Association of health confidence with hospital length of stay and readmission.

BACKGROUND: Length of stay (LOS) is an important measure of hospital quality and may be impacted by patient participation. However, concepts of patient participation, like health confidence, have received little examination in hospitalized patients' LOS, especially in diverse populations. OBJECTIVE: To determine if the Health Confidence Score (HCS) is associated with hospital LOS and readmission in a socioeconomically diverse population. DESIGNS, SETTINGS, AND PARTICIPANTS: We conducted a prospective cohort study in 2022 of adult general medicine patients at an academic hospital in Chicago, Illinois. INTERVENTION: None. MAIN OUTCOME AND MEASURES: Patient-reported responses to the HCS (scored 0 [lowest health confidence] to ‒12 [highest health confidence]), as well as demographic, socioeconomic, and clinical questions, were collected. Primary outcome was LOS and secondary outcomes were 30- and 90-day readmission. RESULTS: Among 2797 socioeconomically diverse patients who completed the survey (response rate 28.5%), there was an average HCS of 9.19 (SD 2.68, range 0-12). Using linear regression, patients with high HCS (HCS ≥ 9) had a 1.53-day lower LOS (p < .01, 95% confidence interval [CI] [-2.11, -0.95]) than patients with a low HCS (HCS < 9). This association remained when examining individual HCS questions and controlling for covariates. In logistic regression, HCS was not significantly associated with readmission, but the question "I am involved in decisions about me" (adjusted model: odds ratio 0.83; 95% CI [0.71, 0.96]; p = .01) was associated with 90-day readmission.

Association of preadmission insomnia symptoms with objective in-hospital sleep and clinical outcomes among hospitalized patients.

STUDY OBJECTIVES: To determine the prevalence of preadmission insomnia symptoms among hospitalized patients and assess the association of insomnia symptoms with objective in-hospital sleep and clinical outcomes. METHODS: We conducted a prospective cohort study of medicine inpatients (age ≥ 50, no previously diagnosed sleep disorders). Participants answered the Insomnia Severity Index (ISI) questionnaire to assess for preadmission insomnia symptoms (scored 0-28; higher scores suggest more insomnia symptoms). Sleep duration and efficiency were measured with actigraphy. Participants self-reported 30-day postdischarge readmissions and emergency department and/or urgent care visits. RESULTS: Of 568 participants, 49% had ISI scores suggestive of possible undiagnosed insomnia (ISI ≥ 8). Higher ISI scores were associated with shorter sleep duration [ß = -2.6, 95% confidence interval (CI) -4.1 to -1.1, P = .001] and lower sleep efficiency (ß = -0.39, 95% CI -0.63 to -0.15, P = .001). When adjusted for age, sex, body mass index, and comorbidities, higher ISI scores were associated with longer length of stay (incidence rate ratio 1.01, 95% CI 1.00-1.02, P = .011), increased risk of 30-day readmission (odds ratio 1.04, 95% CI 1.01-1.07, P = .018), and increased risk of 30-day emergency department or urgent care visit (odds ratio 1.04, 95% CI 1.00-1.07, P = .043). CONCLUSIONS: Among medicine inpatients, there was a high prevalence of preadmission insomnia symptoms suggestive of possible undiagnosed insomnia. Participants with higher ISI scores slept less with lower sleep efficiency during hospitalization. Higher ISI scores were associated with longer length of stay, increased risk of a 30-day postdischarge readmission, and increased risk of a 30-day postdischarge emergency department or urgent care visit. CITATION: Neborak JM, Press VG, Parker WF, et al. Association of preadmission insomnia symptoms with objective in-hospital sleep and clinical outcomes among hospitalized patients. J Clin Sleep Med. 2024;20(5):681-687.

Industry Payments for Vibegron and Prescribing Patterns Among Urologic Clinicians.

This cross-sectional study compares the prescribing practices among urologists and advanced practice clinicians who received vs did not receive payment from drug manufacturers.

Investigation of genomic and transcriptomic risk factors in clopidogrel response in African Americans.

Clopidogrel, an anti-platelet drug, used to prevent thrombosis after percutaneous coronary intervention. Clopidogrel resistance results in recurring ischemic episodes, with African Americans suffering disproportionately. The aim of this study was to identify biomarkers of clopidogrel resistance in African American patients. We conducted a genome-wide association study, including local ancestry adjustment, in 141 African Americans on clopidogrel to identify associations with high on-treatment platelet reactivity (HTPR). We validated genome-wide and suggestive hits in an independent cohort of African American clopidogrel patients (N = 823) from the Million Veteran's Program (MVP) along with in vitro functional follow up. We performed differential gene expression (DGE) analysis in whole blood with functional follow-up in MEG-01 cells. We identified rs7807369, within thrombospondin 7A (THSD7A), as significantly associated with increasing risk of HTPR (p = 4.56 × 10-9). Higher THSD7A expression was associated with HTPR in an independent gene expression cohort of clopidogrel treated patients (p = 0.004) and supported by increased gene expression on THSD7A in primary human endothelial cells carrying the risk haplotype. Two SNPs (rs1149515 and rs191786) were validated in the MVP cohort. DGE analysis identified an association with decreased LAIR1 expression to HTPR. LAIR1 knockdown in a MEG-01 cells resulted in increased expression of SYK and AKT1, suggesting an inhibitory role of LAIR1 in the Glycoprotein VI pathway. Notably, the CYP2C19 variants showed no association with clopidogrel response in the discovery or MVP cohorts. In summary, these finding suggest that other variants outside of CYP2C19 star alleles play an important role in clopidogrel response in African Americans.

Developing an Integrated Longitudinal Dataset for Patient-Centered Outcome Measures in Cost-Related Medication Nonadherence.

BACKGROUND: Cost-related medication nonadherence (CRN) is an important patient-centered outcome measure. Longitudinal follow-up of CRN is rare. OBJECTIVE: We propose to develop a novel integrated dataset to study CRN longitudinally. RESEARCH DESIGN: A dataset of 2000 Medicare beneficiaries at high risk of hospitalization surveyed quarterly on CRN and followed up individually for 8 quarters between 2013 and 2018 was linked to Medicare files. A metric of CRN categorizing persistent, intermittent, and transient CRN during the 8 quarters was developed. An ordered logit model and a logit model were developed to assess the factors influencing CRN overall and persistent CRN, respectively. RESULTS: A total of 1761 patients were included in the analysis, among whom 869 (49.3%) reported CRN at least once in the 8-quarter study period, 178 (10%) reported persistent CRN, 395 (22.4%) reported intermittent CRN, and 296 (16.8%) reported transient CRN. The conditional effect in the logit model for persistent CRN revealed that baseline dual eligibility was negatively associated (adjusted odds ratio = 0.45, P < 0.01) and depression positively associated (adjusted odds ratio = 1.55, P = 0.01) with persistent CRN. The marginal analysis in the ordered logit model revealed a clear pattern of higher probabilities of persistent and intermittent CRN at younger ages while transient CRN was flat. Among the 252 subjects who were deceased, 31 (12.3%) reported persistent CRN, compared with 147 (9.74%) who were alive (P = 0.21 by χ2 test). CONCLUSIONS: A significant number of patients reported persistent CRN, including those who were at the end of life. Research is critically needed to understand behavioral patterns among the younger Medicare population.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide.

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Prevalence and persistence of cost-related medication non-adherence before and during the COVID-19 pandemic among medicare patients at high risk of hospitalization.

OBJECTIVE: To study cost-related medication non-adherence (CRN) for a 30-month period before and during the COVID-19 pandemic using a sample of Medicare patients at high risk of hospitalization. DESIGN: A novel data set of quarterly surveys of CRN was used to evaluate CRN before and during the COVID-19 pandemic. Generalized Estimating Equation (GEE) analyses were conducted to evaluate the adjusted coefficients of change in CRN behaviors controlling for socio-demographic and health characteristics. PARTICIPANTS: Six hundred seventy-seven Medicare beneficiaries at high risk of hospitalization who were alive on January 1, 2020 and followed up through quarterly surveys on CRN for 30 months before and during the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: Two metrics of prevalence and persistence of CRN and their adjusted coefficients in GEE with binomial family distribution and log link function controlling for socio-demographic and health characteristics. RESULTS: A total of 5,990 quarterly surveys were completed by the 677 patients during the 30-month study period. Among the 677 patients, 250 (37%) were men, 591 (87%) were African American, and 288 (42%) were Medicare-Medicaid dual eligible. The unadjusted prevalence of CRN before and during the COVID-19 pandemic was 31.1% and 25.7% respectively (p = 0.02 by Chi-squared test), and persistent CRN rates were 12.1% and 9.7% respectively (p = 0.17 by Chi-squared test). The adjusted odds ratio of CRN prevalence during the pandemic compared to the pre-pandemic level was 0.75 (p<0.01), and 0.74 (p = 0.03) for persistent CRN in GEE estimations. CONCLUSION AND RELEVANCE: There are coherent evidence of a reversal of CRN rates during the COVID-19 pandemic among this high-need, high-cost resource utilization Medicare population. Patients' CRN behaviors may be responsive to exogenous impacts, and the behaviors changed in the same direction with similar magnitude in terms of prevalence (the extensive margin) and persistence (the intensive margin). More research is needed to advance the understanding of the driving forces behind patients' behavioral changes and to identify factors that may be informative for reducing CRN in the long run.

Industry Payments to Urologists and Urologic Advanced Practice Providers in 2021.

OBJECTIVE: To compare industry payments from drug and medical device companies to urologists and urologic advanced practice providers (APPs) in 2021. METHODS: We used the 2020 Medicare Data on Provider Practice and Specialty file to identify single-specialty urology practices, defined as those where the majority of physicians were urologists. We then used the Open Payments Program Year 2021 data to summarize the value and number of industry payments to urologists and APPs, including nurse practitioners and physician assistants, in these practices. We calculated the total value and number of payments and median total value and number of payments per provider for urologists and urologic APPs. RESULTS: We identified 4418 urologists and 1099 APPs working in single-specialty urology practices in 2021 (Table 1). Of these, 3646 (87%) urologists received at least one industry payment, totaling $14,755,003 from 116,039 payments, and 954 urologic APPs (87%) received at least one industry payment, including 463 nurse practitioners (85%), totaling $401,283 from 13,035 payments, and 491 physician assistants (89%), totaling $543,429 from 14,626 payments. We observed significantly greater median total value and number of payments per provider for urologists ($620 and 24 payments) compared to urologic APPs ($473 and 21 payments; P < .001 and P = .017, respectively). CONCLUSION: A similar percentage of urologists and urologic APPs received industry payments in 2021. While urologists received a higher total number and total value of payments in 2021, urologic APPs were a common target of industry marketing payments.

Outcomes of Hematuria Evaluation by Advanced Practice Providers and Urologists.

OBJECTIVE: To examine the quality and costs of care for patients evaluated for hematuria by urologic advanced practice providers (APPs) and urologists. The roles of APPs in urology are growing, but their clinical and financial outcomes compared to urologists are not well understood. METHODS: We conducted a retrospective cohort study of commercially insured patients using data from 2014 to 2020. We included adult beneficiaries with a diagnosis code for hematuria and an initial outpatient evaluation and management visit with a urologic APP or urologist. We assessed receipt of cystoscopy procedure, imaging study, bladder biopsy procedure, and bladder cancer diagnosis within 6 months of the initial visit. Secondary outcomes included the time until each of these outcomes occurred and the out-of-pocket spending and total payments. RESULTS: We identified 59,923 patients who were initially evaluated for hematuria. Visits with urologic nurse practitioners rather than urologists were associated with significantly lower odds of receiving cystoscopy procedures (odds ratio [OR] 0.93, 95% confidence interval [95% CI] 0.54-0.72, P < .001), imaging studies (OR 0.79, 95% CI 0.69-0.91, P < .001), and bladder biopsy procedures (OR 0.61, 95% CI 0.41-0.92, P = .02). Visits with urologic physician assistants were associated with 11% greater out-of-pocket payments (incident risk ratio 1.11, CI 1.01-1.22, P = .02) and 14% greater total payments (incident risk ratio 1.14, CI 1.04-1.25, P = .004). CONCLUSION: There are clinical and financial differences in hematuria care delivered by urologic APPs and urologists. The incorporation of APPs into urologic care warrants further study, and specialty-specific training for APPs should be considered.

The Relationship Between Insufficient Vision and Technology Access and Use Among Hospitalized Adults at an Urban Academic Hospital: Observational Study.

BACKGROUND: The role of sufficient vision in self-management is salient with respect to the growing prevalence of eHealth-based interventions for chronic diseases. However, the relationship between insufficient vision and self-management has been understudied. OBJECTIVE: We aimed to assess differences in access to and use of technology among adults with and without insufficient vision at an academic urban hospital. METHODS: This is an observational study of hospitalized adult general medicine patients that is part of a larger quality improvement study called the hospitalist study. The hospitalist study provided demographic and health literacy data (Brief Health Literacy Screen). Our substudy included several measures. Validated surveys assessed technology access and use, and included benchmarked questions from the National Pew Survey to determine access to, willingness to use, and self-described ability to use technology at home, particularly for self-management, and eHealth-specific questions assessing future willingness to access eHealth post discharge. The eHealth Literacy Scale (eHEALS) was used to assess eHealth literacy. Visual acuity was assessed using the Snellen pocket eye chart with low vision defined as visual acuity ≤20/50 in at least one eye. Descriptive statistics, bivariate chi-square analyses, and multivariate logistic regressions (adjusted for age, race, gender, education level, and eHealth literacy) were performed using Stata. RESULTS: A total of 59 participants completed our substudy. The mean age was 54 (SD 16.4) years. Demographic data from the hospitalist study was missing for several participants. Among those who responded, most identified as Black (n=34, 79%) and female (n=26, 57%), and most reported at least some college education (n=30, 67%). Most participants owned technology devices (n=57, 97%) and had previously used the internet (n=52, 86%), with no significant differences between those with insufficient and sufficient vision (n=34 vs n=25). Though there was a 2x effect size for laptop ownership, with those with sufficient vision more likely to own a laptop, those with insufficient vision versus sufficient vision were less likely to report an ability to perform online tasks without assistance, including using a search engine (n=22, 65% vs n=23, 92%; P=.02), opening an attachment (n=17, 50% vs n=22, 88%; P=.002), and using an online video (n=20, 59% vs n=22, 88%; P=.01). In multivariate analysis, the ability to independently open an online attachment did not remain statistically significant (P=.01). CONCLUSIONS: Technology device ownership and internet use rates are high in this population, yet participants with insufficient vision (vs sufficient vision) reported a reduced ability to independently perform online tasks. To ensure the effective use of eHealth technologies by at-risk populations, the relationship between vision and technology use needs to be further studied.

Assessing Disparities in Video-Telehealth Use and eHealth Literacy Among Hospitalized Patients: Cross-sectional Observational Study.

BACKGROUND: Medicare coverage for audio-only telehealth is slated to end this year after the public health emergency concludes. When the time comes, many patients may be unable to make the transition from audio-only to video telehealth due to digital inexperience. This study explores the second digital divide within video telehealth use, which is primarily characterized by skills and capabilities rather than access, by measuring eHealth literacy (eHL) and video capabilities in hospitalized patients. OBJECTIVE: The aim of this study is to evaluate video capabilities, eHealth literacy, and engagement with video telehealth among hospitalized patients. METHODS: The study design is a cross-sectional observational study of adult inpatients at the University of Chicago Medical Center. We assessed self-reported rates of audio versus video telehealth usage as well as the participants' self-reported willingness to use video telehealth for future health care visits. We used a multivariable binary logistic regression to determine the odds ratio for being unwilling to use video telehealth, adjusted for age, sex, race or ethnicity, educational level, eHL literacy scale (eHEALS), health literacy (brief health literacy screen), technology access, internet access, and video capability. RESULTS: Of the 297 enrolled participants, median age was 58 years, most (n=185, 62%) identified as Black, half (n=149, 50%) were female, one-quarter (n=66, 22%) lacked home internet access, and one-third (n=102, 34%) had inadequate eHL. CONCLUSIONS: Patients with low eHL reported greater participation in audio-only telehealth over video telehealth, of which the former may lose its flexible pandemic reimbursement policy. This may widen the existing health disparities as older adults and patients with low eHL face challenges in accessing video telehealth services. Low eHL is associated with lack of web-based skills, lower rates of video telehealth usage, and lower willingness to use video technology. The study results raise the question of how to improve video capability among patients who, despite having access to smartphones and laptops, face challenges in using telehealth optimally.

Implementation of pharmacogenomics into inpatient general medicine.

Pharmacogenomics is a crucial piece of personalized medicine. Preemptive pharmacogenomic testing is only used sparsely in the inpatient setting and there are few models to date for fostering the adoption of pharmacogenomic treatment in the inpatient setting. We created a multi-institutional project in Chicago to enable the translation of pharmacogenomics into inpatient practice. We are reporting our implementation process and barriers we encountered with solutions. This study, 'Implementation of Point-of-Care Pharmacogenomic Decision Support Accounting for Minority Disparities', sought to implement pharmacogenomics into inpatient practice at three sites: The University of Chicago, Northwestern Memorial Hospital, and the University of Illinois at Chicago. This study involved enrolling African American adult patients for preemptive genotyping across a panel of actionable germline variants predicting drug response or toxicity risk. We report our approach to implementation and the barriers we encountered engaging hospitalists and general medical providers in the inpatient pharmacogenomic intervention. Our strategies included: a streamlined delivery system for pharmacogenomic information, attendance at hospital medicine section meetings, use of physician and pharmacist champions, focus on hospitalists' care and optimizing system function to fit their workflow, hand-offs, and dealing with hospitalists turnover. Our work provides insights into strategies for the initial engagement of inpatient general medicine providers that we hope will benefit other institutions seeking to implement pharmacogenomics in the inpatient setting.

eHealth Literacy and Patient Portal Use and Attitudes: Cross-sectional Observational Study.

BACKGROUND: Throughout the COVID-19 pandemic, patient portals have become more widely used tools of patient care delivery. However, not all individuals have equivalent access or ability to use patient portals. OBJECTIVE: The aim of this study is to evaluate the relationships between eHealth literacy (eHL) and patient portal awareness, use, and attitudes among hospitalized patients. METHODS: Inpatients completed patient portal surveys; eHL was assessed (eHealth Literacy Scale). Multivariable logistic regression analyses adjusted for age, self-reported race, gender, and educational attainment were completed with significance at P<.006 (Bonferroni correction). RESULTS: Among 274 participants, most identified as Black (n=166, 61%) and female (n=140, 51%), mean age was 56.5 (SD 16.7) years, and 178 (65%) reported some college or higher educational attainment. One-quarter (n=79, 28%) had low eHL (mean 27, SD 9.5), which was associated with lower odds of portal access awareness (odds ratio 0.11, 95% CI 0.05-0.23; P<.001), having ever used portals (odds ratio 0.19, 95% CI 0.10-0.36; P<.001), less perceived usefulness of portals (odds ratio 0.20, 95% CI 0.10-0.38; P=.001), and lower likelihood of planning to use portals in the coming years (odds ratio 0.12, 95% CI 0.06-0.25; P<.001). As time through the COVID-19 pandemic passed, there was a trend toward increased perceived usefulness of patient portals (53% vs 62%, P=.08), but average eHL did not increase through time (P=.81). CONCLUSIONS: Low eHL was associated with less awareness, use, and perceived usefulness of portals. Perceived usefulness of portals likely increased through the COVID-19 pandemic, but patients' eHL did not. Interventions tailored for patients with low eHL could ensure greater equity in health care delivery through the COVID-19 pandemic.

A Qualitative Study of Preclinical Medical Students Randomized to Patient-Partnered vs Traditional Clinical Experiences.

Purpose: Longitudinal patient-partnered experiences may promote medical student empathy, but evaluation of such programs is limited. The aim of this study was to compare areas of learning among first-year medical students randomized to a patient-centered track (PCT) or traditional track (TT) longitudinal clinical experience. Methods: PCT students (n=24) were paired with 2 patients and a physician to participate in their patients' care across multiple settings. TT students (n=56) were paired with a physician preceptor and participated in caring for a variety of patients in a single setting. This qualitative study used a phenomenological approach to template analysis, examining and comparing student reflective essays for areas of learning. Results: Three domains of learning emerged: 1) Focus of learning (biomedical, patient-centered); 2) Roles and relationships (clinical skills, relationship-building, teaching from preceptor and patients); and 3) Context of care (health systems science, interprofessional care). PCT students described patient-centered learning, relationship-building, and patients' role as teachers. In contrast, TT students emphasized biomedical learning, clinical skills development, and teaching from physician preceptors. Conclusions: Longitudinal patient-partnered clinical experiences provide rich opportunities for preclinical students to cultivate empathy and develop patient-centered values.

Association between vitamin D supplementation and COVID-19 infection and mortality.

Vitamin D deficiency has long been associated with reduced immune function that can lead to viral infection. Several studies have shown that Vitamin D deficiency is associated with increases the risk of infection with COVID-19. However, it is unknown if treatment with Vitamin D can reduce the associated risk of COVID-19 infection, which is the focus of this study. In the population of US veterans, we show that Vitamin D2 and D3 fills were associated with reductions in COVID-19 infection of 28% and 20%, respectively [(D3 Hazard Ratio (HR) = 0.80, [95% CI 0.77, 0.83]), D2 HR = 0.72, [95% CI 0.65, 0.79]]. Mortality within 30-days of COVID-19 infection was similarly 33% lower with Vitamin D3 and 25% lower with D2 (D3 HR = 0.67, [95% CI 0.59, 0.75]; D2 HR = 0.75, [95% CI 0.55, 1.04]). We also find that after controlling for vitamin D blood levels, veterans receiving higher dosages of Vitamin D obtained greater benefits from supplementation than veterans receiving lower dosages. Veterans with Vitamin D blood levels between 0 and 19 ng/ml exhibited the largest decrease in COVID-19 infection following supplementation. Black veterans received greater associated COVID-19 risk reductions with supplementation than White veterans. As a safe, widely available, and affordable treatment, Vitamin D may help to reduce the severity of the COVID-19 pandemic.

Effect Modification by Social Determinants of Pharmacogenetic Medication Interactions on 90-Day Hospital Readmissions within an Integrated U.S. Healthcare System.

The present study builds on our prior work that demonstrated an association between pharmacogenetic interactions and 90-day readmission. In a substantially larger, more diverse study population of 19,999 adults tracked from 2010 through 2020 who underwent testing with a 13-gene pharmacogenetic panel, we included additional covariates to evaluate aggregate contribution of social determinants and medical comorbidity with the presence of identified gene-x-drug interactions to moderate 90-day hospital readmission (primary outcome). Univariate logistic regression analyses demonstrated that strongest associations with 90 day hospital readmissions were the number of medications prescribed within 30 days of a first hospital admission that had Clinical Pharmacogenomics Implementation Consortium (CPIC) guidance (CPIC medications) (5+ CPIC medications, odds ratio (OR) = 7.66, 95% confidence interval 5.45−10.77) (p < 0.0001), major comorbidities (5+ comorbidities, OR 3.36, 2.61−4.32) (p < 0.0001), age (65 + years, OR = 2.35, 1.77−3.12) (p < 0.0001), unemployment (OR = 2.19, 1.88−2.64) (p < 0.0001), Black/African-American race (OR 2.12, 1.47−3.07) (p < 0.0001), median household income (OR = 1.63, 1.03−2.58) (p = 0.035), male gender (OR = 1.47, 1.21−1.80) (p = 0.0001), and one or more gene-x-drug interaction (defined as a prescribed CPIC medication for a patient with a corresponding actionable pharmacogenetic variant) (OR = 1.41, 1.18−1.70). Health insurance was not associated with risk of 90-day readmission. Race, income, employment status, and gene-x-drug interactions were robust in a multivariable logistic regression model. The odds of 90-day readmission for patients with one or more identified gene-x-drug interactions after adjustment for these covariates was attenuated by 10% (OR = 1.31, 1.08−1.59) (p = 0.006). Although the interaction between race and gene-x-drug interactions was not statistically significant, White patients were more likely to have a gene-x-drug interaction (35.2%) than Black/African-American patients (25.9%) who were not readmitted (p < 0.0001). These results highlight the major contribution of social determinants and medical complexity to risk for hospital readmission, and that these determinants may modify the effect of gene-x-drug interactions on rehospitalization risk.

Pilot Findings of Pharmacogenomics in Perioperative Care: Initial Results From the First Phase of the ImPreSS Trial.

BACKGROUND: Pharmacogenomics, which offers a potential means by which to inform prescribing and avoid adverse drug reactions, has gained increasing consideration in other medical settings but has not been broadly evaluated during perioperative care. METHODS: The Implementation of Pharmacogenomic Decision Support in Surgery (ImPreSS) Trial is a prospective, single-center study consisting of a prerandomization pilot and a subsequent randomized phase. We describe findings from the pilot period. Patients planning elective surgeries were genotyped with pharmacogenomic results, and decision support was made available to anesthesia providers in advance of surgery. Pharmacogenomic result access and prescribing records were analyzed. Surveys (Likert-scale) were administered to providers to understand utilization barriers. RESULTS: Of eligible anesthesiology providers, 166 of 211 (79%) enrolled. A total of 71 patients underwent genotyping and surgery (median, 62 years; 55% female; average American Society of Anesthesiologists (ASA) score, 2.6; 58 inpatients and 13 ambulatories). No patients required postoperative intensive care or pain consultations. At least 1 provider accessed pharmacogenomic results before or during 41 of 71 surgeries (58%). Faculty were more likely to access results (78%) compared to house staff (41%; P = .003) and midlevel practitioners (15%) ( P < .0001). Notably, all administered intraoperative medications had favorable genomic results with the exception of succinylcholine administration to 1 patient with genomically increased risk for prolonged apnea (without adverse outcome). Considering composite prescribing in preoperative, recovery, throughout hospitalization, and at discharge, each patient was prescribed a median of 35 (range 15-83) total medications, 7 (range 1-22) of which had annotated pharmacogenomic results. Of 2371 prescribing events, 5 genomically high-risk medications were administered (all tramadol or omeprazole; with 2 of 5 pharmacogenomic results accessed), and 100 genomically cautionary mediations were administered (hydralazine, oxycodone, and pantoprazole; 61% rate of accessing results). Providers reported that although results were generally easy to access and understand, the most common reason for not considering results was because remembering to access pharmacogenomic information was not yet a part of their normal clinical workflow. CONCLUSIONS: Our pilot data for result access rates suggest interest in pharmacogenomics by anesthesia providers, even if opportunities to alter prescribing in response to high-risk genotypes were infrequent. This pilot phase has also uncovered unique considerations for implementing pharmacogenomic information in the perioperative care setting, and new strategies including adding the involvement of surgery teams, targeting patients likely to need intensive care and dedicated pain care, and embedding pharmacists within rounding models will be incorporated in the follow-on randomized phase to increase engagement and likelihood of affecting prescribing decisions and clinical outcomes.

The Impact of Principal Diagnosis on Readmission Risk among Patients Hospitalized for Community-Acquired Pneumonia.

Coding variation distorts performance/outcome statistics not eliminated by risk adjustment. Among 1596 community-acquired pneumonia patients hospitalized from 1998 to 2012 identified using an evidence-based algorithm, the authors measured the association of principal diagnosis (PD) with 30-day readmission, stratified by Pneumonia Severity Index risk class. The 152 readmitted patients were more ill (Pneumonia Severity Index class V 38.8% versus 25.8%) and less likely to have a pneumonia PD (52.6% versus 69.9%). Among patients with PDs of pneumonia, respiratory failure, sepsis, and aspiration, mortality/readmission rates were 3.9/8.5%, 28.8/14.0%, 24.7/19.6%, and 9.0/15.0%, respectively. The nonpneumonia PDs were associated with a greater risk of adjusted 30-day readmission: respiratory failure odds ratio (OR) 1.89 (95% confidence interval [CI], 1.13-3.15), sepsis OR 2.54 (95% CI, 1.52-4.26), and possibly aspiration OR 1.73 (95% CI, 0.88-3.41). With increasing use of alternative PDs among pneumonia patients, quality reporting must account for variations in condition coding practices. Rigorous risk adjustment does not eliminate the need for accurate, consistent case definition in producing valid quality measures.

Cannabidiol inhibits SARS-CoV-2 replication through induction of the host ER stress and innate immune responses.

The spread of SARS-CoV-2 and ongoing COVID-19 pandemic underscores the need for new treatments. Here we report that cannabidiol (CBD) inhibits infection of SARS-CoV-2 in cells and mice. CBD and its metabolite 7-OH-CBD, but not THC or other congeneric cannabinoids tested, potently block SARS-CoV-2 replication in lung epithelial cells. CBD acts after viral entry, inhibiting viral gene expression and reversing many effects of SARS-CoV-2 on host gene transcription. CBD inhibits SARS-CoV-2 replication in part by up-regulating the host IRE1α RNase endoplasmic reticulum (ER) stress response and interferon signaling pathways. In matched groups of human patients from the National COVID Cohort Collaborative, CBD (100 mg/ml oral solution per medical records) had a significant negative association with positive SARS-CoV-2 tests. This study highlights CBD as a potential preventative agent for early-stage SARS-CoV-2 infection and merits future clinical trials. We caution against use of non-medical formulations including edibles, inhalants or topicals as a preventative or treatment therapy at the present time.