Attractiveness of medical disciplines amongst Swiss first-year medical students allocated to different medical education tracks: cross-sectional study.

BACKGROUND: As most countries, Switzerland is experiencing a shortage of physicians especially in general practice and new medical education tracks with respective focusses have been started in response. This study investigated Swiss medical students' career openness and attractiveness of different medical disciplines as well as the concordance of students' career intentions with assigned medical education tracks. METHODS: Cross-sectional study surveying first year medical students assigned to four different Swiss medical education tracks with distinctive additional education focuses (ETH Zurich: medical technology and engineering, University of St. Gallen and University of Lucerne: primary healthcare and University of Zurich: no distinctive focus). RESULTS: We surveyed 354 medical students (response rate across all included medical education tracks 71.1%), 64.8% female, mean age 20 years. Regarding career openness, we found that 52.8% of medical students had neither a strong commitment nor a strong reservation for any of the proposed career options and 17.0% had a strong commitment. Among medical disciplines, medical subspecialties were attractive to the largest part of students (inpatient subspecialties attractive for 71%, outpatient for 58%), attractiveness of general practice was moderate (30%), academic (22%) and industrial sector (17%) careers were least attractive. Proportions of medical students attracted to general practice were similar at medical education tracks with focus on primary healthcare compared to other medical education tracks (32.2% vs. 25.8%, p = 0.391). Conversely, proportions of medical students attracted to academic or industry careers were significantly higher at the ETH Zurich compared to other medical education tracks (37.2%, vs. 13.1%, p < 0.001 and 31.9%, vs. 8.8%, p < 0.001 respectively). CONCLUSION: While most first-year medical students were open to careers in many medical disciplines, attractiveness of disciplines varied strongly. Students attracted to academic or industrial careers accumulated at the medical education track with concordant teaching focus but students attracted to general practice did not accumulate at medical education tracks focused on primary healthcare. For medical education tracks with primary care teaching focus this is both a challenge and an opportunity to specifically counteract the shortage of general practitioners in Switzerland.

Appropriateness of bone density measurement in Switzerland: a cross-sectional study.

BACKGROUND: According to the WHO, osteoporosis is one of the most important non- communicable diseases worldwide. Different screening procedures are controversially discussed, especially concerning the concomitant issues of overdiagnosis and harm caused by inappropriate Dual X-ray Absorptiometry (DXA). The aim of this study was to evaluate the frequency and appropriateness of DXA as screening measure in Switzerland considering individual risk factors and to evaluate covariates independently associated with potentially inappropriate DXA screening. METHODS: Retrospective cross-sectional study using insurance claim data of 2013. Among all patients with DXA screening, women < 65 and men < 70 years without osteoporosis or risk factors for osteoporosis were defined as receiving potentially inappropriate DXA. Statistics included descriptive measures and multivariable regressions to estimate associations of relevant covariates with potentially inappropriate DXA screening. RESULTS: Of 1,131,092 patients, 552,973 were eligible. Among those 2637 of 10,000 (26.4%) underwent potentially inappropriate DXA screening. Female sex (Odds ratio 6.47, CI 6.41-6.54) and higher age showed the strongest association with any DXA screening. Female gender (Odds ratio 1.84, CI 1.49-2.26) and an income among the highest 5% (Odds ratio 1.40, CI 1.01-1.98) were significantly positively associated with potentially inappropriate DXA screening, number of chronic conditions (Odds ratio 0.67, CI 0.65-0.70) and living in the central region of Switzerland (Odds ratio 0.67, CI 0.48-0.95) negatively. CONCLUSION: One out of four DXAs for screening purpose is potentially inappropriate. Stakeholders of osteoporosis screening campaigns should focus on providing more detailed information on appropriateness of DXA screening indications (e.g. age thresholds) in order to avoid DXA overuse.

Swiss students and young physicians want a flexible goal-oriented GP training curriculum.

BACKGROUND: A growing shortage of general practitioners (GPs), in Switzerland and around the world, has forced countries to find new ways to attract young physicians to the specialty. In 2017, Switzerland began to fund hundreds of new study places for medical students. This wave of young physicians will soon finish University and be ready for postgraduate training. We hypothesized that an attractive postgraduate training program would encourage interested young physicians to pursue a GP career. METHODS: This is a cross-sectional survey of young physicians from the Swiss Young General Practitioners Association (JHaS), members of Cursus Romand de médecine de famille (CRMF), and all current medical students (5th or 6th years) (n = 554) in Switzerland, excluding students indicating definitely not to become GPs. We asked all if they were likely to become a GP (Likert: 1-10), and then asked them to score general features of a GP training curriculum, and likely effects of the curriculum on their career choice (Likert scale). They then rated our model curriculum (GO-GP) for attractiveness and effect (Likert Scales, open questions). RESULTS: Most participants thought they would become GPs (Likert: 8 of 10). Over 90% identified the same features as an important part of a curriculum ("yes" or "likely yes"): Our respondents thought the GO-GP curriculum was attractive (7.3 of 10). It was most attractive to those highly motivated to become GPs. After reviewing the curriculum, most respondents (58%) felt GO-GP would make them more likely to become a GP. Almost 80% of respondents thought an attractive postgraduate training program like GO-GP could motivate more young physicians to become GPs. CONCLUSIONS: Overall, medical students and young physicians found similar features attractive in the general and GO-GP curriculum, regardless of region or gender, and thought an attractive curriculum would attract more young doctors to the GP specialty. Key points An attractive postgraduate training program in general practice can attract more young physicians to become GPs. In this study cross-sectional survey including medical students (n = 242) and young physicians (n = 312) we presented general features for a curriculum and a model curriculum for general practice training, for evaluation of attractiveness to our study population. General practice training curriculum provides flexibility in choice of rotations, access to short rotations in a wide variety of medical specialties, training in specialty practices as well, mentoring and career guidance by GPs and guidance in choosing courses/certificate programs necessary for general practice. These findings help building attractive postgraduate training programs in general practice and fight GP shortage.

Case management to increase quality of life after cancer treatment: a randomized controlled trial.

BACKGROUND: Case management has been shown to be beneficial in phases of cancer screening and treatment. After treatment is completed, patients experience a loss of support due to reduced contact with medical professionals. Case management has the potential to offer continuity of care and ease re-entry to normal life. We therefore aim to investigate the effect of case management on quality of life in early cancer survivors. METHODS: Between 06/2010 and 07/2012, we randomized 95 patients who had just completed cancer treatment in 11 cancer centres in the canton of Zurich, Switzerland. Patients in the case management group met with a case manager at least three times over 12 months. Patient-reported outcomes were assessed after 3, 6 and 12 months using the Functional Assessment of Cancer Therapy (FACT-G) scale, the Patient Assessment of Chronic Illness Care (PACIC) and the Self-Efficacy scale. RESULTS: The change in FACT-G over 12 months was significantly greater in the case management group than in the control group (16.2 (SE 2.0) vs. 9.2 (SE 1.5) points, P = 0.006). The PACIC score increased by 0.20 (SE 0.14) in the case management group and decreased by 0.29 (SE 0.12) points in the control group (P = 0.009). Self-Efficacy increased by 3.1 points (SE 0.9) in the case management group and by 0.7 (SE 0.8) points in the control group (P = 0.049). CONCLUSIONS: Case management has the potential to improve quality of life, to ease re-entry to normal life and to address needs for continuity of care in early cancer survivors. TRIAL REGISTRATION: The study has been submitted to the ISRCTN register under the name "Case Management in Oncology Rehabilitation" on the 12th of October 2010 and retrospectively registered under the number ISRCTN41474586 on the 24th of November 2010.

Internists' career choice towards primary care: a cross-sectional survey.

BACKGROUND: Swiss primary care (PC) is facing workforce shortage. Up to 2011 this workforce was supplied by two board certifications: general medicine and internal medicine. To strengthen them against subspecialties, they were unified into one: general internal medicine. However, since unification general practitioners' career options are no longer restrained by early commitment to PC. This may lead to a decrease of future primary care physicians (PCPs). METHODS: To gain insights in timing and factors influencing career choice of internists, we addressed a cross sectional survey to all board certified internists in the years 2000-2010 (n = 1462). Main measures were: final career choice (PCPs, hospital internists or subspecialists), timing and factors influencing career choice, and attractiveness of PCP career during medical school and residency. RESULTS: Response rate was 53.2%, 44.8% were female and median age was 45 years old. Final career choice was PCP for 39.1% of participants, 15.0% chose to become hospital internists, 41.8% became subspecialists and 4.0% other. Timing of career choice significantly differed between groups. Most of the subspecialists have chosen their career during residency (65.3%), while only 21.9% of the PCPs chose during residency. Work experience in an academic hospital was negatively associated with becoming PCP (P < 0.001). Family influence on career choice was more frequently reported among PCPs and chiefs' influence more reported among non-PCPs (P < 0.001). Fifty-nine percent of the participants considered a career as PCP to be attractive during medical school, this proportion decreased over time. CONCLUSIONS: Timing of career choice of PCPs and subspecialists strongly differed. PCPs opted late for their career and potentially modifiable external factors seem to contribute to their decision. This stresses the importance of fostering attractiveness of PC during medical school as well as during and after residency and of tailored residency positions for future PCPs in the hospital-dominated new general internal medicine training.

From practice employee to (co-)owner: young GPs predict their future careers: a cross-sectional survey.

BACKGROUND: In Switzerland, the mean age of GPs in 1993 was 46. In 2015, it had increased to 55, and GPs over 65 made up 15% of the workforce of the about 6000 GPs. As older, self-employed GPs retire, young doctors will be needed to fill their positions and eventually take over their practices. We set out to determine what kind of employment young GPs wanted, if they thought their preference would change over time, and the working conditions and factors most important in their choice of practice. METHODS: We administered a cross-sectional online survey to members of the Swiss Young General Practitioners Association (n = 443). Our survey relied on closed questions, ratings of attractiveness of fictional job ads, and an open question to capture participants' characteristics, and their preferred type of practice and working conditions. RESULTS: We received 270 (61%) replies. Most were women (71%) and wanted to work in the suburbs or countryside in small GP-owned group practices, with up to five colleagues. Most intended to work part-time: mean desired workload was 78% for men and 66% for women. Positive working climate was a major factor in choosing a GP practice. Most participants projected a career arc from employment to ownership or co-ownership of a practice within five years; only 7-9% preferred to remain employees. CONCLUSIONS: Young and future GPs in Switzerland want to work part-time in small, GP-owned group practices. Practices should offer them employment opportunities with a path to (co-)ownership.

Acceptance of interventions to promote primary care: What do physicians prioritize?

BACKGROUND: Switzerland is facing a shortage of primary care physicians (PCPs); government organizations therefore suggested a broad variety of interventions to promote primary care. The aim of the study was to prioritize these interventions according to the acceptance and perceived barriers of most relevant groups of physicians in this context (hospital physicians and PCPs). METHODS: The study was conducted during summer 2014. An online-based questionnaire assessed demographic data, working conditions and future plans. Participants were asked to rank the usefulness of 22 interventions to promote primary care. Interventions to promote primary care that received ratings of 4 or 5 on the Likert scale (corresponding to "useful" or "very useful") by at least 80 % of the participants were categorized as interventions with very high acceptance. We analyzed whether the groups (PCPs, hospital physicians) ranked the interventions differently using the Mann-Whitney U test. We assumed a two tailed p < 0.05 after Bonferroni correction for multiple testing as statistically significant. RESULTS: Two hundred thirty physicians (response rate 58.4 %) completed the survey. Among those 69 PCPs and 66 hospital physicians were included in the analysis. Among those 14 PCPs were planning to leave clinical practice due to retirement, whereas only 8 hospital physicians planned a career as PCPs. Among PCPs the intervention with the highest acceptance was the increase of reimbursement, whereas family friendly measures achieved highest acceptance among hospital physicians. Financial support for primary care traineeships was considered to be very useful by both groups. CONCLUSIONS: Interventions on PCPs close to retirement or on PCPs considering an early retirement will not adequately prevent shortage of primary care providers. Governmental interventions should therefore also aim at encouraging hospital physicians to start a career in primary care by governmental support for traineeships in primary care and investments in family friendly measures.

[Implementation of an electronic clinical decision aid to support quality of care for COPD in family medicine]. / Implementierung einer elektronischen Entscheidungshilfe zur Unterstützung der Behandlungsqualität der COPD in der Hausarztmedizin.

BACKGROUND: Electronic clinical decision aids (eCDAs) have the potential to improve the quality of chronic disease management (CDM) and, therefore, patient relevant outcomes. However, eCDAs are only sparsely implemented in primary care for chronic obstructive pulmonary disease (COPD). The aim of this pilot study was to develop and implement of an eCDA for COPD primary care in two Swiss primary care practices. METHOD: Two primary care practices, each with five primary care physicians and their assistants, participated in the study. The eCDA was developed in collaboration with one of the two GP practices (Practice 1) following a development cycle encompassing alpha- and beta-testing stages. Long-term testing for one year was conducted in both practices. The implementation of the eCDA was evaluated according to the RE-AIM framework counting occurrences as follows: Reach: the number of patients included in the CDM using the eCDA. EFFECTIVENESS: the number of treatment processes initiated per patient. Adoption: practice utilization of the diverse functions featured in the eCDA. Implementation and Maintenance: health care professionals' attitudes towards the impact of the eCDA on the quality of care and their willingness to continue using the eCDA after long-term testing. Data were collected by the eCDA itself, which was programmed to track user data, and from practice staff using questionnaires. RESULTS: Reach: After the long-term test, the number of patients recorded in the eCDA was 28 in practice 1, and 12 in practice 2. EFFECTIVENESS: The number of evidence-based treatment processes per patient was 14 (IQR 6 to 22) in Practice 1 and 6 (IQR 5 to 8) in Practice 2. Adoption: The utilization profiles of the eCDA differed greatly between practices. Implementation and Maintenance: After the long-term test, respondents were more critical of the quality of the CDM for patients with COPD, and attitudes consistent with interprofessional care were more prevalent compared to baseline. Respondents were optimistic regarding both the potential of the eCDA to improve the quality of CDM and their motivation to continue using the eCDA after long-term testing. CONCLUSION: This pilot study is a roadmap for future projects aiming to develop and implement eCDAs for the CDM of COPD in primary care. Future larger implementation studies in this domain should place greater emphasis on the measurement of structural practice characteristics as potential determinants of patient-relevant outcomes. The modifiable determinants should then be tested for their effects on patient-relevant outcomes in a randomized controlled design.

Prognostic importance of hyponatremia in patients with acute pulmonary embolism.

RATIONALE: Although associated with adverse outcomes in other cardiopulmonary conditions, the prognostic value of hyponatremia, a marker of neurohormonal activation, in patients with acute pulmonary embolism (PE) is unknown. OBJECTIVES: To examine the associations between hyponatremia and mortality and hospital readmission rates for patients hospitalized with PE. METHODS: We evaluated 13,728 patient discharges with a primary diagnosis of PE from 185 hospitals in Pennsylvania (January 2000 to November 2002). We used random-intercept logistic regression to assess the independent association between serum sodium levels at the time of presentation and mortality and hospital readmission within 30 days, adjusting for patient (race, insurance, severity of illness, use of thrombolytic therapy) and hospital factors (region, size, teaching status). MEASUREMENTS AND MAIN RESULTS: Hyponatremia (sodium ≤135 mmol/L) was present in 2,907 patients (21.1%). Patients with a sodium level greater than 135, 130-135, and less than 130 mmol/L had a cumulative 30-day mortality of 8.0, 13.6, and 28.5% (P < 0.001), and a readmission rate of 11.8, 15.6, and 19.3% (P < 0.001), respectively. Compared with patients with a sodium greater than 135 mmol/L, the adjusted odds of dying were significantly greater for patients with a sodium 130-135 mmol/L (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.33-1.76) and a sodium less than 130 mmol/L (OR, 3.26; 95% CI, 2.48-4.29). The adjusted odds of readmission were also increased for patients with a sodium of 130-135 mmol/L (OR, 1.28; 95% CI, 1.12-1.46) and a sodium less than 130 mmol/L (OR, 1.44; 95% CI, 1.02-2.02). CONCLUSIONS: Hyponatremia is common in patients presenting with PE, and is an independent predictor of short-term mortality and hospital readmission.

Wer strebt am Ende des Medizinstudiums eine Hausärztekarriere an? Umfrage unter Schweizer Studierenden.

How Many Advanced Medical Students Aim for a Career as a GP? Survey among Swiss Students Abstract. According to an earlier prognosis for 2025, Switzerland will lack 5000 general practitioners (GP), since only 10-20 % of medical students wanted to choose this profession at the time of the survey. The aim of our investigation among advanced medical students was to record their career intentions anew. Beside the probability of becoming a GP, we looked at the time point of this decision and at factors around family medicine (doctor-patient relation, career possibilities, etc.) influencing this decision. The results showed that measures to promote family medicine have been successful: 60 % of interrogated students are possible GPs (20 % decided, 40 % interested), 15 % are undecided, 25 % have decided not to become a GP. The favorable factors to become a GP were: autonomy, doctor-patient relationship, possibility of part-time work, work content. Less favorable were: income, reputation, political situation. These are the points where action is required to promote careers in family medicine with attractive training and practice conditions.

Can the CalproQuest predict a positive Calprotectin test? A prospective diagnostic study.

BACKGROUND: Diagnosis of inflammatory bowel disease (IBD) in primary care (PC) is challenging and associated with a considerable diagnostic delay. Using a calprotectin test for any PC patient with abdominal complaints would cause significant costs. The 8-item-questionnaire CalproQuest was developed to increase the pre-test probability for a positive Calprotectin. It is a feasible instrument to assess IBD in PC, but has not yet been evaluated in clinical routine. This study, therefore, aimed to validate whether the CalproQuest increases pretest-probability for a positive fecal Calprotectin. METHODS: Prospective diagnostic trial. The CalproQuest consists of 4 major and 4 minor questions suggestive for IBD. It is considered positive if ≥ 2 major or 1 major and 2 minor criteria are positive. Primary outcome: Sensitivity and specificity of the CalproQuest for Calprotectin levels ≥ 50 µg/g and for positive IBD diagnosis among patients referred to endoscopic evaluation at secondary care level. Secondary finding: Patient-reported diagnostic delay. RESULTS: 156 patients from 7 study centers had a complete CalproQuest and fecal Calprotectin test. The sensitivity and specificity of CalproQuest for Calprotectin ≥ 50 µg/g was 36% and 57%. The sensitivity and specificity of the CalproQuest for positive IBD diagnosis was 37% and 67%. The diagnostic delay was 61 months (SD 125.2). CONCLUSION: In this prospective diagnostic study, the sensitivity and specificity of CalproQuest for Calprotectin levels ≥ 50 µg/g and positive IBD diagnosis were poor. Additional prospective studies concerning the ideal cut-off values, validity and cost-effectiveness of a combined use with the Calprotectin test in the PC setting are necessary.

Feasibility of an 8-item questionnaire for early diagnosis of inflammatory bowel disease in primary care.

AIMS: Diagnosis of inflammatory bowel disease (IBD) is often associated with a diagnostic delay. Although faecal calprotectin is a helpful screening tool, the widespread use in primary care (PC) may not be appropriate due to the low prevalence of IBD in this setting. To increase pretest probability for a positive calprotectin test, an 8-item questionnaire (CalproQuest) was tested for its feasibility and acceptability in PC. METHODS: Population: PC patients with unspecific gastrointestinal complaints for at least 2 weeks. The CalproQuest consists of four major and four minor questions specific for IBD. It is considered positive if greater than or equal to two major or one major and two minor criteria are positive. PRIMARY OUTCOME: feasibility of CalproQuest, secondary outcome: patient's acceptance of stool sampling. RESULTS: Of 95 patients with a complete CalproQuest 52 (54.7%) were positive, 39 (41.1%) fulfilled two major and 13 (13.7%) one major and greater than or equal to two minor criteria. Twenty-seven general practitioners completed 83 (87.4%) questionnaires on feasibility which was assessed positive. Eighty-two patients (86.3%) completed questionnaires on acceptance which was high. CONCLUSION: The CalproQuest is a feasible instrument for assessing IBD in PC. Further prospective studies concerning validity and cost effectiveness of a combined use with the calprotectin test in this setting are necessary.

Direct-acting antiviral therapy for hepatitis C infection among people receiving opioid agonist treatment or heroin assisted treatment.

BACKGROUND: Treating chronic hepatitis C virus (HCV) infection among PWID (people who inject drugs) is crucial to achieve the WHO goal of HCV elimination, as this population is highly affected and carries a high risk of transmission. The aim of our study was to provide real-life data on HCV treatment among PWID either in opioid agonist treatment (OAT) or in heroin-assisted treatment (HAT) in a low-threshold access primary care-based addiction medicine institution. METHODS: We conducted a retrospective chart analysis of patients treated with direct-acting antivirals (DAA) between 10/2014 and 08/2017 in the Arud outpatient clinics in Zurich, Switzerland. We reported patient and treatment characteristics and substance use. The outcomes were sustained virological response (SVR) by intention-to-treat (ITT) and modified ITT (mITT) analyses, excluding patients with missing SVR data. RESULTS: We included 64 patients in our analysis. Forty-two (66%) were in OAT, and 22 (34%) were in HAT. Twenty-six patients (41%) reported harmful alcohol use, and 9 patients (14%) reported injecting drug use during DAA treatment. Every patient completed the treatment. Fifty-nine out of 64 achieved SVR resulting in an ITT SVR rate of 92.2%. Two patients had virological failure. Three patients were lost to follow-up between the end of treatment and SVR12 visit. Excluding these 3 patients, our study showed an mITT SVR rate of 96.7%. CONCLUSION: PWID can be treated with DAA treatment integrated in OAT and HAT with an excellent SVR rate. OAT and HAT programs should offer integrated HCV treatment to their patients.

Mobile teledermatology for skin cancer screening: A diagnostic accuracy study.

Skin cancer screening has undoubted potential to reduce cancer-specific morbidity and mortality. Total-body exams remain the prevailing concept of skin cancer screening even if effectiveness and value of this method are controversial. Meanwhile, store and forward teledermatology was shown to be a reliable instrument for several diagnostic purposes mostly in specialized dermatology settings. The objective of this study was to evaluate most convenient mobile teledermatology interventions as instruments for skin cancer screening in a representative population.Prospective diagnostic study with visitors of a skin cancer screening campaign in Switzerland. Histopathology was used as reference standard. Mobile teledermatology with or without dermoscopic images was assessed for performance as a screening test (i.e., rule-in or rule-out the need for further testing). Outcomes were sensitivity, specificity, and predictive values.Seven cases of skin cancer were present among 195 skin lesions. All skin cancers were ruled-in by teledermatology with or without dermoscopic images (sensitivity and negative predictive value 100%). The addition of dermoscopic images to conventional images resulted in higher specificity (85% vs. 77%), allowing reduction of unnecessary further testing in a larger proportion of skin lesions.Store and forward mobile teledermatology could serve as an instrument for population-based skin cancer screening because of favorable test performance.

Quality of secondary prevention of coronary heart disease in Swiss primary care: Lessons learned from a 6-year observational study.

INTRODUCTION: Across Europe, great variations have been identified in the quality of preventive healthcare services delivered in primary care (PC). We aimed to assess the quality of secondary prevention in Swiss PC patients with coronary heart disease (CHD) and its evolution over six years. METHODS: In the database of the Swiss «Family Medicine ICPC Research using Electronic Medical Records¼ (FIRE) project, we identified electronical record data of 2,807 patients with CHD treated for at least 15 months between 2009 and 2014. Primary outcome was the proportion of patients per year meeting four quality indicators of the British Quality and Outcome Framework (QOF): 1) blood pressure (BP) ≤ 150mmHg, 2) total serum cholesterol ≤ 5mmol/L, 3) prescription of anti-platelet therapy, 4) recommended drug prescriptions for patients with previous myocardial infarction (MI). Secondary outcome was the proportion of patients who were ineligible for indicator calculation because of incomplete record data. RESULTS: From 2009 to 2014, 85.9, 83.1, 82.0, 81.9, 81.5, and 81.0 % of the patients met BP targets and 73.6, 77.0, 69.2, 73.6, 69.4, and 69.1% met cholesterol targets. Anti-platelet therapy was prescribed to 74.8, 76.1, 73.9, 70.2, 72.2, and 72.5 % of the patients. Finally, 83.3, 84.4, 87.5, 75.6, 89.8, and 89.2 % of the patients with previous MI received the recommended drug therapy. Changes over time were not significant. Missing BP records concerned 12.4-15.9 % of the patients, and missing cholesterol records 69.0-75.6 %. Females and patients with less cardiovascular comorbidities were more likely to show missing records. CONCLUSIONS: Quality of secondary prevention did not improve when measured against QOF indicators in the period under investigation. Missing data in electronic medical records inhibited full quality indicator assessment. Especially in female patients and those with less cardiovascular comorbidity, closer medical documentation should be encouraged in order to facilitate quality of care measurements.

Elevated admission glucose and mortality in patients with acute pulmonary embolism.

OBJECTIVE: Although associated with adverse outcomes in other cardiopulmonary conditions, the prognostic value of elevated glucose in patients with acute pulmonary embolism (PE) is unknown. We sought to examine the association between glucose levels and mortality and hospital readmission rates for patients with PE. RESEARCH DESIGN AND METHODS: We evaluated 13,621 patient discharges with a primary diagnosis of PE from 185 acute care hospitals in Pennsylvania (from January 2000 to November 2002). Admission glucose levels were analyzed as a categorical variable (≤110, >110-140, >140-170, >170-240, and >240 mg/dL). The outcomes were 30-day all-cause mortality and hospital readmission. We used random-intercept logistic regression to assess the independent association between admission glucose levels and mortality and hospital readmission, adjusting for patient (age, sex, race, insurance, comorbid conditions, severity of illness, laboratory parameters, and thrombolysis) and hospital (region, size, and teaching status) factors. RESULTS: Elevated glucose (>110 mg/dL) was present in 8,666 (63.6%) patients. Patients with a glucose level ≤110, >110-140, >140-170, >170-240, and >240 mg/dL had a 30-day mortality of 5.6, 8.4, 12.0, 15.6, and 18.3%, respectively (P < 0.001). Compared with patients with a glucose level ≤110 mg/dL, the adjusted odds of dying were greater for patients with a glucose level >110-140 (odds ratio 1.19 [95% CI 1.00-1.42]), >140-170 (1.44 [1.17-1.77]), >170-240 (1.54 [1.26-1.90]), and >240 mg/dL (1.60 [1.26-2.03]), with no difference in the odds of hospital readmission. CONCLUSIONS: In patients with acute PE, elevated admission glucose is common and independently associated with short-term mortality.