Sex, Racial/Ethnic, and Regional Disparities in Pulmonary Embolism Mortality Trends in the USA, 1999-2020.

BACKGROUND: While the National Institutes of Health emphasize integrating sex as a biological variable into research, specific considerations of sex-related differences in pulmonary embolism (PE) mortality trends remain scarce. This study examines sex-based PE mortality trends across regional and demographic groups in the USA from 1999 to 2020. METHODS: A retrospective analysis of National Center for Health Statistics mortality data from 1999 to 2020 was conducted. Using ICD-10 code I26, PE decedents were identified. Piecewise linear regression assessed sex-based temporal trends in PE mortality by age, race/ethnicity, and census region. Annual percentage changes and average annual percentage changes were derived using Weighted Bayesian Information Criteria. The 95% confidence intervals were estimated using the empirical quantile method. RESULTS: From 1999 to 2020, a total of 179,273 individuals died in the USA due to PE, resulting in an age-adjusted mortality rate of 2.5 per 100,000 persons (95% CI, 2.5-2.5). While men and women exhibited comparable rates in recent time segments and across most subcategories, a higher mortality trend among males compared to females was observed among non-Hispanic White and Hispanic individuals and residents of the Western US census region. These results remained robust even after excluding data from 2020, accounting for the potential impact of the COVID-19 pandemic. CONCLUSIONS: Our study highlights sex-based disparities in PE mortality trends in the USA from 1999 to 2020. Despite overall stable mortality rates, higher trends among males were evident in specific demographic groups and regions. These findings emphasize the importance of targeted interventions to mitigate PE-related mortality discrepancies across diverse populations.

A Quality Improvement-based Approach to Implementing a Remote Monitoring-Based Bundle in Transitional Care Patients for Heart Failure.

BACKGROUND: Congestive heart failure (HF) is a leading cause of hospitalization and readmission, leading to increased health care utilization and cost. This is complicated by high incidence, prevalence, and hospitalization rates among racial and ethnic minorities, with a widening in the mortality disparity gap. Remote patient monitoring (RPM) has the potential to proactively engage patients after discharge to optimize medication management and intervene to avoid rehospitalization. However, it also may widen the equity gap due to technological barriers and bias. METHODS: A prospective, observational quality improvement (QI) initiative leveraging an amended tool from the Institute for Healthcare Improvement Model for Improvement was incorporated with an equity lens and five Plan-Do-Study-Act (PDSA) cycles at a single site. The intervention used an HF bundle that included RPM, clinical telepharmacy, remote therapeutic monitoring, and community paramedicine. RESULTS: Between May 2022 and March 2023, five PDSA cycles were run involving 90 enrolled patients. In total, 38 (42.2%) patients received the complete HF bundle, 42 (46.7%) a partial bundle, and 10 (11.1%) only RPM. The patients with the complete bundle had a readmission rate of 2.6% compared to 14.3% in the partial bundle and 20.0% in RPM alone. The biggest impact of this program was the incorporation of community paramedicine. The program also noted an improvement in equitable enrollment after adjusting mid-program by avoiding cellular phone-enabled devices and transitioning to a hub-based model. CONCLUSION: This single-site QI-based initiative implemented an HF-based RPM program that leveraged clinical telepharmacy and community paramedicine. This program identified a disparity of care gap regarding the equitable distribution of services and made mid-study adjustments to improve the disparity gap. The program found that use of the HF bundle resulted in a decreased hospital readmission rate.

Equity and Performance Improvement: A Novel Toolkit That Makes Using an Equity Lens the Default.

Performance improvement methodologies do not currently include any structures that encourage analysis of how bias, inequity, or social determinants of health (SDOH) contribute to outcomes. The Montefiore Center for Performance Improvement developed a novel quality improvement (QI) toolkit that ingrains issues of diversity, equity, and inclusion (DEI) and SDOH into the Institute for Healthcare Improvement's tools. The toolkit prompts QI teams to evaluate DEI and SDOH at each step of the journey, including an updated charter and stratified baseline tool, a new fishbone diagram for the discovery phase with a tail to include DEI and SDOH, and additions in the Study and Act sessions of the Plan-Do-Study-Act worksheet to address these issues. After development and dissemination of this toolkit, the authors conducted a pre-post analysis of projects conducted by QI fellows in their institution. Prior to introducing the new toolkit, 22.9% of projects from 2016 to 2021 incorporated DEI/SDOH into any stage of the QI process. After implementing the amended tools, this increased to 88.9% in the 2022 fellowship. These results show that this simple approach can hardwire consideration of DEI and SDOH into improvement projects.

Incidence and predictors of case cancellation within 24 h in patients scheduled for elective surgical procedures.

OBJECTIVE: Avoidable case cancellations within 24 h reduce operating room (OR) efficiency, add unnecessary costs, and may have physical and emotional consequences for patients and their families. We developed and validated a prediction tool that can be used to guide same day case cancellation reduction initiatives. DESIGN: Retrospective hospital registry study. SETTING: University-affiliated hospitals network (NY, USA). PATIENTS: 246,612 (1/2016-6/2021) and 58,662 (7/2021-6/2022) scheduled elective procedures were included in the development and validation cohort. MEASUREMENTS: Case cancellation within 24 h was defined as cancelling a surgical procedure within 24 h of the scheduled date and time. Our candidate predictors were defined a priori and included patient-, procedural-, and appointment-related factors. We created a prediction tool using backward stepwise logistic regression to predict case cancellation within 24 h. The model was subsequently recalibrated and validated in a cohort of patients who were recently scheduled for surgery. MAIN RESULTS: 8.6% and 8.7% scheduled procedures were cancelled within 24 h of the intended procedure in the development and validation cohort, respectively. The final weighted score contains 29 predictors. A cutoff value of 15 score points predicted a 10.3% case cancellation rate with a negative predictive value of 0.96, and a positive predictive value of 0.21. The prediction model showed good discrimination in the development and validation cohort with an area under the receiver operating characteristic curve (AUC) of 0.79 (95% confidence interval 0.79-0. 80) and an AUC of 0.73 (95% confidence interval 0.72-0.73), respectively. CONCLUSIONS: We present a validated preoperative prediction tool for case cancellation within 24 h of surgery. We utilize the instrument in our institution to identify patients with high risk of case cancellation. We describe a process for recalibration such that other institutions can also use the score to guide same day case cancellation reduction initiatives.

Job type, neighborhood prevalence, and risk of coronavirus disease 2019 (COVID-19) among healthcare workers in New York City.

In this study, we compared the risk of coronavirus disease 2019 (COVID-19) between clinical and nonclinical healthcare workers (HCWs) while adjusting for home ZIP codes. Clinical HCWs did not have a higher risk of COVID-19, but living in higher-risk ZIP codes was associated with increased infection rates. However, environmental services workers showed increased risk of COVID-19.

COVID-19 symptoms, duration, and prevalence among healthcare workers in the New York metropolitan area.

OBJECTIVE: To evaluate symptoms, workforce implications, and testing patterns related to the coronavirus disease 2019 (COVID-19) pandemic among healthcare workers (HCWs) in the New York metropolitan area during spring 2020. DESIGN: Retrospective cohort study of occupational health services (OHS) records. SETTING: A large, urban, academic medical center with 5 inpatient campuses and multiple ambulatory centers throughout Bronx and Westchester counties. PARTICIPANTS: We included HCWs who called OHS to report COVID-19 symptoms and had either severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) or IgG antibody testing. METHODS: We analyzed the impact of COVID-19-related symptoms on (1) time from symptom onset to return to work, (2) the results of SARS-CoV-2 nasopharyngeal PCR testing, and (3) the results of SARS-CoV-2 IgG antibody testing in HCWs with mild-to-moderate COVID-19. RESULTS: The median time from symptom onset until return to work for HCWs who did not require hospitalization was 15 days (interquartile range, 10-22). Shortness of breath, fever, sore throat, and diarrhea were significantly associated with longer durations from symptom onset to return to work. Among symptomatic HCWs who had PCR testing during the study period, 51.9% tested positive. Of the previously symptomatic HCWs who had IgG antibody testing, 55.4% had reactive tests. Ageusia was associated with having both positive PCR and reactive antibody tests. Sore throat was associated with both negative PCR and nonreactive antibody tests. CONCLUSION: HCWs with COVID-19 who did not require hospitalization still had prolonged illness. Shortness of breath, fever, sore throat, and diarrhea are associated with longer durations of time away from work.

A Case of Familial Mediterranean Fever with Extensive Lymphadenopathy and Complex Heterozygous Genotype Presenting in the Fourth Decade.

Familial Mediterranean fever (FMF) is an inherited disease caused by loss of function mutations in the MEFV gene encoding pyrin, a negative regulator of interleukin-1. The disease is characterized by recurrent fever and self-limited attacks of joint, chest, and abdominal pain but lymphadenopathy is an infrequent manifestation. While mesenteric lymphadenopathy has been described in several cases in the literature; hilar, paratracheal, axillary, pelvic, and retroperitoneal lymphadenopathy are extremely rare and have been reported separately in very few individuals. In this report, we present a patient with late-onset FMF with extensive lymphadenopathy in all of the aforementioned anatomic regions. Genetic analysis identified three heterozygous pyrin mutations in a patient with no affected family members. Genetic investigation of the patient's mother identified a novel carrier haplotype E148Q/P369S. The proband also inherited the previously described and rare A744S mutation previously not thought to be a disease-defining lesion. This unique compound heterozygous genotype resulted in a novel genotype-phenotype association producing an atypical clinical presentation of FMF that fits within the pattern of several case reports of late-onset disease with respect to clinical course and therapeutic response.

Bridging care transitions: findings from a resident-staffed early postdischarge program.

PROBLEM: Academic medical centers face unique challenges to ensuring patient safety after a hospital discharge, including those related to providing patient follow-up care in practices staffed by residents who are not comfortable managing care transitions. APPROACH: In 2011, the authors designed a quality improvement program for early postdischarge follow-up (bridge visits) at a resident primary care outpatient practice, using existing resources. The authors added a unique appointment template to the outpatient electronic health record to guide residents during the visit. Residents completed both postvisit and postprogram surveys regarding their experience with the program, and patients completed postvisit phone surveys regarding their satisfaction with the program. OUTCOMES: Fifty-eight residents completed postvisit surveys, of which 31.0% (18/58) reported problems with medication reconciliation and 25.9% (15/58) with adherence to discharge medications. Of those residents who completed postprogram surveys, almost half (18/38; 47.4%) agreed that their experience changed the way they discharge patients. Nearly all patients who responded to the postvisit phone surveys reported that the program reinforced their discharge and medication instructions (44/46; 95.7%); 81.8% (18/22) of patients with established providers did not mind seeing an interim physician for expedited postdischarge care. NEXT STEPS: An early postdischarge program at a resident outpatient primary care practice is valuable both in ensuring patient safety and as a model to promote experiential learning in medical education. Findings from this study will be used to develop a formal curriculum in care transitions for all residents.