Treating loss-to-follow-up as a missing data problem: a case study using a longitudinal cohort of HIV-infected patients in Haiti.

BACKGROUND: HIV programs are often assessed by the proportion of patients who are alive and retained in care; however some patients are categorized as lost to follow-up (LTF) and have unknown vital status. LTF is not an outcome but a mixed category of patients who have undocumented death, transfer and disengagement from care. Estimating vital status (dead versus alive) among this category is critical for survival analyses and program evaluation. METHODS: We used three methods to estimate survival in the cohort and to ascertain factors associated with death among the first cohort of HIV positive patients to receive antiretroviral therapy in Haiti: complete case (CC) (drops missing), Inverse Probability Weights (IPW) (uses tracking data) and Multiple Imputation with Chained Equations (MICE) (imputes missing data). Logistic regression was used to calculate odds ratios and 95% confidence intervals for adjusted models for death at 10 years. The logistic regression models controlled for sex, age, severe poverty (living on <$1 USD per day), Port-au-Prince residence and baseline clinical characteristics of weight, CD4, WHO stage and tuberculosis diagnosis. RESULTS: Age, severe poverty, baseline weight and WHO stage were statistically significant predictors of AIDS related mortality across all models. Gender was only statistically significant in the MICE model but had at least a 10% difference in odds ratios across all models. CONCLUSION: Each of these methods had different assumptions and differed in the number of observations included due to how missing values were addressed. We found MICE to be most robust in predicting survival status as it allowed us to impute missing data so that we had the maximum number of observations to perform regression analyses. MICE also provides a complementary alternative for estimating survival among patients with unassigned vital status. Additionally, the results were easier to interpret, less likely to be biased and provided an alternative to a problem that is often commented upon in the extant literature.

New uses of old technology: Can nurse-pagers improve communication between resident-physicians and nurses.

BACKGROUND: Alphanumeric paging is underutilized, despite being the standard mode of communication between physicians and nurses at many hospitals across the United States. OBJECTIVE: We hypothesized that an educational program designed to teach optimal alphanumeric paging behavior in conjunction with providing nurses with alphanumeric pagers would improve the quality and efficiency of nurse pages. METHODS: We implemented an educational program to teach nurses about optimal alphanumeric paging, defined as including four important components-patient identification, clinical scenario, sender identification, and callback number. We also provided each nurse with their own unique pager. Alphanumeric paging logs were reviewed prior to the intervention (baseline study period), and again following implementation of the intervention (intervention study period). Questionnaires were also completed by resident-physicians and nurses before and after implementation. RESULTS: During the intervention period, the percentage of ideal pages increased, and the percentage of suboptimal pages decreased. Compared to baseline, pages during the intervention period more often included patient identity, clinical scenario, and page-sender. Resident-physicians rated the paging-system's impact on patient care and job satisfaction more highly, and reported that disruptions and nurse accessibility were less of a problem during the intervention period compared to baseline. Nurses reported less problems with disruptions, ignored pages, miscommunication, and contentious relationships with resident-physicians. CONCLUSIONS: This study underscores the importance of two-way communication, which can be achieved without expensive technology. Creative use of old technology, such as providing nurses with traditional pagers, can improve communication and workflow, and potentially quality of care and patient safety.

Increasing Incidence and Unique Clinical Characteristics of Spinning-Induced Rhabdomyolysis.

OBJECTIVE: To compare outcomes of spinning-induced rhabdomyolysis to those with exertional rhabdomyolysis from other physical activities. DESIGN: Retrospective cohort study. SETTING: Academic medical center, single-center. PATIENTS: A retrospective chart review was conducted on patients evaluated from December 2010 through November 2014. Patients were selected by ICD-9 code for rhabdomyolysis. Patients were included if the reason for admission was rhabdomyolysis caused by exertion. Cases of rhabdomyolysis caused by trauma or drugs were excluded. MAIN OUTCOME MEASURES: Muscle group involvement, admission, and peak creatine kinase levels, time from activity to hospitalization, length of hospital stay, and incidence of complications. RESULTS: Twenty-nine cases were reviewed with 14 admissions secondary to spinning. Median admission creatine kinase (73 000 IU/L vs 29 000 IU/L, P = 0.02) and peak creatine kinase levels were significantly higher in the spinning group (81 000 IU/L vs 31 000 IU/L, P = 0.007). Hospital admissions for spinning-induced rhabdomyolysis increased over time. CONCLUSION: Health care providers should be aware of the potential dangers of spinning-related rhabdomyolysis especially in otherwise healthy young people.

A Mixed-Methods Study of Pain-related Quality of Life in Sickle Cell Vaso-Occlusive Crises.

The quality of care for sickle cell disease patients hospitalized with a vaso-occlusive crisis (VOC) is poor, resulting in staggeringly high healthcare resource utilization. To evaluate in-patient care for VOC, we conducted a mixed-methods study of all adult sickle cell disease patients admitted with a VOC from 2010-2012. We quantitatively assessed the quality of care for all patients, and qualitatively studied a subset of frequently admitted patients. In total, there were 182 admissions from 57 unique patients. The median length of stay was 6 days and the 30-day readmission rate was 34.0%. We identified red blood cell transfusion and patient controlled analgesia use as predictors of increased length of stay. Interestingly, unlike prior findings, younger patients (18-30 years old) did not have increased healthcare resource utilization. Moreover, older age appeared to increase readmission rate and enhance the effect of patient controlled analgesia use on length of stay. Interviews of high healthcare resource utilizers revealed significant deficiencies in pain management and a strong desire for individualized care. This is the first study to examine in-patient predictors of acute healthcare resource utilization in sickle cell disease patients and to correlate them with qualitative perspectives of high healthcare resource utilizers.

Anemia in general medical inpatients prolongs length of stay and increases 30-day unplanned readmission rate.

OBJECTIVES: Anemia, either chronic or newly developed in the hospital as a result of underlying disease and/or phlebotomy, is seen commonly among general medical inpatients, and its impact on the quality and efficiency of care is unknown. METHODS: This study investigated the relation among hemoglobin level, length of stay, and 30-day unplanned readmission rates in a cohort of 314 general medical inpatients 18 years old and older admitted to a teaching hospital during a period of 4 months in a large urban academic medical center, using retrospective chart review of the electronic health record. RESULTS: Anemia was common among this cohort of general medical inpatients (44.6%), and there was a statistically significant decrease in hemoglobin levels during their hospitalization. Anemic patients, as compared with nonanemic patients, had significantly longer mean and median length of stay. More important, the admission hemoglobin level and its change during hospitalization were significant predictors of increased length of stay. For every 1-U increase in admission hemoglobin level, the median length of stay was reduced by 0.5 days. For every 1-U increase in the level of hemoglobin change, the median length of stay was extended by 1.5 days. Likewise, the discharge hemoglobin level predicted the rate of 30-day unplanned readmission. For every 1-U decrease in discharge hemoglobin level, the readmission rate increased by nearly 4%. These relations remained after adjusting for common demographic and clinical variables, including age, sex, nutritional status, and number of comorbidities. CONCLUSIONS: Anemia is common among general medical inpatients and adversely affects their length of stay and 30-day unplanned readmission rate.

Outcomes after antiretroviral therapy during the expansion of HIV services in Haiti.

BACKGROUND: We report patient outcomes after antiretroviral therapy (ART) initiation in a network of HIV facilities in Haiti, including temporal trends and differences across clinics, during the expansion of HIV services in the country. METHODS: We assessed outcomes at 12 months after ART initiation (baseline) using routinely collected data on adults (≥15 years) in 11 HIV facilities from July 2007-December 2013. Outcomes include death (ascertained from medical records), lost to follow-up (LTF) defined as no visit > 365 days from ART initiation, and retention defined as being alive and attending care ≥ 365 days from ART initiation. Outcomes were compared across calendar year of ART initiation and across facilities. Risk factors for death and LTF were assessed using Cox proportional hazards and competing risk regression models. RESULTS: Cumulatively, 9,718 adults initiated ART with median age 37 years (IQR 30-46). Median CD4 count was 254 cells/uL (IQR 139-350). Twelve months after ART initiation, 4.4% (95% CI 4.0-4.8) of patients died, 21.7% (95% CI 20.9-22.6) were LTF, and 73.9% (95% CI 73.0-74.8) were retained in care. Twelve-month mortality decreased from 13.8% among adults who started ART in 2007 to 4.4% in 2013 (p<0.001). Twelve-month LTF after ART start was 29.2% in 2007, 18.7% in 2008, and increased to 30.1% in 2013 (p<0.001). Overall, twelve-month retention after ART start did not change over time but varied widely across facilities from 61.1% to 86.5%. CONCLUSION: Expansion of HIV services across Haiti has been successful with increasing numbers of patients initiating ART and decreasing twelve-month mortality rates. However, overall retention has not improved, despite differences across facilities, suggesting additional strategies to improve engagement in care are needed.

(Re)turning the pages of residency: the impact of localizing resident physicians to hospital units on paging frequency.

BACKGROUND: Geographic localization of physicians to patient care units may improve communication, decrease interruptions, and reduce resident workload. This study examines whether interns on geographically localized patient care units receive fewer pages than those on teams that are not. METHODS: The study is a retrospective analysis of the number of pages received by interns on 5 internal medicine teams: 2 in a geographically localized model (GLM), 2 in a partial localization model (PLM), and 1 in a standard model (SM) over 1 month at New York-Presbyterian Hospital/Weill Cornell. Multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team. RESULTS: The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.2 (95% confidence interval [CI]: 2.0-2.4) in the GLM, 2.8 (95% CI: 2.6-3.0) in the PLM, and 3.9 (95% CI: 3.6-4.2) in the SM; all differences were statistically significant (P < 0.001). CONCLUSION: Geographic localization of resident teams to patient care units was associated with significantly fewer pages received by interns during the day. Such patient care models may improve resident workload in part by decreasing pages, and consequently has important implications for patient safety and medical education.

The patient care circle: a descriptive framework for understanding care transitions.

BACKGROUND: Reducing hospital readmissions depends on ensuring safe care transitions, which requires a better understanding of the challenges experienced by key stakeholders. OBJECTIVE: Develop a descriptive framework illustrating the interconnected roles of patients, providers, and caregivers in relation to readmissions. DESIGN: Multimethod qualitative study with 4 focus groups and 43 semistructured interviews. Multiple perspectives were included to increase the trustworthiness (internal validity) and transferability (external validity) of the results. Data were analyzed using grounded theory to generate themes associated with readmission. SETTING/PATIENTS: General medicine patients with same-site 30-day readmissions, their family members, and multiple care providers at a large urban academic medical center. RESULTS: A keynote generated from the multiperspective responses was that care transitions were optimized by a well-coordinated multidiscipline support system, described as the Patient Care Circle. In addition, issues pertaining to readmissions were identified and classified into 5 main themes emphasizing the necessity of a coordinated support network: (1) teamwork, (2) health systems navigation and management, (3) illness severity and health needs, (4) psychosocial stability, and (5) medications. CONCLUSION: A well-coordinated collaborative Patient Care Circle is fundamental to ensuring safe care transitions.