Hospital Rating Organizations' Quality and Patient Safety Scores: Analysis of Result Discrepancies.

BACKGROUND: In the USA, multiple organizations rate hospitals based on quality and patient safety data, but few studies have analyzed and compared the rating results. OBJECTIVE: Compare the results of different US hospital-rating organizations. DESIGN: Observational data analysis of US acute care hospital ratings. PARTICIPANTS: Four rating organizations: Hospital Compare® (HC), Healthgrades® (HG), The Leapfrog Group® (Leapfrog), and US News and World Report® (USN). MAIN MEASURES: We analyzed the level of concordance (similar ranking), discordance (difference of 1 or more rankings), and severe discordance (difference of two or more rankings), as well as differences and correlations between the scores. KEY RESULTS: From Feb 1 to Oct 3, 2023, we analyzed data from 2,384 hospitals. In Leapfrog, there were 688 hospitals (29%) with Grade A, 652 (27.3%) with B, 885 (37.1%) with C, 153 (6.4%) with D, and 6 (0.3%) with F. For HC, 333 hospitals (14%) had five stars, 676 (28.4%) four, 695 (29.2%) three, 502 (21.4%) two, and 171 (7.2%) one-star. In ratings between HC and Leapfrog, discordance was 70%, and severe discordance was 25.1%. USN ranked 469 hospitals (19.7%). Within the USN-ranked hospital group, there was a 62% discordance and 19.8% severe discordance between HC and Leapfrog. The analysis of orthopedic procedures from HG and USN showed discordance ranging from 48 to 61.2%. CONCLUSION: The rating organizations' reported metrics were highly discordant. A hospital's ranking by one organization frequently did not correspond to a similar ranking by another. The methodology and included timeline and patient population can help explain the differences. However, the discordant ratings may confuse patients and customers.

Bayesian methods: a potential path forward for sepsis trials.

BACKGROUND: Given the success of recent platform trials for COVID-19, Bayesian statistical methods have become an option for complex, heterogenous syndromes like sepsis. However, study design will require careful consideration of how statistical power varies using Bayesian methods across different choices for how historical data are incorporated through a prior distribution and how the analysis is ultimately conducted. Our objective with the current analysis is to assess how different uses of historical data through a prior distribution, and type of analysis influence results of a proposed trial that will be analyzed using Bayesian statistical methods. METHODS: We conducted a simulation study incorporating historical data from a published multicenter, randomized clinical trial in the US and Canada of polymyxin B hemadsorption for treatment of endotoxemic septic shock. Historical data come from a 179-patient subgroup of the previous trial of adult critically ill patients with septic shock, multiple organ failure and an endotoxin activity of 0.60-0.89. The trial intervention consisted of two polymyxin B hemoadsorption treatments (2 h each) completed within 24 h of enrollment. RESULTS: In our simulations for a new trial of 150 patients, a range of hypothetical results were observed. Across a range of baseline risks and treatment effects and four ways of including historical data, we demonstrate an increase in power with the use of clinically defensible incorporation of historical data. In one possible trial result, for example, with an observed reduction in risk of mortality from 44 to 37%, the probability of benefit is 96% with a fixed weight of 75% on prior data and 90% with a commensurate (adaptive-weighting) prior; the same data give an 80% probability of benefit if historical data are ignored. CONCLUSIONS: Using Bayesian methods and a biologically justifiable use of historical data in a prior distribution yields a study design with higher power than a conventional design that ignores relevant historical data. Bayesian methods may be a viable option for trials in critical care medicine where beneficial treatments have been elusive.

How often do medical students change career preferences over the course of medical school?

INTRODUCTION: During the preclinical years, students typically do not have extensive exposure to clinical medicine. When they begin their clinical rotations, usually in the third year, the majority of the time is spent on core rotations with limited experience in other fields of medicine. Students then must decide on their careers early in their fourth year. We aimed to analyze how often medical students change their career preferences between the end of their second and their fourth year. METHODS: We conducted a retrospective, cohort study using the American Association of Medical Colleges Year 2 Questionnaire (Y2Q) and Graduating Questionnaire (GQ) from 2016 to 2020. RESULTS: 20,408 students answered both surveys, but 2,165 had missing values on the career choice question and were excluded. Of the remaining students, 10,233 (56%) changed their career choice between the Y2 and GQ surveys. Fields into which students preferentially switched by the GQ survey included anesthesia, dermatology, ENT, family medicine, OB/GYN, pathology, PM&R, psychiatry, radiology, urology, and vascular surgery. Many characteristics, including future salary, the competitiveness of the field, and the importance of work-life balance, were significantly associated with a higher likelihood of changing career choices. On the other hand, having a mentor and the specialty content were associated with a lower likelihood of change. CONCLUSION: A majority of students switched their career preferences from the Y2Q to the GQ. Additional research should be focused on curricular design that optimizes student satisfaction with career decisions. This may include early integration of a variety of specialties.

Influence of demographic and socio-economic factors in choosing hospitalist careers among US medical students.

BACKGROUND: The subspecialty of Hospital Medicine (HM) has grown rapidly since the mid-1990s. Diversity and inclusion are often studied in the context of healthcare equity and leadership. However, little is known about the factors potentially associated with choosing this career path among US medical students. METHODS: We analyzed the results of the Annual Association of American Medical Colleges Survey administered to Graduating medical students from US medical schools from 2018 to 2020. RESULTS: We analyzed 46,614 questionnaires. 19.3% of respondents (N = 8,977) intended to work as a Hospital Medicine [HM] (unchanged from 2018 to 2020), mostly combined with specialties in Internal medicine (31.5%), Pediatrics (14.6%), and Surgery (9.1%). Students interested in HM were significantly more likely to identify as female, sexual orientation minorities (Lesbian/Gay or Bisexual), Asian or Black/African-American, or Hispanic. Role models and the ability to do a fellowship were strong factors in choosing HM, as was higher median total debt ($170,000 vs. $155,000). Interest in higher salary and work/life balance negatively impacted the likelihood of choosing HM. There were significant differences between students who chose IM/HM and Pediatrics/HM. CONCLUSION: About one in five US medical students is interested in HM. The probability of choosing future HM careers is higher for students who identify as sexual or racial minorities, with a higher amount of debt, planning to enter a loan forgiveness program, or are interested in doing a fellowship.

Contrast associated nephropathy after intravenous administration: what is the magnitude of the problem?

Intravenous contrast media (CM) is often used in clinical practice to enhance CT scan imaging. For many years, contrast-induced nephropathy (CIN) was thought to be a common occurrence and to result in dire consequences. When treating patients with abnormal renal function, it is not unusual that clinicians postpone, cancel, or replace contrast-enhanced imaging with other, perhaps less informative tests. New studies however have challenged this paradigm and the true risk attributable to intravenous CM for the occurrence of CIN has become debatable. In this article, we review the latest relevant medical literature and aim to provide an evidence-based answer to questions surrounding the risk, outcomes, and potential mitigation strategies of CIN after intravenous CM administration.

Renal Replacement Therapy in the ICU.

OBJECTIVES: The incidence of acute kidney injury in critically ill patients is increasing steeply. Acute kidney injury in this setting is associated with high morbidity and mortality. There is no doubt that renal replacement therapy for the most severe forms of acute kidney injury can be life saving, but there are a number of uncertainties about the optimal application of renal replacement therapy for patients with acute kidney injury. The objective of this synthetic review is to present current evidence supporting best practices in renal replacement therapy for critically ill patients with acute kidney injury. DATA SOURCES: We reviewed literature regarding timing of initiation of renal replacement therapy, optimal vascular access for renal replacement therapy in acute kidney injury, modality selection and dose or intensity of renal replacement therapy, and anticoagulation during renal replacement therapy, using the following databases: MEDLINE and PubMed. We also reviewed bibliographic citations of retrieved articles. STUDY SELECTION: We reviewed only English language articles. CONCLUSIONS: Current evidence sheds light on many areas of controversy regarding renal replacement therapy in acute kidney injury, providing a foundation for best practices. Nonetheless, important questions remain to be answered by ongoing and future investigation.

Timing of norepinephrine in septic patients: NOT too little too late.

After years and years of consensus expert opinion as to mean arterial pressure (MAP) target and vasopressor choice in septic shock management, literature is now emerging that supports the MAP target of 65 mm Hg and norepinephrine as the vasopressor choice. However, the literature remains sparse as to the timing of vasopressors relative to fluid resuscitation and how MAP support is balanced between the choices of vasopressor versus fluid resuscitation. Bai and colleagues report data that reveal an association between earlier vasopressor initiation in septic shock and better outcome. Whether this is a linkage to better care, is related to improved early tissue perfusion, or relates to sparing of fluids to reach the MAP target is not yet known.

A Review of Fluid Bolus in Critically Ill Patients After Initial Volume Expansion: Bayesian Probability Analysis and Case Studies.

Introduction Fluid resuscitation is a crucial intervention for the management of critically ill patients. However, after initial volume expansion, the advantages of fluid bolus administration remain controversial. Our aim was to investigate the probabilistic reasoning against fluid bolus administration in critically ill patients after initial volume expansion. We then applied this reasoning to two hypothetical case studies that evaluated the benefits and risks associated with a fluid bolus for each patient. Methods We analyzed data from 12 previously published studies, totaling 334 patients, on fluid responsiveness in critically ill patients. Owing to differences in these studies, we used a Monte Carlo simulation based on their parameters to improve our Bayesian prior, generate strong estimates, and address uncertainty. Using the established Bayesian prior for volume responsiveness, we scrutinized two hypothetical case studies employing Bayesian mathematical notation to assess the pre-test probability, posterior probability, and likelihood ratios in patients with septic shock. Results The Monte Carlo simulation yielded a mean response rate of 0.54 (SD = 0.026), suggesting that only approximately 54% of patients were responsive to fluid bolus administration. These results had an effective sample size of 17,204 and an R-hat value of 1, demonstrating the reliability of our results. In our Bayesian case studies, we demonstrate the low probabilities of volume and VO2 responsiveness over time using common bedside testing. Conclusion Our analysis shows that the pretest and posttest probabilities for volume responsiveness following initial fluid resuscitation are low. Additional bedside testing should be pursued before administering additional volume. This approach emphasizes the importance of evidence-based decision-making in the management of critically ill patients to optimize patient outcomes and minimize potential risks.

Impact of Povidone Application to Nares in Addition to Chlorhexidine Bath in Critically Ill Patients on Nosocomial Bacteremia and Central Line Blood Stream Infection.

Nosocomial Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia results in a significant increase in morbidity and mortality in hospitalized patients. We aimed to analyze the impact of applying 10% povidone iodine (PI) twice daily to both nares in addition to chlorhexidine (CHG) bathing on nosocomial (MRSA) bacteremia in critically ill patients. A quality improvement study was completed with pre and post-design. The study period was from January 2018 until February 2020 and February 2021 and June 2021. The control period (from January 2018 to May 2019) consisted of CHG bathing alone, and in the intervention period, we added 10% PI to the nares of critically ill patients. Our primary outcome is rates of nosocomial MRSA bacteremia, and our secondary outcome is central line associated blood stream infection (CLABSI) and potential cost savings. There were no significant differences in rates of MRSA bacteremia in critically ill patients. Nosocomial MRSA bacteremia was significantly lower during the intervention period on medical/surgical areas (MSA). CLABSIs were significantly lower during the intervention period in critically ill patients. There were no Staphylococcus aureus CLABSIs in critical care area (CCA)during the intervention period. The intervention showed potential significant cost savings. The application of 10% povidone iodine twice a day in addition to CHG bathing resulted in a significant decrease in CLABSIs in critically ill patients and a reduction in nosocomial MRSA in the non-intervention areas. Further trials are needed to tease out individual patients who will benefit from the intervention.

A new role for statins in sepsis.

Several studies have shown promising results regarding the use of statins as an adjunctive treatment for sepsis. Most of those studies were retrospective or observational in nature. The ASEPSIS trial has reported that the administration of atorvastatin reduced clinical progression of sepsis but did not improve mortality. These findings are promising and further multicenter trials are needed to confirm these outcomes and to establish whether this class of medications will offer utility in this regard.

Prevalence and impact of anemia in hospitalized patients.

OBJECTIVE: The prevalence of anemia is increasing in the general population similarly to other comorbidities and is associated with high mortality in a variety of settings. Most studies, however, have analyzed older adults or specific comorbidities, and the independent impact of anemia on outcomes in a general population of hospitalized patients has not been clearly defined. METHODS: Retrospective analysis of a medical records database of all consecutive patient discharges (aged 18 years or older) admitted to our institution from January 1, 1999 through December 31, 2008. RESULTS: A total of 179,516 admissions were included. Of these, 18,589 patients were diagnosed as having anemia (10.4%). There were 123,586 patients younger than 65 years. The prevalence of anemia among all of the discharges was characterized by a significant linear increase across the 10-year time frame, from 8.7% (1999) to 12.8% (2008), as was the average number of comorbidities. Over time, anemic patients were characterized by increasing comorbidity. Anemia was significantly associated with mortality (6.5% vs 2.5%; P < 0.001, odds ratio 2.68). This association remained significant after additional adjustment for demographic characteristics and comorbidities. The risk of mortality was significantly higher in patients younger than 65 years than it was in patients older than 65 (odds ratio 3.2 vs 2.1, respectively). CONCLUSIONS: The prevalence of anemia increased during a 10-year time frame, as did the average number of associated comorbid conditions. With adjustment for time, demographic factors, and additional comorbidities, anemia remained independently associated with mortality. This association was stronger in younger patients.

Acute kidney injury and chronic kidney disease: it's a two-way street.

Acute kidney injury (AKI) is frequently seen in hospitalized patients and its incidence increases with the severity of illness. Recent studies have further illuminated the interdependent relationship between AKI and chronic kidney disease (CKD). CKD and proteinuria have been demonstrated to be risk factors for AKI. Moreover, the previous dogma that prognosis is excellent for patients who recover after AKI episodes may not be universally accurate as CKD is emerging as a long-term consequence after AKI. Short-term mortality is lower in CKD patients with AKI.

Impact of Food Environments on Obesity Rates: A State-Level Analysis.

Introduction: Limited access to healthy food in areas that are predominantly food deserts or food swamps may be associated with obesity. Other unhealthy behaviors may also be associated with obesity and poor food environments. Methods: We calculated Modified Retail Food Environment Index (mRFEI) to assess food retailers. Using data collected from the Behavioral Risk Factor Surveillance System (BRFSS) survey, the NJ Department of Health (NJDOH), and the US Census Bureau, we conducted a cross-sectional analysis of the interaction of obesity with the food environment and assessed smoking, leisure-time physical activity (LPA), and poor sleep. Results: There were 17.9% food deserts and 9.3% food swamps in NJ. There was a statistically significant negative correlation between mRFEI and obesity rate (Pearson's r -0.13, p < 0.001), suggesting that lack of access to healthy food is associated with obesity. Regression analysis was significantly and independently associated with increased obesity prevalence (adjusted R square 0.74 and p=0.008). Obesity correlated positively with unhealthy behaviors. Each unhealthy behavior was negatively correlated with mRFEI. The mean prevalence for smoking, LPA, and sleep <7 hours was 15.4 (12.5-18.6), 26.5 (22.5-32.3), and 37.3 (34.9-40.4), respectively. Conclusion: Obesity tracks with food deserts and especially food swamps. It is also correlated with other unhealthy behaviors (smoking, LPA, and poor sleep).

Objective Methods of Assessing Fluid Status to Optimize Volume Management in Kidney Disease and Hypertension: The Importance of Ultrasound.

Fluid overload, a prevalent complication in patients with renal disease and hypertension, significantly impacts patient morbidity and mortality. The daily clinical challenges that clinicians face include how to identify fluid overload early enough in the course of the disease to prevent adverse outcomes and to guide and potentially reduce the intensity of the diuresis. Traditional methods for evaluating fluid status, such as pitting edema, pulmonary crackles, or chest radiography primarily assess extracellular fluid and do not accurately reflect intravascular volume status or venous congestion. This review explores the rationale, mechanism, and evidence behind more recent methods used to assess volume status, namely, lung ultrasound, inferior vena cava (IVC) ultrasound, venous excess ultrasound score, and basic and advanced cardiac echocardiographic techniques. These methods offer a more accurate and objective assessment of fluid status, providing real-time, non-invasive measures of intravascular volume and venous congestion. The methods we discuss are primarily used in inpatient settings, but, given the increased pervasiveness of ultrasound technology, some could soon expand to the outpatient setting.

Timing of invasive mechanical ventilation and death in critically ill adults with COVID-19: A multicenter cohort study.

PURPOSE: To investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality. MATERIALS AND METHODS: The data for this study were derived from a multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1-2) versus late (ICU days 3-7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model. RESULTS: Among the 1879 patients included in this analysis (1199 male [63.8%]; median age, 63 [IQR, 53-72] years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 [95% CI, 0.65-0.93]). CONCLUSIONS: In critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.

The fallacy of the BUN:creatinine ratio in critically ill patients.

BACKGROUND AND OBJECTIVES: Acute kidney injury (AKI) is common in critically ill patients and is associated with a high mortality rate. Pre-renal azotemia, suggested by a high blood urea nitrogen to serum creatinine (BUN:Cr) ratio (BCR), has traditionally been associated with a better prognosis than other forms of AKI. Whether this pertains to critically ill patients is unknown. METHODS: We conducted a retrospective observational study of two cohorts of critically ill patients admitted to a single center: a derivation cohort, in which AKI was diagnosed, and a larger validation cohort. We analyzed associations between BCR and clinical outcomes: mortality and renal replacement therapy (RRT). RESULTS: Patients in the derivation cohort (N = 1010) with BCR >20 were older, predominantly female and white, and more severely ill. A BCR >20 was significantly associated with increased mortality and a lower likelihood of RRT in all patients, patients with AKI and patients at risk for AKI. Patients in the validation cohort (N = 10 228) with a BCR >20 were older, predominantly female and white, and more severely ill. A BCR >20 was associated with increased mortality and a lower likelihood of RRT in all patients and in those at risk for AKI, BUN correlated with age and severity of illness. CONCLUSIONS: A BCR >20 is associated with increased mortality in critically ill patients. It is also associated with a lower likelihood of RRT, perhaps because of misinterpretation of the BCR. Clinicians should not use a BCR >20 to classify AKI in critically ill patients.

Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List.

Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.

ED Patient Experience: Does Day of the Week or Time of the Day Matter?

The effect of the arrival day of the week, arrival time of the day, or discharge time of the day on emergency department (ED) patient experience (PE) scores has not been well studied. We performed a retrospective analysis of ED patients between July 1st, 2018 through March 31st, 2021. We recorded demographics, PE scores, arrival day, arrival and discharge times, and total ED and perceived ED times. We performed univariate and multivariable analyses. We sent 49,849 surveys and received back 2423 that we included in our study. The responding patients' median age was 52, with a majority of female gender (62%) and white race (57%). The average arrival time was 1:40 PM, and the average discharge time 2:38 PM. The average total ED time was 261 minutes, while the average perceived ED time was 540 minutes. We found a statistical association between worse PE scores and longer actual ED time but not longer perceived time. A later arrival time was significantly associated with worse PE scores on 4 out of 6 domains of the PE questionnaire. The discharge time and the day of the week were not significantly associated with PE scores. Conclusion: Actual longer ED time was significantly associated with worse PE scores, but not perceived time. Later arrival time was associated with worse PE scores, but not later discharge time. The arrival day of the week was not statistically associated with differences in PE. Further studies are needed to confirm these findings.