Patient Satisfaction with Telehealth at an Academic Medical Center Primary Care Clinic.

Objective: To determine whether the quality of the patient experience differs between video visits and in-person visits for primary care. Methods: Using patient satisfaction survey results from patients who had visits with the internal medicine faculty primary care practice at a large urban academic hospital in New York City from 2018 to 2022, we compared results regarding satisfaction with the clinic, physician, and ease of access to care between patients who attended a video visit and those who attended an in-person appointment. Logistic regression analyses were performed to determine if there was a statistically significant difference in patient experience. Results: In total, 9,862 participants were included in analysis. Mean age of respondents attending in-person visits was 59.0; mean age of respondents attending telemedicine visits was 56.0. There was no statistically significant difference in scores between the in-person and telemedicine groups for likelihood of recommending the practice to others, quality of time spent with the doctor, and how well the clinical team explained care. Patient satisfaction was significantly higher in the telemedicine group compared with the in-person group for ability to get an appointment when needed (4.48 ± 1.00 vs. 4.34 ± 1.04, p < 0.001), how helpful and courteous the person who assisted them was (4.64 ± 0.83 vs. 4.61 ± 0.79, p = 0.009), and ease of reaching the office through phone (4.55 ± 0.97 vs. 4.46 ± 0.96, p < 0.001). Conclusions: This analysis demonstrated parity in patient satisfaction for traditional in-person visits and telemedicine visits in primary care.

Propensity score-matching analysis comparing safety outcomes of appetite-stimulating medications in oncology patients.

PURPOSE: Anorexia and weight loss are common complications in the elderly, advanced cancer population. Appetite stimulants are commonly used therapies for oncology patients with weight loss, yet their safety comparison remains unknown. METHODS: This was a two-center, retrospective, study conducted in New York City at Mount Sinai Beth Israel and New York University Langone from January 2016 to July 2019 in adult patients with histologic evidence of malignancy who were taking either megestrol acetate or mirtazapine as an appetite-stimulating medication. Endpoints included safety concerns of mortality, QTc prolongation, venous thromboembolism, fall, somnolence, xerostomia, and hallucinations. Effectiveness of weight gain or maintenance of weight was not assessed. A propensity score-matching analysis was performed using a logistic regression analysis to assess the two comparable groups. RESULTS: The study included 350 patients (69.56 ± 13.31 years) with the most common malignancies being gastrointestinal, breast, and hematologic with metastasis present in over half the patients. Adverse events were commonly seen in the oncology population. After a propensity score-matched analysis, all safety outcomes associated with mirtazapine compared to megestrol acetate were similar; all-cause mortality (7%, n = 7 vs. 12%, n = 12, p = 0.23), QTc prolongation (31%, n = 31 vs. 31%, n = 31, p = 1.00), thromboembolism (11%, n = 11 vs. 11%, n = 11, p = 1.00), somnolence (29%, n = 30 vs. 22%, n = 23, p = 0.34), xerostomia (27%, n = 28 vs. 18%, n = 19, p = 0.24), and hallucinations (17%, n = 18 vs. 8%, n = 8, p = 0.06), respectfully. CONCLUSION: There were no safety differences seen when evaluating both agents.

Network meta-analysis of anticoagulation strategies for venous thromboembolism in patients with cancer.

Cancer-associated thrombosis (CAT) is a common complication in patients with malignancy. Although direct oral anticoagulants (DOACs) have emerged as a treatment option for CAT, there have not been head-to-head comparisons of these agents. We searched MEDLINE and EMBASE from inception to April 2020 for studies comparing the effect of different long-term anticoagulation strategies for venous thromboembolism (VTE) in patients with cancer. We performed a network meta-analysis comparing the antithrombotic strategies in the selected studies using random-effects model. We identified a total of 20 studies [9 randomized control trials (RCTs) and 11 subgroup analyses from other unique RCTs] with total of 6699 patients for inclusion in our analysis. There was no significant difference in recurrent VTE, all-cause death, major bleeding and clinically relevant non-major bleeding among DOACs. When DOACs were combined, recurrent VTE was significantly decreased in DOACs compared to low-molecular weight heparin (LMWH) and Vitamin K antagonist (VKA) [RR (95% CI) 0.75 (0.59-0.94); RR (95% CI) 0.51 (0.39-0.66), respectively] without significant increase in major bleeding or clinically relevant non-major bleeding. In patients with CAT, there was no significant difference in recurrent thrombotic event among different DOACs. Bleeding risk was comparable among all anticoagulation strategies. When DOACs were combined, DOACs were associated with a significant decrease in recurrent VTE with comparable bleeding risk to LMWH and VKA.

A Case for Case Reports: How to Write One and Promote Mentorship, Scholarship and Faculty Development.

Introduction Case reports form the base layer of the evidence pyramid, describing new or emerging diseases, side effects to treatments, common presentations of rare diseases, or rare presentations of common diseases. An important scholarly pursuit, writing case reports can be hindered by lack of time, training, and mentorship. Here, we describe a workshop incorporating case writing skills with mentorship opportunities to engage faculty and learners. Methods We designed and implemented a virtual, synchronous workshop addressing knowledge and attitudes on case reports for trainees and academic faculty at distributed sites. Participants discussed the contributions of case reports to the medical literature, key features of successful cases, approaches to writing learning objectives, and how to develop interesting cases into dynamic case reports. Case reports were discussed as a way to mentor learners to disseminate interesting cases as a source of clinical experience and academic productivity. A retrospective pre-post survey was collected two months after the workshop to evaluate its utility. Results Fifteen out of 42 participants responded to the survey. As a result of the workshop, respondents noted improvement in confidence in identifying and writing case reports and identifying and working with mentors or mentees, regardless of level of training or specialty. At the follow-up, seven (47%) respondents had identified a case and 10 (67%) had identified a mentor/mentee to write a case report with. Discussion This workshop, successfully delivered virtually, demonstrates the utility of a brief educational intervention in improving participant confidence in identifying and writing case reports with mentorship.

"Insta Residency:" Characteristics of Engagement With an Internal Medicine Residency Program Instagram Account.

Background Traditionally, medical training programs have been viewed and ranked according to factors such as national prestige, research opportunities and productivity, faculty prominence, and alumni success. While these components are still instrumental in attracting high-level applicants, the rise of social media has encouraged applicants to look beyond the traditional media put forth by institutions and turn to sources such as program-specific, departmental, or institutional social media pages for more rapid updates. To date, little has been written on how to maximize residency program social media use to engage target audiences of current residents, current faculty, other physicians, and applicants. To better understand how certain types of content lead to increased engagement, we analyze the Instagram social media platform of the Mount Sinai Beth Israel Internal Medicine Residency Program to identify potential trends in interactions to ultimately enhance the resident experience and institutional standing. Methodology We reviewed 257 posts on our Instagram account and calculated engagement of each category relative to the post count based on a method we developed. We used Instagram analytics to better understand our account's reach. Results Posts highlighting social events had the highest engagement from the online community. Data also show that while the page is viewed by many people with the average medical student age, our page captures an even wider audience. Conclusions Instagram posts about the social element of our residency program generated statistically significant increased engagement. Institutions can use this strategy of focusing on the social aspects of the program to increase reputational scores within the medical and greater community.

Clinical Guideline Highlights for the Hospitalist: Secondary Fracture Prevention for Hospitalized Patients.

GUIDELINE TITLE: Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition RELEASE DATE: September 20, 2019 PRIOR VERSION: Not applicable DEVELOPER: American Society for Bone and Mineral Research Task Force and Multistakeholder Coalition FUNDING SOURCE: American Society for Bone and Mineral Research and the Center for Medical Technology Policy TARGET POPULATION: Adults 65 years or older with a hip or vertebral fracture. This review will focus on the core recommendations and their application in the practice of hospital medicine.

Hands down, COVID-19 will change medical practice.

Coronavirus disease 2019 (COVID-19) has challenged us to incorporate technology into engaging, interacting with, and caring for patients, using televisits and video conferencing in ways that have previously been resisted or derided.

Exploring Perspectives from Internal Medicine Clerkship Directors in the USA on Effective Narrative Evaluation: Results from the CDIM National Survey.

PURPOSE: Clinical performance evaluations play a critical role in determining medical school clerkship grades. This study aimed to provide clarification from clerkship directors in internal medicine on what constitutes an effective and informative narrative description of student performance. METHODS: In September 2016, the Clerkship Directors in Internal Medicine (CDIM) electronically administered its annual, voluntary, and confidential cross-sectional survey of its US membership. One section of the survey asked six questions regarding the helpful components of an effective narrative evaluation. Respondents were asked to rate the effectiveness of elements contained within narrative evaluations of students. RESULTS: Ninety-five CDIM members responded to the survey with an overall response rate of 74.2%. Descriptions of skills and behaviors were felt to be the most important, followed by a description of the overall synthetic or global assessment level of the student. Descriptions of personality and attitude were the next highest rated feature followed by adjectives describing performance. Length was felt to be the least important component. In free-text comments, several respondents indicated that direct observation of performance and specific examples of skills and behaviors are also desirable. CONCLUSIONS: Narrative evaluations of students that explicitly comment on skills, behaviors, and an overarching performance level of the learner are strongly preferred by clerkship directors. Direct observation of clinical performance and giving specific examples of such behaviors give evaluations even more importance. Faculty development on evaluation and assessment should include instruction on these narrative assessment characteristics.

Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Hemodialysis.

BACKGROUND: Patients on long-term dialysis are at increased risk of bleeding. Although oral anticoagulants (OACs) are recommended for atrial fibrillation (AF) to reduce the risk of stroke, randomized trials have excluded these populations. As such, the net clinical benefit of OACs among patients on dialysis is unknown. OBJECTIVES: This study aimed to investigate the efficacy and safety of OACs in patients with AF on long-term dialysis. METHODS: MEDLINE and EMBASE were searched through June 10, 2019, for studies that investigated the efficacy and safety of different OAC strategies in patients with AF on long-term dialysis. The efficacy outcomes were ischemic stroke and/or systemic thromboembolism, all-cause mortality, and the safety outcome was major bleeding. RESULTS: This study identified 16 eligible observational studies (N = 71,877) regarding patients on long-term dialysis who had AF. Only 2 of 16 studies investigated direct OACs. Outcomes for dabigatran and rivaroxaban were limited to major bleeding events. Compared with no anticoagulants, apixaban and warfarin were not associated with a significant decrease in stroke and/or systemic thromboembolism (apixaban 5 mg, hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.30 to 1.17; apixaban 2.5 mg, HR: 1.00; 95% CI: 0.52 to 1.93; warfarin, HR: 0.91; 95% CI: 0.72 to 1.16). Apixaban 5 mg was associated with a significantly lower risk of mortality (vs. warfarin, HR: 0.65; 95% CI: 0.45 to 0.93; vs. apixaban 2.5 mg, HR: 0.62; 95% CI: 0.42 to 0.90; vs. no anticoagulant, HR: 0.61; 95% CI: 0.41 to 0.90). Warfarin was associated with a significantly higher risk of major bleeding than apixaban 5 min/2.5 mg and no anticoagulant (vs. apixaban 5 mg, HR: 1.41; 95% CI: 1.07 to 1.88; vs. apixaban 2.5 mg, HR: 1.40; 95% CI: 1.07 to 1.82; vs. no anticoagulant, HR: 1.31; 95% CI: 1.15 to 1.50). Dabigatran and rivaroxaban were also associated with significantly higher risk of major bleeding than apixaban and no anticoagulant. CONCLUSIONS: This meta-analysis showed that OACs were not associated with a reduced risk of thromboembolism in patients with AF on long-term dialysis. Warfarin, dabigatran, and rivaroxaban were associated with significantly higher bleeding risk compared with apixaban and no anticoagulant. The benefit-to-risk ratio of OACs in patients with AF on long-term dialysis warrants validation in randomized clinical trials.

Systematic Review of the Association Between Worsening Renal Function and Mortality in Patients With Acute Decompensated Heart Failure.

INTRODUCTION: Outcomes in acute decompensated heart failure (ADHF) have remained poor. Worsening renal function (WRF) is common among patients with ADHF. However, the impact of WRF on the prognosis is controversial. We hypothesized that in patients with ADHF, the achievement of concomitant decongestion would diminish the signal for harm associated with WRF. METHODS: We performed a systematic search of PubMed, EMBASE, and the Cochrane Library up to December 2019 for studies that assessed signs of decongestion in patients with WRF during ADHF admission. The primary outcome was all-cause mortality and heart transplantation. RESULTS: Thirteen studies were selected with a pooled population of 8138 patients. During the follow-up period of 60-450 days, 19.2% of patients died. Unstratified, patients with WRF versus no WRF had a higher risk for mortality (odds ratio [OR], 1.71 [95% confidence interval {CI}, 1.45-2.01]; P < 0.0001). However, patients who achieved decongestion had a similar prognosis (OR, 1.15 [95% CI, 0.89-1.49]; P = 0.30). Moreover, patients with WRF who achieved decongestion had a better prognosis compared with those without WRF or decongestion (OR, 0.63 [95% CI, 0.46-0.86]; P = 0.004). This tendency persisted for the sensitivity analyses. CONCLUSIONS: Decongestion is a powerful effect modifier that attenuates harmful associations of WRF with mortality. Future studies should not assess WRF as an endpoint without concomitant assessment of achieved volume status.

Hospital Medicine Update: High-Impact Literature from March 2018 to April 2019.

To assist busy hospital medicine clinicians, we summarized 10 impactful articles from last year. The authors reviewed articles published between March 2018-April 2019 for the Hospital Medicine Updates at the Society of Hospital Medicine and the Society of General Internal Medicine Annual Meetings. The authors voted to select 10 of 30 presented articles based on quality and clinical impact for this summary. The key findings include: (1) Vancomycin or fidaxomicin are the first-line treatment for initial Clostridioides difficile infection; (2) Unnecessary supplemental oxygen is linked to increased mortality; aim for a target oxygen saturation of 90%-94% in most hospitalized patients; (3) Stigmatizing language in medical records impacts physician trainees' attitudes and pain management practices; (4) Consider ablation for atrial fibrillation in patients with heart failure; (5) Patients with opioid use disorder should be offered buprenorphine or methadone therapy; (6) Apixaban is safe and may be preferable over warfarin in patients with atrial fibrillation and end-stage kidney disease; (7) It is probably safe to discontinue antimethicillin-resistant Staphylococcus aureus (MRSA) coverage in patients with hospital-acquired pneumonia who are improving and have negative cultures; (8) Selected patients with left-sided endocarditis (excluding MRSA) may switch from intravenous (IV) to oral antibiotics if they are clinically stable after 10 days; (9) Oral antibiotics may be equivalent to IV antibiotics in patients with joint and soft tissue infections; (10) A history-electrocardiogram-age-risk factors-troponin (HEART) score ≥4 is a reliable threshold for determining the patients who are at risk for short-term major adverse cardiac events and may warrant further evaluation.

Update in Hospital Medicine: Practical Lessons from Current Literature.

BACKGROUND: Hospital medicine continues to grow in workforce, clinical scope, and academic inquiry. This article provides a summary of recent high-impact publications for busy clinicians who provide care to hospitalized adults. METHODS: Authors reviewed articles that were published between March 2017 and March 2018 for the Update in Hospital Medicine presentations at the 2018 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 29 articles presented were selected for this review based on quality and potential to influence practice. RESULTS: The following key insights were gained: (1) the perioperative continuation of aspirin in patients with previous percutaneous intervention is beneficial; (2) delaying hip fracture surgery beyond a 24-hour window increases complications; (3) oral antibiotics may be effective treatment for select bloodstream infections; (4) pulmonary embolism may not be as common a cause of syncope as previously suggested; (5) balanced intravenous fluids and normal saline are similar with respect to hospital-free days but a difference exists in renal events at 30 days favoring balanced crystalloids; (6) speaker introductions may reveal gender bias in academic medicine; (7) edoxaban is a reasonable choice for the treatment of venous thromboembolism in cancer; (8) high-flow nasal cannula reduces the need for intubation in respiratory failure when compared with usual oxygen therapy and noninvasive positive pressure ventilation; and (9) diagnostic errors in spinal epidural abscess lead to delays and morbidity. CONCLUSIONS: This research provides insight into how we can approach common medical problems in the care of hospitalized adults. The selected works have the potential to change or confirm current practices.

Prevalence of fatigue among postgraduate trainees in the United States and Japan.

BACKGROUND: The difference in prevalence of fatigue among postgraduate trainees between the United States and Japan is unknown. METHODS: A cross-sectional survey using Iowa Fatigue Scale was administered on postgraduate trainees in two internal medicine residency programs in New York and five postgraduate residency programs in Japan. RESULTS: Of the 393 trainees, 135 (34%) completed the survey. Seventy-seven (57%) were US trainees. Both fatigue (42% vs 81%) and severe fatigue (4% vs 19%) were more prevalent in Japan (P < .01). US trainees felt more productive during work hours but less fatigued. CONCLUSIONS: Fatigue was more prevalent among postgraduate trainees in Japan.

Update in Hospital Medicine: Practical Lessons from the Literature.

BACKGROUND: Hospital Medicine has a widening scope of practice. This article provides a summary of recent highimpact publications for busy clinicians who provide care to hospitalized adults. METHODS: The authors reviewed articles published between March 2016 and March 2017 for the Update in Hospital Medicine presentations at the 2017 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 20 articles presented were selected for this review based on the article quality and potential to influence practice. RESULTS: The key insights gained include: pulmonary embolism may be a more common cause of syncope and acute exacerbation of COPD than previously recognized; nonthoracic low-tesla MRI is safe following a specific protocol for patients with cardiac devices implanted after 2001; routine inpatient blood cultures for fever are of a low yield with a false positive rate similar to the true positive rate; chronic opioid use after surgery occurs more frequently than in the general population; high-sensitivity troponin and a negative ECG performed 3 hours after an episode of chest pain can rule out acute myocardial infarction; sitting at patients' bedsides enhances patients' perception of provider communication; 5 days of antibiotics for community-acquired pneumonia is equivalent to longer courses; oral proton pump inhibitors (PPI) are as effective as IV PPIs after an esophagogastroduodenoscopy (EGD) for the treatment of bleeding peptic ulcers. CONCLUSIONS: Recent research provides insight into how we approach common medical problems in the care of hospitalized adults. These articles have the potential to change or confirm current practices.

Characterizing Hospitalist Practice and Perceptions of Critical Care Delivery.

BACKGROUND: Intensivist shortages have led to increasing hospitalist involvement in critical care delivery. OBJECTIVE: To characterize the practice of hospitalists practicing in the intensive care unit (ICU) setting. DESIGN: Survey of hospital medicine physicians. SETTING: This survey was conducted as a needs assessment for the ongoing efforts of the Critical Care Task Force of the Society of Hospital Medicine Education Committee. PARTICIPANTS: Hospitalists in the United States. INTERVENTION: An iteratively developed, 25-item, webbased survey. MEASUREMENTS: Results were compiled from all respondents then analyzed in subgroups. Various items were examined for correlations. RESULTS: A total of 425 hospitalists completed the survey. Three hundred and twenty-five (77%) provided critical care services, and 280 (66%) served as primary physicians in the ICU. Hospitalists were significantly more likely to serve as primary physicians in rural ICUs (85% of rural respondents vs 62% of nonrural; P < .001 for association). Half of the rural hospitalists who were primary physicians for ICU patients felt obliged to practice beyond their scope, and 90% at least occasionally perceived that they had insufficient support from board-certified intensivists. Among respondents serving as primary physicians for ICU patients, 67% reported at least moderate difficulty transferring patients to higher levels of ICU care. Difficulty transferring patients was the only item significantly correlated with the perception of being expected to practice beyond one's scope (P < .05 for association). CONCLUSIONS: Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals. Without major changes in intensivist staffi ng or patient distribution, this is unlikely to change.