally ânon-standardizedâ handovers.Study design. The SW-CRTIn an attempt to address the limitations of some previous studies, Parent and colleagues51 studied eight medical and surgical ICUs across two academic tertiary teaching hospitals using an SW-CRT design. Clinician self-assessment of having been inadequately prepared for their shift because of a poor-quality handoff decreased from 35 of 343 handoffs (10.2%) in the control arm to 53 of 740 handoffs (7.2%) postintervention (OR 0.19. 95% CI 0.03 to 0.74. P=0.03).

ÂLast-minuteâ, early morning order writing decreased, and handover duration increased but not significantly (+5.5âmin. 95% CI 0.34 to 9.39. P=0.30). As in the current study of Jorro-BarÃ³n and colleagues,1 who also employed an SW-CRT, there were no associated changes in clinical outcomes such as ICU length of stay, duration of mechanical ventilation or necessity for reintubation. The authors comment that given high baseline quality of care in these ICUs, it was not surprising that there were no changes in outcomes.An SW-CRT is generally considered a rigorous study design as it includes cluster randomisation.

However, though novel and increasingly popular, this approach is complex and may sometimes add confusion rather than clarity.52â57 Its major appeal is that all clusters will at some point, in a random and sequential fashion, transition from control to intervention condition. For an intervention that is perceived by participants as having more potential for good than harm, this may enhance cluster recruitment. It may also make it possible to conduct a randomised study in scenarios where pragmatic considerations, such as the inability to conduct interventions simultaneously across numerous clusters, may make a parallel randomised study (or any study) infeasible.However, as acknowledged even by its proponents, the added practical and statistical complexity of SW-CRTs often makes them more challenging to properly implement, and compared with traditional parallel cluster randomised trials they may be more prone to biases.53â57 A Consolidated Standards of Reporting Trials extension has been specifically developed in response to these concerns.55 Unique design and analytical considerations include the number of clusters, sequences and periods. Clusters per sequence. And cluster-period sizes.55 56 Concerns include recruitment and selection biases.

Proper accounting for secular trends in outcomes (ie, because of the sequential rather than simultaneous nature of the SW-CRT design, observations from the intervention condition occur on average at a later calendar time, so that the intervention effect may be confounded by an underlying time trend). Accounting for repeated measures on participants and clusters in sample size calculations and analyses (ie, data are not independent). Possible time-varying treatment effects. And the potential for within-cluster contamination of observations obtained under the control or intervention condition.52â56Regarding contamination, a secular trend may be responsible if, for example, institutional activities focused on improving patient outcomes include a general emphasis on communications. There might also be more direct contamination of the intervention among clusters waiting to be crossed over, as described in the context of the Matching Michigan programme.58 Participating in a trial and awareness of being observed may change the behaviour of participants.

For example, in the handover intervention of Jorro-BarÃ³n and colleagues,1 some providers in a control condition cluster may, because they are aware of the interest in handovers, begin to implement more standardised practices before the formal shift to the intervention condition. This potentially dilutes any subsequent impact of the intervention by virtue of what could be considered either a Hawthorne effect or a local secular trend, in either case leading to generally better handovers in the preintervention period. Some SW-CRTs include a transition period without any observations to allow for sufficient time to implement the intervention,53 59 thereby creating more contrast. Finally, because of sometimes prolonged PICU length of stay and regularly scheduled resident rotations on and off a unit or service, some patients and providers might overlap the transition from control to intervention state and contribute observations to both, while others will be limited to one or the other. This possibility is not clearly defined by the authors of the current study, but seems unlikely to have had a major statistical effect.Do we need more evidence?.

From an implementation science perspective, handovers are a deeply flawed healthcare process with the demonstrated potential to harm patients. A new toolâI-PASSâhas been developed which can be easily and economically taught and subsequently applied by virtually any provider, and many resources are available to assist in implementation.45 It has few, if any, unintended negative consequences to patients or providers and has been associated in at least two extensive and well-conducted (although non-randomised) trials with dramatic reductions in medical errors and adverse events. Notably, these were conducted at a time when there was much less emphasis on and awareness of handover systems, including I-PASS. Thus, there was much greater separation between control and intervention states than would be possible today.Returning to the question posed at the beginning of this commentary, is the inability to demonstrate a favourable impact on clinical outcomes in studies other than those of the developers34 35 a reason to question the value of I-PASS?. For the reasons discussed above, I think not.

In his classic 2008 article,60 âThe Science of Improvementâ, Dr Don Berwick recounts the transformational development of sophisticated statistical analyses in healthcare, of which the randomised clinical trial is the paradigm. While in many instances randomised controlled trials have been invaluable in scientifically affirming or rejecting the utility of specific treatments or interventions, their limitations are more obvious in interventions involving complex social and behavioural change. Berwick illustrates this challenge with the example of hospital rapid response teams, whose benefit was challenged by the results of a large cluster randomised trial. His comments regarding that conflict are equally applicable to the current challenge of demonstrating the impact of standardised handovers on clinical outcomes:These critics refused to accept as evidence the large, positive, accumulating experience of many hospitals that were adapting rapid response for their own use, such as childrenâs hospitals. How can accumulating local reports of effectiveness of improvement interventions, such as rapid response systems, be reconciled with contrary findings from formal trials with their own varying imperfections?.

The reasons for this apparent gap between science and experience lie deep in epistemology. The introduction of rapid response systems in hospitals is a complex, multicomponent interventionâessentially a process of social change. The effectiveness of these systems is sensitive to an array of influences. Leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn.

Critics who use it as a truth standard in this context are incorrect.Having personally observed the value of I-PASS, as well as the devastating consequences of inadequate handovers, I vote with Dr Berwick. The evidence for effectiveness is overwhelming and the need for action is urgentâall that is lacking is the will to implement.Ethics statementsPatient consent for publicationNot required.Palliative care is associated with improved patient-centred and caregiver-centred outcomes, higher-quality end-of-life care, and decreased healthcare use among patients with serious illness.1â3 The Centre to Advance Palliative Care has established a set of recommended clinical criteria (or âtriggersâ), including a projected survival of less than 1âyear,4 to help clinicians identify patients likely to benefit from palliative care. Nevertheless, referrals often occur within the last 3 months of life5 due in part to clinician overestimation of prognosis.6 A growing number of automated predictive models leverage vast data in the electronic medical record (EMR) to accurately predict short-term mortality risk in real time and can be paired with systems to prompt clinicians to refer to palliative care.7â12 These models hold great promise to overcome the many clinician-level and system-level barriers to improving access to timely palliative care. First, mortality risk prediction algorithms have been shown to outperform clinician prognostic assessment, and clinicianâmachine collaboration may even outperform both.13 Second, algorithm-based ânudgesâ that systematically provide prognostic information could address many cognitive biases, including status quo bias and optimism bias,14 15 that make clinicians less apt to identify patients who may benefit from palliative care. Indeed, such models have been shown to improve the frequency of palliative care delivery and patient outcomes in the hospital and clinic settings.9 16 17 With that said, successful implementation of automated prognostic models into routine clinical care at scale requires clinician and patient engagement and support.In this issue of BMJ Quality &.

Safety, Saunders and colleagues report on the acceptability of using the EMR-based Modified Hospitalised-Patient One-Year Mortality Risk (mHOMR) score to alert clinicians to individual patients with a >21%ârisk of dying within 12 months. The goal of the clinician notification of an elevated risk score was to prompt clinicians to consider palliative care referral.18 In a previously reported feasibility study among 400 hospitalised patients, use of the mHOMR alert was associated with increased rates of goals of care discussions and palliative care consultation in comparison to the preimplementation baseline (34% vs 18%, respectively).19 In the present study, the authors conducted qualitative interviews pre-mHOMR and post-mHOMR implementation among 64 stakeholders, including patients identified at high risk by the mHOMR algorithm, their caregivers, staff and physicians. Thirty-five (55%) participants agreed that the mHOMR tool was acceptable. 14 (22%) were unsure or did not agree. And 15 (23%) did not respond.

Participants identified many potential benefits of the programme, citing the advantages of an automated approach to facilitate and justify clinical decision making. Participants also acknowledged possible barriers, particularly âsituational challengesâ such as the content, timing and mechanism of provider notification. Additional logistical concerns included alert fatigue, potential redundancy, uncertainty regarding next steps and a worry that certain therapeutic options could be withheld from flagged patients. The authors concluded that clinicians and patients found the automated prognostic trigger to be an acceptable addition to usual clinical care.Saunders et alâs work adds to our understanding of critical perceptions regarding end usersâ acceptability of automated prognostic triggers in routine clinical care. The findings from this study align with prior evidence suggesting that clinicians recognise the value of automated, algorithm-based approaches to improve serious illness care.

For example, in a qualitative study of clinicians by Hallen et al, prognostic models confirmed cliniciansâ gestalt and served as a tool to help communicate prognosis to patients.20 Clinicians described prognostic models as a tool to facilitate interclinician disagreements, mitigate medicolegal risk, and overcome the tendency to ignore or overestimate prognosis.20 Clinicians also reported that EMR-generated lists of high-risk patients improved their ability to identify potential palliative care beneficiaries in a mixed-methods study by Mason et al.21 In a single-centre pilot study, we similarly found that most clinicians believed that using an EMR-based prognostic model to encourage inpatient palliative care consultation was acceptable.9 However, in the Saunders et al study, as in prior similar work, clinicians highlighted the importance of delivering notifications without causing excess provider workload, redundancy or alert fatigue.16 18 21 Clinicians also raised concerns regarding the accuracy of the prognostic information and the potential for negative effects on patients due to common misperceptions about palliative care being equivalent to hospice.18 20 21 Ultimately, Saunders et alâs work complements and builds on existing literature, demonstrating a general perception that integration of automated prognostic models into routine clinical care could be beneficial and acceptable.Important gaps remain in this literature which were not addressed by the Saunders et al study. For example, there is a need to capture more diverse clinician and patient perspectives, and there was no information provided about the sociodemographic or clinical characteristics of the study participants. Additionally, important themes found in prior studies were not identified in this study. For example, two prior studies of cliniciansâ perspectives on automated prognostic triggers for palliative care revealed concerns that prognosis alone may not be a sufficient surrogate indicator of actual palliative care need, or may inadvertently engender clinician overconfidence in an individual patientâs prognosis.9 21 The brevity of the interviews in Saunders et alâs study (mean. 12âmin) could suggest all relevant themes may not have emerged in the data analysis.

Additionally, while the inclusion of patient and caregiver perceptions is an important addition, limited information is provided about their perspectives and whether certain themes differed among the stakeholders. In the study from Mason et al, themes unique to patients and caregivers were identified, such as hesitancy due to a lack of understanding of palliative care, a preference to âfocus on the presentâ, and a worry that a clinician would not have the time to adequately address advanced care planning or palliative care during their visit.21 Healthcare systems should therefore be prepared to consider their unique workflows, patients and staff prior to implementing one of these programmes.Achieving stakeholder acceptability prior to widespread implementation is essential. An intervention should ideally undergo multiple cycles of optimisation with ongoing appraisal of patient and clinician perspectives prior to wide-scale implementation.22 23 Additionally, it is unclear whether cliniciansâ acceptability of the intervention in one setting will generalise to other inpatient health settings. For instance, Saunders et al found that some providers were leery about the use of mHOMR due the need to balance the patientâs acute needs that brought them to the hospital with their long-term priorities that may be better served in the outpatient setting.18 Clinical workflows, patient acuity and patientâprovider relationships are markedly different between the inpatient and outpatient settings, suggesting Saunders et alâs findings cannot be extrapolated to outpatient care. This is particularly relevant as many âoff-the-shelfâ prognostic algorithms are now commercially available that, while accurate, may not be as familiar or acceptable to clinicians as a homegrown model.

Therefore, while Saunders et alâs work is a great addition to the field, additional assessments are needed across different healthcare environments and varying clinical and demographic cohorts to demonstrate that this approach is acceptable in other health settings. It is likely that multiple implementation strategies will be needed to successfully adapt automated prognostic models across a range of clinical settings.Thoughtful consideration of the many forces that alter clinical decision making will also be critical for downstream success of these interventions. Suboptimal clinical decision making is often a result of systemic biases, such as status quo and optimism bias, which result in clinician resistance to change current practice and a belief that their patients are less prone to negative outcomes.14 15 Intentional application of targeted behavioural economics principles will help ensure that the use of prognostic triggers to improve palliative care effectively changes clinical behaviour.24 For example, using an âopt-outâ approach for palliative care referral may make the optimal choice the path of least resistance, increasing uptake among clinicians.16 These approaches will need to be balanced against rising clinician alert fatigue25 and resource constraints.Given the implementation challenges that accompany an intervention using prognostic triggers, hybrid effectiveness trials that test both clinical effectiveness and implementation outcomes offer one strategy to advance the integration of automated prognostic models.26 Implementation outcomes are typically based on a framework which provides a systematic way to develop, manage and evaluate interventions. For example, Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) is a framework that measures the impact of a programme based on five factors. Reach, effectiveness, adoption, implementation and maintenance.27 Due to their pragmatic approach, hybrid trials frequently include heterogenous samples and clinical settings that optimise external validity and generalisability.26 28 They can be designed to primarily test the effects of a clinical interventions while observing and gathering information on implementation outcomes (type I), for equal evaluation of both the clinical intervention and implementation strategies (type II), or to primarily assess implementation outcomes while collecting effectiveness data (type III).26 29 For example, Beidas et al used a type I hybrid effectivenessâimplementation trial design to test the effectiveness of an exercise intervention for breast cancer.

This study not only evaluated the effectiveness of the intervention but also identified multiple significant implementation barriers such as cost, referral logistics and patient selection challenges which informed their subsequent dissemination efforts.30 Prospective, randomised, hybrid effectivenessâimplementation designs focusing on other key implementation outcomes are a logical and necessary next step in advancing the field. In total, the work by Saunders et al demonstrates the potential acceptability of an automated prognostic model to improve the timeliness of palliative care, setting the stage for further work to optimise and implement these programmes into real-world clinical care.Ethics statementsPatient consent for publicationNot required..