Hospital Length of Stay With a Proactive Psychiatric Consultation Model in the Medical Intensive Care Unit: A Prospective Cohort Analysis.

BACKGROUND: Previous studies have demonstrated that proactive psychiatric consultation reduces hospital length of stay (LOS) in the general medical setting; however this model has not been studied in the intensive care unit (ICU). OBJECTIVE: To compare outcomes between a conventional consultation model and a proactive psychiatric consultation model. METHODS: Two medical ICUs (MICUs) were randomized to proactive psychiatric consultation vs conventional consultation psychiatric models. Proactive consultation included embedding a psychiatrist into daily MICU team rounds on all patients. In the conventional consultation MICU, psychiatric consultations were activated when deemed necessary. Primary outcomes were hospital LOS and MICU LOS. Secondary outcomes included delirium-coma-free hours and ventilator-free hours. RESULTS: A total of 429 patients were admitted to the proactive consultation MICU; 393 patients were admitted to the conventional consultation MICU. The consultation rate for the intervention group was 24.2% vs 6.1% in the control group (p < 0.001). Time to psychiatric consultation was shorter in the intervention group. Median hospital LOS was 6.92 days, interquartile range 3.70-14.31 in the intervention group vs 7.69 days, interquartile range 3.95-16.21 in the control group (p = 0.113). MICU LOS, delirium-coma-free hours, and ventilator-free hours were not significantly different between the 2 groups. Among the respiratory failure subgroup, hospital LOS was shorter in the intervention vs control group (median 9.46 days, interquartile range 4.95-17.56 vs 12.29 days, interquartile range 6.58-21.10, p = 0.011). CONCLUSIONS: Proactive psychiatric consultation in a MICU was associated with decreased time to consultation among all patients and shorter hospital LOS among patients with respiratory failure.

"Make the Implicit Explicit": Measuring Perceptions of Gender Bias and Creating a Gender Bias Curriculum for Internal Medicine Residents.

BACKGROUND: Gender bias in clinical training has been well established; however, little is known about how perceptions differ between men and women. Furthermore, few curricular options have been developed to discuss gender bias. OBJECTIVE: To measure the prevalence of gender bias, examine qualitative differences between men and women, and create a gender bias curriculum for internal medicine residents. METHODS: We surveyed 114 residents (response rate of 53.5%) to identify the prevalence and types of gender bias experienced in training. We compared estimates between genders and organized qualitative results into shared themes. We then developed a curriculum to promote and normalize discussions of gender bias. RESULTS: Among surveyed residents, 61% reported personal experiences of gender bias during training, with 98% of women and 19% of men reporting experiences when stratified by gender. We identified two domains in which gender bias manifested: role misidentification and a difficult working environment. Residents identified action items that led to the development of a gender bias curriculum. The curriculum includes didactic conferences and training sessions, a microaggression response toolkit, dinners for men and women residents, participation in a WhatsApp support group, and participation in academic projects related to gender bias in training. CONCLUSION: We confirmed a wide prevalence of gender bias and developed a scalable curriculum for gender bias training. Future work should explore the long-term impacts of these interventions.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

BACKGROUND: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. RESULTS: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. CONCLUSIONS: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

ED-based care coordination reduces costs for frequent ED users.

OBJECTIVES: We evaluated a pilot quality improvement intervention implemented in an urban academic medical center emergency department (ED) to improve care coordination and reduce ED visits and hospitalizations among frequent ED users. STUDY DESIGN: Randomized controlled trial. METHODS: We identified the most frequent ED users in both the 30 days prior to the intervention and the 12 months prior to the intervention. We randomized the top 72 patients to receive either our pilot intervention or usual care. The intervention consisted of a community health worker who assisted patients with navigating care and identifying unmet social needs and an ED-based clinical team that developed interdisciplinary acute care plans for eligible patients. After 7 months, we analyzed ED visits, hospitalizations, and costs for the intervention and control groups. RESULTS: We randomized 72 patients to the intervention (n = 36) and control (n = 36) groups. Patients randomized to the intervention group had 35% fewer ED visits (P = .10) and 31% fewer admissions from the ED (P = .20) compared with the control group. Average ED direct costs per patient were 15% lower and average inpatient direct costs per patient were 8% lower for intervention patients compared with control patients. CONCLUSIONS: ED-based care coordination is a promising approach to reduce ED use and hospitalizations among frequent ED users. Our program also demonstrated a decrease in costs per patient. Future efforts to promote population health and control costs may benefit from incorporating similar programs into acute care delivery systems.

The critical components of an electronic care plan tool for primary care: an exploratory qualitative study.

BACKGROUND: A critical need exists for effective electronic tools that facilitate multidisciplinary care for complex patients in patient-centered medical homes.Objective To identify the essential components of a primary care (PC) based electronic care plan (ECP) tool that facilitates coordination of care for complex patients. METHOD: Three focus groups and nine semi-structured interviews were conducted at an academic PC practice in order to identify the ideal components of an ECP. RESULTS: Critical components of an ECP identified included: 1) patient background information, including patient demographics, care team member designation and key patient contacts, 2) user- and patient-centric task management functionalities, 3) a summary of a patient's care needs linked to the responsible member of the care team and 4) integration with the electronic medical record. We then designed an ECP mockup incorporating these components. CONCLUSION: Our investigation identified key principles that healthcare software developers can integrate into PC and patient-centered ECP tools.

The intersection of genetic and chemical genomic screens identifies GSK-3α as a target in human acute myeloid leukemia.

Acute myeloid leukemia (AML) is the most common form of acute leukemia in adults. Long-term survival of patients with AML has changed little over the past decade, necessitating the identification and validation of new AML targets. Integration of genomic approaches with small-molecule and genetically based high-throughput screening holds the promise of improved discovery of candidate targets for cancer therapy. Here, we identified a role for glycogen synthase kinase 3α (GSK-3α) in AML by performing 2 independent small-molecule library screens and an shRNA screen for perturbations that induced a differentiation expression signature in AML cells. GSK-3 is a serine-threonine kinase involved in diverse cellular processes, including differentiation, signal transduction, cell cycle regulation, and proliferation. We demonstrated that specific loss of GSK-3α induced differentiation in AML by multiple measurements, including induction of gene expression signatures, morphological changes, and cell surface markers consistent with myeloid maturation. GSK-3α-specific suppression also led to impaired growth and proliferation in vitro, induction of apoptosis, loss of colony formation in methylcellulose, and anti-AML activity in vivo. Although the role of GSK-3ß has been well studied in cancer development, these studies support a role for GSK-3α in AML.

Enhancing quality of primary care using an ambulatory ICU to achieve a patient- centered medical home.

RESEARCH OBJECTIVE: The Patient-Centered Medical Home (PCMH) has been advocated as a model to address the lack of coordination and continuity in the health system. However, implementation in practice has been slow and incompletely described. STUDY DESIGN: Patients referred into the program received intensive nurse follow-up focused on medication adherence, care coordination, and education. Patients graduate from the program when treatment goals are met. POPULATION STUDIED: The first 100 patients enrolled into the PCMH focused program of a primary care clinic in an urban, academic medical center. The main outcome measures are goal adherence and emergency room use. PRINCIPAL FINDINGS: Ninety percent of enrollees met the health goals set for them at enrollment. During their enrollment, 31.6% of patients with diabetes reduced and maintained their blood glucose readings; 24.6% of patients with hypertension reduced and maintained their blood pressure readings. Emergency department use in the time period following enrollment dropped 46.7%. CONCLUSIONS: The ambulatory intensive care unit program showed an improvement in health outcomes and health care use.This program also helps to move the practice toward PCMH by centralizing care through a primary care provider, enhancing access to care, and by focusing on the patient holistically through rapport with a nurse. IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: This care delivery method drives the clinic closer to the PCMH and toward the Accountable Care Organization (ACO) model.

Pancreatic adenocarcinoma in the pregnant patient: a case report and literature review.

Pancreatic cancer is the fifth most common cause of cancer-related death in the USA. However, the antepartum diagnosis of pancreatic adenocarcinoma in the pregnant patient is exceedingly rare, with only six cases previously reported in the literature. Optimizing both maternal and fetal health outcomes is particularly challenging when surgical procedures are necessary for staging and/or therapeutic purposes--as these interventions often pose significant risks to both the mother and the developing fetus. In this article, we report a case of pancreatic adenocarcinoma diagnosed during pregnancy and review the literature on the management issues confronted in this unique clinical situation.

Proteomic and genetic approaches identify Syk as an AML target.

Cell-based screening can facilitate the rapid identification of compounds inducing complex cellular phenotypes. Advancing a compound toward the clinic, however, generally requires the identification of precise mechanisms of action. We previously found that epidermal growth factor receptor (EGFR) inhibitors induce acute myeloid leukemia (AML) differentiation via a non-EGFR mechanism. In this report, we integrated proteomic and RNAi-based strategies to identify their off-target, anti-AML mechanism. These orthogonal approaches identified Syk as a target in AML. Genetic and pharmacological inactivation of Syk with a drug in clinical trial for other indications promoted differentiation of AML cells and attenuated leukemia growth in vivo. These results demonstrate the power of integrating diverse chemical, proteomic, and genomic screening approaches to identify therapeutic strategies for cancer.