Integrative genomic analysis of pediatric T-cell lymphoblastic lymphoma reveals candidates of clinical significance.

T-cell lymphoblastic lymphoma (T-LBL) is a heterogeneous malignancy of lymphoblasts committed to T-cell lineage. The dismal outcomes (15%-30%) after T-LBL relapse warrant establishing risk-based treatment. To our knowledge, this study presents the first comprehensive, systematic, integrated, genome-wide analysis including relapsed cases that identifies molecular markers of prognostic relevance for T-LBL. NOTCH1 was identified as the putative driver for T-LBL. An activated NOTCH/PI3K-AKT signaling axis and alterations in cell cycle regulators constitute the core oncogenic program for T-LBL. Mutated KMT2D was identified as a prognostic marker. The cumulative incidence of relapse was 47% ± 17% in patients with KMT2D mutations, compared with 14% ± 3% in wild-type KMT2D. Structural analysis of the mutated domains of KMT2D revealed a plausible impact on structure and functional consequences. These findings provide new insights into the pathogenesis of T-LBL, including high translational potential. The ongoing LBL 2018 trial (www.clinicaltrials.gov #NCT04043494) allows for prospective validation and subsequent fine tuning of the stratification criteria for T-LBL risk groups to improve survival of pediatric patients.

A Public Health Critical Race Praxis Informed Congestive Heart Failure Quality Improvement Initiative on Inpatient General Medicine.

BACKGROUND: Prior evaluation at our hospital demonstrated that, compared to White patients, Black and Latinx patients with congestive heart failure (CHF) were less likely to be admitted to the cardiology service rather than the general medicine service (GMS). Patients admitted to GMS (compared to cardiology) had inferior rates of cardiology follow-up and 30-day readmission. OBJECTIVE: To develop and test the feasibility and impacts of using quality improvement (QI) methods, in combination with the Public Health Critical Race Praxis (PHCRP) framework, to engage stakeholders in developing an intervention for ensuring guideline-concordant inpatient CHF care across all patient groups. METHODS: We compared measures for all patients admitted with CHF to GMS between September 2019 and March 2020 (intervention group) to CHF patients admitted to GMS in the previous year (pre-intervention group) and those admitted to cardiology during the pre-intervention and intervention periods (cardiology group). Our primary measures were 30-day readmissions and 14- and 30-day post-discharge cardiology follow-up. RESULTS: There were 79 patients admitted with CHF to GMS during the intervention period, all of whom received the intervention. There were similar rates of Black and Latinx patients across the three groups. Compared to pre-intervention, intervention patients had a significantly lower 30-day readmission rate (18.9% vs. 24.8%; p=0.024), though the cardiology group also had a decrease in 30-day readmissions from the pre-intervention to intervention period. Compared to pre-intervention, intervention patients had significantly higher 14-day and 30-day post-discharge follow-up visits scheduled with cardiology (36.7% vs. 24.8%, p=0.005; 55.7% vs. 42.3%, p=0.0029), but no improvement in appointment attendance. CONCLUSION: This study provides a first test of applying the PHCRP framework within a stakeholder-engaged QI initiative for improving CHF care across races and ethnicities. Our study design cannot evaluate causation. However, the improvements in 30-day readmission, as well as in processes of care that may affect it, provide optimism that inclusion of a racism-conscious framework in QI initiatives is feasible and may enhance QI measures.

Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19.

BACKGROUND: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN: Retrospective cohort. SETTING: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS: Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Safety and utility of indwelling pleural catheters in lung transplant recipients.

INTRODUCTION: The safety and efficacy of indwelling pleural catheters (IPCs) in lung allograft recipients is under-reported. METHODS: We performed a multicenter, retrospective analysis between 1/1/2010 and 6/1/2022 of consecutive IPCs placed in lung transplant recipients. Outcomes included incidence of infectious and non-infectious complications and rate of auto-pleurodesis. RESULTS: Seventy-one IPCs placed in 61 lung transplant patients at eight centers were included. The most common indication for IPC placement was recurrent post-operative effusion. IPCs were placed at a median of 59 days (IQR 40-203) post-transplant and remained for 43 days (IQR 25-88). There was a total of eight (11%) complications. Infection occurred in five patients (7%); four had empyema and one had a catheter tract infection. IPCs did not cause death or critical illness in our cohort. Auto-pleurodesis leading to the removal of the IPC occurred in 63 (89%) instances. None of the patients in this cohort required subsequent surgical decortication. CONCLUSIONS: The use of IPCs in lung transplant patients was associated with an infectious complication rate comparable to other populations previously studied. A high rate of auto-pleurodesis was observed. This work suggests that IPCs may be considered for the management of recurrent pleural effusions in lung allograft recipients.

Cognitive and emotional regulation processes of spontaneous facial self-touch are activated in the first milliseconds of touch: Replication of previous EEG findings and further insights.

Spontaneously touching one's own face (sFST) is an everyday behavior that occurs in people of all ages, worldwide. It is-as opposed to actively touching the own face-performed without directing one's attention to the action, and it serves neither instrumental (scratching, nose picking) nor communicative purposes. These sFST have been discussed in the context of self-regulation, emotional homeostasis, working memory processes, and attention focus. Even though self-touch research dates back decades, neuroimaging studies of this spontaneous behavior are basically nonexistent. To date, there is only one electroencephalography study that analyzed spectral power changes before and after sFST in 14 participants. The present study replicates the previous study on a larger sample. Sixty participants completed a delayed memory task of complex haptic relief stimuli while distracting sounds were played. During the retention interval 44 of the participants exhibited spontaneous face touch. Spectral power analyses corroborated the results of the replicated study. Decreased power shortly before sFST and increased power right after sFST indicated an involvement of regulation of attentional, emotional, and working memory processes. Additional analyses of spectral power changes during the skin contact phase of sFST revealed that significant neurophysiological changes do not occur while skin contact is in progress but at the beginning of sFST (movement toward face and initial skin contact). The present findings clearly illustrate the complexity of sFST and that the specific trigger mechanisms and functions of this spontaneous behavior need to be further investigated in controlled, experimental studies.

"Our Hands Are Tied Until Your Doctor Gets Here": Nursing Perspectives on Inter-hospital Transfers.

BACKGROUND: The transfer of patients between hospitals (inter-hospital transfer, or IHT) is a common occurrence for patients, but guidelines to ensure safe and effective IHTs are lacking. Poor IHTs result in higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Nurses are often the first point of contact for IHT patients and can provide valuable insights on key challenges to IHT processes. OBJECTIVE: To characterize the experiences of inpatient floor-level bedside nurses caring for IHT patients and identify care coordination challenges and solutions. DESIGN/PARTICIPANTS/APPROACH: Qualitative study using semi-structured focus groups and interviews conducted from October 2019 to July 2020 with 21 inpatient floor-level nurses caring for adult medicine patients at an academic hospital. Nurses were recruited using a purposive convenience sampling approach. A combined inductive and deductive coding approach guided by thematic analysis was used for data analysis. KEY RESULTS: Results from this study are mapped to the Agency for Healthcare Research and Quality Care Coordination Measurement Framework domains of communication, assessing needs and goals, and negotiating accountability. The following key themes characterize nurses' experiences with IHT related to these domains: (1) challenges with information exchange and team communication during IHT, (2) environmental and information preparation needed to anticipate transfers, and (3) determining responsibility and care plans after the IHT patient has arrived at the accepting facility. CONCLUSIONS: Nurses described the absence of standardized processes to coordinate care before or at the time of patient arrival. Challenges to communication and coordination during IHTs negatively impacted patient care and nursing professional satisfaction. To streamline care for IHT patients and reduce nursing stress, future IHT interventions should include standardized handoff reports, timely identification and easy access to admitting clinicians, and timely clinician evaluation and orders.

Identifying Racial/Ethnic Disparities in Interhospital Transfer: an Observational Study.

BACKGROUND: Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ethnic disparities in IHT have been suggested but are not well-characterized. OBJECTIVE: To evaluate the association between race/ethnicity and IHT. DESIGN: Cross-sectional analysis of 2016 National Inpatient Sample data. PATIENTS: Patients aged ≥ 18 years old with common medical diagnoses at transfer, including acute myocardial infarction, congestive heart failure, arrhythmia, stroke, sepsis, pneumonia, and gastrointestinal bleed. MAIN MEASURES: We performed a series of logistic regression models to estimate adjusted odds of transfer by race/ethnicity controlling for patient demographics, clinical variables, and hospital characteristics and to identify potential mediators. In secondary analyses, we estimated adjusted odds of transfer among patients at community hospitals (those more likely to transfer patients) and performed subgroup analyses by region and primary medical diagnosis. KEY RESULTS: Of 5,774,175 weighted hospital admissions, 199,015 (4.5%) underwent IHT, including 4.7% of White patients, compared with 3.9% of Black patients and 3.8% of Hispanic patients. Black (OR 0.83, 95% CI 0.78-0.89) and Hispanic (OR 0.81, 95% CI 0.75-0.87) patients had lower crude odds of transfer compared with White patients, but this became non-significant after adjusting for hospital-level characteristics. In secondary analyses among patients hospitalized at community hospitals, Hispanic patients had lower adjusted odds of transfer (aOR 0.89, 95% CI 0.79-0.98). Disparities in IHT by race/ethnicity varied by region and medical diagnosis. CONCLUSIONS: Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.

Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.

BACKGROUND: The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1. METHODS: MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient. DISCUSSION: A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

Does Studying Veterinary Medicine Improve Students' Haptic Perception Ability? A Pilot Study With Two Age-Groups.

Haptic perception is an important tool for veterinarians. The present study analyzed the association between the haptic perception threshold of veterinary students and their palpatory experience. To approach this goal, 35 female students of veterinary medicine were divided into two groups with different levels of experience: (a) students with little practical experience, at the beginning of their studies (first year), and (b) students close to the end of their theoretical training (fourth year). To thoroughly evaluate the students' sense of touch, three different test procedures were used: the Haptic Threshold Test (HTT), the Haptic Figures Test (HFT), and tactile acuity. Contrary to our expectations, we found worse mean haptic perception thresholds (HTT) in the more experienced students than in the less experienced group. This effect was significantly correlated with age. Furthermore, we found that longer exploration times were not sufficient to compensate for shortcomings in haptic perception. We also found large interindividual differences. Future studies should investigate whether and to what extend these effects have an impact on students' palpation performance on simulators and live animals. Moreover, which beneficial effects may be achieved through an additional haptic training for students with inferior haptic thresholds should be investigated. Improving haptic perception abilities in veterinary students could be one important step toward achieving satisfactory Day One Competences in university graduates.

Phospholipid:Diacylglycerol Acyltransferase-Mediated Triacylglyerol Synthesis Augments Basal Thermotolerance.

High temperatures rapidly induce a genetically programmed heat-shock response (HSR) that is essential to establish short-term acquired thermotolerance. In addition, an immediate HSR-independent metabolic response is triggered, resulting in an accumulation of unsaturated triacylglycerols (TAGs) in the cytosol. The metabolic processes involved in heat-induced TAG formation in plants and their physiological significance remain to be clarified. Lipidomic analyses of Arabidopsis (Arabidopsis thaliana) seedlings indicated that during heat stress, polyunsaturated fatty acids from thylakoid galactolipids are incorporated into cytosolic TAGs. In addition, rapid conversion of plastidic monogalactosyl diacylglycerols (MGDGs) into oligogalactolipids, acylated MGDGs, and diacylglycerols (DAGs), the direct precursor of TAGs, was observed. For TAG synthesis, DAG requires a fatty acid from the acyl-CoA pool or phosphatidylcholine. Since seedlings deficient in PHOSPHOLIPID:DIACYLGLYCEROL ACYLTRANSFERASE1 (PDAT1) were unable to accumulate TAGs after heat stress, phosphatidylcholine appears to be the major fatty acid donor. Results suggest that rapid plastid lipid metabolism drives TAG accumulation during heat stress. PDAT1-mediated TAG accumulation was found to increase heat resistance, since nonacclimated pdat1 mutant seedlings were more sensitive to severe heat stress, as indicated by a more dramatic decline of the maximum efficiency of PSII and lower seedling survival compared to wild-type seedlings. In contrast, nonacclimated trigalactosyldiacylglycerol1 (tgd1) mutants overaccumulating TAGs and oligogalactolipids were more resistant to heat stress. Hence, thylakoid lipid metabolism and TAG formation increases thermotolerance in addition to the genetically encoded HSR.

Current status and future directions of T-lymphoblastic lymphoma in children and adolescents.

The main challenges in the treatment of T-cell lymphoblastic lymphoma (T-LBL) in children and adolescents are twofold: to increase survival rates in concert with reduction of acute and long-term toxicities including the rate of secondary malignancies. The need for molecular and prognostic markers in T-LBL is crucial to allow for systematic treatment optimization and may serve as targets for new treatment approaches.

T160­phosphorylated CDK2 defines threshold for HGF dependent proliferation in primary hepatocytes.

Liver regeneration is a tightly controlled process mainly achieved by proliferation of usually quiescent hepatocytes. The specific molecular mechanisms ensuring cell division only in response to proliferative signals such as hepatocyte growth factor (HGF) are not fully understood. Here, we combined quantitative time-resolved analysis of primary mouse hepatocyte proliferation at the single cell and at the population level with mathematical modeling. We showed that numerous G1/S transition components are activated upon hepatocyte isolation whereas DNA replication only occurs upon additional HGF stimulation. In response to HGF, Cyclin:CDK complex formation was increased, p21 rather than p27 was regulated, and Rb expression was enhanced. Quantification of protein levels at the restriction point showed an excess of CDK2 over CDK4 and limiting amounts of the transcription factor E2F-1. Analysis with our mathematical model revealed that T160 phosphorylation of CDK2 correlated best with growth factor-dependent proliferation, which we validated experimentally on both the population and the single cell level. In conclusion, we identified CDK2 phosphorylation as a gate-keeping mechanism to maintain hepatocyte quiescence in the absence of HGF.

Accumulation of extra-chloroplastic triacylglycerols in Arabidopsis seedlings during heat acclimation.

Heat acclimation enables plants to tolerate and survive short-term heat stress on hot days. In Arabidopsis thaliana, a genetically programmed heat shock response can be rapidly triggered in the temperature range of 32-38°C through activation of heat shock transcription factors (HSF). The heat shock response leads to heat acclimation and confers short-term protection against temperatures above 40°C. However, little is known about metabolic adjustments during heat acclimation.Untargeted metabolite analyses of A. thaliana seedlings revealed that levels of polyunsaturated triacylglycerols (TG) rapidly and dramatically increase during heat acclimation. TG accumulation was found to be temperature dependent in a temperature range of 32-50°C (optimum at 42°C) and reversible after a return from 37°C to normal growth temperatures. Heat-induced TGs accumulated in extra-chloroplastic compartments and increased in both roots and shoots to a similar extent. Analysis of mutants deficient in all four HSFA1 master regulator genes or the HSFA2 gene revealed that TG accumulation was not dependent on HSFs. Moreover, the TG response was not limited to heat stress because drought and salt stress also triggered an accumulation of TGs, but not short-term osmotic, cold, and high light stress. Lipid analysis revealed that heat-induced accumulation of TGs was not due to massive de novo fatty acid synthesis. It is hypothesized that TGs serve as transient stores for fatty acids that may be required for membrane remodelling during heat acclimation.

Multi-Institution Survey of Accepting Physicians' Perception of Appropriate Reasons for Interhospital Transfer: A Mixed-Methods Evaluation.

OBJECTIVES: There is a lack of evidence-based guidelines to direct best practices in interhospital transfers (IHTs). We aimed to identify frontline physicians' current and ideal reasons for accepting IHT patients to inform future IHT research and guidelines. METHODS: We conducted a cross-sectional survey of hospitalist physicians across 11 geographically diverse hospitals. The survey asked respondents how frequently they currently consider and should consider various factors when triaging IHT requests. Responses were dichotomized into "highly considered" and "less considered" factors. Frequencies of the "highly considered" factors (current and ideal) were analyzed. Write-in responses were coded into themes within a priori domains in a qualitative analysis. RESULTS: Of the 666 hospitalists surveyed, 238 (36%) responded. Respondents most frequently identified the need for specialty procedural and nonprocedural care and bed capacity as factors that should be considered when triaging IHT patients in current and ideal practice, whereas the least frequently considered factors were COVID-related care, insurance/financial considerations, and patient/family preference. More experienced respondents considered patient/family preference more frequently in current and ideal practice compared with less experienced respondents (33% versus 11% [ P = 0.0001] and 26% versus 9% [ P = 0.01], respectively). Qualitative analysis identified several themes in the domains of Criteria for Acceptance, Threshold for Acceptance, and Indications for Physician-to-Physician Communication. CONCLUSIONS: This geographically diverse sample of hospitalist physicians responsible for accepting IHT patients showed general agreement between primary factors that are currently and that should be considered for IHT acceptance, with greatest weight placed on patients' need for specialty care.

Refraining from spontaneous face touch is linked to personality traits, reduced memory performance and EEG changes.

Spontaneous touches of one's face (sFST) were suggested to serve cognitive-emotional regulation processes. During the pandemic, refraining from face-touching was recommended, yet, accompanying effects and the influence of personal attributes remain unclear. Ninety participants (45 female, 45 male) filled out a questionnaire concerning personality, anxiety screening and ADHD screening. Subsequently, they performed a delayed verbal memory recall task four times. After two times, sixty participants were instructed to refrain from face-touching (experimental group). Thirty participants did not receive behavioral instructions (control group). To identify face-touches and conduct further analysis, Video, EMG, and EEG data were recorded. Two samples were formed, depending on the adherence to completely refrain from face-touching (adherent, non-adherent sample) and compared to each other and the control group. EEG analyses uncovered that refraining from face-touching is accompanied by increased beta-power at sensorimotor sites and, exclusively in the non-adherent sample, at frontal sites. Decreased memory performance was found exclusively in subsamples, who non-adherently touched their face while retaining words. In terms of questionnaire results, lower Conscientiousness and higher ADHD screening scores were revealed by the non-adherent compared to the adherent sample. No differences were found among the subsamples. The presented results indicate that refraining from face-touching is related to personal attributes, accompanied by neurophysiological shifts and for a portion of humans by lower memory performance, supporting the notion that sFST serve processes beyond sensorimotor.

Investigating racial and ethnic disparities in interhospital transfer within an academic integrated healthcare system: A matched cohort study.

The presence of racial and ethnic disparities in interhospital transfer (IHT) within integrated healthcare systems has not been fully explored. We matched Black and Latinx patients admitted to community hospitals in our integrated healthcare system between June 2015 and December 2019 to White patients by origin hospital, age, time of year, and disease severity. We performed conditional logistic regression models to determine if race or ethnicity was associated with IHT in one of the tertiary academic medical centers in the system, adjusting for covariates. The sample contained 107,895 admissions (82.6% White, 7.8% Black, and 9.6% Latinx). Transfer rates were 2.2% versus 2.2% after the Black/White match and 1.8% versus 1.8% after the Latinx/White match. After adjusting for covariates, there was no association between race or ethnicity and IHT (Black vs. White odds ratio [OR]: 0.87, 95% confidence interval [CI]: 0.72-1.07; Latinx vs. White OR: 1.05, 95% CI: 0.79-1.40). This may be due to reduced barriers to transfer with an integrated healthcare system.

Enhancing Early Detection of Cognitive Decline in the Elderly: A Comparative Study Utilizing Large Language Models in Clinical Notes.

Background: Large language models (LLMs) have shown promising performance in various healthcare domains, but their effectiveness in identifying specific clinical conditions in real medical records is less explored. This study evaluates LLMs for detecting signs of cognitive decline in real electronic health record (EHR) clinical notes, comparing their error profiles with traditional models. The insights gained will inform strategies for performance enhancement. Methods: This study, conducted at Mass General Brigham in Boston, MA, analyzed clinical notes from the four years prior to a 2019 diagnosis of mild cognitive impairment in patients aged 50 and older. We used a randomly annotated sample of 4,949 note sections, filtered with keywords related to cognitive functions, for model development. For testing, a random annotated sample of 1,996 note sections without keyword filtering was utilized. We developed prompts for two LLMs, Llama 2 and GPT-4, on HIPAA-compliant cloud-computing platforms using multiple approaches (e.g., both hard and soft prompting and error analysis-based instructions) to select the optimal LLM-based method. Baseline models included a hierarchical attention-based neural network and XGBoost. Subsequently, we constructed an ensemble of the three models using a majority vote approach. Results: GPT-4 demonstrated superior accuracy and efficiency compared to Llama 2, but did not outperform traditional models. The ensemble model outperformed the individual models, achieving a precision of 90.3%, a recall of 94.2%, and an F1-score of 92.2%. Notably, the ensemble model showed a significant improvement in precision, increasing from a range of 70%-79% to above 90%, compared to the best-performing single model. Error analysis revealed that 63 samples were incorrectly predicted by at least one model; however, only 2 cases (3.2%) were mutual errors across all models, indicating diverse error profiles among them. Conclusions: LLMs and traditional machine learning models trained using local EHR data exhibited diverse error profiles. The ensemble of these models was found to be complementary, enhancing diagnostic performance. Future research should investigate integrating LLMs with smaller, localized models and incorporating medical data and domain knowledge to enhance performance on specific tasks.

Impact of hospital teaching intensity on quality of care and patient outcomes.

BACKGROUND: Proposed changes to financing of teaching hospitals and new quality-based performance incentives may differentially impact the financial health of teaching and safety-net institutions. Few data have examined the potential impact of these financial changes on teaching institutions. OBJECTIVES: To determine the association of hospital teaching intensity with processes and outcomes of care for the most common inpatient diagnoses in the United States. RESEARCH DESIGN: Cross-sectional analysis of the 2008 Hospital Quality Alliance and 2007 American Hospital Association databases, adjusted for hospital characteristics. SUBJECTS: A total of 2418 hospitals distributed across the country with available data on teaching intensity (resident-to-bed ratio), quality-of-care process measures, and risk-adjusted readmission and mortality rates for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. MEASURES: Hospital-level quality-of-care process indicators and 30-day risk-adjusted readmission and mortality rates for AMI, CHF, and pneumonia. RESULTS: Multivariable analysis demonstrates that all hospitals perform uniformly well on quality-of-care process measures for AMI, CHF, and pneumonia. However, when compared with nonteaching hospitals, increasing hospital teaching intensity is significantly associated with improved risk-adjusted mortality for AMI and CHF, but higher risk-adjusted readmission rates for all 3 conditions. Among high teaching intensity hospitals, those with larger Medicaid populations (safety-net institutions) had particularly high readmission rates for AMI and CHF. CONCLUSIONS: In this nationally representative evaluation, we found significant variation in performance on risk-adjusted mortality and readmission rates, and differences in readmission rates based on safety-net status. Our findings suggest that high teaching intensity and safety-net institutions may be disproportionately affected by upcoming changes in hospital payment models.