Implementation of pharmacogenomics into inpatient general medicine.

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

Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients.

Background: Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame. Objective: To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability. Design: Prospective cohort study. Setting: 10 academic medical centers in the United States. Patients: 822 adults readmitted to a general medicine service. Measurements: For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics. Results: Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions. Limitation: Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results. Conclusion: Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions. Primary Funding Source: Association of American Medical Colleges.

The Relative Ability of Comorbidity Ascertainment Methodologies to Predict In-Hospital Mortality Among Hospitalized Community-acquired Pneumonia Patients.

BACKGROUND: Despite widespread use of comorbidities for population health descriptions and risk adjustment, the ideal method for ascertaining comorbidities is not known. We sought to compare the relative value of several methodologies by which comorbidities may be ascertained. METHODS: This is an observational study of 1596 patients admitted to the University of Chicago for community-acquired pneumonia from 1998 to 2012. We collected data via chart abstraction, administrative data, and patient report, then performed logistic regression analyses, specifying comorbidities as independent variables and in-hospital mortality as the dependent variable. Finally, we compared area under the curve (AUC) statistics to determine the relative ability of each method of comorbidity ascertainment to predict in-hospital mortality. RESULTS: Chart review (AUC, 0.72) and administrative data (Charlson AUC, 0.83; Elixhauser AUC, 0.84) predicted in-hospital mortality with greater fidelity than patient report (AUC, 0.61). However, multivariate logistic regression analyses demonstrated that individual comorbidity derivation via chart review had the strongest relationship with in-hospital mortality. This is consistent with prior literature suggesting that administrative data have inherent, paradoxical biases with important implications for risk adjustment based solely on administrative data. CONCLUSIONS: Although comorbidities derived through administrative data did produce an AUC greater than chart review, our analyses suggest a coding bias in several comorbidities with a paradoxically protective effect. Therefore, chart review, while labor and resource intensive, may be the ideal method for ascertainment of clinically relevant comorbidities.

Discharge disposition as an independent predictor of readmission among patients hospitalised for community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is the most common non-obstetrical reason for hospital admission, the leading infectious cause of death, and a target for public reporting. CAP has thus become a target of quality improvement and pay-for-performance efforts. However, the relationship between discharge disposition and readmission risk has not been investigated. METHODS: We studied CAP patients admitted to the University of Chicago from 11/2011 to 04/2015. We collected demographic information, comorbidities, laboratory values, vital signs, a modified pneumonia severity index (PSI), length of stay (LOS), clinical instabilities before discharge, discharge disposition and 30-day all-cause readmission. A multivariate logistic regression was performed, specifying readmission as the dependent variable, including as independent variables gender, ethnicity, insurance status, discharge disposition, PSI tertile, the number of clinical instabilities, LOS and comorbidities. RESULTS: Of the 2892 CAP patients identified, 14.9% were readmitted. The distribution of discharge disposition was: 43.0% home without services, 26.1% home with home health care (HHC), 16.2% to a skilled nursing or subacute rehabilitation facility and 14.8% to an acute rehabilitation or long-term acute care facility. Of patients discharged home with HHC, 20.1% were readmitted, compared to 11.5% discharged home without services. In the multivariate regression model, being discharged home with HHC was associated with a markedly greater risk of readmission (Odds ratio 1.58 [95% confidence interval 1.21-2.07]). CONCLUSIONS: Discharge home with HHC is an independent predictor of readmission risk among hospitalised CAP patients. Discharging providers should carefully consider follow-up care and social factors that may impact the risk of readmission among such patients.

Physician Perspectives on Factors Contributing to Readmissions and Potential Prevention Strategies: A Multicenter Survey.

BACKGROUND: The transition out of the hospital is a vulnerable time for patients, relying heavily on communication and coordination of resources across care settings. Understanding the perspectives of inpatient and outpatient physicians regarding factors contributing to readmission and potential preventive strategies is crucial in designing appropriately targeted readmission prevention efforts. OBJECTIVE: To examine and compare inpatient and outpatient physician opinions regarding reasons for readmission and interventions that might have prevented readmission. DESIGN: Cross-sectional multicenter study. PARTICIPANTS: We identified patients readmitted to general medicine services within 30 days of discharge at 12 US academic medical centers, and surveyed the primary care physician (PCP), discharging physician from the index admission, and admitting physician from the readmission regarding their endorsement of pre-specified factors contributing to the readmission and potential preventive strategies. MAIN MEASURES: We calculated kappa statistics to gauge agreement between physician dyads (PCP-discharging physician, PCP-admitting physician, and admitting-discharging physician). KEY RESULTS: We evaluated 993 readmission events, which generated responses from 356 PCPs (36 % of readmissions), 675 discharging physicians (68 % of readmissions), and 737 admitting physicians (74 % of readmissions). The most commonly endorsed contributing factors by both PCPs and inpatient physicians related to patient understanding and ability to self-manage. The most commonly endorsed preventive strategies involved providing patients with enhanced post-discharge instructions and/or support. Although PCPs and inpatient physicians endorsed contributing factors and potential preventive strategies with similar frequencies, agreement among the three physicians on the specific factors and/or strategies that applied to individual readmission events was poor (maximum kappa 0.30). CONCLUSIONS: Differing opinions among physicians on factors contributing to individual readmissions highlights the importance of communication between inpatient and outpatient providers at discharge to share their different perspectives, and suggests that multi-faceted, broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors.

Sequence patterns in the resolution of clinical instabilities in community-acquired pneumonia and association with outcomes.

BACKGROUND: In patients hospitalized with community-acquired pneumonia (CAP), indicators of clinical instability at discharge (fever, tachycardia, tachypnea, hypotension, hypoxia, decreased oral intake and altered mental status) are associated with poor outcomes. It is not known whether the order of indicator stabilization is associated with outcomes. OBJECTIVES: To describe variation in the sequences, including whether and in what order, indicators of clinical instability resolve among patients hospitalized with CAP, and to assess associations between patterns of stabilization and patient-level outcomes. DESIGN/PARTICIPANTS / MAIN MEASURES: Chart review ascertained whether and when indicators stabilized and other data for 1,326 adult CAP patients in six U.S. academic medical centers. The sequences of indicator stabilization were characterized using sequence analysis and grouped using cluster analysis. Associations between sequence patterns and 30-day mortality, length of stay (LOS), and total costs were modeled using regression analysis. KEY RESULTS: We found 986 unique sequences of indicator stabilization. Sequence analysis identified eight clusters of sequences (patterns) derived by the order or speed in which instabilities resolved or remained at discharge and inpatient mortality. Two of the clusters (56% of patients) were characterized by almost complete stabilization prior to discharge alive, but differing in the rank orders of four indicators and time to maximum stabilization. Five other clusters (42% of patients) were characterized by one to three instabilities at discharge with variable orderings of indicator stabilization. In models with fast and almost complete stabilization as the referent, 30-day mortality was lowest in clusters with slow and almost complete stabilization or tachycardia or fever at discharge [OR = 0.73, 95% CI = (0.28-1.92)], and highest in those with hypoxia with instabilities in mental status or oral intake at discharge [OR = 3.99, 95% CI = (1.68-9.50)]. CONCLUSIONS: Sequences of clinical instability resolution exhibit great heterogeneity, yet certain sequence patterns may be associated with differences in days to maximum stabilization, mortality, LOS, and hospital costs.

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

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

A most unusual patient at the Massachusetts General Hospital.

This year marks 200 years of patient care at the Massachusetts General Hospital (MGH). In celebration of this milestone, a unique Grand Rounds case is presented. A 450-year-old rotund man admitted 60 times presents with a classic triad of periumbilical pain, bilateral plantar burns, and a frozen scalp. Although this triad may at first strike a cord of familiarity among seasoned clinicians, the disease mechanism is truly noteworthy, being clarified only after a detailed occupational history. Ergo, the lessons hark back to the days of yesteryear, when the history and physical served as the cornerstone of Yuletide clinical diagnosis. A discussion of epidemiology and prognosis accompanies a detailed examination of the pathophysiholiday. Although some consider this patient uncouth, as you will see, he is quite a medical sleuth. The long-standing relationship between this patient and the MGH prompted his family to write a letter of appreciation, which will remind the reader of the meaning that our care brings to patients and their families. Harvey Cushing, who completed his internship at the MGH in 1895, professed "A physician is obligated to consider more than a diseased organ, more even than the whole man-he must view the man in his world." We hope this unusual Grand Rounds case intrigues you as it reminds you of Cushing's lesson and wishes you a joyous holiday season.

Applicability of Pharmacogenomically Guided Medication Treatment during Hospitalization of At-Risk Minority Patients.

Known disparities exist in the availability of pharmacogenomic information for minority populations, amplifying uncertainty around clinical utility for these groups. We conducted a multi-site inpatient pharmacogenomic implementation program among self-identified African-Americans (AA; n = 135) with numerous rehospitalizations (n = 341) from 2017 to 2020 (NIH-funded ACCOuNT project/clinicaltrials.gov#NCT03225820). We evaluated the point-of-care availability of patient pharmacogenomic results to healthcare providers via an electronic clinical decision support tool. Among newly added medications during hospitalizations and at discharge, we examined the most frequently utilized medications with associated pharmacogenomic results. The population was predominantly female (61%) with a mean age of 53 years (range 19-86). On average, six medications were newly prescribed during each individual hospital admission. For 48% of all hospitalizations, clinical pharmacogenomic information was applicable to at least one newly prescribed medication. Most results indicated genomic favorability, although nearly 29% of newly prescribed medications indicated increased genomic caution (increase in toxicity risk/suboptimal response). More than one of every five medications prescribed to AA patients at hospital discharge were associated with cautionary pharmacogenomic results (most commonly pantoprazole/suboptimal antacid effect). Notably, high-risk pharmacogenomic results (genomic contraindication) were exceedingly rare. We conclude that the applicability of pharmacogenomic information during hospitalizations for vulnerable populations at-risk for experiencing health disparities is substantial and warrants continued prospective investigation.

Trends in mortality and medical spending in patients hospitalized for community-acquired pneumonia: 1993-2005.

BACKGROUND: Community-acquired pneumonia (CAP) is the most common infectious cause of death in the United States. To understand the effect of efforts to improve quality and efficiency of care in CAP, we examined the trends in mortality and costs among hospitalized CAP patients. METHODS: Using the National Inpatient Sample between 1993 and 2005, we studied 569,524 CAP admissions. The primary outcome was mortality at discharge. We used logistic regression to evaluate the mortality trend, adjusting for age, gender, and comorbidities. To account for the effect of early discharge practices, we also compared daily mortality rates and performed a Cox proportional hazards model. We used a generalized linear model to analyze trends in hospitalization costs, which were derived using cost-to-charge ratios. RESULTS: Over time, length of stay declined, while more patients were discharged to other facilities. The frequency of many comorbidities increased. Age/gender-adjusted mortality decreased from 8.9% to 4.1% (P < 0.001). In multivariable analysis, the mortality risk declined through 2005 (odds ratio, 0.50; 95% confidence interval, 0.48-0.53), compared with the reference year 1993. The daily mortality rates demonstrated that most of the mortality reduction occurred early during hospitalization. After adjusting for early discharge practices, the risk of mortality still declined through 2005 (hazard ratio, 0.74; 95% confidence interval, 0.70-0.78). Median hospitalization costs exhibited a moderate reduction over time, mostly because of reduced length of stay. CONCLUSIONS: Mortality among patients hospitalized for CAP has declined. Lower in-hospital mortality at a reduced cost suggests that pneumonia is a case of improved productivity in health care.

Paradoxical doppler echocardiographic parameters during recovery of left atrial contractility after spontaneous conversion from paroxysmal atrial fibrillation to sinus rhythm.

Paroxysmal atrial fibrillation (PAF) reduces atrial contractility due to atrial remodeling, but little is known about the process by which contractile function is reconstituted after spontaneous conversion to sinus rhythm (SR). A 63-year-old healthy man developed PAF. PAF persisted for 2 days before spontaneous conversion to SR. Serial echocardiograms were performed at 1, 24 h, 3/4/7 days after conversion. Longitudinal myocardial strain during the pump phase of the left atrium (LA) was generally reduced at 1 h. Normal strain of the LA was restored at 3 days with the exception of the lateral wall, where restoration was delayed until 4 days. The ratio between the mitral early and atrial diastolic velocities (E/A) at 24 h was within a pseudonormal range at 1.8, but the ratio between E and early mitral annulus velocity (e': E/e') remained normal. The E/A ratio gradually decreased until 7 days post conversion, but the E/e' ratio remained normal throughout the observation period.

Association of Preferences for Participation in Decision-making With Care Satisfaction Among Hospitalized Patients.

Importance: The association of patient desire to participate in health care decisions with care satisfaction is poorly understood. The contributions of such desire, expectations of care, and quality of care in assessing patient satisfaction are not known. Objective: To investigate the association of hospitalized patients' desire to delegate decisions to their physician with care dissatisfaction. Design, Setting, and Participants: Survey study in an academic research setting. As part of The University of Chicago Hospitalist Study, data were collected on 13 902 hospitalized patients admitted to the general internal medicine service of The University of Chicago Medical Center between July 1, 2004, and September 30, 2012, who answered an inpatient survey administered soon after the time of admission and a 30-day follow-up survey. The dates of analysis were January 2014 to June 2015. Exposure: Patient-reported preference to leave medical decisions to their physician (definitely agree or somewhat agree vs somewhat disagree or definitely disagree). Main Outcomes and Measures: The main outcomes were patient-reported dissatisfaction with overall service, dissatisfaction with physician care, and lack of confidence and trust in the physicians providing treatment, which were obtained from the 30-day follow-up survey. Results: The sample population included 13 902 patients (mean [SD] age, 56.7 [19.1] years; 60.4% female [n = 8397] and 74.2% African American [n = 10 310]) who completed both surveys. Overall, 53.2% had no higher educational attainment, 22.7% were insured by Medicaid, and 51.1% reported a general self-assessed health status of fair or poor. The proportions of respondents who agreed and disagreed with delegating decisions to the responsible physician were 71.1% and 28.9%, respectively. A statistically significantly higher proportion of those who agreed rated their overall care as excellent or very good compared with those who disagreed (68.0% vs 62.5%; P < .001). Similarly, a statistically significantly higher proportion of those who agreed were extremely satisfied with the physician care received (67.8% vs 62.5%; P < .001). In the multivariable logistic regression models, compared with those patients who definitely agreed with delegation, patients who definitely disagreed were more likely to be dissatisfied with overall service (odds ratio [OR], 1.86; 95% CI, 1.54-2.24) and the physician care received (OR, 1.78; 95% CI, 1.42-2.22) and lack confidence and trust in the physicians providing treatment (OR, 2.05; 95% CI, 1.62-2.59). Conclusions and Relevance: The findings suggest that patient preferences to participate in medical decision-making are statistically significantly associated with dissatisfaction of hospitalized patients. Clinicians should individualize their encouragement of patient participation in diagnostic and management decisions to maximize patient satisfaction.

Hospital Ward Adaptation During the COVID-19 Pandemic: A National Survey of Academic Medical Centers.

IMPORTANCE: Although intensive care unit (ICU) adaptations to the coronavirus disease of 2019 (COVID-19) pandemic have received substantial attention , most patients hospitalized with COVID-19 have been in general medical units. OBJECTIVE: To characterize inpatient adaptations to care for non-ICU COVID-19 patients. DESIGN: Cross-sectional survey. SETTING: A network of 72 hospital medicine groups at US academic centers. MAIN OUTCOME MEASURES: COVID-19 testing, approaches to personal protective equipment (PPE), and features of respiratory isolation units (RIUs). RESULTS: Fifty-one of 72 sites responded (71%) between April 3 and April 5, 2020. At the time of our survey, only 15 (30%) reported COVID-19 test results being available in less than 6 hours. Half of sites with PPE data available reported PPE stockpiles of 2 weeks or less. Nearly all sites (90%) reported implementation of RIUs. RIUs primarily utilized attending physicians, with few incorporating residents and none incorporating students. Isolation and room-entry policies focused on grouping care activities and utilizing technology (such as video visits) to communicate with and evaluate patients. The vast majority of sites reported decreases in frequency of in-room encounters across provider or team types. Forty-six percent of respondents reported initially unrecognized non-COVID-19 diagnoses in patients admitted for COVID-19 evaluation; a similar number reported delayed identification of COVID-19 in patients admitted for other reasons. CONCLUSION: The COVID-19 pandemic has required medical wards to rapidly adapt with expanding use of RIUs and use of technology emerging as critical approaches. Reports of unrecognized or delayed diagnoses highlight how such adaptations may produce potential adverse effects on care.

The impact of marital status on health care utilization among Medicare beneficiaries.

To explain prior literature showing that married Medicare beneficiaries achieve better health outcomes at half the per person cost of single beneficiaries, we examined different patterns of healthcare utilization as a potential driver.Using the Medicare Current Beneficiary Survey (MCBS) data, we sought to understand utilization patterns in married versus currently-not-married Medicare beneficiaries. We analyzed the relationship between marital status and healthcare utilization (classified based on setting of care utilization into outpatient, inpatient, and skilled nursing facility (SNF) use) using logistic regression modeling. We specified models to control for possible confounders based on the Andersen model of healthcare utilization.Based on 13,942 respondents in the MCBS dataset, 12,929 had complete data, thus forming the analytic sample, of whom 6473 (50.3%) were married. Of these, 58% (vs. 36% of those currently-not-married) were male, 45% (vs. 47%) were age >75, 24% (vs. 70%) had a household income below $25,000, 18% (vs. 14%) had excellent self-reported general health, and 56% (vs. 36%) had private insurance. Compared to unmarried respondents, married respondents had a trend toward higher odds of having a recent outpatient visit (unadjusted odds ratio (OR) 1.11, 95% confidence interval (CI) 1.04-1.19, adjusted odds ratio (AOR) 1.10, (CI) 0.99-1.22), and lower odds in the year prior to have had an inpatient stay (AOR 0.84, CI 0.72-0.99) or a SNF stay (AOR 0.55, CI 0.40-0.75).Based on MCBS data, odds of self-reported inpatient and SNF use were lower among married respondents, while unadjusted odds of outpatient use were higher, compared to currently-not-married beneficiaries.

Gastric varices and splenic vein obstruction during steroid treatment for autoimmune pancreatitis: A case report and literature review.

RATIONALE: Few cases of autoimmune pancreatitis (AIP) complicated by gastric varices, in the absence of splenic vein obstruction, have been described in the medical literature. The findings in this case parallel those of 3 previously described cases from Japan and support a pathologic explanation for the evolution of gastric varices in relation to early splenomegaly and the role of steroid therapy for AIP. PATIENT CONCERNS: A 50-year-old male with a history of transfusion-requiring erosive gastritis and recently diagnosed AIP on steroid therapy for 2 weeks presented with a 2-day history of lightheadedness, abdominal pain, and melena. DIAGNOSIS: Esophagogastroduodenoscopy (EGD) revealed prominent varices in the gastric fundus. An abdominal ultrasound with Doppler demonstrated patency of the splenic, hepatic, and portal veins. Review of previous imaging revealed that the splenic vein and the superior mesenteric vein (SMV) were occluded prior to the diagnosis of AIP and steroid therapy initiation. OUTCOME: Following resolution of hemodynamic instability through fluid resuscitation and blood transfusion, the remainder of his hospital course was uneventful. Subsequent to discontinuation of steroid therapy, he developed near total reocclusion of both the splenic vein and SMV. LESSON: Early steroid treatment should be considered in patients with uncomplicated AIP to prevent the occlusive vascular complications that are frequently associated with the pathophysiology of this disease process.