Effect of Ward-Based High-Flow Nasal Cannula (HFNC) Oxygen Therapy on Critical Care Utilization During the COVID-19 Pandemic: A Retrospective Cohort Analysis.

BACKGROUND: Hospitals expanded critical care capacity during the COVID-19 pandemic by treating COVID-19 patients with high-flow nasal cannula oxygen therapy (HFNC) in non-traditional settings, including general internal medicine (GIM) wards. The impact of this practice on intensive care unit (ICU) capacity is unknown. OBJECTIVE: To describe how our hospital operationalized the use of HFNC on GIM wards, assess its impact on ICU capacity, and examine the characteristics and outcomes of treated patients. DESIGN: Retrospective cohort study of all patients treated with HFNC on GIM wards at a Canadian tertiary care hospital. PARTICIPANTS: All patients admitted with COVID-19 and treated with HFNC on GIM wards from December 28, 2020, to June 13, 2021, were included. MAIN MEASURES: We combined administrative data on critical care occupancy daily with chart-abstracted data for included patients to establish the total number of patients receiving ICU-level care at our hospital per day. We also collected data on demographics, medical comorbidities, illness severity, COVID-19 treatments, HFNC care processes, and patient outcomes. KEY RESULTS: We treated 124 patients with HFNC on the GIM wards (median age 66 years; 48% female). Patients were treated with HFNC for a median of 5 days (IQR 3 to 8); collectively, they received HFNC for a total of 740 hospital days, 71% of which were on GIM wards. At peak ICU capacity strain (144%), delivering HFNC on GIM wards added 20% to overall ICU capacity by managing up to 14 patients per day. Patients required a median maximal fraction of inspired oxygen of 80% (IQR 60 to 95). There were 18 deaths (15%) and 85 patients (69%) required critical care admission; of those, 40 (47%) required mechanical ventilation. CONCLUSIONS: With appropriate training and resources, treatment of COVID-19 patients with HFNC on GIM wards appears to be a feasible strategy to increase critical care capacity.

Physician antimicrobial prescribing and patient outcomes on general medical wards: a multicentre retrospective cohort study.

BACKGROUND: Variability in antimicrobial prescribing may indicate an opportunity for improvement in antimicrobial use. We sought to measure physician-level antimicrobial prescribing in adult general medical wards, assess the contribution of patient-level factors to antimicrobial prescribing and evaluate the association between antimicrobial prescribing and clinical outcomes. METHODS: Using the General Medicine Inpatient Initiative (GEMINI) database, we conducted a retrospective cohort study of physician-level volume and spectrum of antimicrobial prescribing in adult general medical wards in 4 academic teaching hospitals in Toronto, Ontario, between April 2010 and December 2019. We stratified physicians into quartiles by hospital site based on volume of antimicrobial prescribing (days of therapy per 100 patient-days and antimicrobial-free days) and antibacterial spectrum (modified spectrum score). The modified spectrum score assigns a value to each antibacterial agent based on the breadth of coverage. We assessed patient-level differences among physician quartiles using age, sex, Laboratory-based Acute Physiology Score, discharge diagnosis and Charlson Comorbidity Index. We evaluated the association of clinical outcomes (in-hospital 30-day mortality, length of stay, intensive care unit [ICU] transfer and hospital readmission) with antimicrobial volume and spectrum using multilevel modelling. RESULTS: The cohort consisted of 124 physicians responsible for 124 158 hospital admissions. The median physician-level volume of antimicrobial prescribing was 56.1 (interquartile range 51.7-67.5) days of therapy per 100 patient-days. We did not find any differences in baseline patient characteristics by physician prescribing quartile. The difference in mean prescribing between quartile 4 and quartile 1 was 15.8 days of therapy per 100 patient-days (95% confidence interval [CI] 9.6-22.0), representing 30% higher antimicrobial prescribing in the fourth quartile than the first quartile. Patient in-hospital deaths, length of stay, ICU transfer and hospital readmission did not differ by physician quartile. In-hospital mortality was higher among patients cared for by prescribers with higher modified spectrum scores (odds ratio 1.13, 95% CI 1.04-1.24). INTERPRETATION: We found that physician-level variability in antimicrobial prescribing was not associated with differences in patient characteristics or outcomes in academic general medicine wards. These findings provide support for considering the lowest quartile of physician antimicrobial prescribing within each hospital as a target for antimicrobial stewardship.

Outcomes in patients with and without disability admitted to hospital with COVID-19: a retrospective cohort study.

BACKGROUND: Disability-related considerations have largely been absent from the COVID-19 response, despite evidence that people with disabilities are at elevated risk for acquiring COVID-19. We evaluated clinical outcomes in patients who were admitted to hospital with COVID-19 with a disability compared with patients without a disability. METHODS: We conducted a retrospective cohort study that included adults with COVID-19 who were admitted to hospital and discharged between Jan. 1, 2020, and Nov. 30, 2020, at 7 hospitals in Ontario, Canada. We compared in-hospital death, admission to the intensive care unit (ICU), hospital length of stay and unplanned 30-day readmission among patients with and without a physical disability, hearing or vision impairment, traumatic brain injury, or intellectual or developmental disability, overall and stratified by age (≤ 64 and ≥ 65 yr) using multivariable regression, controlling for sex, residence in a long-term care facility and comorbidity. RESULTS: Among 1279 admissions to hospital for COVID-19, 22.3% had a disability. We found that patients with a disability were more likely to die than those without a disability (28.1% v. 17.6%), had longer hospital stays (median 13.9 v. 7.8 d) and more readmissions (17.6% v. 7.9%), but had lower ICU admission rates (22.5% v. 28.3%). After adjustment, there were no statistically significant differences between those with and without disabilities for in-hospital death or admission to ICU. After adjustment, patients with a disability had longer hospital stays (rate ratio 1.36, 95% confidence interval [CI] 1.19-1.56) and greater risk of readmission (relative risk 1.77, 95% CI 1.14-2.75). In age-stratified analyses, we observed longer hospital stays among patients with a disability than in those without, in both younger and older subgroups; readmission risk was driven by younger patients with a disability. INTERPRETATION: Patients with a disability who were admitted to hospital with COVID-19 had longer stays and elevated readmission risk than those without disabilities. Disability-related needs should be addressed to support these patients in hospital and after discharge.

Characteristics and outcomes of hospital admissions for COVID-19 and influenza in the Toronto area.

BACKGROUND: Patient characteristics, clinical care, resource use and outcomes associated with admission to hospital for coronavirus disease 2019 (COVID-19) in Canada are not well described. METHODS: We described all adults with COVID-19 or influenza discharged from inpatient medical services and medical-surgical intensive care units (ICUs) between Nov. 1, 2019, and June 30, 2020, at 7 hospitals in Toronto and Mississauga, Ontario. We compared patient outcomes using multivariable regression models, controlling for patient sociodemographic factors and comorbidity level. We validated the accuracy of 7 externally developed risk scores to predict mortality among patients with COVID-19. RESULTS: There were 1027 hospital admissions with COVID-19 (median age 65 yr, 59.1% male) and 783 with influenza (median age 68 yr, 50.8% male). Patients younger than 50 years accounted for 21.2% of all admissions for COVID-19 and 24.0% of ICU admissions. Compared with influenza, patients with COVID-19 had significantly greater in-hospital mortality (unadjusted 19.9% v. 6.1%, adjusted relative risk [RR] 3.46, 95% confidence interval [CI] 2.56-4.68), ICU use (unadjusted 26.4% v. 18.0%, adjusted RR 1.50, 95% CI 1.25-1.80) and hospital length of stay (unadjusted median 8.7 d v. 4.8 d, adjusted rate ratio 1.45, 95% CI 1.25-1.69). Thirty-day readmission was not significantly different (unadjusted 9.3% v. 9.6%, adjusted RR 0.98, 95% CI 0.70-1.39). Three points-based risk scores for predicting in-hospital mortality showed good discrimination (area under the receiver operating characteristic curve [AUC] ranging from 0.72 to 0.81) and calibration. INTERPRETATION: During the first wave of the pandemic, admission to hospital for COVID-19 was associated with significantly greater mortality, ICU use and hospital length of stay than influenza. Simple risk scores can predict in-hospital mortality in patients with COVID-19 with good accuracy.

Value of routine echocardiography in the management of stroke.

BACKGROUND: Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention. METHODS: We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada. Clinically actionable echocardiographic findings for secondary stroke prevention included cardiac thrombus, patent foramen ovale, atrial myxoma or valvular vegetation. We identified patient characteristics associated with clinically actionable findings using logistic regression. RESULTS: Of the 1862 patients with stroke or TIA we identified, 1272 (68%) had at least 1 echocardiogram. Nearly all echocardiograms were transthoracic; 1097 (86%) were normal, 1 (0.08%) had an atrial myxoma, 2 (0.2%) had a valvular vegetation, 11 (0.9%) had a cardiac thrombus and 66 (5.2%) had a PFO. Patent foramen ovale was less likely among patients older than 60 years (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.20-0.57), with prior stroke or TIA (adjusted OR 0.31, 95% CI 0.09-0.76) or with dyslipidemia (adjusted OR 0.39, 95% CI 0.15-0.84). Among the 130 patients with cryptogenic stroke who had an echocardiogram (n = 110), a PFO was detected in 19 (17%) on transthoracic echocardiogram. INTERPRETATION: Most patients with stroke or TIA had a normal echocardiogram, with few having clinically actionable findings for secondary stroke prevention. Clinically actionable findings, specifically PFO, were more common in patients with cryptogenic stroke.

Prevalence and Costs of Discharge Diagnoses in Inpatient General Internal Medicine: a Multi-center Cross-sectional Study.

BACKGROUND: Understanding the most common and costly conditions treated by inpatient general medical services is important for implementing quality improvement, developing health policy, conducting research, and designing medical education. OBJECTIVE: To determine the prevalence and cost of conditions treated on general internal medicine (GIM) inpatient services. DESIGN: Retrospective cross-sectional study involving 7 hospital sites in Toronto, Canada. PARTICIPANTS: All patients discharged between April 1, 2010 and March 31, 2015 who were admitted to or discharged from an inpatient GIM service. MAIN MEASURES: Hospital administrative data were used to identify diagnoses and costs associated with admissions. The primary discharge diagnosis was identified for each admission and categorized into clinically relevant and mutually exclusive categories using the Clinical Classifications Software (CCS) tool. KEY RESULTS: Among 148,442 admissions, the most common primary discharge diagnoses were heart failure (5.1%), pneumonia (5.0%), urinary tract infection (4.6%), chronic obstructive pulmonary disease (4.5%), and stroke (4.4%). The prevalence of the 20 most common conditions was significantly correlated across hospitals (correlation coefficients ranging from 0.55 to 0.95, p ≤ 0.01 for all comparisons). No single condition represented more than 5.1% of all admissions or more than 7.9% of admissions at any hospital site. The costliest conditions were stroke (median cost $7122, interquartile range 5587-12,354, total cost $94,199,422, representing 6.0% of all costs) and the group of delirium, dementia, and cognitive disorders (median cost $12,831, IQR 9539-17,509, total cost $77,372,541, representing 4.9% of all costs). The 10 most common conditions accounted for only 36.2% of hospitalizations and 36.8% of total costs. The remaining hospitalizations included 223 different CCS conditions. CONCLUSIONS: GIM services care for a markedly heterogeneous population but the most common conditions were similar across 7 hospitals. The diversity of conditions cared for in GIM may be challenging for healthcare delivery and quality improvement. Initiatives that cut across individual diseases to address processes of care, patient experience, and functional outcomes may be more relevant to a greater proportion of the GIM population than disease-specific efforts.

Communicating wisely: teaching residents to communicate effectively with patients and caregivers about unnecessary tests.

BACKGROUND: With rising healthcare costs and a focus on quality, there is a growing need to promote resource stewardship in medical education. Physicians need to be able to communicate effectively with patients/caregivers seeking tests and treatments that are unnecessary. This study aimed to evaluate the impact of an interactive workshop on residents' knowledge of resource stewardship and communication skills when counseling patients/caregivers about requests for unnecessary testing. METHODS: Participants were 83 Internal Medicine and Pediatrics residents at the University of Toronto in 2014-15. The evaluation compared resource stewardship knowledge and communication skills of 57 (69%) residents that attended the resource stewardship workshop to 26 residents (31%) who did not. Knowledge and communication skills assessment consisted of a written test and a structured assessment using standardized patient raters, respectively. A linear regression was applied to determine predictors of overall communication skills performance. RESULTS: Workshop attendance resulted in better performance on the knowledge test (4.3 ± 1.9 vs. 3.1 ± 1.7 out of 8, p = 0.01), but not better performance on the communication skills assessment (4.1 ± 0.8 vs. 4.0 ± 0.9 out of 5, p = 0.56). Higher training level (p = 0.01) and knowledge test scores (p = 0.046) were independent predictors of better overall communication skills, after adjusting for gender, training level, workshop attendance, knowledge and self-reported prior feedback on communication skills. CONCLUSIONS: An interactive workshop can improve knowledge of resource stewardship, but improving communication skills with patients/caregivers about unnecessary testing may require additional training or reinforcement in the clinical learning environment. These teaching and assessment approaches can support the integration of education on resource stewardship into medical education.

Caractéristiques et issues des hospitalisations pour les cas de COVID-19 et d'influenza dans la région de Toronto.

CONTEXTE: Les caractéristiques des patients, les soins cliniques, l'utilisation des ressources et les issues cliniques des personnes atteintes de la maladie à coronavirus 2019 (COVID-19) hospitalisées au Canada ne sont pas bien connus. MÉTHODES: Nous avons recueilli des données sur tous les adultes hospitalisés atteints de la COVID-19 ou de l'influenza ayant obtenu leur congé d'unités médicales ou d'unités de soins intensifs médicaux et chirurgicaux entre le 1er novembre 2019 et le 30 juin 2020 dans 7 centres hospitaliers de Toronto et de Mississauga (Ontario). Nous avons comparé les issues cliniques des patients à l'aide de modèles de régression multivariée, en tenant compte des facteurs sociodémographiques et de l'intensité des comorbidités. Nous avons validé le degré d'exactitude de 7 scores de risque mis au point à l'externe pour déterminer leur capacité à prédire le risque de décès chez les patients atteints de la COVID-19. RÉSULTATS: Parmi les hospitalisations retenues, 1027 patients étaient atteints de la COVID-19 (âge médian de 65 ans, 59,1 % d'hommes) et 783 étaient atteints de l'influenza (âge médian de 68 ans, 50,8 % d'hommes). Les patients âgés de moins de 50 ans comptaient pour 21,2 % de toutes les hospitalisations dues à la COVID-19 et 24,0 % des séjours aux soins intensifs. Comparativement aux patients atteints de l'influenza, les patients atteints de la COVID-19 présentaient un taux de mortalité perhospitalière (mortalité non ajustée 19,9 % c. 6,1 %; risque relatif [RR] ajusté 3,46 %, intervalle de confiance [IC] à 95 % 2,56­4,68) et un taux d'utilisation des ressources des unités de soins intensifs (taux non ajusté 26,4 % c. 18,0 %; RR ajusté 1,50, IC à 95 % 1,25­1,80) significativement plus élevés, ainsi qu'une durée d'hospitalisation (durée médiane non ajustée 8,7 jours c. 4,8 jours; rapport des taux d'incidence ajusté 1,45; IC à 95 % 1,25­1,69) significativement plus longue. Le taux de réhospitalisation dans les 30 jours n'était pas significativement différent (taux non ajusté 9,3 % c. 9,6 %; RR ajusté 0,98 %, IC à 95 % 0,70­1,39). Trois scores de risque utilisant un pointage pour prédire la mortalité perhospitalière ont montré une bonne discrimination (aire sous la courbe [ASC] de la fonction d'efficacité du récepteur [ROC] 0,72­0,81) et une bonne calibration. INTERPRÉTATION: Durant la première vague de la pandémie, l'hospitalisation des patients atteints de la COVID-19 était associée à des taux de mortalité et d'utilisation des ressources des unités de soins intensifs et à une durée d'hospitalisation significativement plus importants que les hospitalisations des patients atteints de l'influenza. De simples scores de risque peuvent prédire avec une bonne exactitude le risque de mortalité perhospitalière des patients atteints de la COVID-19.

Design and methods of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen SignificantlY) study: An investigator-blinded randomized controlled trial of education and feedback intervention to reduce inappropriate echocardiograms.

BACKGROUND: Appropriate use criteria (AUC) for transthoracic echocardiography (TTE) were developed to address concerns regarding inappropriate use of TTE. A previous pilot study suggests that an educational and feedback intervention can reduce inappropriate TTEs ordered by physicians in training. It is unknown if this type of intervention will be effective when targeted at attending level physicians in a variety of clinical settings. AIMS: The aim of this international, multicenter study is to evaluate the hypothesis that an AUC-based educational and feedback intervention will reduce the proportion of inappropriate echocardiograms ordered by attending physicians in the ambulatory environment. METHODS: In an ongoing multicentered, investigator-blinded, randomized controlled trial across Canada and the United States, cardiologists and primary care physicians practicing in the ambulatory setting will be enrolled. The intervention arm will receive (1) a lecture outlining the AUC and most recent available evidence highlighting appropriate use of TTE, (2) access to the American Society of Echocardiography mobile phone app, and (3) individualized feedback reports e-mailed monthly summarizing TTE ordering behavior including information on inappropriate TTEs and brief explanations of the inappropriate designation. The control group will receive no education on TTE appropriate use and order TTEs as usual practice. CONCLUSIONS: The Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly in an education RCT) study is the first multicenter randomized trial of an AUC-based educational intervention. The study will examine whether an education and feedback intervention will reduce the rate of outpatient inappropriate TTEs ordered by attending level cardiologists and primary care physicians (www.clinicaltrials.gov identifier NCT02038101).

A simple electronic medical record-based predictors of illness severity in sepsis (sepsis) score.

OBJECTIVE: Current scores for predicting sepsis outcomes are limited by generalizability, complexity, and electronic medical record (EMR) integration. Here, we validate a simple EMR-based score for sepsis outcomes in a large multi-centre cohort. DESIGN: A simple electronic medical record-based predictor of illness severity in sepsis (SEPSIS) score was developed (4 additive lab-based predictors) using a population-based retrospective cohort study. SETTING: Internal medicine services across four academic teaching hospitals in Toronto, Canada from April 2010-March 2015 (primary cohort) and 2015-2019 (secondary cohort). PATIENTS: We identified patients admitted with sepsis based upon receipt of antibiotics and positive cultures. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital mortality and secondary outcomes were ICU admission at 72 hours, and hospital length of stay (LOS). We calculated the area under the receiver operating curve (AUROC) for the SEPSIS score, qSOFA, and NEWS2. We then evaluated the SEPSIS score in a secondary cohort (2015-2019) of hospitalized patients receiving antibiotics. Our primary cohort included 1,890 patients with a median age of 72 years (IQR: 56-83). 9% died during hospitalization, 18.6% were admitted to ICU, and mean LOS was 12.7 days (SD: 21.5). In the primary and secondary (2015-2019, 4811 patients) cohorts, the AUROCs of the SEPSIS score for predicting in-hospital mortality were 0.63 and 0.64 respectively, which were similar to NEWS2 (0.62 and 0.67) and qSOFA (0.62 and 0.68). AUROCs for predicting ICU admission at 72 hours, and length of stay > 14 days, were similar between scores, in the primary and secondary cohorts. All scores had comparable calibration for predicting mortality. CONCLUSIONS: An EMR-based SEPSIS score shows a similar ability to predict important clinical outcomes compared with other validated scores (qSOFA and NEWS2). Because of the SEPSIS score's simplicity, it may prove a useful tool for clinical and research applications.

Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study.

BACKGROUND: Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors. METHODS: We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more. RESULTS: We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit. INTERPRETATION: Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.

COVID-19 vaccine uptake among healthcare workers: an achievable quality improvement target.

There is a need to optimize SARS-CoV-2 vaccination rates amongst healthcare workers (HCWs) to protect staff and patients from healthcare-associated COVID-19 infection. During the COVID-19 pandemic, many organizations implemented vaccine mandates for HCWs. Whether or not a traditional quality improvement approach can achieve high-rates of COVID-19 vaccination is not known. Our organization undertook iterative changes that focused on the barriers to vaccine uptake. These barriers were identified through huddles, and addressed through extensive peer outreach, with a focus on access and issues related to equity, diversity and inclusion. The outreach interventions were informed by real-time data on COVID-19 vaccine uptake in our organization. The vaccine rate reached 92.3% by 6 December 2021 with minimal differences in vaccine uptake by professional role, clinical department, facility or whether the staff had a patient facing role. Improving vaccine uptake should be a quality improvement target in healthcare organizations and our experience shows that high vaccine rates are achievable through concerted efforts targeting specific barriers to vaccine confidence.

Imaging delays among medical inpatients in Toronto, Ontario: A cohort study.

BACKGROUND: Imaging procedures are commonly performed on hospitalized patients and waiting for these could increase length-of-stay. The study objective was to quantify delays for imaging procedures in General Internal Medicine and identify contributing patient, physician, and system factors. METHODS: This was a retrospective cohort study of medical inpatients admitted to 5 hospitals in Toronto, Ontario (2010-2019), with at least one imaging procedure (CT, MRI, ultrasound, or peripherally-inserted central catheter [PICC] insertion). The primary outcome was time-to-test, and the secondary outcome was acute length-of-stay after test ordering. RESULTS: The study cohort included 73,107 hospitalizations. Time-to-test was longest for MRI (median 22 hours) and shortest for CT (median 7 hours). The greatest contributors to time-to-test were system factors such as hospital site (up to 22 additional hours), location of test ordering (up to 10 additional hours), the timing of test ordering relative to admission (up to 13 additional hours), and ordering during weekends (up to 21 additional hours). Older patient age, having more comorbidities, and residence in a low-income neighborhood were also associated with testing delays. Each additional hour spent waiting for a test was associated with increased acute length-of-stay after test ordering, ranging from 0.4 additional hours for CT to 1.2 hours for MRI. CONCLUSIONS: The greatest contributors to testing delays relate to when and where a test was ordered. Wait times affect length-of-stay and the quality of patient care. Hospitals can apply our novel approach to explore opportunities to decrease testing delays locally.

Using the Hospital Frailty Risk Score to assess mortality risk in older medical patients admitted to the intensive care unit.

BACKGROUND: Prognostic information at the time of hospital discharge can help guide goals-of-care discussions for future care. We sought to assess the association between the Hospital Frailty Risk Score (HFRS), which may highlight patients' risk of adverse outcomes at the time of hospital discharge, and in-hospital death among patients admitted to the intensive care unit (ICU) within 12 months of a previous hospital discharge. METHODS: We conducted a multicentre retrospective cohort study that included patients aged 75 years or older admitted at least twice over a 12-month period to the general medicine service at 7 academic centres and large community-based teaching hospitals in Toronto and Mississauga, Ontario, Canada, from Apr. 1, 2010, to Dec. 31, 2019. The HFRS (categorized as low, moderate or high frailty risk) was calculated at the time of discharge from the first hospital admission. Outcomes included ICU admission and death during the second hospital admission. RESULTS: The cohort included 22 178 patients, of whom 1767 (8.0%) were categorized as having high frailty risk, 9464 (42.7%) as having moderate frailty risk, and 10 947 (49.4%) as having low frailty risk. One hundred patients (5.7%) with high frailty risk were admitted to the ICU, compared to 566 (6.0%) of those with moderate risk and 790 (7.2%) of those with low risk. After adjustment for age, sex, hospital, day of admission, time of admission and Laboratory-based Acute Physiology Score, the odds of ICU admission were not significantly different for patients with high (adjusted odds ratio [OR] 0.99, 95% confidence interval [CI] 0.78 to 1.23) or moderate (adjusted OR 0.97, 95% CI 0.86 to 1.09) frailty risk compared to those with low frailty risk. Among patients admitted to the ICU, 75 (75.0%) of those with high frailty risk died, compared to 317 (56.0%) of those with moderate risk and 416 (52.7%) of those with low risk. After multivariable adjustment, the risk of death after ICU admission was higher for patients with high frailty risk than for those with low frailty risk (adjusted OR 2.86, 95% CI 1.77 to 4.77). INTERPRETATION: Among patients readmitted to hospital within 12 months, patients with high frailty risk were similarly likely as those with lower frailty risk to be admitted to the ICU but were more likely to die if admitted to ICU. The HFRS at hospital discharge can inform prognosis, which can help guide discussions for preferences for ICU care during future hospital stays.

Analysis of Resident and Attending Physician End-of-Rotation Changeover Days and Association With Patient Length of Stay.

Importance: End-of-rotation resident physician changeover is a key part of postgraduate training but could lead to discontinuity in patient care. Objective: To test whether patients exposed to end-of-rotation resident changeover have longer hospital stays and whether this association is mitigated by separating resident and attending changeover days. Design, Setting, and Participants: This retrospective cohort analysis included adult patients admitted to general internal medicine. The changeover day was the same day (first Monday of month) for both resident and attending physicians until June 30, 2013 (preseparation period), and then intentionally staggered by 1 or more days after July 1, 2013 (postseparation period). This was a multicenter analysis at 4 teaching hospitals in Ontario, Canada, from July 1, 2010, to June 30, 2019. Data analysis was conducted from July 2022 to January 2023. Exposures: Patients were classified as changeover patients if the first Monday was a resident changeover day and as control patients if the first Monday was not a resident changeover day. Main Outcomes and Measures: The primary outcome was length of hospital stay. Secondary outcomes were transfer to critical care, in-hospital death, and rate of discharge per 100 patients on the index day. Results: Of 95 282 patients. 22 773 (24%; mean [SD] age, 67.8 [18.8] years; 11 156 [49%] female patients) were exposed to resident changeover, and 72 509 (76%; mean [SD] age, 67.8 [18.7] years; 35 293 [49%] female patients) were not exposed to resident changeover. Exposure to resident changeover day was associated with a slightly longer hospital stay compared with control days (0.20 [95% CI, 0.09-0.30] days; P < .001) and decreased relative risk of patient discharge on the index day (relative risk, 0.92; 95% CI, 0.86-1.00; P = .047). These associations were similar in the preseparation and postseparation periods. Resident changeover was not associated with an increased risk of transfer to critical care or in-hospital death. Conclusions and Relevance: In this study, a small positive association between exposure to resident physician changeover and length of hospital stay as well as reduced rate of discharge was found. These findings suggest that separating changeover days for resident and attending physicians may not significantly change these associations.

Osmotic Demyelination Syndrome in Patients Hospitalized with Hyponatremia.

BACKGROUND: Osmotic demyelination syndrome (ODS) is a rare but potentially devastating neurologic complication of hyponatremia. The primary objective of this study was to identify the proportion of patients who developed ODS in a large, contemporary, multicenter cohort of patients admitted to the hospital with hyponatremia. METHODS: We conducted a multicenter cohort study of patients admitted with hyponatremia at five academic hospitals in Toronto, Ontario, Canada, between April 1, 2010, and December 31, 2020. All adult patients presenting with hyponatremia (serum sodium level 8 mmol/l in any 24-hour period). RESULTS: Our cohort included 22,858 hospitalizations with hyponatremia. Approximately 50% were women, the average age was 68 years, and mean initial serum sodium was 125 mmol/l (standard deviation, 4.6), including 11.9% with serum sodium from 110 to 119 mmol/l and 1.2% with serum sodium less than 110 mmol/l. Overall, rapid correction of serum sodium occurred in 3632 (17.7%) admissions. Twelve patients developed ODS (0.05%). Seven (58%) patients who developed ODS did not have rapid correction of serum sodium. CONCLUSIONS: In this large multicenter study of patients with hyponatremia, rapid correction of serum sodium was common (n=3632 [17.7%]), but ODS was rare (n=12 [0.05%]). Future studies with a higher number of patients with ODS are needed to better understand potential causal factors for ODS.

Identifying clusters of coexisting conditions and outcomes among adults admitted to hospital with community-acquired pneumonia: a multicentre cohort study.

BACKGROUND: Little is known about patterns of coexisting conditions and their influence on clinical care or outcomes in adults admitted to hospital for community-acquired pneumonia (CAP). We sought to evaluate how coexisting conditions cluster in this population to advance understanding of how multimorbidity affects CAP. METHODS: We studied 11 085 adults admitted to hospital with CAP at 7 hospitals in Ontario, Canada. Using cluster analysis, we identified patient subgroups based on clustering of comorbidities in the Charlson Comorbidity Index. We derived and replicated cluster analyses in independent cohorts (derivation sample 2010-2015, replication sample 2015-2017), then combined these into a total cohort for final cluster analyses. We described differences in medications, imaging and outcomes. RESULTS: Patients clustered into 7 subgroups. The low comorbidity subgroup (n = 3052, 27.5%) had no comorbidities. The DM-HF-Pulm subgroup had prevalent diabetes, heart failure and chronic lung disease (n = 1710, 15.4%). One disease category defined each remaining subgroup, as follows: pulmonary (n = 1621, 14.6%), diabetes (n = 1281, 11.6%), heart failure (n = 1370, 12.4%), dementia (n = 1038, 9.4%) and cancer (n = 1013, 9.1%). Corticosteroid use ranged from 11.5% to 64.9% in the dementia and pulmonary subgroups, respectively. Piperacillin-tazobactam use ranged from 9.1% to 28.0% in the pulmonary and cancer subgroups, respectively. The use of thoracic computed tomography ranged from 5.7% to 36.3% in the dementia and cancer subgroups, respectively. Adjusting for patient factors, the risk of in-hospital death was greater in the cancer (adjusted odds ratio [OR] 3.12, 95% confidence interval [CI] 2.44-3.99), dementia (adjusted OR 1.57, 95% CI 1.05-2.35), heart failure (adjusted OR 1.66, 95% CI 1.35-2.03) and DM-HF-Pulm subgroups (adjusted OR 1.35, 95% CI 1.12-1.61), and lower in the diabetes subgroup (adjusted OR 0.67, 95% CI 0.50-0.89), compared with the low comorbidity group. INTERPRETATION: Patients admitted to hospital with CAP cluster into clinically recognizable subgroups based on coexisting conditions. Clinical care and outcomes vary among these subgroups with little evidence to guide decision-making, highlighting opportunities for research to personalize care.

Data-driven approach to identifying potential laboratory overuse in general internal medicine (GIM) inpatients.

BACKGROUND: Reducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge. OBJECTIVE: To develop a simple, data-driven approach to identify potential sources of laboratory overuse by combining the total cost, proportion of abnormal results and physician-level variation in use of laboratory tests. DESIGN, SETTING AND PARTICIPANTS: A multicentre, retrospective study at three academic hospitals in Toronto, Canada. All general internal medicine (GIM) hospitalisations between 1 April 2010 and 31 October 2017. RESULTS: There were 106 813 GIM hospitalisations during the study period, with median hospital length-of-stay of 4.6 days (IQR: 2.33-9.19). There were 21 tests which had a cumulative cost >US$15 400 at all three sites. The costliest test was plasma electrolytes (US$4 907 775), the test with the lowest proportion of abnormal results was red cell folate (0.2%) and the test with the greatest physician-level variation in use was antiphospholipid antibodies (coefficient of variation 3.08). The five tests with the highest cumulative rank based on greatest cost, lowest proportion of abnormal results and highest physician-level variation were: (1) lactate, (2) antiphospholipid antibodies, (3) magnesium, (4) troponin and (5) partial thromboplastin time. In addition, this method identified unique tests that may be a potential source of laboratory overuse at each hospital. CONCLUSIONS: A simple multidimensional, data-driven approach combining cost, proportion of abnormal results and physician-level variation can inform interventions to reduce laboratory test overuse. Reducing low value laboratory testing is important to promote high value, patient-centred care.

Beyond Microsystem Fixes: Targeting National Drivers of Low-Value Care Comment on "Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands".

Low-value care drivers and interventions are often focused on a microsystem (eg, clinic or inpatient ward) or within a health system. Identification of national drivers such as payment structure and medical culture of overuse can help identify regional approaches to reducing low-value care. However, these approaches in isolation are insufficient and require additional strategies. These can include policy and payment changes and adopting shared decision-making (SDM). SDM has the potential to move medical culture away from the 'more is better' paternalistic and physician-centric culture to one that actively engages patients as full partners in managing their care.

Bedspacing and clinical outcomes in general internal medicine: A retrospective, multicenter cohort study.

BACKGROUND: Admitting hospitalized patients to off-service wards ("bedspacing") is common and may affect quality of care and patient outcomes. OBJECTIVE: To compare in-hospital mortality, 30-day readmission to general internal medicine (GIM), and hospital length-of-stay among GIM patients admitted to GIM wards or bedspaced to off-service wards. DESIGN, PARTICIPANTS, AND MEASURES: Retrospective cohort study including all emergency department admissions to GIM between 2015 and 2017 at six hospitals in Ontario, Canada. We compared patients admitted to GIM wards with those who were bedspaced, using multivariable regression models and propensity score matching to control for patient and situational factors. KEY RESULTS: Among 40,440 GIM admissions, 10,745 (26.6%) were bedspaced to non-GIM wards and 29,695 (73.4%) were assigned to GIM wards. After multivariable adjustment, bedspacing was associated with no significant difference in mortality (adjusted hazard ratio 0.95, 95% confidence interval [CI]: 0.86-1.05, p = .304), slightly shorter median hospital length-of-stay (-0.10 days, 95% CI:-0.20 to -0.001, p = .047) and lower 30-day readmission to GIM (adjusted OR 0.89, 95% CI: 0.83-0.95, p = .001). Results were consistent when examining each hospital individually and outcomes did not significantly differ between medical or surgical off-service wards. Sensitivity analyses focused on the highest risk patients did not exclude the possibility of harm associated with bedspacing, although adverse outcomes were not significantly greater. CONCLUSIONS: Overall, bedspacing was associated with no significant difference in mortality, slightly shorter hospital length-of-stay, and fewer 30-day readmissions to GIM, although potential harms in high-risk patients remain uncertain. Given that hospital capacity issues are likely to persist, future research should aim to understand how bedspacing can be achieved safely at all hospitals, perhaps by strengthening the selection of low-risk patients.